2023-11-07 Spotlight: Retired Pilot Went to Hospital

DignityMA editor’s note: While this report covers a guardianship situation in Florida, there are similar occurrences throughout the nation including Massachusetts. The Post has received almost 3600 comments online. We welcome comments from Dignity Digest readers which can be submitted via info@DignityAllianceMA.org. Comments may be posted in future issues of The Digest.

The retired pilot went to the hospital. Then his life went into a tailspin.

The Washington Post (free access), November 4, 2023, By Mary Jordan

Many older people are one medical emergency away from a court-appointed guardian taking control of their lives.

When Douglas Hulse pulled his Ford Mustang convertible into a Florida gas station three years ago, he looked so distressed that someone called 911.

An ambulance rushed him to Orlando Health South Seminole Hospital, where doctors said he had a stroke. At 80, the retired pilot who had flown famous passengers around the country could no longer care for himself.

But Hulse lived alone — as 3 out of 5 Americans in their 80s do.

A hospital can be liable if a patient is discharged into an unsafe environment. Because Hulse lived alone and the hospital officials saw no sign that he had family, that put them in a bind when his health didn’t improve. So, they argued in court that he was no longer capable of making his own decisions and needed a guardian — a caretaker with enormous legal power.

When a judge agreed, Hulse lost basic freedoms: He couldn’t spend his own money or decide where to live. The lifelong Republican who had just cast his ballot in the 2020 presidential primary even lost his right to vote. He was quickly moved to a nursing home. His new guardian, a woman he had never met, began selling his house and his belongings.

Hulse had joined 1 million Americans in a guardianship, a court-sanctioned arrangement created to protect vulnerable people — some young, but many elderly. The system has been widely criticized for inviting abuse and theft. Local judges give extraordinary power to a guardian, including access to the bank account of the person in their care, despite a lack of effective ways to monitor them. When excessive billing, missing money and other abuses are discovered, guardians are rarely punished. Prosecutors are keenly aware a judge appointed them.

As America ages, there is new focus on this legal arrangement, especially in Florida, a mecca for seniors where state officials have called the rising number of elderly the “silver tsunami.” Already, Florida has 2 million residents 75 or older — more than the entire population of 14 other states. Many moved here from other parts of the country, far from family, and are showing up alone in emergency rooms.

What happened to Hulse over the past three years shines a light on the serious flaws in this government system and on the hospital pipeline that thrust Hulse into it. During the coronavirus pandemic, more hospitals went to court to seek guardianships; it was a way to legally move out patients and free up beds. Today, the practice quietly continues as an efficient way to discharge elderly patients who cost hospitals money the longer they stay.

“This should scare people to death,” said Rick Black, the founder of the Center for Estate Administration Reform who has examined thousands of guardianship cases and has seen a rise in hospitals initiating them. “This is a common practice nationwide, and its adoption is growing.”

In court, the Orlando hospital requested that Hulse be assigned Dina Carlson, a 51-year-old former real estate agent who became a professional guardian. After a judge assigned her, Hulse was immediately moved out of the hospital and into a nursing home. Carlson’s sale of his home raised suspicions because of its seemingly low price in a hot market, and an inspector general’s investigation later found “probable cause” of exploitation of an elderly person and a scheme to defraud.

Carlson denied any wrongdoing, and no criminal investigation was ever opened. “I am a little bit salty about this whole thing,” Carlson said in an interview. She said she wanted “to be a ray of sunshine” for elderly people.

Guardianships are not well understood. Rules vary by jurisdiction, and key information is often sealed by judges.

“People don’t realize how abusive the system is,” said Pinellas County Circuit Court Clerk Ken Burke, who led a recent Florida task force to improve guardianships. “If they knew, there would be bigger cries for reform.”

Very often, the person in a guardianship is unable to publicly complain and has nobody in their life to do it for them.

But it turned out Hulse did have family, and they were searching for him.

