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J Gen Intern Med. Dec 2008; 23(12): 2031–2045.
Published online Sep 18, 2008. doi:  10.1007/s11606-008-0771-1
PMCID: PMC2596520

Engaging Homeless Persons in End of Life Preparations

John Song, MD, MPH, MAT,corresponding author1,3 Melanie M. Wall, PhD,2 Edward R. Ratner, MD,1,3 Dianne M. Bartels, RN, PhD,1,3 Nancy Ulvestad, BSN, MART,1 and Lillian Gelberg, MD, MSPH4

Abstract

Background

There are no prospective studies that have investigated the effects of an intervention to improve end of life (EOL) care in an underserved population.

Objective

To determine whether homeless persons will complete an advance directive (AD).

Design

Randomized trial comparing two modes of providing an opportunity for homeless persons to complete an AD. Half of the subjects were randomized to a self-guided group (SG) who were given an AD and written instructions; the other half were given the same material but, in addition, were offered the opportunity to receive guidance to complete the AD (CG).

Participants

Fifty-nine homeless persons recruited from a drop-in center.

Measures

Rate of AD completion and baseline and 3-month follow-up EOL-related knowledge, attitudes, and behaviors.

Results

The overall AD completion rate was 44%, with a statistically significant higher completion rate of 59% in the CG group compared to 30% in the self-guided only group. Frequency of worry about death decreased among those who filled out an AD from 50% to 12.5%, and also among those who did not (25% to 12.5%) ( < .05). Among those who filled out an AD, there were increases in plans to write down EOL wishes (56% to 100%;  < .05) and plans to talk about these wishes with someone (63% to 94%;  < .05).

Conclusion

This study demonstrates that people living in dire economic and social situations will complete an AD when offered the opportunity. While offering guidance resulted in higher rates of completion; even a simple self-guided AD process can achieve completion of ADs in this population.

KEY WORDS: homelessness, poverty, end of life, advance directives

BACKGROUND

Improving end of life (EOL) care is an important goal of the US health system1. One main finding of the NIH State of the Science conference on EOL care was that the majority of EOL research has been conducted on narrowly defined populations2. Consensus recommendations included more study of under-represented populations, such as the underserved or underinsured. The limited EOL research examining individuals from lower socioeconomic strata is mainly descriptive but indicates that disparities exist in the delivery and experience of EOL care.

A core process in good EOL care is advance care planning (ACP) and writing advance directives (ADs)1, but these are known to occur less often within disadvantaged populations. There are, for example, associations between lower levels of education, socioeconomic (SES) and insurance status, minority status and lower completion rates of ADs39.

Homeless persons face the most disadvantaged financial and social circumstances. Poverty is the greatest risk factor for homelessness10—half of all homeless adults receive less than $300 a month in income11. This population is significant, with a point prevalence of several hundred thousand12,13 and a lifetime prevalence of 7.4%14. Homeless persons suffer from poor health disproportionately15,16, have many barriers to health care17,18 and die at 3 to 10 times the rate of domiciled populations1921. In addition, there are high rates of mental illness and substance abuse among homeless persons2224, which are associated with poorer health status and outcomes2527. These morbidities may be hypothesized to similarly adversely affect EOL care and outcomes; perhaps by presenting additional barriers to care or affecting specific aspects of care, such as pain control28.

Recent empirical work has demonstrated that homeless persons are concerned about EOL care2832, and have unique challenges, barriers, and wishes when seeking or obtaining EOL care2831. One normative theme that emerges from this nascent literature is the prescription for making one’s EOL wishes known, particularly through written means, such as ADs2831.

However, in addition to the empirical evidence that homeless persons value and desire written ADs, there are conceptual justifications to explore the use of ADs among the homeless. In a population characterized by poor quality personal33,34 and health care relationships17,18,35,36, it is likely that many homeless persons lack surrogate decision-makers. In addition, they may be less likely to have persons emerge who might overrule an AD. Research demonstrates that written documentation may be all that exists among homeless persons to direct care providers should they become seriously ill and/or unable to express their wishes about medical care2831. In this context, then, ADs, tailored to the unique concerns of homeless persons, can be hypothesized to be completed at a higher rate than in the general population.

