Effect of a dementia friends information session on health professional students' attitudes and knowledge related to dementia.

Despite the growing prevalence of dementia, few models of training for health professional students on this topic have been formally evaluated or widely disseminated. The Dementia Friends (DF) initiative is part of a global movement to improve the way people think, act, and talk about dementia. The impact of these sessions on the dementia-related knowledge and attitudes of health professional trainees has not been adequately assessed. Health professional students (medicine n = 70, physical therapy n = 30, pharmacy n = 28) participated in one-hour DF information sessions, offered in-person or via videoconference. The Dementia Attitudes Scale (DAS), a validated 20-item questionnaire, was administered before and after each session. Pre- and post-session DAS scores were compared using a paired t-test. Students' dementia-friendly action plans were analyzed qualitatively. Of 128 students, 102 (80%) completed both the pre- and post-DAS. The mean DAS score increased significantly from 105.8 (12.3) to 120.8 (10.5) following the DF sessions (p < .001). Students' dementia-friendly action plans included improving communication, promoting quality of life, and learning more about dementia. The DF information session model significantly increased the knowledge and positive attitudes of health professional students toward those living with dementia. Further use and study of this model is appropriate.

An evaluation of a sustained senior mentor program for medical students.

Background/Objective Medical student geriatrics education using community-based volunteer older persons, known as a Senior Mentor Program (SMP), began decades ago. Though these programs have been described and evaluated against curriculum objectives, the full breadth of students' learning from SMPs has not been reported. Methods We conducted a qualitative study using content analysis of reflections of Year 2 medical students submitted during a single visit home-based SMP. Written reflections of 102 randomly selected students from 2016-2018 were inductively coded and grouped into themes. Older persons from the SMP site assisted in coding and quotation selection. Results We discerned six themes from the evaluation of student reflections: student insight, interview and exam, social community, challenges with aging, strengths (responses to challenges), and physical infrastructure. Conclusion A single home visit with older adults enables pre-clinical medical students to learn about multiple positive aspects of aging.

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews.

BACKGROUND: With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP). METHODS: We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors). RESULTS: Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP. DISCUSSION: Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.

Does Cognitive Training Prevent Cognitive Decline?: A Systematic Review.

Background: Structured activities to stimulate brain function-that is, cognitive training exercises-are promoted to slow or prevent cognitive decline, including dementia, but their effectiveness is highly debated. Purpose: To summarize evidence on the effects of cognitive training on cognitive performance and incident dementia outcomes for adults with normal cognition or mild cognitive impairment (MCI). Data Sources: Ovid MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and PsycINFO through July 2017, supplemented by hand-searches. Study Selection: Trials (published in English) lasting at least 6 months that compared cognitive training with usual care, waitlist, information, or attention controls in adults without dementia. Data Extraction: Single-reviewer extraction of study characteristics confirmed by a second reviewer; dual-reviewer risk-of-bias assessment; consensus determination of strength of evidence. Only studies with low or medium risk of bias were analyzed. Data Synthesis: Of 11 trials with low or medium risk of bias, 6 enrolled healthy adults with normal cognition and 5 enrolled adults with MCI. Trainings for healthy older adults were mostly computer based; those for adults with MCI were mostly held in group sessions. The MCI trials used attention controls more often than trials with healthy populations. For healthy older adults, training improved cognitive performance in the domain trained but not in other domains (moderate-strength evidence). Results for populations with MCI suggested no effect of training on performance (low-strength and insufficient evidence). Evidence for prevention of cognitive decline or dementia was insufficient. Adverse events were not reported. Limitation: Heterogeneous interventions and outcome measures; outcomes that mostly assessed test performance rather than global function or dementia diagnosis; potential publication bias. Conclusion: In older adults with normal cognition, training improves cognitive performance in the domain trained. Evidence regarding prevention or delay of cognitive decline or dementia is insufficient. Primary Funding Source: Agency for Healthcare Research and Quality.

Pharmacologic Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review.