A pilot who thought he would live forever
Douglas Hulse was born in 1939 and raised in McLean, Va., where his father was a lobbyist for the trucking industry. In the 1950s, Hulse enrolled in a Florida college and became a pilot.

Like his father, Hulse was a Republican who loved to talk politics. He also drew caricatures of every president in the last half century. After flying Henry Kissinger and Alexander Haig, former Republican secretaries of state, he proudly showed off photos he took of them to his sister, niece, and nephew.

He never married or had children. He kept busy, teaching flying and taekwondo. But when he retired he spent more time alone. Five residents on his street in Lake Mary, near Orlando, said they barely knew the tall, blue-eyed neighbor. He had lived there 25 years, longer than many in a transient place.

Raymond Charest, president of the Seminole County Gun and Archery Association, said that in the 1990s Hulse taught members about how to safely handle and store guns but that recently he wasn’t involved in the club. “I would see him shooting out there. But it was just, ‘Hey, how are you doing?’ and that was it.”

Katie Thompson, Hulse’s niece, said for years her uncle regularly visited her mother, father, brother and her in the Philadelphia area. She also went to see him at his three-bedroom Florida home full of exceptional items he collected in his travels, including a Las Vegas-style slot machine.

But his visits stopped when his sister, Katie’s mother, developed dementia before she died in 2018. Hulse had seen his own mother die the same way. “I think it just got too hard for him,” his niece said.

After Hulse’s only sibling passed away, he became harder to reach, but he eventually responded to calls and emails.

After his stroke, Hulse was confused and apparently unable to tell anyone to call his family. It’s unclear what efforts the hospital made to track down any relatives.

Geo Morales, a spokesman for the Orlando Health South Seminole Hospital, said he could not discuss details of Hulse’s case because of privacy laws. He emailed a statement that said the hospital works “with various community partners in an attempt to reach next of kin. However, reaching a patient’s next of kin is not always possible.”

“We are seeing more of these patients with dementia and other ailments who live alone and/or are estranged from relatives,” Morales said in an email. He strongly urged people to draw up a will or designate someone to make their health decisions and to note this in their medical file.

Hulse had not. In these cases, court records show, hospitals often turn to guardianships, even though they are widely considered a last resort and difficult to reverse.

A safety net built for a different era
For generations, judges have been assigning a relative or close friend as the protector of someone unable to make their own decisions. But more people are socially isolated and have no one they can count on at the end of their life. Even many people with close relatives are estranged from them.

In many societies, family members of different generations live under one roof. But one of the most dramatic shifts in the American lifestyle is single-person households. Many live alone beginning in their 20s and by the time they are in their 80s, most live by themselves.

So, judges now often assign professional guardians, a person paid to care for someone they don’t know. Carlson told the court she was already caring for 18 others when she was assigned to Hulse. Carlson charged him $65 an hour, according to her bills filed in court. When a judge signed off, she paid herself from Hulse’s bank account.

In some states, the only requirement to be a guardian is to be 18 years old. Florida has more requirements including a background and credit check. But still, compare the 40-hour training course with, for instance, the 900 educational hours required to become a licensed barber.

Yet these caretakers control people’s lives and money. In just one Florida county, Palm Beach, guardians control about $1 billion, according to Anthony Palmieri, deputy inspector general for the Palm Beach Circuit Court.

“You have your nail techs and tennis pros — their business is not so good and they want something more lucrative and they’re jumping into guardianship,” Palmieri said.

But adding an independent monitor from outside the court, a frequent recommendation, is expensive. “The system would be cured, in my opinion, by the Department of Elder Affairs taking responsibility for guardianship” said Burke, the Pinellas court clerk.

In Florida, even funding a statewide guardianship database was a battle. Currently, there isn’t an official number of how many people are in them; best estimates are about 50,000. Each county keeps its own records, and some do that better than others. When the database goes online, it will give the first statistical snapshot of the system.

