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Public guardians are individuals appointed by the state to care for the interests of incapacitated citizens. The nature and quality of their care is examined at sites in Maryland, Delaware, Tennessee, and Virginia. In the first three states public guardianship programs have been running for at least ten years; in Virginia two pilot projects are currently underway. All sites use different service delivery models. In addition to studying case file notes, public guardians, program supervisors, and wards were observed and interviewed with regard to their background, their views on public guardianship, accountability and effectiveness, and services provided. The aim of this study is to contribute to a better qualitative understanding of how well state public guardian programs intersect intimately with individuals for whom no other responsible decision maker exists. The study concludes with recommendations regarding the roles of the public guardian in improving wards' quality of life through substitute decision making and in enhancing democratic governance to give voice to wards through their own participation in decision making and relationships with their public guardian.