Perspectives on Care at the Close of Life Section Editor: Margaret A. Winker, MD, Deputy Editor, JAMA.
Author Affiliations: Division of General Internal Medicine, University of California, San Francisco, San Francisco General Hospital (Dr Kushel) and Department of Physiologic Nursing, University of California, San Francisco, School of Nursing, San Francisco (Dr Miaskowski).
Homelessness annually affects an estimated 2.3 million to 3.5 million individuals living in the United States. Homeless people face difficulties in meeting their basic needs. Many have substance abuse problems and mental illness, lack social support, and have no medical insurance. These challenges complicate the homeless patient's ability to engage in end-of-life advanced planning, adhere to medications, and find an adequate site to receive terminal care. Employing a multidisciplinary team to care for homeless patients can help address their needs and improve care. For patients who continue to use illicit substances while receiving end-of-life care, experts recommend scheduling frequent clinic visits, using long-acting pain medications, dispensing small quantities of medications at a time, and using a written pain agreement. Homeless people are less likely to have a surrogate decision maker. Clinicians should have frequent, well-documented conversations with these patients about end-of-life wishes. Homeless people can rarely use hospice services because they lack the financial resources for inpatient hospice and have neither the home nor the social support required for home hospice. Developing inpatient palliative care services at hospitals that serve many homeless people could improve the end-of-life care homeless people receive.
Kushel MB, Miaskowski C. End-of-Life Care for Homeless Patients: “She Says She Is There to Help Me in Any Situation”. JAMA. 2006;296(24):2959–2966. doi:10.1001/jama.296.24.2959
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