Advertisement

Journal of General Internal Medicine

, Volume 22, Issue 4, pp 427–434 | Cite as

Experiences With and Attitudes Toward Death and Dying Among Homeless Persons

  • John SongEmail author
  • Edward R Ratner
  • Dianne M. Bartels
  • Lucy Alderton
  • Brenda Hudson
  • Jasjit S. Ahluwalia
Original Article

Background

Homeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect. Few studies have explored their experiences and attitudes toward death and dying. Unfortunately, studies done in other populations may not apply to homeless persons. Exploring these experiences and attitudes may provide insight into life, health care, and end-of-life (EOL) concerns of this population.

Objective

To explore the experiences and attitudes toward death and dying among homeless persons.

Design

Qualitative study utilizing focus groups.

Participants

Fifty-three homeless persons recruited from homeless service agencies.

Measurements

In-depth interviews, which were audiotaped and transcribed.

Results

We present seven themes, some of which are previously unreported. Homeless persons described many significant experiences with death and dying, and many participants suffered losses while very young. These encounters influenced participants’ attitudes toward risks and risky behavior: e.g., for some, these experiences provided justification for high-risk behaviors and influenced their behaviors while living on the streets. For others, they may be associated with their homelessness. Finally, these experiences informed their attitudes toward death and dying as well as EOL care; homeless persons believe that care will be poor at the EOL.

Conclusions

Findings from this study have implications for addressing social services, health promotion, prevention, and EOL care for homeless persons, as well as for others who are poor and disenfranchised.

Key words

homelessness death end-of-life care focus groups poverty 

Notes

Acknowledgements

The authors would like to thank the clients and staff of St. Stephen’s shelter; Holy Rosary Church; Listening House; Hennepin County Outreach Services; Health Care for the Homeless, Minneapolis; and Our Saviors Church who were so generous with their time, thoughts, and dedication to serving others. We would also like to thank LeeAnne Hoekstra for administrative support, Tybee Types for transcription, and Karen Howard for manuscript preparation.

This study was funded by the National Institute of Nursing Research, National Institutes of Health, grant no. RO3 NR008586-02.

Potential Financial Conflicts of Interest

None disclosed.

