Engaging Homeless Persons in End of Life Preparations

  • John SongEmail author
  • Melanie M. Wall
  • Edward R. Ratner
  • Dianne M. Bartels
  • Nancy Ulvestad
  • Lillian Gelberg
Populations at Risk



There are no prospective studies that have investigated the effects of an intervention to improve end of life (EOL) care in an underserved population.


To determine whether homeless persons will complete an advance directive (AD).


Randomized trial comparing two modes of providing an opportunity for homeless persons to complete an AD. Half of the subjects were randomized to a self-guided group (SG) who were given an AD and written instructions; the other half were given the same material but, in addition, were offered the opportunity to receive guidance to complete the AD (CG).


Fifty-nine homeless persons recruited from a drop-in center.


Rate of AD completion and baseline and 3-month follow-up EOL-related knowledge, attitudes, and behaviors.


The overall AD completion rate was 44%, with a statistically significant higher completion rate of 59% in the CG group compared to 30% in the self-guided only group. Frequency of worry about death decreased among those who filled out an AD from 50% to 12.5%, and also among those who did not (25% to 12.5%) (p < .05). Among those who filled out an AD, there were increases in plans to write down EOL wishes (56% to 100%; p < .05) and plans to talk about these wishes with someone (63% to 94%; p < .05).


This study demonstrates that people living in dire economic and social situations will complete an AD when offered the opportunity. While offering guidance resulted in higher rates of completion; even a simple self-guided AD process can achieve completion of ADs in this population.


homelessness poverty end of life advance directives 



We are grateful to the director, Rose Marie Reger Rumsey, Mari Uutala, M.A., the staff and the clients of Listening House, St. Paul Minnesota, who so graciously shared their space, their time, and their fears with the research team. Funding for this project was provided by the National Institute for Nursing Research, NIH, 5RO3-NR008586–02, which supported the following: design and conduct of the study, and collection, management, analysis, and interpretation of the data. All authors are responsible for the content of the manuscript, conception and design of the study; acquisition, management, analysis, and interpretation of the data; and critical revision of the manuscript. Drs. Song and Wall are responsible for the drafting of the manuscript, and 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.

Conflict of Interest

Dr. Bartels serves as a consultant for Advanced Circulatory Systems on an NIH-funded project, the ResQ trial. None of the other authors have any real or potential conflicts of interests to disclose or report.


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Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • John Song
    • 1
    • 3
    Email author
  • Melanie M. Wall
    • 2
  • Edward R. Ratner
    • 1
    • 3
  • Dianne M. Bartels
    • 1
    • 3
  • Nancy Ulvestad
    • 1
  • Lillian Gelberg
    • 4
  1. 1.Center for BioethicsUniversity of MinnesotaMinneapolisUSA
  2. 2.Division of BiostatisticsUniversity of Minnesota School of Public HealthMinneapolisUSA
  3. 3.Department of MedicineUniversity of Minnesota Medical SchoolMinneapolisUSA
  4. 4.Department of Family MedicineDavid Geffen School of Medicine at UCLAMinneapolisUSA

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