OBJECTIVE

There is a need for research on interventions that may improve EOL care in impoverished subgroups2. A comprehensive literature search found no prospective trials tailored to improving EOL care in poor or underserved populations. This paper describes a prospective, randomized pilot trial to improve the EOL decision-making process for homeless persons by facilitating ACP. The intervention is derived from EOL concerns elicited from previous investigations of homeless persons2931. The following were the primary study questions: 1) Given the opportunity, will homeless persons complete an AD, and is the completion rate higher when one-on-one guidance is offered as compared to self-guided material only and 2) Did completion of an AD improve knowledge and change attitudes and beliefs regarding EOL care among homeless persons?

PARTICIPANTS

Participants were recruited in September 2006 from Listening House, a drop-in center for homeless individuals located in St. Paul, Minnesota. Participants represent a convenience sample. On the recruitment day, a general announcement was made and the project described orally to potential participants by the investigators as a “study to see whether homeless persons would fill out a Living Will if given the chance and whether filling one out would change your attitudes and beliefs about EOL planning.” Participants were then invited to participate and screened for eligibility. Participants were required to speak English, be at least 18 years old, and have been homeless during the previous six months, using the operational definition of homelessness adapted from the Stewart B. McKinney Homeless Assistance Act (P.L. 100–77 enacted in July 1987). For this study, homeless adults are defined as persons age 18 or older who spent the previous night in one of the following situation: 1) in a public or private shelter or 2) “on the streets” (in a public or private place not designed for, or ordinarily used as, regular sleeping accommodations for humans. These include, for example, public or abandoned buildings or places out-of-doors like parks)37. All potential participants met study criteria and were then enrolled after informed consent was obtained. The study was approved by the IRB of the University of Minnesota.

DESIGN

After consent was obtained, all participants completed a baseline survey including demographics and questions about EOL and ACP knowledge, attitude, and behaviors (KAB). After completion of the survey, subjects received compensation and were then randomized into one of two intervention arms: self-guided AD materials (self-guided, SG) or self-guided AD materials plus the opportunity to receive one-on-one guidance from a counselor (counselor guided, CG). Participants were informed of their assigned arm and also instructed that there would be no additional compensation for completing an AD. It was very important for the integrity of the main study outcome to make it clear that completion of an AD was voluntary and not associated with compensation.

All participants received an AD entitled HELP (Honoring End of Life Preferences) and written educational materials about ADs and ACP. Participants randomized to the SG group were invited to fill out the HELP form on their own and, if requested, were given limited assistance including witnessing signatures to insure legality of the document. Participants randomized to the CG group were provided with the same self-guided AD as the SG participants and told that they could either complete it on their own or, should they choose, meet with an investigator for one-on-one counseling to complete the AD on another, scheduled day.

All participants were offered assistance in storing the completed ADs at Listening House. They were also encouraged to keep the original document—several requested multiple copies to distribute to health care providers, loved ones, and other relevant parties.

The HELP AD was specifically designed for marginalized populations and is constructed from three components: 1) elements necessary so that it would be a legal document in Minnesota; 2) the core elements of the dignity conserving care model (DCC) proposed by Chochinov38,39; and 3) adaptations for the homeless population based on previous studies2931. Dignity has been identified as one of the most basic requirements in caring for the dying patient2,38,39. The HELP AD includes the higher level, dignity-related needs identified in the DCC model and also incorporates EOL concerns identified by homeless persons, some of which are unique to this population, such as a fear of improper body disposal or dying anonymously2931.

Three months after enrollment, post-intervention assessments were conducted with both SG and CG subjects. Participants were compensated for returning for this 3-month follow-up survey.

MEASUREMENT

The primary outcome of interest was the completion of the HELP AD. A document was considered complete if a copy was given physically to the investigators at any time during the duration of the study or self-reported as completed at follow-up, and could only be counted once. If a participant did not return for the 3-month follow-up visit or did not turn in a copy of the HELP document, it was assumed that the participant did not complete an AD.

