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Effect of an End-of-Life Planning Intervention on the Completion of Advance Directives in Homeless Persons: A Randomized Trial

John Song, MD, MPH, MAT; Edward R. Ratner, MD; Melanie M. Wall, PhD; Dianne M. Bartels, RN, PhD; Nancy Ulvestad, BSN, MART; Dawn Petroskas, BSN; Melissa West, MD; Anne Marie Weber-Main, PhD; Leah Grengs; and Lillian Gelberg, MD, MSPH
[+] Article and Author Information

From the University of Minnesota Center for Bioethics, University of Minnesota Medical School, University of Minnesota School of Public Health, and Veterans Affairs Medical Center, Minneapolis, Minnesota, and David Geffen School of Medicine and School of Public Health, University of California, Los Angeles, Los Angeles, California.


Note: All authors are responsible for the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, and approval of the manuscript. 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.

Grant Support: By the National Institute for Nursing Research and the National Center on Minority Health and Health Disparities (RO1-NR009815).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2548.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Song (e-mail, songx006@umn.edu).

Requests for Single Reprints: John Song, MD, MPH, MAT, Center for Bioethics, University of Minnesota, N504 Boynton Hall, 410 Church Street SE, Minneapolis, MN 55455; e-mail, songx006@umn.edu.

Current Author Addresses: Drs. Song and Bartels, Ms. Ulvestad, Ms. Petroskas, and Ms. Grengs: University of Minnesota Center for Bioethics, N504 Boynton, 410 Church Street SE, Minneapolis, MN 55455-0346.

Dr. Ratner: MMC 741 A460 Mayo Building, 420 Delaware Street SE, Minneapolis, MN 55455.

Dr. Wall: MMC 303 Mayo Building, 420 Delaware Street SE, Minneapolis, MN 55455.

Dr. West: Community Living Center, Veterans Affairs Medical Center, One Veterans Drive, Minneapolis, MN 55417.

Dr. Weber-Main: Department of Medicine, University of Minnesota, Suite 166, Office 170, 717 Delaware Street SE, Minneapolis, MN 55414.

Dr. Gelberg: David Geffen School of Medicine, University of California, Los Angeles, 10880 Wilshire Boulevard, Suite 1800, Los Angeles, CA 90024.

Author Contributions: Conception and design: J. Song, E.R. Ratner, M. Wall, D.M. Bartels, N. Ulvestad, M. West, L. Gelberg.

Analysis and interpretation of the data: J. Song, E.R. Ratner, M. Wall, D.M. Bartels, N. Ulvestad, D. Petroskas, A.M. Weber-Main, M. West, L. Gelberg.

Drafting of the article: J. Song, E.R. Ratner, M. Wall, A.M. Weber-Main, L. Gelberg.

Critical revision of the article for important intellectual content: J. Song, E.R. Ratner, M. Wall, D.M. Bartels, A.M. Weber-Main, M. West, L. Gelberg.

Final approval of the article: J. Song, E.R. Ratner, M. Wall, D.M. Bartels, D. Petroskas, A.M. Weber-Main, M. West, L. Gelberg.

Provision of study materials or patients: D.M. Bartels, N. Ulvestad.

Statistical expertise: M. Wall.

Obtaining of funding: J. Song, E.R. Ratner, L. Gelberg.

Administrative, technical, or logistic support: J. Song, E.R. Ratner, D.M. Bartels, N. Ulvestad, D. Petroskas.

Collection and assembly of data: J. Song, E.R. Ratner, D.M. Bartels, N. Ulvestad, M. West, D. Petroskas.


Ann Intern Med. 2010;153(2):76-84. doi:10.7326/0003-4819-153-2-201007200-00003
Text Size: A A A

Background: Few interventions have focused on improving end-of-life care for underserved populations, such as homeless persons.

Objective: To determine whether homeless persons will complete a counseling session on advance care planning and fill out a legal advance directive designed to assess care preferences and preserve the dignity of marginalized persons.

Design: Prospective, single-blind, randomized trial comparing self-guided completion of an advance directive with professionally assisted advance care planning. (ClinicalTrials.gov registration number: NCT00546884)

Setting: 8 sites serving homeless persons in Minneapolis, Minnesota.

Participants: 262 homeless persons recruited between November 2007 and August 2008.

Intervention: Minimal, self-guided intervention consisting of advance directive forms and written educational information versus a one-on-one advance planning intervention consisting of counseling and completing an advance directive with a social worker.

Measurements: Rate of advance directive completion, assessed by inspection of completed documents.

Results: 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: 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.

Conclusion: Both a simple and complex intervention successfully engaged a diverse sample of homeless persons in advance care planning. One-on-one assistance significantly increased the completion rate. Homeless persons 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.

Primary Funding Source: National Institute for Nursing Research and National Center on Minority Health and Health Disparities.

Figures

Grahic Jump Location
Figure.
Study flow diagram.

AD = advance directive.

* Left the session owing to difficulty hearing. † Failed decisional capacity test.

Grahic Jump Location

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Summary for Patients

End-of-Life Planning Intervention and the Completion of Advance Directives in Homeless Persons

The summary below is from the full report titled “Effect of an End-of-Life Planning Intervention on the Completion of Advance Directives in Homeless Persons. A Randomized Trial.” It is in the 20 July 2010 issue of Annals of Internal Medicine (volume 153, pages 76-84). The authors are J. Song, E.R. Ratner, M.M. Wall, D.M. Bartels, N. Ulvestad, D. Petroskas, M. West, A.M. Weber-Main, L. Grengs, and L. Gelberg.

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