Offering HOPE
On the University's Duluth campus, medical students and faculty are working on plans to establish their own PNC-like clinic for their city's homeless adults.
Although the HOPE clinic — for Health of People Everywhere — is in its earliest stage of development, Duluth students are already hard at work laying the groundwork for the facility. Last year, Amanda Noska and Tria Lor, then second-year medical students, began looking at potential sites, developing a mission statement, doing community assessments, and exploring just how such a facility would help local residents. Another pair of second-year students, Hope Pogemiller and Tessa Pierson, continues that work this year.
"We are in the infancy of exploring a student-run facility that would be supervised by faculty here at the University," explains Ruth Westra, D.O., M.P.H., chair of the University's Department of Family Medicine and Community Health, Duluth.
Like the Phillips Neighborhood Clinic, the Duluth site would be open one night a week for two or three hours at a time and staffed by student volunteers from a range of disciplines. Currently, Duluth faculty and students are collaborating with Central Hillside United Ministry (CHUM), a homeless shelter in Duluth where second-year medical students are taking blood pressure and giving health talks to help create a presence in the adult homeless community.
While the students are providing an important community service, they clearly benefit as well, says Westra. "There's a big learning curve when it comes to caring for an underserved population and finding out their needs rather than coming in with preconceived notions," she says. "The HOPE clinic will provide our students with an opportunity to learn not only about this particular group of people but also about how the health-care professions work together to provide treatment."
Dignity at life's end
Other University initiatives are charting new territory in caring for homeless populations, and the National Institutes of Health (NIH) is taking notice.
John Song, M.D., M.P.H., a faculty member in the University's Center for Bioethics and cofounder of the Phillips Neighborhood Clinic, has a longtime interest in helping homeless people. Today, Song is about to embark on a new three-year, NIH-funded study that will combine research with clinical intervention to see whether homeless people will create living wills and whether those wills have a positive effect on their end-of-life care.
"We want to see not only if homeless people will fill out living wills but also whether they will do so at a higher rate if they have some counseling," Song explains. Ultimately, the study's goal is also to discover whether the existence of advance directives will help the homeless preserve personal autonomy over the treatment they receive at the end of life.
To conduct the study, Song and his research team, including bioethics center colleagues Dianne Bartels, R.N., Ph.D., and Edward Ratner, M.D., will work with Minneapolis homeless shelters, health-care agencies, outreach programs, and soup kitchens — eight organizations in all. It will begin with baseline surveys of homeless patrons to establish attitudes toward end-of-life care. Half of the group surveyed will be provided with living will forms and information about how to fill them out. The other half will in addition be offered advance directive counseling by staff members at Heartland Hospice and Hospice of the Twin Cities.
"We'd like to see if there is any difference between the two groups because of the intensive intervention," says Song. "We expect that the group that receives counseling will be more likely to make a living will, but we don't know that at this point. If this turns out to be the case," he says, "shelters might be encouraged to offer advance planning counseling to their clients." Song says he is also interested in other changes the counseling might elicit. "We expect some psychosocial outcomes [among our subjects], like reconnecting with families and friends because of this."
In its final stage, the study will examine local hospital records to discover whether study participants have been admitted for end-of-life care and, if so, whether their living wills were accessed and had an impact on treatment.
Trying to improve end-of-life care for a population struggling to survive day-to-day may seem counterintuitive at first, but the new study builds on research showing that issues surrounding death and dying are a major concern among the homeless. In a way, that should come as no surprise. Nationally, the average life expectancy of a homeless individual is 40 years. Many, if not most, homeless people have experienced the death of friends living on the streets and have many fears about how they themselves will be treated both at the end of their lives and after they have died.