Secondary outcomes include EOL and ACP KAB variables measured through a questionnaire administered at baseline and at 3-month follow-up. As a comprehensive literature search did not produce an appropriate instrument that had been validated in this population, a questionnaire was developed incorporating EOL concerns shown to be relevant among homeless persons2931.

ANALYSES

Descriptive summary frequencies characterizing the baseline sample are presented. Proportions of participants completing an AD stratified by baseline characteristics and intervention assignment (SG vs. CG) are estimated by observed percents and tested for differences using Fisher’s exact tests and Cochran–Armitage trend tests. Longitudinal trends in EOL KAB are based on the individuals who had complete data, i.e. those who returned for the 3-month follow-up. Potential differences in baseline characteristics between 3-month responders and non-responders are examined. The longitudinal models tested for the following: A) overall difference in EOL KAB outcomes between those who filled out an AD versus those who did not; B) overall longitudinal changes in EOL KAB outcomes; and C) differential longitudinal change in EOL KAB outcomes for those who filled out an AD compared to those who did not. Generalized estimating equations regressions (PROC GENMOD in SAS with a REPEATED statement) which account for correlated measurements within individuals were used to test the effects.

RESULTS

Fifty-nine individuals were enrolled in the study. The mean age was 45, and 89% had at least a high school education (Table 1). 57% lived in a shelter, 22% in outdoor areas, and 40% had not seen their family in over a year. Forty-one percent of all participants ( = 24) returned for the three-month follow-up (9 of 29 from the CG and 15 of 30 from the SG group). There were no significant baseline demographic differences between those who returned for follow-up and those who did not.

Table 1
Descriptive Characteristics of Study Population and Corresponding Percent Who Filled out the Advanced Directive by Each Category

Completion of Advance Directive

The overall HELP AD completion rate was 44% (26/59), with a higher rate of 59% (17/29) in the CG group compared to 30% (9/30) in the SG group (-value = .02). While not statistically significant, higher education and female gender were associated with a higher completion rate. Half of blacks completed the HELP form compared to one-third of whites. Half of persons with a recent serious illness completed an AD, compared to 42% of those who did not report one.

Change in EOL Knowledge, Attitudes, and Behaviors

Longitudinal regression analyses performed on those who returned for follow-up (n = 24) demonstrated no change in knowledge tested about EOL care (Table 2). Those participants who did not fill out an AD had a greater belief that there were “people who could help make decisions for me if I were seriously ill” (-value = .05) than those who completed one. Similarly, there was an increase in belief that “someone will know and follow my wishes” among those who did not fill out an AD while those who completed an AD showed a decrease in this belief (-value = .07).

Table 2
Change from Baseline to 3-Month Follow-up for EOL Knowledge, Attitudes/Feelings, and Behaviors/Intentions for Those Who Filled out HELP form and Those Who Did Not (n = 24 returned for 3-month follow-up).

Frequency of worry about death decreased among those who filled out an AD from 50% to 12.5%, but also among those who did not (25% to 12.5%) (-value = .05). Among those who filled out an AD, there were statistically significant increases in plans to write down EOL wishes (56% to 100%) and plans to talk about these wishes with someone (63% to 94%) as well as overall higher baseline tendencies for these plans and behaviors. Finally, those that filled out an AD had overall higher reporting of plans for a funeral and carrying of contact information in case of emergency.

DISCUSSION

Encouraging individuals to document preferences for EOL care through ADs has been central to efforts to improve EOL care. The importance of this process is recognized in the Patient Self Determination Act, which mandates that health care institutions ask patients about ADs and offer an opportunity to complete one. ADs, however, cannot resolve all conflicts about EOL care and have been subject to conceptual and empirical criticism in recent years2. Some experts, for example, believe that written ADs, as traditionally constructed and executed, are inadequate for several reasons, including difficulty completing such documents40,41; their inability to address changing circumstances4042; poor rates of completion40,43,44; being unavailable when needed40,45; or being overruled by family or health care providers40. Evidence also suggests that they may not affect care received46,47.

