Dec272025
Guardianship Q&A Series

How do I get legal authority to make medical decisions for an elderly relative in a nursing home if they can’t understand or sign paperwork? – North Carolina

Short Answer

In North Carolina, the usual way to get clear legal authority to make medical decisions for an elderly relative who cannot understand or sign documents is to seek a court-appointed guardianship (often a “guardian of the person”) through the Clerk of Superior Court. A health care power of attorney generally requires the relative to have enough understanding to appoint an agent and to execute the document with the required witnesses and notarization, even if the signature is made by mark. If a guardianship is not yet in place, North Carolina law may still allow certain family or other qualified persons to consent to treatment under the state’s informed-consent statute, depending on who is available and the medical situation.

Understanding the Problem

In North Carolina guardianship cases, the central question is: when an elderly nursing home resident cannot understand what documents mean or cannot validly sign them, what legal step gives another person the authority to make medical decisions on that resident’s behalf. The decision point usually turns on whether the resident can still understand and choose a decision-maker, or whether a court must first determine incapacity and appoint someone to act. The setting often involves a nursing facility asking for a clear legal decision-maker for treatment decisions and medical records access.

Apply the Law

North Carolina law recognizes two main paths to medical decision-making authority for an adult who lacks capacity: (1) a valid health care power of attorney (where the person had capacity to appoint a health care agent and properly executed the document), or (2) a court-appointed guardian with authority over the person (who can consent to care). When the person cannot understand or sign paperwork in a meaningful way, guardianship is commonly the most reliable method because it comes from a court order and formal “Letters of Guardianship.” Guardianship begins with an incompetency proceeding before the Clerk of Superior Court, which is the exclusive procedure for adjudicating an adult incompetent.

Key Requirements

  • Lack of capacity for medical decisions (or to appoint an agent): The starting point is whether the elderly relative can make and communicate health care decisions or can understand enough to appoint someone else to do it. If not, a power of attorney may be vulnerable, and guardianship may be needed.
  • Proper court appointment with the right scope: A “guardian of the person” (or a general guardian with powers over the person) is the role that typically has authority to consent to medical care and arrange living placement, subject to any limits in the court order.
  • Priority of existing documents: If a valid health care power of attorney already exists, the health care agent generally keeps authority unless the Clerk suspends the agent’s authority in a guardianship proceeding.

What the Statutes Say

Analysis

Apply the Rule to the Facts: The facts describe an elderly nursing home resident with cognitive disability who may not be able to understand or sign documents and may only be able to sign by an “X.” That raises a capacity concern: even if a mark can function as a signature, a health care power of attorney still depends on the person understanding what is being signed and choosing an agent. If the relative cannot do that reliably, a guardianship proceeding in front of the Clerk of Superior Court is typically the clearest way to obtain medical decision-making authority, because the resulting order and Letters of Guardianship give third parties (like hospitals and nursing facilities) a concrete basis to accept consent under North Carolina law.

Process & Timing

  1. Who files: A family member or other “interested person” typically starts the case. Where: The Office of the Clerk of Superior Court in the county where the elderly relative resides (often the county of the nursing facility). What: A petition/verified pleading asking the Clerk to adjudicate the relative incompetent and to appoint an appropriate guardian (commonly a guardian of the person for medical decisions). When: As soon as medical decision authority is needed and there is no valid health care power of attorney in place.
  2. Evaluation and hearing setup: The process typically involves notice to required parties and a hearing before the Clerk. The court process exists to determine incompetency and the least restrictive appointment needed, and to issue an order that third parties can rely on.
  3. Appointment and proof of authority: If the Clerk adjudicates incompetency and appoints a guardian, the guardian receives Letters of Guardianship. Those letters are usually what the nursing home and medical providers ask for when they need proof of authority to consent to treatment and coordinate care.

Exceptions & Pitfalls

  • A signature by “X” is not the only issue: Even if a mark can be used as a signature, the bigger risk is whether the elderly relative had the mental capacity to understand and appoint a health care agent at the time of signing. If capacity is doubtful, medical providers and family members may later question the document’s validity.
  • Existing health care power of attorney may control: If a valid health care power of attorney already exists, the health care agent generally has priority to make decisions. A guardian may need to ask the Clerk to suspend the agent’s authority if there is a serious reason to do so.
  • Not every medical decision is the same: Some categories of decisions can require additional court involvement or have special statutory rules. Planning for the scope of authority in the guardianship order matters.
  • Relying on “next-of-kin” informally can break down: North Carolina’s informed-consent law provides a priority list of people who can consent when the patient lacks capacity, but facilities often prefer court documentation when there is family conflict, uncertainty about who is “reasonably available,” or ongoing decision-making needs.

Conclusion

In North Carolina, when an elderly nursing home resident cannot understand or sign documents in a meaningful way, the most dependable way to obtain legal authority to make medical decisions is to file an incompetency/guardianship case with the Clerk of Superior Court and seek appointment as guardian of the person (or general guardian with powers over the person). A health care power of attorney usually requires capacity plus proper execution formalities. The next step is to file the guardianship petition with the Clerk in the county where the relative resides as soon as medical decisions cannot wait.

Talk to a Guardianship Attorney

If a family is dealing with an elderly relative in a nursing home who cannot understand or sign paperwork and a clear medical decision-maker is needed, a guardianship case may be the fastest path to reliable authority. Our firm has experienced attorneys who can help explain options, paperwork, and timelines in North Carolina. Call us today at (919) 341-7055.

Disclaimer: This article provides general information about North Carolina law based on the single question stated above. It is not legal advice for your specific situation and does not create an attorney-client relationship. Laws, procedures, and local practice can change and may vary by county. If you have a deadline, act promptly and speak with a licensed North Carolina attorney.

Category: Guardianship Q&A Series

Author: jpierce

Attorney Jared Pierce is the founder of Pierce Law Group in Raleigh, North Carolina, a firm he established with a dedicated focus on probate administration and estate planning across North Carolina. Born and raised in the Republic of South Africa, Jared moved to Durham with his family in 2001, bringing with him a rich cultural background and a distinctive accent that often serves as a conversation starter.