Decision making for a homeless person can be challenging unless planned for in advance.
Issues:
(1) competency of the person
(2) availability of family or friends to serve as surrogate decision makers
(3) documenting wishes for care
(4) having access to directives when needed
Documentation of wishes:
(1) This should be done in advance of illness whenever possible.
(2) It may take some time for the homeless person to trust that his or her wishes will be followed.
(3) The physician should ask the person about common scenarios that might be encountered (need for mechanical ventilation, resuscitation, etc.)
Places to store copies of a directive:
(1) on his or her person
(2) with a trusted friend or person
(3) in the hospital medical record
Problems arise when:
(1) the person is mentally incompetent
(2) the person goes to many health care providers at different hospitals
(3) the person has no friends or acquaintances familiar with his or her wishes
(4) the person has no family willing to be involved with his or her care
(5) the advanced directive cannot be located
In the absence of a surrogate decision maker or an advanced directive, then decisions about care may need to be made by:
(1) the courts
(2) the hospital ethics committee
(3) the physician, typically in consultation with another physician