Background: Optimal treatment to prevent or delay cognitive decline, mild cognitive impairment (MCI), or dementia is uncertain. Purpose: To summarize current evidence on the efficacy and harms of pharmacologic interventions to prevent or delay cognitive decline, MCI, or dementia in adults with normal cognition or MCI. Data Sources: Several electronic databases from January 2009 to July 2017, bibliographies, and expert recommendations. Study Selection: English-language trials of at least 6 months' duration enrolling adults without dementia and comparing pharmacologic interventions with placebo, usual care, or active control on cognitive outcomes. Data Extraction: Two reviewers independently rated risk of bias and strength of evidence; 1 extracted data, and a second checked accuracy. Data Synthesis: Fifty-one unique trials were rated as having low to moderate risk of bias (including 3 that studied dementia medications, 16 antihypertensives, 4 diabetes medications, 2 nonsteroidal anti-inflammatory drugs [NSAIDs] or aspirin, 17 hormones, and 7 lipid-lowering agents). In persons with normal cognition, estrogen and estrogen-progestin increased risk for dementia or a combined outcome of MCI or dementia (1 trial, low strength of evidence); high-dose raloxifene decreased risk for MCI but not for dementia (1 trial, low strength of evidence); and antihypertensives (4 trials), NSAIDs (1 trial), and statins (1 trial) did not alter dementia risk (low to insufficient strength of evidence). In persons with MCI, cholinesterase inhibitors did not reduce dementia risk (1 trial, low strength of evidence). In persons with normal cognition and those with MCI, these pharmacologic treatments neither improved nor slowed decline in cognitive test performance (low to insufficient strength of evidence). Adverse events were inconsistently reported but were increased for estrogen (stroke), estrogen-progestin (stroke, coronary heart disease, invasive breast cancer, and pulmonary embolism), and raloxifene (venous thromboembolism). Limitation: High attrition, short follow-up, inconsistent cognitive outcomes, and possible selective reporting and publication. Conclusion: Evidence does not support use of the studied pharmacologic treatments for cognitive protection in persons with normal cognition or MCI. Primary Funding Source: Agency for Healthcare Research and Quality.

Over-the-Counter Supplement Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review.

Background: Optimal interventions to prevent or delay cognitive decline, mild cognitive impairment (MCI), or dementia are uncertain. Purpose: To summarize the evidence on efficacy and harms of over-the-counter (OTC) supplements to prevent or delay cognitive decline, MCI, or clinical Alzheimer-type dementia in adults with normal cognition or MCI but no dementia diagnosis. Data Sources: Multiple electronic databases from 2009 to July 2017 and bibliographies of systematic reviews. Study Selection: English-language trials of at least 6 months' duration that enrolled adults without dementia and compared cognitive outcomes with an OTC supplement versus placebo or active controls. Data Extraction: Extraction performed by a single reviewer and confirmed by a second reviewer; dual-reviewer assessment of risk of bias; consensus determination of strength of evidence. Data Synthesis: Thirty-eight trials with low to medium risk of bias compared ω-3 fatty acids, soy, ginkgo biloba, B vitamins, vitamin D plus calcium, vitamin C or ß-carotene, multi-ingredient supplements, or other OTC interventions with placebo or other supplements. Few studies examined effects on clinical Alzheimer-type dementia or MCI, and those that did suggested no benefit. Daily folic acid plus vitamin B12 was associated with improvements in performance on some objectively measured memory tests that were statistically significant but of questionable clinical significance. Moderate-strength evidence showed that vitamin E had no benefit on cognition. Evidence about effects of ω-3 fatty acids, soy, ginkgo biloba, folic acid alone or with other B vitamins, ß-carotene, vitamin C, vitamin D plus calcium, and multivitamins or multi-ingredient supplements was either insufficient or low-strength, suggesting that these supplements did not reduce risk for cognitive decline. Adverse events were rarely reported. Limitation: Studies had high attrition and short follow-up and used a highly variable set of cognitive outcome measures. Conclusion: Evidence is insufficient to recommend any OTC supplement for cognitive protection in adults with normal cognition or MCI. Primary Funding Source: Agency for Healthcare Research and Quality.