References

  1. 1.
    Breakey WR, Fischer PJ, Kramer M. Health and mental problems of homeless men and women in Baltimore. JAMA 1989;262:1352–57.PubMedCrossRefGoogle Scholar
  2. 2.
    Gelberg L, Linn LS. Assessing the physical health of homeless adults. JAMA 1989; 262:1973–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Gallagher TC, Andersen RM, Koegel P, Gelberg L. Determinants of regular source of care among homeless adults in Los Angeles. Med Care 1997;35(8):814–30.PubMedCrossRefGoogle Scholar
  4. 4.
    Gelberg L, Andersen RM, Leake BD. Healthcare access and utilization among homeless persons. Health Serv Res 2000;34(6):1273–314.PubMedGoogle Scholar
  5. 5.
    Gelberg L, Thompson L. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health 1997; 87:217–20.PubMedGoogle Scholar
  6. 6.
    Hwang SW, O’Connell JJ, Lebow JM, Bierer MF, Orav EJ, Brennan TA. Health care utilization among homeless adults prior to death. J Health Care Poor Underserved Feb 2001;12(1):50–8.PubMedGoogle Scholar
  7. 7.
    Barrow SM, Herman DB, Cordova, PBA. Mortality among shelter residents in New York City. Am J Public Health 1999;89:529–34.PubMedGoogle Scholar
  8. 8.
    Hibbs JR, Benner L. Mortality in a cohort of homeless adults in Philadelphia. New Engl J Med 1994;331:304–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Cheung AM, Hwang SW. Risk of death among homeless women: a cohort study and review of the literature. CMAJ 2004;170(8):1243–7.PubMedGoogle Scholar
  10. 10.
    Hwang SW, Orav EJ, O’Connell JJ, Lebow JM, Brennan TA. Causes of death in homeless adults in Boston. Ann Intern Med 1996;126:625–8.Google Scholar
  11. 11.
    King County Public Health 2004. Available at: http://www.metrokc.gov/HEALTH/hchn/2004-annual-report-HD.pdf. Accessed 20 Jan 2006.
  12. 12.
    National Health Care for the Homeless Coalition. HCH Clinicians Can Help Homeless Persons Die with Dignity. Available at: http://www.nhchc.org/Network/HealingHands/2004/Final_Healing_Hands_2_27_04.pdf. Accessed 20 Jan 2006.
  13. 13.
    CDC. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4830a4.htm. Accessed 27 Aug 2006.
  14. 14.
    The Secretary’s Work Group on Ending Chronic Homelessness. Ending chronic homelessness: strategies for action. Washington, DC: U.S. Department of Health and Human Services, 2003, p. 58.Google Scholar
  15. 15.
    Burt MR. Homelessness: Definitions and Counts. In: Baumohl J, ed. Homelessness in America. Phoenix, AZ: Oryx Press, 1996, pp. 15–23.Google Scholar
  16. 16.
    The United States Conference of Mayors. Status Report on Hunger and Homelessness in America’s Cities 2002. Available at: http://www.usmayors.org/uscm/hungersurvey/2002/onlinereport/HungerAndHomelessReport2002.pdf. Accessed 27 Aug 2006.
  17. 17.
    Song J, Ratner E, Bartels D. Dying while homeless: is it a concern when life itself is such a struggle? J Clin Ethics Fall 2005;16(3):251–61.PubMedGoogle Scholar
  18. 18.
    Tarzian, A., Neal M., O’Neil J. Attitudes, experiences, and beliefs affecting end-of-life decision-making among homeless individuals. J Palliat Med Feb 2005;8(1):36–48.PubMedCrossRefGoogle Scholar
  19. 19.
    Norris W, Nielson E, Engelberg R, Curtis JR. Treatment preferences for resuscitation and critical care among homeless persons. Chest 2005; 127(6):2180–7.PubMedCrossRefGoogle Scholar
  20. 20.
    Buck DS, Monteiro FM, Kneuper S, et al. Design and validation of the health professionals’ attitudes toward the homeless inventory. Med Educ Jan 2005;5(1):2.CrossRefGoogle Scholar
  21. 21.
    Zrinyi M. Balogh Z. Student nurse attitudes towards homeless clients: a challenge for education and practice. Nurs Ethics 2004;11(4):334–48.PubMedCrossRefGoogle Scholar
  22. 22.
    Elvy, A. Access to Care. In: Brickner PW, Sharer LK, Conanan B, Elvy A, Savarase M, eds. Health Care of Homeless People. New York: Springer Publishing Company, 1985, p. 349.Google Scholar
  23. 23.
    Michaels D, Zoloth SR, Alcabes P, Braslow CA, Safyer S. Homelessness and other indicators of mental illness in New York City’s correctional system. Hosp Community Psychiatry Feb 1992;43(2):150–5.PubMedGoogle Scholar
  24. 24.
    Martell DR, Rosner A, Harmon RB. Base rate estimates of criminal behavior by homeless mentally ill patients in New York City. Psychiatr Serv Jun 1995;46(6):596–601.PubMedGoogle Scholar
  25. 25.
    Sosin, M. R. Explaining adult homelessness in the US by stratification or situation. J Commuity Appl Soc Psychol 2003;(13):91–104.Google Scholar
  26. 26.
    Rossi, P. Down and Out in America: The Origins of Homelessness. Chicago: University of Chicago Press, 1989.Google Scholar
  27. 27.
    Greenberg M, Baumohl J. Income Maintenance: Little Help Now, Less on the Way. In: Baumohl J, ed. Homelessness in America. Phoenix, AZ: Oryx Press, 1996, pp. 85–9.Google Scholar
  28. 28.
    Susser ES, Lin SP, Conover SA. Risk factors for homelessness among patients admitted to a state mental hospital. Am J Psychiatry 1991; 148:1659–64.PubMedGoogle Scholar
  29. 29.
    Winkleby M, Rockhill B, Jatulis D, Fortmann S. The medical origins of homelessness. Am J Public Health 1992;82:1394–8.PubMedGoogle Scholar
  30. 30.
    Zorza J. Women battering: a major cause of homelessness. Clgh Rev 1991;25(4):421–9.Google Scholar
  31. 31.
