In re Keri (Continued)
In re Keri
When this litigation commenced two years ago, Mildred Keri (Keri), now ninety years old, lived alone in her New Brunswick home. Since 1995, she had been dependent exclusively on the care of her two sons, Richard Keri (Richard or petitioner) and *54 Charles Keri (Charles). To forestall placing her in a nursing home, both men visited her regularly on alternating days and made numerous arrangements for their mother’s care in their absence. Among other things, they arranged for Keri’s lunch to be delivered daily at noon by Meals on Wheels, and provided her evening meal themselves when they visited with her.
In the months preceding this litigation, Keri became increasingly difficult to care for, refusing her sons’ requests for her to live with them and neglecting to maintain her personal hygiene. After finding her house filled with smoke one day, her sons had the stove disconnected and capped to prevent future harm to their mother. Her condition deteriorated to the point where Richard and Charles finally determined that they could no longer avoid placing her in a nursing home. Keri’s treating physicians certified she suffered from an irreversible dementia that had so impaired her cognitive abilities that she could no longer care for herself. They concluded Keri would not experience any significant improvement in the future even with treatment. In their view, her condition would render her vulnerable to abuse, exploitation, and neglect.
Financially, Keri’s unencumbered residence was found to constitute the bulk of her net worth (at approximately $170,000 according to appraisals requested by the petitioner), FN1 whereas her pension benefits and Social Security provided a monthly income of $1,575.45. Although Keri’s will divides her estate equally between her two sons, petitioner is her agent by a general power of attorney executed on November 11, 1996. That instrument allowedpetitioner *55 to apply for Medicaid benefits for his mother, but did not authorize him to make gifts on her behalf for any reason.
FN1. There is some discrepancy in the record as to the value of Keri’s assets. The trial court stated that she had about $40,000 in liquid assets in addition to her home, and Richard, in his testimony, affirmed the judge’s estimate. According to Richard’s certification, however, his mother only had about $17,000 in other assets-$500 in jewelry, and the remainder in a checking account. Estimates of the home’s value also differed. The average value given by two real estate brokers, whose certifications were attached to the complaint, was $161,250.00; the average value given by two appraisers, whose reports were attached to a later certification submitted by petitioner, was $183,500.00.
On May 10, 2002, pursuant to N.J.S.A. 3B:12-25, petitioner sought guardianship of his mother and her estate. He also submitted for court approval his proposed Medicaid “spend-down plan.” He sought authority to sell his mother’s house and transfer a significant portion of the proceeds to himself and his brother in equal shares as a means of “spending down” her assets to accelerate her Medicaid eligibility. FN2 Assuming that his mother’s monthly **912 nursing home expenses would be $6,500 and that the sale of her house would net $170,000, Richard determined that, after subtracting her monthly income of $1,575.45, Keri would need $4,924.55 per month from her savings to cover her stay. Based on those figures, petitioner sought permission to transfer $92,000 of the proceeds to himself and his brother in equal shares. According to his calculations, the remaining $78,000 would be sufficient to pay his mother’s nursing home bills during the sixteen-month period of Medicaid ineligibility triggered by the transfer.FN3 In other words, seventeen months after the proposed transfer, Keri would have “spent down” enough of her assets to qualify for Medicaid.
FN2. To qualify for Medicaid in New Jersey based on age, a state resident must not have available resources exceeding $2,000. N.J.A.C. 10:71-3.1, -3.4, – 3.9(a)1, and -4.5(b). Keri’s house would not be considered an asset for Medicaid-eligibility purposes if it remained her principal residence. N.J.A.C. 10:71-4.4(b)1. However, petitioner seeks to sell his mother’s residence and transfer monies to himself and his brother because, under federal law, the state is authorized to impose a lien on Keri’s house for reimbursement of Medicaid costs as she is unlikely to return to it. 42 U.S.C.A. § 1396p(a)(1)(B)..
