Effect of an end-of-life planning intervention on the completion of advance directives in homeless persons a randomized trial
There are not many interventions that have focused on improving end-of-life care for underserved populations, such as people who are homeless. The objective of this study was to determine whether people who are homeless will complete a counseling session on end-of-life planning and fill out the legal paperwork needed to determine care preferences. The trial used prospective, single-blind, randomized trial comparing self-guided completion of an advance directive with professionally assisted advance care planning in 8 sites in Minneapolis, Minnesota that serve people who are homeless. Two hundred and sixty two people who are homeless were recruited between November 2007 and August 2008. Intervention was limited to a self-guided intervention that consisted of the legal forms and written educational information, as opposed to a one-on-one end-of-life planning intervention consisting of counseling and completing the legal forms with a social worker. The trial measure the rate of legal forms completion, assessed by inspection of completed documents.
The overall completion rate for advance directives was 26.7% (95% CI, 21.5% to 32.5%), with a higher rate in the counselor-guided group (37.9%) than in the self-guided group (12.8%) (CI of adjusted difference, 15.3 to 34.3 percentage points). This difference persisted across all sites and most subgroups. The advance directive's 4 clinical scenarios found a preference for surrogate decision making in 29% to 34% of written responses. Limitations of this trial include the fact that sampling was limited to a more stable subset of the homeless population in Minneapolis and may have been subject to selection bias. Modest compensation to complete the preintervention survey could have influenced participants to complete advance directives. Both a simple and complex intervention successfully engaged a diverse sample of people who are homeless in advance care planning. One-on-one assistance significantly increased the completion rate. People who are homeless can respond to an intervention to plan for end-of-life care and can express specific preferences for care or a surrogate decision maker, but additional studies are needed to assess the effect of these directives on subsequent care.
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