However, in disenfranchised populations, such as the homeless, there are good empirical and theoretical justifications for pursuing ADs. Homeless people have less trust and greater worry about how they will be cared for by health professionals. They also are frequently alienated from family and have less confidence in surrogate decision-makers.2831 Homeless persons have demonstrated their belief in and desire for ADs to help direct medical decision-making and preserve autonomy2831, and there are reasons to believe ADs may prove effective among persons who are alienated. The process of exploring and documenting preferences for EOL care may provide a means of preserving autonomy, enhancing dignity, and giving voice to the unique concerns of disenfranchised and impoverished groups such as homeless persons.

This study demonstrates that homeless individuals can and will carefully consider and document their EOL preferences. The AD completion rate, even in the self-guided (SG) group, was higher than generally described in other populations, typically in the range of 20%48,49. This study also demonstrates that a simple, reproducible one-on-one counseling guidance (CG) can have profound effects on the completion of ADs in this population, doubling the rate of completion from 30% to 59%.

Just as significant is the effect of the interventions on the attitudes towards EOL care and expression of autonomy. Completing an AD appeared to affect how homeless participants viewed their ability to control their death and dying process. For example, there was a decrease in pessimism about the worth of ADs among those who completed one, and an increase in those who did not; i.e., filling out an AD was associated with the belief that ADs could enhance one’s autonomy and fulfillment of wishes in health care setting.

The intervention also had a significant effect on the amount of worry about EOL care and dying among homeless subjects. Reflecting the prevalence of worry described in a Minnesota statewide survey of homeless persons50, this study found that nearly half of the participants worried about whether they would receive appropriate EOL care if they were sick or dying. Among those who filled out an AD, the prevalence of worry decreased from 50% to 12.5%, which may reflect confidence that making EOL wishes known would contribute to the provision of appropriate care. There was also a trend towards decreasing worry among those who did not complete an AD, which may reflect discussions with family or others without written documentation. Another plausible explanation accounting for the decrease in worry among both groups is the speculation that merely raising this issue and encouraging discussion in a safe context may alleviate some of the fears around dying and EOL care.

Advance care planning forces consideration of the social circumstances one might face in event of serious illness. For example, those who filled out an AD were less likely to believe they would have surrogate decision makers, and the completion of an AD was associated with decreasing confidence that someone would know and carry out their wishes. In the context of alienation faced by many homeless persons, ACP and ADs reflect estrangement from family or potential surrogates and are most attractive to those with the least confidence in their relationships

Beyond affecting attitudes and beliefs, completing an AD appears to have fostered empowering and autonomy preserving EOL planning behaviors among participants. Among those who filled out an AD, for example, there were significant increases in plans to write down wishes about care and plans to discuss their desires with others; these behaviors are recognized to be an integral part of good EOL care and planning1.

Limitations of this study include its small sample size, which limits generalizability, and findings may not be generalizable to homeless persons who did not obtain services from Listening House; however, our sample reflected the demographics in a Minnesota survey of homelessness50, and is also similar in composition to that found nationally13. It is also possible that the success of the intervention might not be replicable in settings where program staff would conduct the intervention, rather than our trained and motivated research staff.

Given that our attrition rate at the three months was higher than 50%, it is possible that subjects who stayed in the study differed from those lost-to-follow-up; however, there were no baseline differences between these two groups. Surprisingly, a greater proportion of subjects from the SG group were retained at 3 months than the CG group. We had expected that the greater attention received by the CG group would have resulted in greater retention rates. Several explanations are possible, but one might be that SG participants may have returned expecting or desiring assistance in completing an AD. Alternatively, it is possible that the CG group had met their objectives by completing an AD. Future studies might reduce the high attrition rate by 1) having sufficient resources for tracking and follow-up, as seen in previous large longitudinal studies of homeless persons51,52; and 2) revising the study design after consulting homeless persons and shelter staff regarding barriers and facilitators to follow-up.

