Homeless persons prefer more aggressive medical care than the physicians making decisions for them

Homeless persons prefer more aggressive medical care than the physicians making decisions for them, which may result in treatment preferences of homeless persons being overlooked.

A new study published in the June issue of CHEST, the peer-reviewed journal of the American College of Chest Physicians, reports that homeless persons are more likely than physicians to want lifesaving procedures performed on them. As a result, homeless persons who must rely on physicians as surrogate decision makers for medical care may receive less aggressive treatment than they would choose for themselves.

"Homeless persons are at an increased risk for critical illnesses and admissions to the intensive care unit. They also are less likely to have family or friends to be surrogate decision makers, leaving physicians to make the decisions for them," said study author J. Randall Curtis, MD, MPH, FCCP, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA. "Previous research indicates that physicians who make medical decisions independently may make these decisions based on their own preferences. Consequently, homeless individuals are at an increased risk of having life-support decisions made that do not reflect their wishes."

Using a cross-sectional survey, researchers from the University of Washington compared treatment preferences of 229 homeless individuals with preferences of 236 physicians and 111 patients with oxygen-dependent chronic obstructive pulmonary disease (COPD). Participants were asked whether they would want intubation and mechanical ventilation and whether they would want cardiopulmonary resuscitation (CPR) in four health scenarios: current health, permanent coma, dementia unable to recognize family or friends, or bed-bound, dependent on others for care. Compared to physicians, homeless individuals were more likely to want CPR and mechanical ventilation in coma and dementia scenarios. Homeless participants also were more likely to prefer resuscitative measures than those with COPD; however, patients with COPD were more likely to want CPR or mechanical ventilation than physicians. Although homeless persons reported better health status than patients with COPD, current health status did not affect treatment preferences for either group. In regard to gender and race, homeless men were more likely than homeless women to want CPR or mechanical ventilation in the coma and dementia scenarios and nonwhite homeless participants were more likely than white homeless to want resuscitation.

"Our findings show that medical treatment for the homeless should not be based on the preferences of physicians or patients with chronic illness, who, in general, prefer less aggressive medical care than homeless individuals," said Dr. Curtis. "The reasons behind our findings are not clear, but it may be because homeless people generally do not have good access to medical care and other societal benefits, therefore, they may be more reluctant to have potential medical benefits withheld from them."

Homeless participants also were asked who they would want to make medical decisions for them if they could not make decisions on their own. The majority of homeless individuals indicated they had contact with their families and would want a family member to make medical decisions for them. Of the homeless persons who did not have contact with family or did not want family members to make decisions for them, the majority indicated they would want their primary care physician or hospital physician to make medical decisions for them. When given the choice between a physician and court-appointed guardian to make decisions, the majority of homeless individuals chose a physician.

"These findings taken together, suggest that physicians should be involved in decision-making for homeless patients without surrogate decision-makers, but that they should be aware of these findings and cautious not to impose their own preferences on patients," said Dr. Curtis. "Hospitals that serve homeless individuals should consider developing policies to ensure that ethical and consistent decisions are made that are in the best interests of the patients who do not have surrogate decision-makers. In addition, organizations assisting homeless persons should consider options for encouraging advance directives for the individuals they serve."

"Advance directives are an important part of end-of-life care," said Paul A. Kvale, MD, FCCP, President of the American College of Chest Physicians. "Physicians should encourage all patients to make their treatment preferences known to family members, friends, or health-care professionals."

http://www.chestnet.org/