FN3. Congress imposes periods of Medicaid ineligibility for applicants who give away their assets for less than fair market value within thirty-six months of their applications. 42 U.S.C.A. § 1396p(c); see N.J.A.C. 10:71-4.10(a) (complying with federal Medicaid requirement by imposing period of ineligibility). The period of ineligibility, in months, is determined by dividing the amount divested for less than fair market value by the average monthly cost of nursing home care in New Jersey. N.J.A.C. 10:71-4.10(m)1.
Throughout the trial below, petitioner maintained that, if not so ill, his mother would have approved of and undertaken such an *56 estate planning strategy to preserve a significant portion of her assets for her two sons. His brother, Charles, did not object to the proposal. As required, Keri’s court-appointed counsel prepared a Report of a Court Appointed Attorney recommending that the court approve petitioner’s estate plan, although he did not offer any evidence or cross-examine Richard.
On June 26, 2002, the trial court granted petitioner’s guardianship application and ordered the sale of Keri’s residence and her placement in a nursing home. The trial court denied petitioner authority to execute the Medicaid spend-down plan, however, refusing to approve strategies designed to “[pauperize] human beings and citizens in the United States solely to make them [wards] of the taxpayers.”
The Appellate Division affirmed in part, reversed in part, and remanded for further proceedings. In re Keri, 356 N.J.Super. 170, 172, 811 A. 2d 942 (2002). Because the panel would not presume that a competent and reasonable adult would engage in spend-down Medicaid planning, it held that courts should employ a purely subjective standard “to protect the incompetent’s right to self-determination.” Id.at 179, 811 A.2d 942. Under that standard, approval of a spend-down plan proposed by an incompetent’s self-sufficient adult children should occur only when the incompetent person has indicated that preference before losing competency. Ibid. Keri had never expressed a preference, and therefore the Appellate Division found that the trial court properly rejected petitioner’s proposal. Further, out of concern for Keri’s wishes and best interests, the Appellate Division reversed and remanded the matter for reconsideration whether petitioner should be permitted to sell his mother’s house and place her in a nursing facility, and directed the trial court to seek intervention of the Public Guardian on Keri’s behalf pursuant to N.J.S.A. 52:27G-25h. Id. at 180,811 A.2d 942.
We granted Richard’s petition for certification, In re Keri, 175 N.J. 549, 816 A. 2d 1050 (2003), and, also, the participation of amici, Office of the Public Guardian for Elderly Adults, New *57 Jersey State Bar Association, Legal Services of New Jersey, New Jersey Chapter of the National Academy of Elder Law Attorneys, and the National Academy of Elder Law Attorneys and Guardianship Association of New Jersey. We now reverse.
N.J.S.A. 3B:12-49 states, in pertinent part:
The court has, for the benefit of the ward, his dependents and members of his household, all the powers over his estate and affairs which he could exercise, if present and not under a disability, except the power to make a will, and may confer those powers upon a guardian of his estate. These powers include, but are not limited to power to convey or release the ward’s present and contingent and expectant interests in real and personal property, … and to renounce any interest by testate or intestate succession or by inter vivos transfer.
Those powers are integral to a statutory scheme in which courts and guardians are authorized to manage the estates of minors and incompetent persons. N.J.S.A. 3B:12-36 to -64. Under that scheme courts mayexercise, or direct the exercise of, or release the powers of appointment of which the ward is donee, … renounce interests, … make gifts in trust or otherwise, or … change beneficiaries under insurance and annuity policies, only if satisfied, after notice and hearing, that it is in the best interests of the ward.
Additionally,[i]f the estate is ample to provide for the purposes implicit in the distributions authorized by [the statute], a guardian for the estate of a mental incompetent may apply to the court for authority to make gifts to charity and other objects as the ward might have been expected to make.
  In short, when managing the estates of incompetent persons, including the exercise of the power to make gifts, our courts must find that the proposed action is in “the best interests of the ward,” N.J.S.A.3B:12-50, and that any gifts proposed are such “as the ward might have been expected to make,”N.J.S.A. 3B:12-58. Together, those statutory provisions incorporate and reconcile the best interests standard with the common law equitable*58 doctrine of substituted judgment. Only when the estate contains the resources necessary for the benefit of the ward (best interests), may the guardian make gifts “in the same manner as the incompetent would if able to function at full capacity” (substituted judgment). In re Labis, 314 N.J.Super. 140, 146, 714 A. 2d 335 (App.Div.1998).
