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James R, Flemming K, Hodson M, Oxley T. Palliative care for homeless and vulnerably housed people: scoping review and thematic synthesis. BMJ Support Palliat Care 2023; 13:401-413. [PMID: 33941575 DOI: 10.1136/bmjspcare-2021-003020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION People who are homeless or vulnerably housed are subject to disproportionately high risks of physical and mental illness and are further disadvantaged by difficulties in access to services. Research has been conducted examining a wide range of issues in relation to end-of-life care for homeless and vulnerably housed people, however, a contemporary scoping review of this literature is lacking. OBJECTIVES To understand the provision of palliative care for people who are homeless or vulnerably housed from the perspective of, and for the benefit of, all those who should be involved in its provision. DESIGN Scoping review with thematic synthesis of qualitative and quantitative literature. DATA SOURCES MEDLINE, Embase, PsycINFO, Social Policy and Practice and CINAHL databases were searched, from inception to May 2020. Citation chasing and manual searching of grey literature were also employed. RESULTS Sixty-four studies, involving 2117 homeless and vulnerably housed people were included, with wide variation in methodology, population and perspective. The thematic synthesis identified three themes around: experiences, beliefs and wishes; relationships; and end-of-life care. CONCLUSION Discussion highlighted gaps in the evidence base, especially around people experiencing different types of homelessness. Existing evidence advocates for service providers to offer needs-based and non-judgemental care, for organisations to use existing assets in co-producing services, and for researchers to address gaps in the evidence base, and to work with providers in transforming existing knowledge into evaluable action.
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Affiliation(s)
- Richard James
- Public Health, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Flemming
- Department of Health Sciences, University of York, York, UK
| | | | - Tammy Oxley
- Palliative Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Barker PC, Holland NP, Shore O, Cook RL, Zhang Y, Warring CD, Hagen MG. The Effect of Health Literacy on a Brief Intervention to Improve Advance Directive Completion: A Randomized Controlled Study. J Prim Care Community Health 2021; 12:21501327211000221. [PMID: 33719708 PMCID: PMC7968018 DOI: 10.1177/21501327211000221] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Completion of an advance directive (AD) document is one component of advanced care planning. We evaluated a brief intervention to enhance AD completion and assess whether the intervention effect varied according to health literacy. METHODS A randomized controlled study was conducted in 2 internal medicine clinics. Participants were over 50, without documented AD, no diagnosis of dementia, and spoke English. Participants were screened for health literacy utilizing REALM-SF. Participants were randomized in a 1:1 ratio to the intervention, a 15-minute scripted introduction (grade 7 reading level) to our institution's AD forms (grade 11 reading level) or to the control, in which subjects were handed blank AD forms without explanation. Both groups received reminder calls at 1, 3, and 5 months. The primary outcome was AD completion at 6 months. RESULTS Five hundred twenty-nine subjects were enrolled; half were of limited and half were of adequate health literacy. The AD completion rate was 21.7% and was similar in the intervention vs. the control group (22.4% vs 22.2%, P = .94).More participants with adequate health literacy completed an AD than those with limited health literacy (28.4% vs 16.2%, P = .0008), although the effect of the intervention was no different within adequate or limited literacy groups. CONCLUSION A brief intervention had no impact on AD completion for subjects of adequate or limited health literacy. PRACTICE IMPLICATIONS Our intervention was designed for easy implementation and to be accessible to patients of adequate or limited health literacy. This intervention was not more likely than the control (handing patients an AD form) to improve AD completion for patients of either limited or adequate health literacy. Future efforts and research to improve AD completion rates should focus on interventions that include: multiple inperson contacts with patients, contact with a trusted physician, documents at 5th grade reading level, and graphic/video decision aids. TRIAL REGISTRATION NUMBER NCT02702284, Protocol ID IRB201500776.