Critics have called for a uniform system with more oversight. But several Florida officials said those who benefit from the current, complex system, including lawyers, impede reform. Efforts to make attorneys’ fees in these cases more publicly visible have also failed.

“There are a lot of great attorneys out there,” Burke said. But the court clerk said there has been pushback from the Real Property, Probate and Trust Law Section of the Florida Bar, adding, “It’s a trade union for all practical purposes, and it protects their members and the fees they receive.”
These attorneys are influential in the state legislature, where their expertise is often sought to draft laws related to guardianships and estates.

John Moran, chair-elect of the Florida Bar’s Real Property, Probate and Trust Section, said far from blocking improvements, it has stated policy positions that seek reforms, including more transparency. Asked why legal fees cannot be more readily known, Moran cited privacy concerns of the incapacitated person. He also emphasized that “no lawyer gets paid without a judge’s approval.”

So, the system with few guardrails continues. Court clerks audit guardians’ reports that detail how they spend the money of the person in their care, among other things. Any irregularities are to be flagged to a judge. But clerks are swamped, with little time to read through a case file that is often thousands of pages.

Grant Maloy, the Seminole County court clerk, said his office has a far bigger caseload today than 15 years ago yet a smaller budget.

The judges are overloaded, too. Pinellas County has two judges and two magistrates overseeing 3,000 guardianships — in addition to other types of cases.
No witness or body camera accompanies a guardian into a person’s home. They are trusted to accurately inventory all valuables in their court report. “There could be $5,000 stuffed under the sofa, and if the guardian pocketed it, who would know?” said Burke, the Pinellas court clerk.

The task force organized by the state clerks and comptrollers last year said hospitals should find a less drastic way to deal with patients costing them money, such as authorizing someone to be their power of attorney or health surrogate. It also sought a ban on requesting a specific guardian because that raises concerns about the guardian’s allegiance — is it to the patient or the hospital giving them work?

A Washington Post review of guardianship records in central Florida found scores of recent petitions by hospitals seeking a guardian for patients 65 and older, and many asked for a specific professional guardian.

Hulse’s guardianship
In April 2020, when Hulse was ready to be discharged, a staff member of the Orlando hospital signed a petition to the court stating that he had “no one to take care of the financial and medical decisions.”

Hulse, like most patients over 65, was covered by Medicare. It pays the hospital by diagnosis, not length of stay, an attempt to stop excessive billing. Generally, it pays a hospital $23,000 for an elderly stroke patient in Orlando, a sum that assumes a five-day stay. After that, a hospital starts losing money. A new patient in the same bed would bring in thousands of dollars a day.

The American Hospital Association said more patients are staying “excessive days” and has lobbied for increased Medicare payments. Many hospitals are also overwhelmed by people who are homeless or have a mental illness and other patients unable to pay their bills. An AHA spokesman also said a hospital may initiate a guardianship but a judge approves it.

Laura Sterling, an attorney hired by the Orlando hospital, recommended Carlson as Hulse’s guardian. In Florida, lawyers represent guardians in court, and Sterling was Carlson’s lawyer. In her court filing that requested Carlson, Sterling does not mention that if Carlson was assigned, she also would be paid as her lawyer, at a rate of $300 an hour.

Sterling did not respond to requests for comment. There is no Florida rule prohibiting a lawyer from representing both the hospital and the guardian the hospital recommended in the same case.

Moran, from the Florida Bar, said he could not speak for the lawyers’ group but said that scenario raised “all kinds of red flags.”

Sterling’s role in Hulse’s case was largely to file court motions. One sought approval for a monthly transfer of $10,000 from Hulse’s brokerage account to his checking account so Carlson could pay his nursing home and other bills. Another asked the court for $2,925 for Carlson, for time spent opening Hulse’s mail, arranging physical therapy and other tasks during her first four months. The money to pay Sterling and Carlson came from Hulse’s accounts, which had more than $1.5 million, according to a note in his file.

