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Treatment Preferences for Resuscitation and Critical Care Among Homeless Persons^*

^* From the Division of Pulmonary and Critical Care Medicine (Dr. Norris, Ms. Nielsen, and Dr. Curtis), Department of Medicine, School of Medicine, University of Washington; and Program in Social and Behavioral Sciences (Dr. Engelberg), Department of Health Services, School of Public Health, University of Washington, Seattle, WA.

Correspondence to: J. Randall Curtis, MD, MPH, FCCP, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, Box 359762, 325 Ninth Ave, Seattle, WA 98104-2499; e-mail: jrc{at}u.washington.edu

Context: Homeless people are at increased risk of critical illness and are less likely to have surrogate decision makers when critically ill. Consequently, clinicians must make decisions independently or with input from others such as ethics committees or guardians. No prior studies have examined treatment preferences of homeless to guide such decision makers.

Design: Interviewer-administered, cross-sectional survey of homeless persons.

Setting: Homeless shelters in Seattle, WA.

Participants: Two hundred twenty-nine homeless individuals with two comparison groups: 236 physicians practicing in settings where they are likely to provide care for homeless persons and 111 patients with oxygen-dependent COPD.

Measurements: Participants were asked whether they would want intubation with mechanical ventilation or cardiopulmonary resuscitation in their current health, if they were in a permanent coma, if they had severe dementia, or if they were confined to bed and dependent on others for all care.

Results: Homeless men were more likely to want resuscitation than homeless women (p < 0.002) in coma and dementia scenarios. Homeless men and women were both more likely to want resuscitation in these scenarios than physicians (p < 0.001). Nonwhite homeless were more likely to want resuscitation than white homeless people (p < 0.033), and both were more likely to want resuscitation than physicians (p < 0.001). Homeless are also more likely to want resuscitation than patients with COPD. The majority (80%) of homeless who reported not having family or not wanting family to make medical decisions prefer a physician make decisions rather than a court-appointed guardian.

Conclusions: Homeless persons are more likely to prefer resuscitation than physicians and patients with severe COPD. Since physicians may be in the position of making medical decisions for homeless patients and since physicians are influenced by their own preferences when making decisions for others, physicians should be aware that, on average, homeless persons prefer more aggressive care than physicians. Hospitals serving homeless individuals should consider developing policies to address this issue.

Key Words: homeless • mechanical ventilation • resuscitation • treatment preferences

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