Since the subjects were not blinded to intervention allocation, it is possible this knowledge may have affected how they responded to the study. However, blinding was not possible in this study—the subjects had to be told about the content of the arm to which they were randomized. In addition, the baseline survey was completed prior to randomization and was thus not affected by their assignment.

Finally, additional research is needed to determine whether AD completion leads to a change in care received; but, as noted earlier, it can be theorized that these written directives would have greater impact in an estranged population like the homeless. However, issues of dissemination and availability of these documents needs to be studied further as other studies in general populations have demonstrated that ADs are often not readily accessible40,45; this may be exacerbated by homelessness and the episodic, fragmented health care associated with unstable housing.

Despite these limitations, this study demonstrates that people living in dire economic and social contexts are extremely interested in and worried about EOL care, and can be engaged to complete and continue autonomy and dignity preserving behaviors with a simple intervention. These data call for further investigation—in larger populations with longer follow-up times. Also, with longer follow-up periods, other outcomes should be studied, such as whether homeless persons’ expressed wishes are followed when they become ill or die.

Acknowledgements

We are grateful to the director, Rose Marie Reger Rumsey, Mari Uutala, M.A., the staff and the clients of Listening House, St. Paul Minnesota, who so graciously shared their space, their time, and their fears with the research team. Funding for this project was provided by the National Institute for Nursing Research, NIH, 5RO3-NR008586–02, which supported the following: design and conduct of the study, and collection, management, analysis, and interpretation of the data. All authors are responsible for the content of the manuscript, conception and design of the study; acquisition, management, analysis, and interpretation of the data; and critical revision of the manuscript. Drs. Song and Wall are responsible for the drafting of the manuscript, and Dr. Song had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of Interest Dr. Bartels serves as a consultant for Advanced Circulatory Systems on an NIH-funded project, the ResQ trial. None of the other authors have any real or potential conflicts of interests to disclose or report.

Appendix A

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Footnotes

This study was funded by the National Institute of Nursing Research, National Institutes of Health, grant RO3 NR008586–02.

