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End-of-Life Care

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Use of a multidisciplinary team to care for homeless patients can address their end-of-life needs and improve their care

From 2.3 to 3.5 million persons in the United States are homeless each year, with 10 to 20 percent becoming homeless for more than 1 year. Many homeless persons have substance abuse problems and mental illness, lack social support, and have no medical insurance. These challenges complicate their ability to engage in end-of-life advance planning, adhere to medications, and find an adequate site to receive terminal care.

By acknowledging the realities of the patients' life and introducing end-of-life planning over repeated visits, the clinician and a multidisciplinary team have the opportunity to build trust despite the prevalence of mental illness, substance abuse, and chronic illness in this population.

New paradigms such as "housing first" and ensuring that curative and palliative care are not contingent upon cessation of street drug use, are necessary to improve care at the end of life for chronically homeless individuals, suggest Margot B. Kushel, M.D., and Christine Miaskowski, R.N., Ph.D., of the University of California, San Francisco.

In a recent paper, the researchers discuss the challenges of providing end-of-life care for homeless people and offer specific management recommendations. They assert that social workers, discharge planners, and case managers have expertise regarding local resources and are central to a multidisciplinary approach to caring for homeless patients.

The authors recommend providing homeless patients with a written pain agreement, prescribing once-daily medications when possible, avoiding those that require refrigeration, minimizing those that need to be taken with food or water or that have adverse effects that require frequent use of restrooms, and dispensing small quantities of medication with frequent refills (to reduce the temptation to sell or trade medications).

They also recommend performing a comprehensive pain, substance abuse, and psychiatric assessment. Chronically homeless persons may chafe at institutional care such as skilled nursing facilities. The creation of palliative care services in hospitals that serve large numbers of homeless people would provide a setting for end-of-life care. The study was supported in part by the Agency for Healthcare Research and Quality (HS11415).

See "End-of-life care for homeless patients," by Drs. Kushel and Miaskowski, in the December 27, 2006, Journal of the American Medical Association 296(24), pp. 2959-2966.

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