Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.
Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California Center; University of California, San Francisco, California.
J Am Geriatr Soc. 2018 Jul;66(6):1068-1074. doi: 10.1111/jgs.15417. Epub 2018 May 9.
Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. 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 healthcare settings.
尽管高龄无家可归者的发病率和死亡率较高，但他们参与预先护理计划（ACP）的程度较低。我们对加利福尼亚州奥克兰的 350 名 50 岁及以上有过无家可归经历的成年人进行了一项队列的横断面分析。我们评估了潜在替代决策人的流行率、ACP 的思考、讨论和 ACP 文件（代理指定、预先指示）。我们使用多变量逻辑回归来研究与 ACP 讨论和文件相关的因素。队列的中位数年龄为 59 岁（范围 52-82 岁），75.2%为男性，82.1%为黑人。61%报告有潜在的替代决策者，21.5%讨论过 ACP，19.0%报告了 ACP 文件。在多变量模型中，与没有替代决策者相比，有 1 到 5 个知己的参与者（调整后的优势比（aOR）=5.8，95%置信区间（CI）=1.7-20.0），有 3 种或更多慢性疾病的参与者（aOR=2.3，95%CI=0.9-5.6），最近进行过初级保健就诊的参与者（aOR=2.1，95%CI=1.0-4.4）与更高的 ACP 讨论几率相关，而每增加 5 年的无家可归经历（aOR=0.7，95%CI=0.5-0.9）与更低的几率相关。与没有替代决策者相比，有 1 到 5 个知己的参与者（aOR=5.0，95%CI=1.4-17.5）、黑人（aOR=5.5，95%CI=1.5-19.5）和具有足够而非有限的文化程度的参与者（aOR=7.0，95%CI=1.5-32.4）与更高的 ACP 记录几率相关，而使用非法药物的几率（aOR=0.3，95%CI=0.1-0.9）较低。尽管大多数有过无家可归经历的高龄成年人都有潜在的替代决策者，但很少有人讨论或记录他们的 ACP 意愿；社交网络更大时，这两种情况的几率都会增加。未来的干预措施必须针对社交网络有限的个人进行定制，并解决无家可归的不稳定性、健康素养以及安全网医疗保健环境的限制。