    Bluthenthal RN, Kral AH. Use of an illegal syringe exchange and injection-related risk behaviors among street-recruited injection drug users in Oakland, California, 1992 to 1995. J Acquir Immune Defic Syndr Hum Retrovirol 1998;18:505–11.PubMedGoogle Scholar
  32. 32.
    Celentano DD, Vlahov D, Cohn S et al. Risk factors for shooting gallery use and cessation among intravenous drug users. Am J Public Health 1991;81:1291–5.PubMedGoogle Scholar
  33. 33.
    Clatts MC, Beardsley M et al. Homelessness and Risk Behavior Among U.S. Drug Injectors: Implications for Prevention Policy. In: Program and abstracts of the 8th International Conference on AIDS, Amsterdam, The Netherlands, July 19–24, 1992. Abstract # PoD 5354.Google Scholar
  34. 34.
    El-Bassel N, Schilling RF et al. Sex trading and psychological distress among women recruited from the streets of Harlem. Am J Public Health 1997;87:66–70.PubMedGoogle Scholar
  35. 35.
    National Institutes of Health State-of-the-Science Conference Statement on Improving End-of-Life Care December 6–8, 2004. Available at: http://www.consensus.nih.gov/2004/2004EndOfLifeCareSOS024html.htm. Accessed 16 Mar 2006.
  36. 36.
    Stewart B. McKinney Homeless Assistance Act (42 U.S.C. 11431 et seq.)Google Scholar
  37. 37.
    Bernard HR. Research Methods in Cultural Anthropology. Beverly Hills, CA: Sage Publications, 1988.Google Scholar
  38. 38.
    Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications, 2000.Google Scholar
  39. 39.
    Hill CE, Thompson BJ, Williams EN. A guide to conducting consensual qualitative research. Couns Psychol 1997;25:517–72.CrossRefGoogle Scholar
  40. 40.
    McCarthy Veach P, Bartels DM, LeRoy BS. Ethical and professional challenges posed by patients with genetic concerns: a report of focus group discussions with genetic counselors, physicians, and nurses. J Genet Couns 2001;10:97–117.CrossRefGoogle Scholar
  41. 41.
    Brickner PW, et al. Providing health services for the homeless: a stitch in time. Bull N Y Acad Med 1993;70:146–69.PubMedGoogle Scholar
  42. 42.
    McMurray-Avila M. Organizing Health Services for Homeless People: A Practical Guide. Nashville, TN: Nat HCH Council, 1997.Google Scholar
  43. 43.
    Caton C, Hasin D, Shrout P, et al. Risk factors for homelessness among indigent urban adults with no history of psychotic illness: a case-control study. Am J Public Health 2000; 90,258–63.PubMedGoogle Scholar
  44. 44.
    Crane M, Byrne K, Fu R, Lipmann B, Mirabelli F, Rota-Bartelink MA. The causes of homelessness in later life: findings from a 3-nation study. J Geront Ser B Psychol Sci Soc Sci 2005; 60:S152–S9.Google Scholar
  45. 45.
    Koegel P, Melamid E, Burnam MA. Childhood risk factors for homelessness among homeless adults. Am J Public Health 1995; 85:1642–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Crane, M. Understanding Older Homeless People: Their Circumstances, Problems and Needs. Buckingham: Open University Press, 1999.Google Scholar
  47. 47.
    Braine N, Des Jarlais DC, Goldblatt C, Zadoretzky C, Turner C. HIV risk behavior among amphetamine injectors at U.S. syringe exchange programs. AIDS Educ Prev 2005;17(6):515–24.PubMedCrossRefGoogle Scholar
  48. 48.
    Tucker JS, D’Amico EJ, Wenzel SL, Golinelli D, Elliott MN, Williamson S. A prospective study of risk and protective factors for substance use among impoverished women living in temporary shelter settings in Los Angeles County. Drug Alcohol Depend 2005; 80(1):35–43.PubMedCrossRefGoogle Scholar
  49. 49.
    Nyamanthi N, Wenzel S, Lesser J, Fladesrud J. Comparison of behavioral and psychosocial profiles of victimized and nonvictimized homeless women and their intimate partners. Res Nurs Health 2001; 24:324–35.CrossRefGoogle Scholar
  50. 50.
    Linn JG. Brown M. Kendrick L. Injection drug use among homeless adults in the Southeast with severe mental illness. J Health Care Poor Underserved 2005;16(4 suppl A):83–90.PubMedCrossRefGoogle Scholar
  51. 51.
    Rokack A. The causes of loneliness in homeless youth. J Psychol Sept 2005; 139(5):469–80.Google Scholar
  52. 52.
    Breakey WR. Mental Health Services for Homeless People. In: Robertson MJ, Greenblatt M eds. Homelessness: A National Perspective. New York: Plenum Press, 1992, pp. 101–7.Google Scholar
  53. 53.
    Susser E, Stuening EL, Conover S. Psychiatric problems in homeless men. Arch Gen Psychol 1989; 46:845–50.Google Scholar
  54. 54.
    Oakley D, Dennis DL. Responding to the Needs of Homeless People with Alcohol, Drug, and/or Mental Disorders. In: Baumohl J, ed. Homelessness in America. Phoenix, AZ: Oryx Press, 1996, pp. 180–5.Google Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • John Song
    • 1
    • 2
    Email author
  • Edward R Ratner
    • 1
    • 2
  • Dianne M. Bartels
    • 1
    • 2
  • Lucy Alderton
    • 3
  • Brenda Hudson
    • 4
  • Jasjit S. Ahluwalia
    • 2
    • 4
  1. 1.Center for BioethicsUniversity of MinnesotaMinneapolisUSA
  2. 2.Department of Medicine, Medical SchoolUniversity of MinnesotaMinneapolisUSA
  3. 3.Division of Chronic DiseasesCity of Philadelphia Department of Public HealthPhiladelphiaUSA
  4. 4.Office of Clinical Research, Academic Health CenterUniversity of MinnesotaMinneapolisUSA

Personalised recommendations