The concepts found in the statutes governing the powers of courts and guardians have long been a part of our law. Prior to the enactment of N.J.S.A. 3B:12-36 to -64, our courts relied on the doctrine ofparens patriae to “intervene in the management and administration of an incompetent’s estate in a given case for the benefit of the incompetent or of his estate.” In re Trott, 118 N.J.Super. 436, 440, 288A. 2d 303 (Ch.Div.1972). In Trott, the court permitted a guardian to transfer $100,000 and make yearly gifts of the ward’s estate to her four living descendents as a means of reducing the ward’s estate tax burden. Id. at 438-39, 444, 288 A.2d 303. The court endorsed the principle that
in the management of the estate of [an] incompetent, “the guardian should be authorized to act as a reasonable and prudent [person] would act [in the management of his own estate] under the same circumstances, unless there is evidence of any settled intention of the incompetent, formed while sane, to the contrary.”
[Id. at 441, 288 A. 2d 303 (third alteration in original) (quoting **914In re Guardianship of Christiansen,248 Cal.App. 2d 398, 56 Cal.Rptr. 505, 521 (1967) ).]
In accepting that thesis, the court relied on the approach of the Supreme Judicial Court of Massachusetts in Strange v. Powers, wherein that court stated:We agree with the modern trend of cases both in England and in the United States. There is no reason why an individual, simply because he happens to be a ward, should be deprived of the privilege of making an intelligent commonsense decision in the area of estate planning, and in that way forced into favoring the taxing authorities over the best interests of his estate.
[358 Mass. 126, 260 N.E. 2d 704, 709 (1970).]
 To answer in a specific case the question whether the guardian should be permitted “to make the gifts proposed,” Trott, supra, requires the guardian to establish five criteria:
*59 (1) the mental and physical condition of the incompetent are such that the possibility of her restoration to competency is virtually nonexistent; (2) the assets of the estate of the incompetent remaining after the consummation of the proposed gifts are such that, in the light of her life expectancy and her present condition of health, they are more than adequate to meet all of her needs in the style and comfort in which she now is (and since the onset of her incompetency has been) maintained, giving due consideration to all normal contingencies; (3) the donees constitute the natural objects of the bounty of the incompetent by any standard …; (4) the transfer will benefit and advantage the estate of the incompetent by a reduction of death taxes; (5) there is no substantial evidence that the incompetent, as a reasonably prudent person, would, if competent, not make the gifts proposed in order to effectuate a saving of death taxes.
[118 N.J.Super. at 442-43, 288 A. 2d 303.]
See also Christiansen, supra, 56 Cal.Rptr. at 523-25 (establishing factors substantially similar to those of Trott ). After finding that the proposed financial plan met those criteria, the Trott court authorized the guardian to execute the plan. 118 N.J.Super. at 444, 288 A. 2d 303.
The Trott criteria, which we now adopt, have been applied by our courts in exercising their statutory authority to determine whether estate-planning proposals offered by guardians are in the wards’ best interests and give effect to the wards’ wishes had they been able to express them. See Labis, supra,314 N.J.Super. at 147, 714 A. 2d 335 (observing that relevant provisions of Title 3B “incorporated the concepts of Trott “); see also In re Conroy, 98 N.J. 321, 360, 486 A. 2d 1209 (1985) (“[T]he goal of decision-making for incompetent patients should be to determine and effectuate, insofar as possible, the decision that the patient would have made if competent.”). In effect, Trott provides a framework consisting of a set of objective tests (criteria (1), (3) and (4)) for the application of substituted judgment, taking into account the ward’s best interests (criterion (2)). Criterion (5), however, introduces a subjective test with a high evidentiary burden to rebut substituted judgment: that “there is no substantial evidence” the ward, “if competent,” would not approve a Medicaid spend-down plan.
