I knew I wanted to take a case manager position in Guardianship at JF&CS. When I asked my mentor about it, she replied, "Guardianship? Ah. Fascinating work with significantly challenging ethical dilemmas. Be prepared to develop a thicker skin." She was right: not only is my skin thicker but my heart has expanded. Working with older adults with Alzheimer's disease and other dementias, chronic mental illness, brain injury, and developmental disability at risk for neglect, self-neglect, physical and mental abuse or financial exploitation will undoubtedly invite personal growth.

Guardianship is the next stop after exhaustive intervention from Elder Protective Services. When an at-risk elder is evaluated as no longer having cognitive capacity, Elder Protective Services may petition with the Probate Court for a guardian. Taking on a guardianship case requires astute problem solving and a leap of faith into the unknown. Family dysfunction, loss, and crisis are at the forefront of a guardianship referral.

Gallows humor, chocolate, and a commitment to self-care provide the groundwork for guardianship case managers to remain calm and carry on. Our unwavering frame of reference reminds us that dysfunction and loss are, in fact, transformable. The privilege of working in guardianship is found in our opportunity to create space for change, diligently collaborating within complex institutional and familial systems as to ensure safety and foster self-determination to the fullest extent possible in our most vulnerable citizens.

Recently, Edith*, an 86-year-old woman with Alzheimer's, psychosis, and hoarding behavior was reported by Protective Services as living alone in a run-down home. I was the case manager authorized on behalf of JF&CS to manage the health, medical, and financial decisions for the client.

A colleague and I went to meet with Edith, who was reported carrying a knife with her, paranoid of anyone who crossed her path. When we arrived, she was sitting on her porch and shouting at the family with two small children across the street, "I know you come into my house at night! I wish your house would burn to the ground!" We watched as pedestrians passing by averted their eyes.

What these pedestrians didn't know is that Edith's spouse had recently died followed by her only son's death a few months later from a drug overdose. On top of that, JF&CS, an agency unknown to her prior to the Protective Services hearing, was now managing all aspects of her life. Understandably, Edith was extremely suspicious and feared loss of independence.

With the help of Guardianship, Edith was able to remain in her own home but is no longer living alone in fear. Our role calls for substituted judgement, in which we are ethically bound to make decisions that Edith herself may have wanted before loss of cognitive capacity. Guardianship case managers approach clients in a reassuring, supportive, and collaborative manner.

Since our initial appointment, Edith has shown significant improvements in health. She attends medical appointments regularly and receives 24 hour home care services with medication management. She now has a working telephone, television, and weekly grocery delivery—basic needs that were absent at our first meeting. Now that her physical and psychological needs are met, she will soon start attending an Adult Day Health program, helping to reduce Edith's isolation.

An initial guardianship appointment is the start of the transformation process. Guardianship case managers often find themselves unwelcomed, stepping directly into deeply-rooted family dynamics. Every day we make challenging ethical decisions to ensure the safety and well-being of our clients, providing substituted judgment, advocacy, crisis intervention, case management, and collateral work within complex institutions. It may have required a thicker skin, but I am privileged to make a difference in the lives of at-risk older adults every day.

*Name changed to protect privacy.

Jamie joined JF&CS Guardianship in May 2015. She has an MSW from Simmons College with a concentration in trauma and interpersonal violence. Before joining JF&CS, Jamie worked with children, teens, adults, and older adults in both clinical and case management roles, always approaching the work from a trauma-informed perspective. Jamie enjoys the arts and being in nature.