References

1. Field MJ, Cassel CK, eds.Approaching death: improving care at the end of life/Committee on Care at the End of Life, Division of Health Care Services, Institute of Medicine. Washington, D.C.: National Academy Press, 1997.
2. National Institutes of Health State-of-the-Science Conference Statement on Improving End-of-Life Care. National Institutes of Health State-of-the-Science Conference Statement December 6–8, 2004. Available at: http://consensus.nih.gov/2004/2004EndOfLifeCareSOS024html.htm. Accessed on: August 6, 2008.
3. Meier DE, Fuss BR, O’Rourke D. Marked improvement in recognition and completion of health care proxies. Arch Intern Med. 1996;156:1227–32. [PubMed]
4. Hanson LC, Rodgman E. The use of living wills at the end of life. Arch Intern Med. 1996;156:1018–22. [PubMed]
5. Degenholtz HB, Arnold RA, Meisel A, Lave JR. Persistence of racial disparities in advance care plan documents among nursing home residents. J Am Geriatr Soc. 2002;50(2):378–81. [PubMed]
6. Phillips RS, Hamel MB, Teno JM, et al. Race, resource use, and survival in seriously ill hospitalized adults. J Gen Intern Med. 1996;11:387–96. [PubMed]
7. Patel RV, Sinuff T, Cook DJ. Influencing advance directive completion rates in non-terminally ill patients: a systematic review. J Crit Care. 2004;19(1):1–9. [PubMed]
8. Caralis PV, Davis B, Wright K, Marcial E. The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia. J Clin Ethics. 1993;4(2):155–65. [PubMed]
9. Morrison RS, Morrison EW, Glickman DF. Physician reluctance to discuss advance directives. Arch Intern Med. 1994;154:2311–8. [PubMed]
10. National Coalition for the Homeless. Why are People Homeless? Available at: http://www.nationalhomeless.org/publications/facts/Why.pdf. Accessed August 6, 2008.
11. National Law Center on Homelessness and Poverty. Homelessness and Poverty in America. Available at: http://www.nlchp.org/press_releases.cfm?FA=7. Accessed: August 6, 2008.
12. National Coalition for the Homeless. How Many People are Homeless? Available at: http://www.nationalhomeless.org/publications/facts/How_Many.pdf. Accessed: August 6, 2008.
13. Burt MR. Homelessness: Definitions and counts. In: Baumohl J, ed. Homelessness in America. Phoenix, AZ: Oryx Press; 1996:15–23.
14. Link BG, Susser E, Stueve A, et al. Lifetime and five-year prevalence of homelessness in the United States. Am J Public Health. 1994;84:1907–12. [PMC free article] [PubMed]
15. Gelberg L, Linn LS. Assessing the physical health of homeless adults. JAMA. 1989;262:1973–9. [PubMed]
16. Breakey WR, Fischer PJ, Kramer M. Health and mental problems of homeless men and women in Baltimore. JAMA. 1989;262:1352–7. [PubMed]
17. Gelberg L, Andersen RM, Leake BD. Healthcare access and utilization. Health Serv Res. 2000;34(6):1273–314. [PMC free article] [PubMed]
18. Lim YW, Andersen R, Leake B, Cunningham W, Gelberg L. How accessible is medical care for homeless women? Med Care. 2002;40(6):510–20. [PubMed]
19. Hibbs JR, Benner L. Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med. 1994;331:304–9. [PubMed]
20. Barrow SM, Herman DB, Cordova PBA. Mortality among shelter residents in New York City. Am J Public Health. 1999;89:529–34. [PMC free article] [PubMed]
21. Cheung AM, Hwang SW. Risk of death among homeless women: A cohort study and review of the literature. CMAJ. 2004;170:1243–7. [PMC free article] [PubMed]
22. Greenberg GA, Rosenheck RA. Jail incarceration, homelessness, and mental health: a national study. Psych Services. 2008;59(2):170–7. [PubMed]
23. Nyamathi A, Dixon EL, Shoptaw S, Marfisee M, Gelberg L, Williams S, et al. Profile of lifetime methamphetamine use among homeless adults in Los Angeles. Drug and Alcohol Depend. 2008;92(1–3):277–81. [PMC free article] [PubMed]
24. Dietz TL. Predictors of reported current and lifetime substance abuse problems among a national sample of U.S. homeless. Subst Use Misuse. 2007;42(11):1745–66. [PubMed]
25. Riley ED, Gandhi M, Hare C, Cohen J, Hwang S. Poverty, unstable housing, and HIV infection among women living in the United States. Curr HIV/AIDS Rep. 2007;4(4):181–6. [PubMed]
26. Kyle T, Dunn JR. Effects of housing circumstances on health, quality of life and healthcare use for people with severe mental illness: a review. Health and Social Care in the Community. 2008;16(1):1–15. [PubMed]