Thus, in Labis, supra, a case that in many respects resembles the case at bar, the Appellate Division reversed an order of the trial court preventing petitioner (who was her husband’s court-appointed*60guardian) from carrying out an interspousal transfer of the marital residence as a Medicaid estate planning measure. 314 N.J.Super. at 142, 714 A. 2d 335. Applying the Trott factors, the appellate court allowed**915 the transfer to proceed because the ward’s wife and two adult children were the natural objects of his bounty, the transfer would neither interrupt nor detract from the quality or duration of his medical care, and he was expected never to regain competency. Id. at 147-48, 714 A.2d 335.
Significantly, the panel dismissed as “erroneous [the] view that the proposed interspousal transfer was contrary to public policy.” Id. at 144, 714 A.2d 335. The trial court had reasoned that an injustice would arise from the transfer in that the wife, if she predeceased her husband, could then bequeath the marital home to their adult children ” ‘free of the claims of the public.’ ” Ibid. The Appellate Division acknowledged the likelihood of that result, but concluded the court below had “failed to consider that the interspousal transfer would benefit [the ward] in carrying forth his probable actions if he were competent to address the situation,” and that federal Medicaid legislation had established eligibility rules related to such transfers. Ibid. Because the ward had prepared a will leaving his assets to the petitioner, the court believed it “[safe to] assume that if … competent he would take any lawful and reasonable action to minimize obligations to the State … in order to secure the maximum amount available to support his wife … and benefit his children.” Id. at 148, 714 A.2d 335. Pursuant to N.J.S.A.3B:12-49 and 3B:12-50, as informed by the Trott criteria, the Appellate Division approved the guardian’s request. Ibid.
In Cohen, supra, similar reasoning led the Appellate Division to reject a settlement proposed by beneficiaries under the will of an incompetent testator and by her guardian, and approved by the chancery court in the face of contentions that the parties had never reached agreement. 335N.J.Super. at 15-16, 760 A. 2d 1128. The product of a complicated series of interfamilial wranglings, the approved settlement provided for the “division [of the *61 incompetent’s estate] … into equal family shares and the immediate gifting of large portions of the estate to the beneficiaries under [a prior] trust agreement” executed by the incompetent when she was of sound mind. Id. at 25, 760 A.2d 1128. The settlement both revoked that prior trust, a beneficiary of which was one of the incompetent’s two adult sons, and authorized a distribution to that son’s second wife, who had been excluded from the ward’s initial testamentary plan. Id. at 31, 760 A.2d 1128.
The Appellate Division found that the settlement agreement failed to satisfy three of the Trott criteria (as had the Labis court, Cohen turned to Trott for guidance in the exercise of its power under Title 3B). Id.at 29, 760 A. 2d 1128. Specifically, the court determined that Title 3B permits “sweeping changes to an incompetent’s testamentary plan” only when the donees are natural objects of the incompetent’s bounty, the transfer benefits the ward, his family, or his estate, and there is an absence of substantial evidence indicating contrary intent. Id. at 32, 760 A.2d 1128. In Cohen, when she was well, the incompetent had “prepared a detailed testamentary plan … [that] was deliberate[ly] and carefully crafted” to prevent her son’s second wife from sharing in her estate even though that result meant higher death and transfer taxes. Id. at 30, 760 A.2d 1128. By providing, among other things, a “benefit for [the son’s second wife],” the settlement agreement “alter[ed] the substance of the will and authorize[d] a large distribution to someone who [was] not an object of [the ward’s] bounty as expressed in her will.” Id. at 32, 760 A.2d 1128. The agreement failed the Trott criteria because substantial evidence demonstrated that it was “contrary to [the **916 ward’s] clear testamentary intent.”Id. at 33, 760 A.2d 1128.
The New Jersey cases we have reviewed support the petitioner’s claim that when a Medicaid spend-down plan does not interrupt or diminish a ward’s care, involves transfers to the natural objects of a ward’s bounty, and does not contravene an expressed *62 prior intent or interest, the plan, a fortiori,provides for the best interests of the ward and satisfies the law’s goal to effectuate decisions an incompetent would make if he or she were able to act. That approach accords with decisions of the New York courts addressing the same issues.
