For five years, Alexandra Siliezar tried to keep her older brother alive.
Abraham, an insatiable reader and adoring uncle, suffered from post-traumatic stress disorder after serving in the Marines, turning to alcohol to escape. And when the San Francisco resident sustained a brain injury in a street attack in 2015, he developed dementia and seizures.
The siblings spoke almost every day, Alexandra reminding Abraham to eat or to take his medicine. They sat together at church in the Mission. They celebrated holidays at Alexandra's home, where he would squeeze her daughter in bear hugs. Their phone calls ended with "I love you."
On nights when she didn't hear from him, Alexandra would call hospitals, which he cycled through with alarming frequency — and often tried to leave, against doctors' advice. Alexandra, a mental health therapist, knew he was losing weight from chronic vomiting and missing doctor's appointments, leaving pill bottles unopened and sometimes eating rotten food.
Alexandra believed her brother couldn't care for himself. So she asked his doctors to evaluate his mental capacity. She needed a specific document to ask a judge to appoint her as his conservator, giving her the power to make medical decisions for him even if he was resistant. She believed he didn't understand how sick he was, an issue echoed by some of his health care providers.
But as time passed, those providers were split over whether Abraham needed a conservatorship. In July 2020, a doctor and a social worker agreed that Abraham needed additional support, but said her brother didn't qualify for one type of conservatorship, while the other type available might not give Alexandra the help she sought.
"I always told them: When is it going to be bad enough — when he's dead?" Alexandra said.
In August 2020, Abraham disappeared after leaving his supportive housing unit in downtown San Francisco. A month later, U.S. Park Police found his body. He was in a ravine off a trail in Lands End near the San Francisco Veterans Affairs Medical Center, where he was often treated. He was 56.
Standing in the ravine four months after he disappeared, talking about her brother, Alexandra choked up.
"I wanted to apologize and tell him, 'I'm sorry I was not there to take care of you when you died,'" she said. "I fought so hard for five years to prevent this."
There's no way to know whether conservatorship would have saved her brother. But Alexandra is convinced it would have helped.
Abraham's plight reveals how challenging and complicated it can be for loved ones to find the best care for people who become mentally impaired. It also highlights an intensifying debate about whether California's laws on conservatorship, made stricter half a century ago to prevent mass institutionalization, are too narrow.
The issue is particularly fraught in San Francisco, where thousands of people who need treatment for mental illness or addiction are unhoused, and where available services can be limited or expensive. Judges have approved around 1,300 new conservatorships in the city over roughly the past five years.
Critics of conservatorship complain that forcing people into treatment can strip them of their civil rights, and that caregivers too often turn to conservatorships when they should be pursuing less invasive options. California law allows a court-appointed conservator to compel treatment only if someone is "gravely disabled" or cannot care for themselves.
Those concerns have been animated most recently by the fight over pop star Britney Spears, who was conserved for mental health issues. After she argued the arrangement was abusive, a judge suspended her father as conservator . Advocates for reforming conservatorships view that case as an outlier.
Abraham had housing, health insurance, concerned relatives and a team of VA social workers and doctors. Still, Alexandra believes a fractured health care system, insufficient social services and gaps in conservatorship laws failed him. His death, she argues, was avoidable.
Exactly why Abraham died is unknown, as is the reason he ended up in the ravine, according to the city medical examiner and park police. Investigators ruled out foul play.
The Chronicle reviewed thousands of pages of medical records and military discharge papers for Abraham, along with reports from the city medical examiner, police and the courts, and 911 calls and emails.
Alexandra, who provided some of the records, said she wanted to make decisions about Abraham's treatment and place him in a facility with more medical supervision, even if he was resistant, because she believed he couldn't make sound choices for himself.
At least five VA staff members wrote that Abraham needed to be conserved as early as three years before his death, records show. But at least another four providers in that time period wrote that Abraham either could make decisions for himself or that conservatorship wasn't the best way to help him.
The VA declined The Chronicle's interview requests.
"We are still deeply saddened by this tragic and unfortunate situation, and send our condolences to Mr. Siliezar's family," Angelo Dalmacio, a VA spokesperson, said in an email. "As general practice, we do not discuss the private health information of past or current patients."
There are two kinds of conservatorships in California.
The Lanterman-Petris-Short Act of 1967 sets out one path, in which a judge appoints a conservator to make decisions about treatment for people with serious mental illnesses or chronic alcoholism who are determined to be "gravely disabled," meaning they can't provide for their own basic needs, and have been unable to accept treatment. Health care providers initiate these so-called LPS conservatorships and a special county office investigates and then petitions the court to secure them if appropriate. San Francisco rarely receives referrals based on chronic alcoholism. The court can renew LPS annually if the need remains.
Under what is called a probate conservatorship, a judge grants a conservator power to make medical or financial decisions, or both. A judge can also grant the conservator power to place a person in a secure facility. Counties, families and professional conservators can petition a court for a probate conservatorship, with a doctor's recommendation. Typically, caregivers use them for people with dementia. A subset are limited conservatorships, reduced in scope and primarily used for individuals with developmental disabilities.