27. Walley AY, Cheng DM, Libman H, Nunes D, Horsburgh CR Jr, Saitz R, Samet JH. Recent drug use, homelessness and increased short-term mortality in HIV-infected persons with alcohol problems. AIDS. AIDS 2008;22(3):415–20. [PMC free article] [PubMed]
28. Kushel MB, Miaskowski C. End-of-life care for homeless patients: “she says she is there to help me in any situation”. JAMA. 2007;296(24):2959–66. [PubMed]
29. Song J, Bartels DM, Ratner ER, Alderton L, Hudson B, Ahluwalia JS. Dying on the streets: Homeless persons’ concerns and desires about end of life care. J Gen Intern Med. 2007;22:435–41. [PMC free article] [PubMed]
30. Song J, Ratner ER, Bartels DM, Alderton L, Hudson B, Ahluwalia JS. Experiences with and attitudes toward death and dying among homeless persons. J Gen Intern Med. 2007;22:427–34. [PMC free article] [PubMed]
31. Song J, Ratner E, Bartels D. Dying While Homeless: Is it a concern when life itself is such a struggle? J Clin Ethics. 2005;16(3):251–61, Fall. [PubMed]
32. Tarzian A, Neal M, O’Neil J. Attitudes, experiences, and beliefs affecting end-of-life decision-making among homeless individuals. J Palliat Med. 2005;8(1):36–48, Feb. [PubMed]
33. Rossi PH, Wright JD. The determinants of homelessness. Health Affairs. 1987;6:19–32. [PubMed]
34. Crane M, Byrne K, Fu R, Lipmann B, Mirabelli F, Rota-Bartelink MA, et al. The causes of homelessness in later life: findings from a 3-nation study. J Geront Ser B Psychol Sci Soc Sci. 2005;60:S152–9. [PubMed]
35. Buchanan D, Rohr L, Stevak L, Sai T. Documenting attitude changes towards homeless people: comparing two standardised surveys. Med Educ. 2007;41(4):346–8. [PubMed]
36. Wen CK, Hudak PL, Hwang SW. Homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters. J Gen Intern Med. 2007;22(7):1011–7. [PMC free article] [PubMed]
37. McKinney Act (P.L. 100–77, sec 103(2)(1), 101 sat. 485 (1987)). Available at www.huduser.org/publications/homeless/mckin/intro.html, accessed on September 1, 2008.
38. Chochinov HM, Hack T, McClement S, Kristjanson L, Harlos M. Dignity in the terminally ill: a developing empirical model. Soc Sci Med. 2002;54:433–43. [PubMed]
39. Chochinov HM. Dignity-conserving care-a new model for palliative care: Helping the patient feel valued. JAMA. 2002;287:2253–60. [PubMed]
40. Fagerlin A, Schneider CE. Enough: The failure of the living will. Hastings Center Report. 2004;34:30–42. [PubMed]
41. Teno JM. Advance directives: time to move on. Ann Intern Med. 2004;141(2):159–60. [PubMed]
42. Gready RM, Ditto PH, Danks JH, Coppola KM, Lockhart LK, Smucker WD. Actual and perceived stability of preferences for life-sustaining treatment. J Clin Ethics. 2000;11(4):334–46. [PubMed]
43. Hare J, Nelson C. Will outpatients complete living wills? A comparison of two interventions. J Gen Intern Med. 1991;6:41–6. [PubMed]
44. Hopp FP. Preferences for surrogate decision makers, informal communication, and advance directives among community-dwelling elders: results from a national study. Gerontologist. 2000;40(4):449–57. [PubMed]
45. Morrison RS, Olson E, Mertz KR, Meier DE. The inaccessibility of advance directives on transfer from ambulatory to acute care settings. JAMA. 1995;274:478–82. [PubMed]
46. Prendergast TJ. Advance care planning: pitfalls, progress, promise. Crit Care Med. 2001;29(2 Suppl):N34–9. [PubMed]
47. The SUPPORT Investigators. A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). J Am Med Assoc. 1995;274:1591–8. [PubMed]
48. Jezewski MA, Meeker MA, Sessanna L, Finnell DS. The Effectiveness of Interventions to Increase Advance Directive Completion Rates. J Aging Health. 2007; 19:519–536. [PubMed]
49. Lo B. Advance care planning. Am J Geriatr Cardiol. 2004;13(6):316–20. [PubMed]
50. Wilder Research Center. Homeless adults and children in Minnesota Statewide survey of people without permanent shelter. Available at: http://www.wilder.org/reportsummary.0.html?&no_cache=1&tx_ttnews[swords]=homeless&tx_ttnews[pointer]=1&tx_ttnews[tt_news]=484&tx_ttnews[backPid]=311&cHash=23bb1d0f0b. Accessed: August 6, 2008.
51. Gelberg L, Andersen R, Leake B. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes. Health Serv Res. 2000;3461273–302. [PMC free article] [PubMed]
52. Robertson MJ, Zlotnick C, Westerfelt A. Drug use disorders and treatment contact among homeless adults in Alameda County, California. Am J Public Health. 1997;87:221–8. [PMC free article] [PubMed]

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