Advance Care Planning for Older Homeless‐Experienced Adults: Results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age Study

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)55.8, 95% confidence interval (CI)51.7-20.0), 3 or more chronic conditions versus none (aOR52.3, 95% CI50.9-5.6), and a recent primary care visit (aOR52.1, 95% CI51.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR50.7, 95% CI50.5-0.9) with lower odds. Having 1 to 5 confidants (aOR55.0, 95% CI51.4-17.5), being black (aOR55.5, 95% CI51.5-19.5), and having adequate versus limited literacy (aOR57.0, 95% CI51.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR50.3, 95% CI50.1-0.9) with lower odds. Although the majority of older homelessexperienced 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.

Barriers and Solutions to Advance Care Planning among Homeless-Experienced Older Adults

“…The barriers, including lack of knowledge, social isolation and mistrust, competing demands and lack of training in ACP among staff within and outside the clinic setting provide context to the low prevalence of completion of ACP among the growing population of homeless-experienced older adults. 4 The participants suggested strategies to overcome these barriers, including: reframing the discussion away from death to promote empowerment, moving the ACP discussions out of the clinic visit, capitalizing on the period after housing, and using easy-to-read ACP materials tailored to the specific needs of homeless populations.…”

“…25 However, in a prior study in older homeless-experienced adults, we found that 61% reported having a potential surrogate. 4 Professionals working with homeless-experienced older adults should not assume that individuals do not have surrogates but should acknowledge that to initiate ACP, it is not required to have a surrogate or to reach out to family, if the participant chooses to not do so.…”

“…3 Despite increased mortality and disease burden, few older homeless-experienced older adults (those with a current or recent experience of homelessness) have discussed ACP wishes with others or completed advance directives (ADs). 4 People experiencing homelessness face barriers to ACP, including mistrust in the healthcare system, limited health literacy, lack of longitudinal relationships with primary care providers, and receipt of healthcare in resource-limited settings. [5][6][7] They are more likely than the general population to report social isolation, substance use, and mental health disorders, which can impede engagement in ACP.…”

“…[5][6][7] They are more likely than the general population to report social isolation, substance use, and mental health disorders, which can impede engagement in ACP. 4 Little is known about the barriers to ACP engagement among homelessexperienced older adults, or strategies to overcome them. 8 While there are ACP materials designed for underserved populations, they do not target the full spectrum of ACP engagement for homeless-experienced older adults, who may face unique barriers.…”

"We Take Care of Patients, but We Don't Advocate for Them": Advance Care Planning in Prison or Jail

“…A previous study noted that effective ACP was contingent on psychosocial support but further research is needed to understand inmates’ unique psychosocial needs during ACP. Future research should also explore whether knowledge of historical instances of unethical treatment of prisoners could affect decision‐making and the extent to which provider distrust, a barrier to ACP found in ethnic minorities and homeless people, is a challenge in prisons and jails. Because participants identified the need to address policies that limit ACP, the development of a guide that describes exemplary correctional ACP policies could benefit all systems.…”