San Francisco also runs a pilot program to conserve people with a serious mental illness and substance use disorder who have been placed under involuntary psychiatric holds, commonly known as 5150s, and have refused treatment multiple times.
The VA doesn't have legal authority to serve as conservator for people like Abraham, legal experts said. The health system does refer cases to counties, but the counties defer to family members if they are willing to be conservators.
That's what happened in 2016 when Abraham's social worker reached out to the county about conserving him while he was hospitalized for his brain injury, records show. What the VA could do in a case like Abraham's, experts said, is sign the mental-capacity assessment that Alexandra needed to petition.
Assessing a person's mental capacity can be challenging, especially for patients with brain injuries, said Dr. Geoffrey Manley, chief of neurosurgery at San Francisco General Hospital. Better follow-up care for these patients is needed, he said, and negotiating the conservatorship process is more difficult with these patients than with people suffering from dementia.
Manley said he has struggled to conserve dozens of patients over the past 20 years. Some repeatedly returned to the hospital with related injuries. A few of them, he said, died in preventable accidents.
"We need to go back and revisit this complex issue of conservatorship in patients with traumatic brain injuries because the system is not serving these people well today," he said. "A lot of people are in harm's way."
State Sen. Scott Wiener, who represents San Francisco, said conservatorship should be used very sparingly to help "save lives," but believes California's laws are "badly broken."
"There has to be a commitment by the county to actually conserve people who need it," he said. "San Francisco has not shown that commitment for a long time and has been way too conservative and cautious in using even the tools that it has."
The city has conserved only two people under the pilot program, authored by Wiener, for people with a history of psychiatric holds and refusing treatment. Officials said they've been challenged by the strict eligibility requirements and are working hard to help more people who could benefit from the pilot and other paths to conservatorship. But they also say the city must proceed with discretion.
"The law really stresses that conservatorship must absolutely be the last intervention. It only can be pursued if all other less restrictive options are tried first," said Jill Nielsen, who as Public Conservator under the San Francisco Human Services Agency investigates, petitions for and manages some conservatorships. However, she said, the "law doesn't necessarily flex to provide for some of the nuances that I hear from the community that I wish it would."
Zoe Brennan-Krohn, a San Francisco-based attorney with the ACLU Disability Rights Program, said conservatorships are "over-relied" upon. Less restrictive alternatives — such as granting a person power of attorney to make decisions for another person based on their wishes — are "not used adequately and sometimes not sufficiently available."
Jessica Lehman, who directs Senior and Disability Action in San Francisco, said the city needs more voluntary services including housing, treatment and social support. "Conservatorship doesn't work because it's forced treatment," she said. "We're not giving people the option of getting what they want when they want it."
Lehman acknowledged, though, that the current gaps often leave family members "in a terrible situation where they can't get what they need for the people they love."
Abraham Siliezer, who used a different spelling of the family name, was born in El Salvador, the oldest of three children and a smart and gentle child, in his mother's memory. His family moved to San Francisco when he was 14. After high school, he joined the Marines and was deployed for nearly two years in the 1980s, serving in Asia.
It's not clear what led to his PTSD, though medical records mention combat against rebels in the Philippines. Alexandra recalls him describing an ambush and having to "engage to survive."
He started drinking in the service to deal with trauma, according to the records. The military awarded him a Good Conduct Medal before honorably discharging him from active service in 1988 and the reserves in the early 1990s.
He attended UC Berkeley, a French speaker majoring in sociology. His cousin, Christian Cagigal, remembered him as thoughtful, intellectual and philosophical. His family said he always dressed in a suit.
Abraham worked with a city housing task force, with nonprofit groups and in security, but didn't find steady work after 2009, instead spending many hours in the San Francisco Botanical Garden. He yearned to have a job and family and to buy a home, his sister said.
Abraham tried alcohol rehab and bounced between living with his mom and sister and in short-term motels just before he moved into supportive housing in mid-2015. He secured a room in the Stanford Hotel on Kearny Street, run by Swords to Plowshares, which offered independent living with some additional support. His family said he needed more care but couldn't afford more with his Social Security income.
Abraham's condition worsened after someone punched him on the street in November 2015. A police report describes an unprovoked assault that caused Abraham to fall and hit his head on the sidewalk. The impact broke his cranium and caused his brain to bleed, landing him in the hospital for five months.
More than 3,700 pages of medical records document Abraham's decline over the next four years. After his first seizure in January 2017, a pattern emerged: He would wind up in the hospital after a fall or seizure, then often try to leave against medical advice. Sometimes hospital staff physically restrained him.
In one case documented in the records, Alexandra stroked his arm and convinced him to stay.
Records show divergent recommendations as health care providers tried to help Abraham.
It appears the closest Abraham got to conservatorship was in 2018, when a psychologist wrote he should be conserved and a special VA team assessed his mental capacity. The team members wrote that they gave Alexandra information about conservatorship, including where she may be able to obtain free legal help for part of the process, which lawyers say generally costs clients $5,000 to $10,000. Alexandra recalls only that the VA advised her to get an attorney.