In August 2020, after Hulse had fallen five times at the Lake Mary nursing home, Carlson moved him to a smaller facility. She also started liquidating his possessions, reporting to the court that she sold his cars, paintings, a diamond ring, camera equipment and guns. Many items were sold in cash at an estate sale, according to neighbors who went to it. It’s unclear how much Carlson reported earning for Hulse; most financial details are kept sealed.

In April 2021, Carlson signed an agreement to sell Hulse’s house with Kimberly and Mark Adams, husband-and-wife real estate agents who lived in her gated community lined with palm trees, giving them a 6 percent commission, an amount typically split between the seller’s and buyer’s agents. Carlson quickly sold the home for $215,000 before it was even publicly known to be on the market, according to the inspector general’s investigation. A company called Harding Street Homes bought Hulse’s home and resold it a few months later for $347,000 — $132,000 more than Hulse got for it. Efforts to reach the person who runs that company were unsuccessful.

Soon after the home was sold, Katie Thompson, Hulse’s niece, expanded her search for her uncle. Busy with her job and her first baby, she had not realized for months that her brother and father also had not heard from Hulse. She was a legal researcher who used Westlaw, an online legal database, and when she typed her uncle’s name into it, she was stunned to see him listed in a guardianship case.

“How could the hospital do this?” she thought. Since older people end up in an emergency room, she figured there must be a system for contacting family. “If they just called me none of this would have happened.”

In the days after Carlson became Hulse’s guardian, she did not call his relatives, either. Carlson said it was unfortunate but no one’s fault: “How does a person find out about somebody who doesn’t live in the same state? About family who don’t have the same last name? I didn’t have anybody’s name to Google.”

Thompson has her own regrets. For one thing, she wished she had gotten on a plane earlier despite worries about the pandemic.

On top of everything else, she said, she and her brother were helping their father, heartbroken over the death of their mother. “I kept thinking if something was really wrong with my uncle I would have gotten a call,” she said.

Thompson and her brother began calling those involved in the court case. But nobody answered their key question: Where was Hulse?

Finally, a court clerk advised them to write a letter to the court.

“We want to know where our uncle is, that he is safe and well cared for, and that his money was being well-stewarded so that he can remain so,” Katie Thompson wrote on July 28, 2021, to Seminole County Circuit Court Judge Donna Goerner. “We want to be able to be in contact with him.”

Months passed with no reply.

A watchdog helping from her kitchen table
Around the start of 2022, Hillary Hogue was sitting at her kitchen table in Naples, Fla., scrolling online through guardianship cases, when she randomly clicked on Hulse’s.

“I look for red flags and when you see a hospital is involved, it’s a red flag,” said Hogue. A single mom of two teenage boys, she became an unpaid citizen watchdog after her own horrible guardianship experience. To get her father released from one, she paid over $100,000 in legal fees. He now lives with her.

Hogue knew other cases where hospitals did not notify relatives before setting in motion a hard-to-stop legal process. “It’s just outrageous. Doesn’t anyone care about Mr. Hulse?”

She zeroed in on the price of Hulse’s home, which seemed remarkably low to her, especially after she looked up more information about it. Aware of other cases where guardians sold homes at bargain rates to friends or for kickbacks, Hogue filed a complaint with the office that regulates guardians, knowing it would draw scrutiny to Hulse’s case.

Katie Thompson, meanwhile, inquired about getting her uncle released from his guardianship. The Florida lawyer she contacted told her that she could spend $20,000 trying, with no guarantee of success. Hulse’s health was worsening and soon, any hope she had of moving him to Pennsylvania so she could manage his care became less of an option.

In January 2022, Carlson finally contacted the family. She called Jonathan Thompson, Hulse’s nephew, who believes her call was prompted by the family’s letter to the judge six months earlier. “I guess the letter finally got to the top of someone’s pile,” he said.

