There is very little known about which end of life (EOL) interventions are effective in populations with different ethnic, cultural, and socioeconomic backgrounds 2. This proposal addresses EOL care for homeless people, the most extreme examples of these overlooked populations. They have the greatest risk of death in the US 9-11, unique perspectives of good EOL care 12-15, encounter significant barriers to care 16-19, and lack the resources and relationships necessary for good EOL care 20. Despite this, there are no interventional studies determining whether EOL care can be improved in this population. Encouraging individuals to plan for EOL care through Advance Directives (ADs), has been central to efforts to improve EOL care. ADs, however, have been subject to criticism 2, particularly that they may not ultimately affect EOL care received2. However, these shortcomings have been mainly demonstrated in specific and similar populations 2. There are reasons to believe that ADs and advance care planning have different utility and efficacy for homeless persons and are much desired in this population12-14. this proposal builds upon four years of research, including an NIH/NINR-funded investigation, regarding EOL care, dying, and death. This research is some of the first work defining the concerns of homeless persons regarding EOL care and confirmed the relevance and potential of ADs in this population to impact EOL care positively 12-14. We seek to test an intervention to improve EOL care for homeless persons: 300 participants will be randomized into two arms, guided intervention (Gl) and minimal intervention (Ml). The Gl condition will expose participants to education, guidance and counseling, and an AD tool, designated HELP (Appendix A), specifically designed for underserved and estranged populations. The Ml condition will expose participants to the provision of HELP and instructions, mimicking community standards and the requirements of the federal PSDA 21. Primary Aim 1: To determine whether homeless individuals will complete an AD and whether guidance enhances rates of completion. This primary outcome will be the completion of an AD. Primary Aim 2: To determine whether completion of ADs by homeless individuals lead to their use during county hospital care encounters over 18 months after the intervention. The primary outcome will be evidence of AD utilization and impact on the care received, using multiple measures. It is important to test appropriate, reproducible interventions in underserved populations, and insights from this project will be significant in several ways: they will help address the EOL concerns of homeless persons, and provide the basis to address the needs of others who are disenfranchised from loved ones and/or receive fragmented, episodic care, such as the rural and urban poor, homebound persons, or undocumented persons. ? ? ?
| Vawter, Lem; Ratner, Edward (2010) The need for POLST: Minnesota's initiative. Minn Med 93:42-6 |