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Affiliation(s)
| | | | | | | | - Yang Zhang
- University of Florida, Gainesville, FL, USA
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Abstract
Given the barriers to advance care planning (ACP) and low utilization of outpatient advance directives in hospital settings, it is unclear if ACP in primary care for adults who have experienced homelessness is effective and a valuable use of clinical time. As part of our ACP Project, we examined the feasibility and outcomes of ACP in primary care for patients who have experienced homelessness. We found that such efforts had significant impacts on patients' hospital care and allowed their wishes to be honored when they lost capacity for medical decision-making, particularly at the end of life. Here, we present six case studies demonstrating the outcomes of ACP in primary care for homeless adults and highlight lessons learned. To our knowledge, this is the first case series showing how ACP for homeless adults in primary care has been utilized during hospital care. Based on our findings, we believe that outpatient ACP even for the most socially vulnerable patients is feasible, often impactful, and should be integrated into routine primary care.
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Affiliation(s)
- Laura Kaplan-Weisman
- Institute for Family Health, New York, NY, USA.
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, IMI L5-40, Box 1029, New York, NY, 10029, USA.
- Care for the Homeless, New York, NY, USA.
| | - Jessica Tam
- Institute for Family Health, New York, NY, USA
- Hunter-Bellevue School of Nursing, Hunter College, New York, NY, USA
| | - Casey Crump
- Institute for Family Health, New York, NY, USA
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, 1468 Madison Avenue, IMI L5-40, Box 1029, New York, NY, 10029, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kaplan-Weisman L, Sansone S, Walter E, Crump C. Feasibility of Advance Care Planning in Primary Care for Homeless Adults. J Aging Health 2019; 32:880-891. [DOI: 10.1177/0898264319862420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: As the homeless population ages, it is imperative to improve access to advance care planning (ACP) and document preferences in case medical decision-making capacity is lost. Methods: We implemented an ACP Project to discuss and document advance care plans with all patients aged 45 and older who received primary care at our adult Homeless Program clinics. Results: Over 14 months, ACP was discussed with 48% ( n = 138) of the population and health care proxy (HCP) appointment with 91% ( n = 125) of these patients. Most (62%; n = 77) appointed a HCP from personal relationships, though a significant minority (38%; n = 48) could not and were considered “surrogateless.” End-of-life preferences varied. Approximately 20% of patients wanted to defer to a surrogate for each decision. Discussion: ACP is feasible in primary care for adults who have experienced homelessness and should be incorporated into routine care.
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Affiliation(s)
- Laura Kaplan-Weisman
- The Institute for Family Health, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Care for the Homeless, New York, NY, USA
| | - Sara Sansone
- The Institute for Family Health, New York, NY, USA
- Hunter College, New York, NY, USA
- City University of New York School Graduate School of Public Health and Health Policy, New York City, USA
| | - Eve Walter
- The Institute for Family Health, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Casey Crump
- The Institute for Family Health, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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West KJ, Wrobel B, Pallotta S, Coatsworth A. Bearing Witness: Exploring the End-of-Life Needs of Homeless Persons and Barriers to Appropriate Care. OMEGA-JOURNAL OF DEATH AND DYING 2018; 82:63-91. [PMID: 30278821 DOI: 10.1177/0030222818801150] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Traditional models of palliative care are largely inaccessible to homeless persons, and their preferences regarding end-of-life care are poorly understood. The purpose of the present scoping review is to summarize the burgeoning gray and academic literature on end-of-life care for homeless persons. Five medical databases, seven social science databases, and four gray literature databases were searched, resulting in 57 relevant titles. Six themes emerged: (a) Characteristics of homeless persons who require end-of-life care; (b) preferences and concerns of homeless persons approaching the end of life; (c) the role of spirituality for homeless persons at the end of life; (d) barriers to care at the patient, provider, and institutional or structural levels; (e) inclusive models of palliative care; and (f) implications for policy and practice. Practitioners and homeless persons must negotiate many obstacles in the provision and receipt of palliative care. However, there is tremendous potential and opportunity to improve the quality of life at the end of life for this vulnerable population.
