Posted on 01/18/2007 5:45:05 PM PST by shrinkermd
On december 27,2006, kusheland miaskowski' introduced Mr K, a 66-year-old African American man who has lived on the streets for nearly 50 years and for most of those years has used heroin and other illicit drugs daily. Mr K was diagnosed with advanced renal adenocarcinoma in February 2002 at a large urban hospital. For unclear reasons, resection was made contingent upon cessation of drug use and was not done.
Thereafter, Mr K was lost to follow up for almost a year, until he presented to the emergency department with abdominal pain and heroin withdrawal. He was then referred for palliative care to Dr E, in the hospital's palliative care clinic.
As the authors describe, homelessness annually affects an estimated 2.3 to 3.5 million individuals living in the United States. Homeless people face difficulties meeting their basic needs; many struggle with substance abuse, have mental illness, lack social support, and lack medical insurance.
These challenges complicate the homeless patient's ability to engage in end-of-life advanced planning, adhere to medications, and find a fitting site to receive terminal care. However, as demonstrated by Mr K and Dr E, trusting relationships can be formed between homeless patients and their clinicians, and effective palliative care can be delivered.' Using a mullidiscipHilary team can help address the many needs and improve the care of homeless patients.
For patients who continue to use illicit substances while receiving end-of-life care, Kushel and Miaskowski1 recommend scheduling frequent clinic visits, using long-acting pain medications, dispensing small quantities of medications at a time, and developing a written pain agreement. Because homeless people are less likely to have a surrogate decision maker, clinicians should have frequent, well-documented conversations with them about their end-of-life wishes. Homeless people can rarely use hospice services because they lack the financial resources for inpatieni hospice and have neither the home nor the social support required for home hospice. Developing inpatient palliative care services at hospitals that serve many homeless people could improve their end-of-life care.
Dr E was reinterviewed in August 2006
dr E: Believe it or not, Mr K is still alive. He appears to have some metosloses to the lung now, as wed as Lo Lhe ribs and spine.
He is a candidate for hospice and has been on it in the past, but things did not go too well. He does not like to have to stay in one place. Consequently, it was very hard for the hospice people to find him, even when he supposedly had a fixed address. He also felt that they were trying to tell him what to do, which he resented. He and the hospice agency parted ways after a few months, and he has not been interested in pursuing it again.
About a year ago, October 2005, Mr K presented with confusion, no! eating, feeling lousy. Always before, he had rejected the idea of dialysis. But at this admission, he felt so badly that he capitulated. He is on dialysis because of end-stage renal disease, probably secondary to a combination of factors (he declined kidney biopsy) .. . including heroin use and hepatitis C, [and] a lifetime of uncontrolled hypertension.
It has been very difficult to get him to comply with antihypertensives. After several years of chronic renal insufficiency, he now presented with uremic symptoms and electrolyte abnormalilies and elected to remain on dialysis because it made him fed so much better. I don't know that the stage of cancer is necessarily important in relation to the dialysis—even though the cancer is very advanced, the symptomatic benefit is substantial.
He and I had talked a lot about his drug use, but ihe decision to quit was his own, and he. quit withoutformal intervention. He tells me he is not using heroin anymore because he does not have the energy "to hustle for it."
His social situation continues to be a little problematic. He bounces from place to place but adamantly refuses nursing home placement. For a while, he lived with a young, woman. Eventually, (his living arrangement ended. He remains very cheerful and positive through it all and comes to visit us once a month. At this visit, we make sure his pain is controlled, talk about where he is staying and how to get in touch, as this changes frequently. The thing that makes me the happiest about this is that in every earlier interaction with the health care system, Mr K hasjled, but we've really forged a great relationship, he has stayed with us, and I feel that this is a real accomplishment.
AmyJ, Markowitz, JD Stephen J. MePhee, MD
1. Kushel MB, Miaskowski C. End-of-life care for homeless patients
The issues of homelessness are more complex for the troubled and troubling alchohol and substance habituation user. This is an extreme case, but problems similar to this are common.
It breaks my heart to see people living on the streets.
I donate money to homeless shelters here in Philly regularly.
I agree with you completely on this.
If I wasn't pushed into a crack rehab program by a judge threatening me with the alternative of prison I don't know if I ever would have recovered. Period.
And I was a straight A student who graduated first in my college class with a perfect 4.0 GPA.
I NEEDED that incentive from the court requiring my committment.....and years later I thank God for it. And for that judge.
I have my life back now as a result.
Pro-life bump.
I donate money to homeless shelters here in Philly regularly
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My wife does a lot for our local Rescue Mission. One of the best things about it is they hold their clients accountable.
With God's grace some of them learn to hold themselves accountable.
I'm sorry, but I think part of the problem is calling vagrant drug addicts and winos homeless, an appellation created to garner sympathy for the plight of people who have chosen, in the face of myriad social services and expenditure, to live the life they are living.
You get more of what you subsidize and less of what you discourage, and the population of bums proves it.
God bless all those who minister to the homeless....I am seeing so many young homeless people around now. It is very heartbreaking. Jorge - your post is hope for many who seem hopeless. I hope and pray others "out there" have someone who comes along and give that motivation that so many no longer have to get help and get well.
Excellent.
I try to donate to Christian based missions that give people a vision of hope that includes personal responsibility and reliance on God that supercedes the cirumstances in this present world.
I think all of us need that type of hope...but especially those who are alone on the streets.
There, but for the Grace of God go YOU.
Many of these people are so ill, both emotionally and sometimes physically, that they have no alternatives.
Compassion is not inconsistent with conservative values.
I agree with your post. It is terribly sad. How good of you to donate your money!
"There, but for the Grace of God go YOU. "
Nope.
Actually I can sympathize because I lived on the streets when I was 16 years old, for almost a year.
For me, to see someone sleeping on a grate in Philly, knowing this is someone's child, brother or sister...and see where they have ended up, is beyond words.
Nope.
YES YOU.
Please don't tempt God with such ignorant responses.
For your own sake.
You don't know what could happen to you tomorrow.
Excellent post (#3 in its entirety) and thread, I hope many will read it and give it some thought.
Unclear to whom? Lifelong drug addicts who refuse to quit until they are physically unable to go out and get the stuff do not deserve one cent of medical care at the expense of taxpayers.
While I agree with you that involuntary commitment is what's needed in many cases, even that shouldn't be allowed to become a huge drain on taxpayers. Few people with an inclination to live this way will ever become productive citizens, and the current maze of regulations and laws wildly inflate the expense of running of inpatient mental institutions, and prohibit requiring the patients to perform valuable work to support the operation of the institution. The money would be better spent on higher quality care for people who really have no ability to help themselves, even under confinement and pressure (severely retarded, brain-damaged, Alzheimer's patients, etc.).
part of the problem is calling vagrant drug addicts and winos homeless
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Kinda like calling people who consider flipping burgers (only one example) "beneath their dignity" unemployed?
Kinda like calling an IQ of 50 'differently abled.'
Exactly. I wouldn't be so cocky as to make such a statement.
I'll bet 90% of homeless people never would have imagined it happening to them.
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