Physical Activity Interventions in Preventing Cognitive Decline and Alzheimer-Type Dementia: A Systematic Review.

Background: The prevalence of cognitive impairment and dementia is expected to increase dramatically as the population ages, creating burdens on families and health care systems. Purpose: To assess the effectiveness of physical activity interventions in slowing cognitive decline and delaying the onset of cognitive impairment and dementia in adults without diagnosed cognitive impairments. Data Sources: Several electronic databases from January 2009 to July 2017 and bibliographies of systematic reviews. Study Selection: Trials published in English that lasted 6 months or longer, enrolled adults without clinically diagnosed cognitive impairments, and compared cognitive and dementia outcomes between physical activity interventions and inactive controls. Data Extraction: Extraction by 1 reviewer and confirmed by a second; dual-reviewer assessment of risk of bias; consensus determination of strength of evidence. Data Synthesis: Of 32 eligible trials, 16 with low to moderate risk of bias compared a physical activity intervention with an inactive control. Most trials had 6-month follow-up; a few had 1- or 2-year follow-up. Evidence was insufficient to draw conclusions about the effectiveness of aerobic training, resistance training, or tai chi for improving cognition. Low-strength evidence showed that multicomponent physical activity interventions had no effect on cognitive function. Low-strength evidence showed that a multidomain intervention comprising physical activity, diet, and cognitive training improved several cognitive outcomes. Evidence regarding effects on dementia prevention was insufficient for all physical activity interventions. Limitation: Heterogeneous interventions and cognitive test measures, small and underpowered studies, and inability to assess the clinical significance of cognitive test outcomes. Conclusion: Evidence that short-term, single-component physical activity interventions promote cognitive function and prevent cognitive decline or dementia in older adults is largely insufficient. A multidomain intervention showed a delay in cognitive decline (low-strength evidence). Primary Funding Source: Agency for Healthcare Research and Quality.

Live-in "strangers": An experiential account of gerontology educational immersion in senior housing.

Gerontology education programs that combine elements of experiential service-learning, community participation, and residential immersion have been emerging in the United States and internationally. Combining fieldwork, interviews, and immersion methods, this study draws on qualitative ethnographic and phenomenologic design, whereby a student lived in senior housing for 3.5 years. The study is among the longest and most intensive gerontological field experiences ever reported. It is based on more than 2,000 hours of observations and conversational interviews with 14 residents. Major patterns based on observational data show the importance of shared history, support for one another, negotiating environmental tensions, and demand for attention on the part of residents. Major themes derived from interviews elaborate on family conflict, conflict between residents, and life decisions. Results show that a unique combination of physical and social proximity in an intergenerational alliance enables life enhancement for older adults and learning opportunities for students. A recommendation is made to implement a live-in role more formally.

Decision aids for advance care planning: an overview of the state of the science.

Advance care planning honors patients' goals and preferences for future care by creating a plan for when illness or injury impedes the ability to think or communicate about health decisions. Fewer than 50% of severely or terminally ill patients have an advance directive in their medical record, and physicians are accurate only about 65% of the time when predicting patient preferences for intensive care. Decision aids can support the advance care planning process by providing a structured approach to informing patients about care options and prompting them to document and communicate their preferences. This review, commissioned as a technical brief by the Agency for Healthcare Research and Quality Effective Health Care Program, provides a broad overview of current use of and research related to decision aids for adult advance care planning. Using interviews of key informants and a search of the gray and published literature from January 1990 to May 2014, the authors found that many decision aids are widely available but are not assessed in the empirical literature. The 16 published studies testing decision aids as interventions for adult advance care planning found that most are proprietary or not publicly available. Some are constructed for the general population, whereas others address disease-specific conditions that have more predictable end-of-life scenarios and, therefore, more discrete choices. New decision aids should be designed that are responsive to diverse philosophical perspectives and flexible enough to change as patients gain experience with their personal illness courses. Future efforts should include further research, training of advance care planning facilitators, dissemination and access, and tapping potential opportunities in social media or other technologies.