Under N.Y. Mental Hyg. Law § 81.21 (a) (McKinney 1996), a
court may authorize the guardian to exercise those powers necessary and sufficient … to transfer a part of the incapacitated person’s assets to or for the benefit of another person on the ground that the incapacitated person would have made the transfer if he or she had the capacity to act.
Those powers include the power to make gifts of all or part of the ward’s estate. Id. § 81.21(a)(1). Also, the statute enumerates factors that our sister state’s courts must consider in determining whether to approve a guardian’s application to transfer a ward’s assets. Those factors, which the New York courts have construed as “g[iving] … recognition to the common-law doctrine of ‘substituted judgment[,]’ ” In re John XX, 226 A.D. 2d 79, 652 N.Y.S. 2d 329, 332 (1996), appeal denied, 89 N.Y. 2d 814, 659 N.Y.S.2d 854, 681 N.E. 2d 1301 (1997), closely follow the Trott court’s formulation.FN4 See also In re Shah,257 A.D. 2d 275, 694 N.Y.S. 2d 82, 87 (1999) ( “The relief granted pursuant to Mental Hygiene Law article 81 is designed to permit an incapacitated person to do, by way of a surrogate, those essential things such a person could do but for his or her incapacity.”), aff’d, 95 N.Y. 2d 148, 711 N.Y.S. 2d 824, 733 N.E. 2d 1093 (2000).
FN4. Other state courts also have employed the substituted judgment approach in guardianship cases. See, e.g., Christiansen, supra, 56 Cal.Rptr. at 522-23 (holding that guardian may transfer ward’s property for tax purposes if ward, as “reasonably prudent” person, would have, absent evidence of contrary intent); Rainey v. Guardianship of Mackey, 773 So. 2d 118, 122 (Fla.Dist.Ct.App.2000) (stating court should use substituted judgment standard to assess Medicaid spend-down proposal).
  When legal guardians have satisfied the statutory requirements, New York permits them to engage in Medicaid planning even when the guardians themselves may be the recipients of transfers from the wards’ assets. *63In re Shah, 95 N.Y. 2d 148, 711 N.Y.S. 2d 824, 733 N.E. 2d 1093, 1098-99 (2000); John XX, supra, 652 N.Y.S. 2d at 332; In re DaRonco, 167 Misc. 2d 140, 638 N.Y.S. 2d 275, 278 (Sup.Ct.1995); In re Daniels, 162 Misc. 2d 840, 618 N.Y.S. 2d 499, 502-504 (Sup.Ct.1994). Indeed, New York has established a presumption in favor of approving Medicaid spend-down proposals on the ground that a reasonable and competent person ” ‘would prefer that the costs of his care be paid by the State, as opposed to his family.’ ” Shah, supra, 711 N.Y.S. 2d 824, 733 N.E. 2d at 1099 (quoting Shah, supra, 694 N.Y.S. 2d at 87); see also Daniels, supra, 618 N.Y.S. 2d at 504 (noting that a “competent, reasonable individual … would prefer that his property pass to his child rather than serve as a source of payment for Medicaid and nursing home care bills”).
 We agree with the New York courts. We find, further, that the Trott criteria impliedly establish a presumption in favor of spend-down proposals by recognizing**917 the benefit to the ward’s estate of increasing the amounts available to beneficiaries by reducing payments to the government out of the estate. Trott, supra, 118 N.J.Super. at 443, 288 A. 2d 303. Also significant, Trott requires “substantial evidence that the incompetent, as a reasonably prudent person, would, if competent, not make the gifts proposed.” Id. at 443-44, 288 A. 2d 303; see also John XX, supra, 652 N.Y.S. 2d at 331 (presumption can be overcome with clear and convincing evidence under N.Y. Mental Hyg. Law § 81.21 (e)(3) that incompetent individual “manifested … intention inconsistent with the proposed transfer”). Thus, underTrott, which we have adopted today, the presumption can be overcome only with “substantial evidence,” a high threshold that is consonant with the approach in New York.