Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California, USA.
Division of General Internal Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA.
J Palliat Med. 2020 Oct;23(10):1300-1306. doi: 10.1089/jpm.2019.0550. Epub 2020 Mar 17.
Older homeless-experienced adults have low rates of advance care planning (ACP) engagement despite high rates of morbidity and mortality. To inform intervention development, we examined potential barriers and solutions to ACP engagement. Cross-sectional qualitative study. We recruited adults who were homeless in the prior three years and ≥50 years of age in the San Francisco Bay Area, and recruited clinical stakeholders from a national meeting of homeless providers. We analyzed qualitative data using thematic analysis. We conducted semistructured interviews with homeless-experienced older adults ( = 20) and focus groups with clinical stakeholders ( = 24) about perceived barriers and solutions to ACP engagement. Participants considered ACP important, reflecting on deaths of people in their networks who had died. Participant-identified barriers to ACP included poor ACP knowledge, lack of familial ties and social isolation, competing priorities, avoidance and lack of readiness, fatalism and mistrust, and lack of ACP training for clinical and nonclinical staff. They identified solutions that included framing ACP as a way to provide meaning and assert choice, providing easy-to-read written documents focused on the populations' unique needs, tailoring content and delivery, initiating ACP in nonclinical settings, such as permanent supportive housing, and providing incentives. Both older homeless-experienced adults and clinical stakeholders believe that ACP is important, but acknowledge multiple barriers that impede engagement. By focusing on potential solutions, including capitalizing on opportunities outside of health care settings, focusing on the period after housing, and tailoring content, there are opportunities to improve ACP uptake.
尽管患有疾病和死亡率高，但无家可归经历的老年成年人参与预先护理计划（ACP）的比例较低。为了为干预措施的制定提供信息，我们研究了参与 ACP 的潜在障碍和解决方案。这是一项横断面定性研究。我们招募了在过去三年中无家可归且年龄在 50 岁及以上的旧金山湾区的无家可归成年人，并从全国无家可归者服务提供者会议中招募了临床利益相关者。我们使用主题分析对定性数据进行了分析。我们对有过无家可归经历的老年成年人（ = 20）进行了半结构化访谈，并对临床利益相关者（ = 24）进行了焦点小组讨论，了解他们对参与 ACP 的看法和障碍。参与者认为 ACP 很重要，他们反思了自己社交网络中那些没有进行 ACP 而去世的人的死亡。参与者确定的 ACP 障碍包括对 ACP 缺乏了解、缺乏家庭关系和社会孤立、优先事项冲突、回避和缺乏准备、宿命论和不信任以及临床和非临床工作人员缺乏 ACP 培训。他们确定的解决方案包括将 ACP 作为提供意义和表达选择的一种方式、提供针对人群独特需求的易于阅读的书面文件、定制内容和交付方式、在非临床环境中启动 ACP（如永久性支持性住房）以及提供激励措施。有过无家可归经历的老年成年人和临床利益相关者都认为 ACP 很重要，但也承认有多种障碍会阻碍参与。通过关注潜在的解决方案，包括利用医疗保健环境之外的机会、关注住房后的时期以及定制内容，有机会提高 ACP 的采用率。