What the VA can teach us about geriatric care.

The innovation now being demanded by Medicare is creating new opportunities for health care organizations to redesign how they deliver care for elderly people. For many years, the VA Health System has experimented with ways to deliver care more effectively and efficiently. Hospital-based postacute and palliative care and home-based primary care are two examples of successful approaches that non-VA providers should be looking at as they move away from fee-for-service reimbursement and invent new care-delivery models.

Effects of Nurse Staffing on Resident Outcomes in Nursing Homes: A Systematic Review.

OBJECTIVES: To evaluate the evidence on effects of nurse staffing in nursing homes on resident outcomes. DESIGN: Systematic review. SETTING AND PARTICIPANTS: Studies evaluating the effects of nurse staffing levels, total staffing, or skill mix on pressure ulcers, nursing home associated infections, and pain outcomes for adult residents in US nursing homes. METHODS: We searched MEDLINE, Embase, CINAHL, and the Cochrane Database for English-language articles published between January 2000 and May 2021. We also searched for gray literature and sought expert referrals. Two reviewers participated in determination of eligibility, assessment of methodological quality, and abstraction of data. Abstracted data included study design; setting and population characteristics; and resident outcomes. We rated overall certainty of evidence (very low, low, moderate, and high) for each outcome using GRADE. RESULTS: Of 9152 unique citations, 378 articles underwent full-text review. We identified 22 eligible studies that addressed pressure ulcers (k = 15), COVID-19 cases and/or mortality (k = 4), other infections (k = 8), and moderate-severe pain among residents (k = 7); some examined multiple outcomes. Most studies (k = 17) were rated moderate or high quality. All studies were observational. Overall, registered nurse (RN) staffing was probably associated with fewer pressure ulcers (moderate certainty) and possibly fewer COVID-19 infections/mortality (low certainty), other infections (low certainty) and lower rates of moderate-severe pain (low certainty). Higher skill mix was probably associated with fewer pressure ulcers, higher resident COVID-19 infections, fewer other infections, and lower rates of moderate-severe pain (low certainty for all outcomes). CONCLUSIONS AND IMPLICATIONS: Higher RN staffing and skill mix may be associated with better nursing home resident outcomes, while results were mixed for total staffing. Increasing RN staffing levels and skill mix are one of a variety of approaches to improve nursing home care.

Effect of an End-of-Life Planning Intervention on the completion of advance directives in homeless persons: a randomized trial.

BACKGROUND: Few interventions have focused on improving end-of-life care for underserved populations, such as homeless persons. OBJECTIVE: To determine whether homeless persons will complete a counseling session on advance care planning and fill out a legal advance directive designed to assess care preferences and preserve the dignity of marginalized persons. DESIGN: Prospective, single-blind, randomized trial comparing self-guided completion of an advance directive with professionally assisted advance care planning. (ClinicalTrials.gov registration number: NCT00546884) SETTING: 8 sites serving homeless persons in Minneapolis, Minnesota. PARTICIPANTS: 262 homeless persons recruited between November 2007 and August 2008. INTERVENTION: Minimal, self-guided intervention consisting of advance directive forms and written educational information versus a one-on-one advance planning intervention consisting of counseling and completing an advance directive with a social worker. MEASUREMENTS: Rate of advance directive completion, assessed by inspection of completed documents. RESULTS: The overall completion rate for advance directives was 26.7% (95% CI, 21.5% to 32.5%), with a higher rate in the counselor-guided group (37.9%) than in the self-guided group (12.8%) (CI of adjusted difference, 15.3 to 34.3 percentage points). This difference persisted across all sites and most subgroups. The advance directive's 4 clinical scenarios found a preference for surrogate decision making in 29% to 34% of written responses. LIMITATIONS: Sampling was limited to a more stable subset of the homeless population in Minneapolis and may have been subject to selection bias. Modest compensation to complete the preintervention survey could have influenced participants to complete advance directives. CONCLUSION: Both a simple and complex intervention successfully engaged a diverse sample of homeless persons in advance care planning. One-on-one assistance significantly increased the completion rate. Homeless persons can respond to an intervention to plan for end-of-life care and can express specific preferences for care or a surrogate decision maker, but additional studies are needed to assess the effect of these directives on subsequent care. PRIMARY FUNDING SOURCE: National Institute for Nursing Research and National Center on Minority Health and Health Disparities.

