The majority of older homeless-experienced adults have a potential surrogate for health care decisions, but few have discussed or documented their advance care planning (ACP) wishes, according to a study published in the June issue of the Journal of the American Geriatrics Society.

In a population-based cohort of older homeless experienced adults with a median age of 59 and significant comorbidity, the researchers found a low prevalence of engagement in a full range of ACP behaviors, including contemplation, discussions, and formal ACP documentation.

More than half of our study population reported a potential surrogate, lower than that observed in similar safety-net populations, albeit still substantial, but fewer than one-fifth had formally appointed a surrogate.

One-third had thought about their ACP wishes, but fewer than one-tenth had completed an advance directive, a level of ACP engagement significantly lower than the general or safety net populations.

Rebecca L. Sudore, M.D., from the University of California in San Francisco, and colleagues assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives) among 350 homeless-experienced adults aged 50 and older (75.2% male and 82.1% black) in Oakland, Calif.

The researchers found that 61% of study participants reported a potential surrogate, 21.5% had discussed ACP, and 19% reported ACP documentation.

Higher odds of ACP discussions were seen with having one to five confidants versus none (adjusted odds ratio [aOR], 5.8; 95% confidence interval (CI), 1.7 to 20), three or more chronic conditions versus none (aOR, 2.3; 95% CI, 0.9 to 5.6), and a recent primary care visit (aOR, 2.1; 95% CI, 1.0 to 4.4). Lower odds of ACP discussions were seen for each additional five years of homelessness (aOR, 0.7; 95% CI, 0.5 to 0.9).

There were higher odds of ACP documentation with having one to five confidants (aOR, 5; 95% CI, 1.4 to 17.5), being black (aOR, 5.5; 95% CI, 1.5 to 19.5), and having adequate versus limited literacy (aOR, 7; 95% CI, 1.5 to 32.4). Illicit drug use was associated with lower odds of ACP documentation (aOR, 0.3; 95% CI, 0.1 to 0.9).

"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 health care settings," noted the authors.

ACP Engagement

A total of 61% of participants reported having a potential surrogate, and 35.8% had contemplated ACP. More than one-fifth of participants had discussed ACP wishes with someone: 15.7% with a family member, 3.3% with a friend, 4.0% with a healthcare provider, and 1.1% with a social worker. A sum of 19% reported formal ACP documentation; 18.0% had designated a surrogate, and 8.8% had completed an advance directive.