She could have petitioned the court on her own, but needed the doctor-signed assessment. When Alexandra asked the VA to fill it out in 2019, a doctor determined that Abraham "demonstrates decision-making capacity at this time," according to medical records.
And although three health care providers wrote last spring that Abraham needed conservatorship, the VA's final assessment did not agree.
On July 6, 2020, a geriatrician met with Abraham and two social workers for two hours. Alexandra joined by phone. The doctor wrote that Abraham didn't understand his medical conditions or drinking problem, demonstrated self-neglect and wasn't capable of making many of his own health care decisions.
But the doctor and one of the social workers didn't recommend conservatorship.
Abraham wouldn't qualify for LPS conservatorship because he didn't have a qualifying mental health diagnosis, they said. Probate, meanwhile, was an "arduous and expensive process," the social worker wrote, that wouldn't guarantee Abraham's placement into a locked facility or "necessarily achieve anything" beyond what Alexandra could already do with power of attorney.
The doctor wrote that "the limiting factor to services or a better place to stay is often financial rather than related to the presence of a substitute decision maker." The doctor told Alexandra the VA would put Abraham on a lengthy wait list for a waiver to pay for an assisted-living facility and try to negotiate more regular visits from city in-home supportive services workers to help with meals and medication.
Although Alexandra, through power of attorney, could make health care decisions for her brother when he no longer had the capacity to do so, she couldn't make choices that went against his wishes, including placing him in a secure facility if a judge granted that power, three legal experts told The Chronicle.
Alexandra said different housing might have helped, but that what she needed was control over Abraham's medical care, even if it was against his will. She disagreed at times when doctors released him from the hospital.
"He had the legal right to make decisions for himself," she said. "He made decisions that ultimately hurt him."
The last time Alexandra saw Abraham, she idled her car outside his building to hand him groceries. He was overjoyed to see his niece after months of separation. Alexandra, worried about COVID-19, didn't let the two hug.
"I will regret that for the rest of my life," she said.
About a week later, on the evening of Aug. 9, 2020, Abraham told Alexandra over the phone that he had a stomachache, a headache, fever and vomiting. She called 911. Paramedics spoke to Abraham, who told them he hadn't called, then closed the incident, records show, even though Alexandra called back to plead with them to take him to the hospital.
The next morning, Alexandra called Abraham's VA social worker and the front desk staff at the Stanford Hotel requesting they check on Abraham. Security footage captured Abraham leaving the building an hour and a half later. The welfare checks were both conducted after that.
Swords to Plowshares, the building operator, was not responsible for Abraham's case management or his health care. Chief Operating Officer Tramecia Garner said that while the nonprofit determined that its staff followed protocol, the loss of any veteran makes the organization "question everything."
A security camera on Bush Street recorded Abraham that morning, the last known sighting. Alexandra filed a missing persons report with police the next day. Phone calls connected city agencies and the VA as they tried to find Abraham, and a social worker met with Alexandra a week after he disappeared to see how the agency could help.
On Aug. 19, a team of VA health care providers met about Abraham and directed staff to be on alert in case he showed up, records show. They also recommended that social workers consider "a systemic expansion" of applications seeking waivers to place people in assisted-living facilities, and advocate for more VA or state-funded resources for secure residential care facilities for veterans who can't afford such care.
More than 50 relatives, friends and strangers joined Alexandra and police in a search for her brother, scouring homeless camps, train stations, parks and beaches. She posted more than 1,000 flyers and called hospitals as far away as Nevada.
She kept searching until Oct. 12, when the medical examiner called her. The office had identified Abraham's body. U.S. Park Police had recovered it on Sept. 11 after two homeless people happened upon it. The cause of death was unknown, the medical examiner concluded. His body had no obvious signs of trauma and was negative for COVID-19. There were no drugs or alcohol at the scene.
Alexandra is convinced her brother wouldn't have gone into the ravine knowingly or willingly. She wonders whether he fell after a seizure or if someone lured him. She's grateful for the police and everyone else who helped her, but wants more investigation and for the city to devote more resources to missing persons' cases.
She also wants more help for people like her brother — affordable housing for veterans with intensive support and more effective paths to conservatorship for people with brain injuries.
"We could not save our loved one, but we need to make change," Alexandra said.
Their mother, Rosa Aminta Rosales, said, "My daughter always helped him, and I tried to do my best, but he didn't receive attention."
On Oct. 30, 2020, Abraham's family buried him in a Colma cemetery. His pastor and a VA employee who had worked with him remembered him as grateful. Friends expressed frustration that the system couldn't protect him. A rifle volley cracked the air as each family member threw a yellow flower onto the coffin.
Alexandra still prays for Abraham every day, remembering the refrain he always told his beloved niece: "Sleep with the angels, because to me you are an angel."
Mallory Moench is a San Francisco Chronicle staff writer. Email: [email protected] Twitter:@mallorymoench
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