The educational and financial impact of using patient educators to teach introductory physical exam skills.

PURPOSE: Physical exam skills are essential to core competencies for physicians in training. It is increasingly difficult to secure time and funding for physician faculty to teach these critical skills. This study was designed to determine whether Patient Educators (PE) (non-physician instructors) in an introductory clinical medicine (ICM) course (1) were as effective as physician faculty in teaching the physical exam, (2) impacted consistency of student performance on a final practical exam, and (3) whether this model was cost effective. METHOD: PE were introduced into an ICM course at the University of Minnesota from 2006 to 2008. Each year, students' physical exam competencies were evaluated by a performance-based head-to-toe examination and 6 months later by an objective structured clinical examination (OSCE). Differences in test scores between years and variability (i.e., consistency) among yearly scores were assessed. The cost per student was calculated by considering a stable compensation cost per hour for the required number of physician faculty, standardized patients, and PE in each year. RESULTS: Mean student performance was statistically lower with PE, but only by two percentage points. The amount of variation within the medical student classes' physical exam skills remained stable as the use of PE expanded. Total educator salary costs per student declined from $449 in 2006 to $196 in 2008. CONCLUSIONS: In terms of sustainability and student performance, the use of trained lay educators has equivalent outcomes and is less costly for physical exam instruction in the pre-clinical years.

The need for POLST: Minnesota's initiative.

In 2008, the Minnesota Medical Association created a task force to develop a standardized Physician/Provider Orders for Life-SustainingTreatment (POLST) form that could be used throughout Minnesota. Whereas advance directives are created by patients to communicate their wishes about end-of-life care to a physician or other health care provider, POLST forms are used by a physician (or other designated health care provider) to document and communicate a person's end-of-life wishes to other health care professionals, including other physicians. Several states have adopted POLSTforms. This article describes the effort to create a POLST initiative and form in Minnesota.

Engaging homeless persons in end of life preparations.

BACKGROUND: There are no prospective studies that have investigated the effects of an intervention to improve end of life (EOL) care in an underserved population. OBJECTIVE: To determine whether homeless persons will complete an advance directive (AD). DESIGN: Randomized trial comparing two modes of providing an opportunity for homeless persons to complete an AD. Half of the subjects were randomized to a self-guided group (SG) who were given an AD and written instructions; the other half were given the same material but, in addition, were offered the opportunity to receive guidance to complete the AD (CG). PARTICIPANTS: Fifty-nine homeless persons recruited from a drop-in center. MEASURES: Rate of AD completion and baseline and 3-month follow-up EOL-related knowledge, attitudes, and behaviors. RESULTS: The overall AD completion rate was 44%, with a statistically significant higher completion rate of 59% in the CG group compared to 30% in the self-guided only group. Frequency of worry about death decreased among those who filled out an AD from 50% to 12.5%, and also among those who did not (25% to 12.5%) (p < .05). Among those who filled out an AD, there were increases in plans to write down EOL wishes (56% to 100%; p < .05) and plans to talk about these wishes with someone (63% to 94%; p < .05). CONCLUSION: This study demonstrates that people living in dire economic and social situations will complete an AD when offered the opportunity. While offering guidance resulted in higher rates of completion; even a simple self-guided AD process can achieve completion of ADs in this population.

Experiences with and attitudes toward death and dying among homeless persons.