Carlson outlined Hulse’s medical problems and said he probably had a series of strokes. Because of the pandemic, she said, for a long stretch at the start of the guardianship she had not met him in person. She offered to arrange FaceTime calls. and soon Katie and Jonathan were talking to Hulse about old family trips to Gettysburg, Pa., and Cape Canaveral, Fla.

But they were wary. A state investigator, spurred by Hogue’s complaint, had called them, asking questions about Carlson.

They had their own questions: Since Carlson knew Hulse had the money for in-home aides why was he in a strange place that added to his confusion? Didn’t she see their cards mailed to his home or their contacts in his phone? And, why would a former real estate agent undersell a home without advertising it?

The investigation
In July 2022, the inspector general’s office issued a critical report, a copy of which was obtained by The Post through a Freedom of Information Act request.

It stated that Carlson, when seeking court approval for the sale of Hulse’s home, submitted a “deficient, deceptive, and fraudulent” comparative market analysis supplied by Kimberly Adams, the real estate agent. Hulse’s home was “undervalued” and not publicly advertised.

The inspector general’s investigation also found no permits required for significant renovation. It concluded that after “superficial changes,” Hulse’s home was “flipped” for a big profit for the buyer — money that Hulse lost out on.

The inspector general’s office, lacking the investigative power of law enforcement, including the ability to subpoena bank records, pushed for a criminal investigation. It urged law enforcement to look into the handling of Hulse home and two others Carlson sold with the same real estate agents, stressing it had found “probable cause” that Carlson and the real estate agents “engaged in a scheme to defraud.”

Reached by phone, Kimberly Adams denied knowing anything about the inspector general investigation: “I honestly don’t know what you are referring to … I sell property all the time.”
Mark Adams did not return phone calls.

Carlson defended her sale of Hulse’s home. She told a state investigator that it was in “very poor condition,” according to the inspector general report, and that “it wasn’t safe to allow the general public” inside because there were “a lot of valuables in the house, a lot of guns and a lot of ammo as well.”

But Hulse’s family said he kept his guns in a safe, and Carlson billed Hulse for finding locksmiths to open his gun safe.

In The Post interview, Carlson said there are ways to improve the guardianship system but most importantly family should take care of their relatives. Then she quickly added, “In Doug’s case, no one knew about his family.”

Carlson did not answer questions about whether she saw the names and addresses of Hulse’s niece and nephew on cards and gifts mailed to his home. She also distanced herself from hospitals: “I have never met anyone at the hospital. Lawyers do.”

Carlson said she got Hulse’s case when “a lawyer” sent an email to her and other professional guardians, asking if anyone had “the bandwidth” to care for another patient leaving a hospital.

In February, Katie Thompson did not meet Carlson when she flew to Orlando with her 3-month-old, her second child, to visit her uncle. He seemed comforted by the photos she brought of his childhood home in Virginia, of her mother and him when they were young. “He was very sick then. I was grateful for the time with him.”

On March 16, the Florida Department of Law Enforcement said its preliminary inquiry found “no evidence” to warrant a criminal investigation “at this time,” according to an email received in the FOIA request.

Advocates for the elderly say police and prosecutors often do not treat financial exploitation of elderly people seriously enough and are reluctant to sink time into cases where the only witness has dementia, if still alive.

Two days after the state declined to pursue a criminal investigation, Hulse died.

Carlson had prepaid for the same basic cremation package she purchases for many in her care. Hulse’s family had his ashes buried with his parents on Long Island.

Katie Thompson received a small box from Carlson with photos and a few other items that belonged to her uncle. She and her brother are now waiting to learn what is left in his estate.

The Florida Department of Elder Affairs, after being contacted by The Post, reprimanded Carlson for her failure to file timely reports. Her penalty: She must take eight more hours of classroom training.

“Not even a slap on the wrist,” said Hogue. “The result is the corruption continues, and it only gets worse, bigger and bigger.” Said Katie Thompson, “This system trusts a person to be a guardian angel, but people are not.”