The role of dignity in advance care planning among homeless individuals
Dignity is an important issue in end of life care, but has not been considered as a possible predictor of advance care planning (ACP). This presentation will describe a study to determine predictors of willingness to participate in ACP among homeless persons, determinants of loss of dignity, and contributors to dignity at the end of life. A prospective, single-blind, randomised trial comparing self-guided completion of an advance directive (AD) with professionally assisted ACP at 8 sites serving homeless persons recruited 262 homeless persons in 2007-08. Subjects were offered a brief presentation and written materials related to ACP versus one-on-one ACP counselling by a social worker. Measures included pre-intervention written surveys and subsequent AD content analysis. The overall completion rate for ADs was 26.7%. Older age, problems finding a place to sleep (OR = 0.29), and feeling a loss of dignity (OR = 0.37) were independently predictive of completion of an AD, with either a self-guided process or individual counselling. Loss of dignity almost every day was reported by 35% of subjects. Being treated with dignity was described as 1) being respected 2) having preferences honoured, 3) receiving adequate care, and 4) having comfort maintained. In summary, lacking a place to sleep and loss of dignity negatively predict willingness to complete an AD among the homeless. Loss of dignity is a frequent problem in this population. There are practical ways providers can maintain dignity in care of homeless at the end of life.
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