BACKGROUND: Homeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect. Few studies have explored their experiences and attitudes toward death and dying. Unfortunately, studies done in other populations may not apply to homeless persons. Exploring these experiences and attitudes may provide insight into life, health care, and end-of-life (EOL) concerns of this population. OBJECTIVE: To explore the experiences and attitudes toward death and dying among homeless persons. DESIGN: Qualitative study utilizing focus groups. PARTICIPANTS: Fifty-three homeless persons recruited from homeless service agencies. MEASUREMENTS: In-depth interviews, which were audiotaped and transcribed. RESULTS: We present seven themes, some of which are previously unreported. Homeless persons described many significant experiences with death and dying, and many participants suffered losses while very young. These encounters influenced participants' attitudes toward risks and risky behavior: e.g., for some, these experiences provided justification for high-risk behaviors and influenced their behaviors while living on the streets. For others, they may be associated with their homelessness. Finally, these experiences informed their attitudes toward death and dying as well as EOL care; homeless persons believe that care will be poor at the EOL. CONCLUSIONS: Findings from this study have implications for addressing social services, health promotion, prevention, and EOL care for homeless persons, as well as for others who are poor and disenfranchised.

Dying on the streets: homeless persons' concerns and desires about end of life care.

BACKGROUND: There is little understanding about the experiences and preferences at the end of life (EOL) for people from unique cultural and socioeconomic backgrounds. Homeless individuals are extreme examples of these overlooked populations; they have the greatest risk of death, encounter barriers to health care, and lack the resources and relationships assumed necessary for appropriate EOL care. Exploring their desires and concerns will provide insight for the care of this vulnerable and disenfranchised population, as well as others who are underserved. OBJECTIVE: Explore the concerns and desires for EOL care among homeless persons. DESIGN: Qualitative study utilizing focus groups. PARTICIPANTS: Fifty-three homeless persons recruited from agencies providing homeless services. MEASUREMENTS: In-depth interviews, which were audiotaped and transcribed. RESULTS: We present 3 domains encompassing 11 themes arising from our investigation, some of which are previously unreported. Homeless persons worried about dying and EOL care; had frequent encounters with death; voiced many unique fears, such as dying anonymously and undiscovered; favored EOL documentation, such as advance directives; and demonstrated ambivalence towards contacting family. They also spoke of barriers to EOL care and shared interventions to improve dying among the very poor and estranged. CONCLUSIONS: Homeless persons have significant personal experience and feelings about death, dying, and EOL care, much of which is different from those previously described in the EOL literature about other populations. These findings have implications not only for homeless persons, but for others who are poor and disenfranchised.

Managing chronic disease through home telehealth.

This article describes the use of telehealth to monitor chronic illness in a home setting. It discusses the state of the art in commercial telehealth systems as well as 3 research projects undertaken by the University of Minnesota's program in health informatics that explore the potential of home telehealth to aid in care of patients with chronic conditions.

Formation and operation of a statewide commission on end-of-life care in Minnesota.

BACKGROUND: Innovative approaches to improving end-of-life care are needed. One strategy involves government/community partnerships to improve care. OBJECTIVE: Engage health care provider and health care consumer communities in the State of Minnesota to improve end-of-life care. DESIGN: The Minnesota Commission on End of Life Care was formed to make recommendations that would be used by public and private policy makers to improve care in the state. RESULTS: An innovative selection process brought together a broad group of people to identify, prioritize, and make recommendations regarding end-of-life care in the state. Carefully selected leadership, good planning, and organization ensured a successful process that kept all appointed commission members engaged throughout the 18-month project. Using a consensus process, the Commission endorsed a framework for end-of-life care and made specific recommendations for improving access, education and public policy. This paper describes the process of developing and implementing the Commission, the challenges, successes, and lessons learned.

A perspective on homelessness, ethics, and medical care.

People who are homeless are known to have high rates of morbidity and mortality. Yet their attitudes, values, and desires regarding end-of-life care have not been studied. This article reports on the findings from interviews with groups of homeless individuals in the Twin Cities performed by University of Minnesota researchers. It explores the implications of homelessness on two commonly discussed ethical principles-autonomy and justice.