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Affiliation(s)
- Keri J West
- Factor-Inwentash Faculty of Social Work, University of Toronto, Ontario, Canada
| | - Brittany Wrobel
- Factor-Inwentash Faculty of Social Work, University of Toronto, Ontario, Canada
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Sudore RL, Cuervo IA, Tieu L, Guzman D, Kaplan LM, Kushel M. Advance Care Planning for Older Homeless-Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study. J Am Geriatr Soc 2018; 66:1068-1074. [PMID: 29741765 PMCID: PMC6105505 DOI: 10.1111/jgs.15417] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.
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Affiliation(s)
- Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Lina Tieu
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - David Guzman
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - Lauren M Kaplan
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
| | - Margot Kushel
- Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General, San Francisco, California
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Lunder U, Červ B, Kodba-Čeh H. Impact of advance care planning on end-of-life management. Curr Opin Support Palliat Care 2018; 11:293-298. [PMID: 28957882 DOI: 10.1097/spc.0000000000000306] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to critically appraise the recent evidence on different aspects of impact of advance care planning (ACP) in palliative care and to reflect on further implications on practice and research in the future. RECENT FINDINGS Evidence about various ACP impacts is rapidly growing and most common outcome measures are still advance directive completion, change in hospital admission rate and patients' and families' views and experiences with ACP. Mainly descriptive studies bring new information of ACP impact for specific groups of patients, their families, settings, countries, contexts, staff and healthcare system as such. It is not yet clear who and when would best conduct ACP, from general practitioners (GPs) to specialists in the hospitals and even lay-navigators for cancer patients; from early ACP conversations to critical ACP in acute events at the end-of-life. The need for ACP impacts high-quality evidence is becoming more urgent because latest future projections are showing higher palliative care needs than previously expected. SUMMARY Recent studies on various ACP impacts reveal variety of outcomes for different patient groups and settings, and are contributing to a wider picture of ACP situation around the world. However, high-quality evidence on ACP impact is still urgently expected in times of growing need for system-level changes for effective ACP implementation.
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Affiliation(s)
- Urška Lunder
- Research Department, University Clinic for Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
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Shulman C, Hudson BF, Low J, Hewett N, Daley J, Kennedy P, Davis S, Brophy N, Howard D, Vivat B, Stone P. End-of-life care for homeless people: A qualitative analysis exploring the challenges to access and provision of palliative care. Palliat Med 2018; 32:36-45. [PMID: 28672115 PMCID: PMC5758927 DOI: 10.1177/0269216317717101] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Being homeless or vulnerably housed is associated with death at a young age, frequently related to medical problems complicated by drug or alcohol dependence. Homeless people experience high symptom burden at the end of life, yet palliative care service use is limited. AIM To explore the views and experiences of current and formerly homeless people, frontline homelessness staff (from hostels, day centres and outreach teams) and health- and social-care providers, regarding challenges to supporting homeless people with advanced ill health, and to make suggestions for improving care. DESIGN Thematic analysis of data collected using focus groups and interviews. PARTICIPANTS Single homeless people ( n = 28), formerly homeless people ( n = 10), health- and social-care providers ( n = 48), hostel staff ( n = 30) and outreach staff ( n = 10). RESULTS This research documents growing concern that many homeless people are dying in unsupported, unacceptable situations. It highlights the complexities of identifying who is palliative and lack of appropriate places of care for people who are homeless with high support needs, particularly in combination with substance misuse issues. CONCLUSION Due to the lack of alternatives, homeless people with advanced ill health often remain in hostels. Conflict between the recovery-focused nature of many services and the realities of health and illness for often young homeless people result in a lack of person-centred care. Greater multidisciplinary working, extended in-reach into hostels from health and social services and training for all professional groups along with more access to appropriate supported accommodation are required to improve care for homeless people with advanced ill health.
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Affiliation(s)
- Caroline Shulman
- Pathway Charity, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- King’s Health Partners, King’s College Hospital, London, UK
| | - Briony F Hudson
- Pathway Charity, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Joseph Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | | | | | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | - Diana Howard
- Coordinate My Care, The Royal Marsden NHS Foundation Trust, London, UK
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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