Table 2 Concerns, care needs and future preferences for care and treatment among seriously ill homeless people

Physical domain

 • Concerns about serious illnesses and physical distress related to specific illnesses, e.g. heart disease, open heart surgery, multiple broken bones [28, 29, 31]

 • Fear of inappropriate and/or prolonged medical care and heroic treatments [28, 33]

 • Concerns about losing control over basic physical functions [24]

 • Concerns about being off medication [31]

Psychological domain

 • Fear of death and dying, partly due to bad and lonely deaths of other homeless people [24, 28, 29, 32,33,34, 37]

 • Concerns about psychiatric disorders, in particular schizophrenia, mental illness, depression, affective disorder, anxiety, hearing voices, PTSD, bipolarity, uncontrolled anger [24, 31]

 • Fear of experiencing death by accident or violence [24, 33]

Social domain

 • Concerns about being a burden on others [24, 28, 31, 35]

 • Fear of losing independence [24, 31, 33]

 • Concerns about dying alone [24, 31, 33]

 • Worries about relationships with friends and family, e.g. family not being notified, leaving a wife and children behind, lack of resources to cover burial costs, being alone, family may not show up [31, 33]

 • Fear of dying anonymously and no-one will be there to view their body [28, 33]

 • Fear that family may not know wishes, peers might help to a certain extent, but no assumptions of this help [33]

 • Concerns about being homeless [31]

Spiritual domain

 • Fear of the unknown [31]

 • Fear that the death rituals for their culture may not take place [33]

Care domain

 • Many patients had bad experiences from previous healthcare and social service encounters, homeless persons believe that care will be poor at the end of life [23, 29, 36, 37]

 • Concerns about lack of insurance and receiving sub-optimal treatment due to discrimination by HCP’s/insurance companies [31, 39]

 • Concerns about what will happen to the body after death, fear that their body will not be respected or taken care of [28, 33]

 • Homeless people who completed an advance direction worry more about the care they would receive if seriously ill or dying [36]

 • Fear of what will happen if no-one can speak for them [33]

 • Fear of being transferred to a nursing home [34]

Attitudes/behaviour of healthcare professionals

 • Homeless patients want to be treated with respect and dignity, e.g. treat patients like others, no judging/labelling, accept patients for who they are [28, 31, 38]

 • Physicians are preferred as decision-makers regarding end-of-life care treatment [23, 40]

 • Wish for companionship at the end of life, seeking relationship-centred, compassionate care [28, 39]

 • Acknowledging emotions; many homeless people have experienced tremendous losses in life. Intensifying of emotions could interfere with participants’ future decision-making process [39]

 • Providers who tell the truth [31]

 • Providers who respect privacy [31]

 • Providers should recognize cultural differences, this will serve as the basis for increasing sensitivity and trust [23]

 • Death and dying are perceived to be temporary matters, and many thought dwelling on the end of life situation was undesirable [23]

 • Patients prefer to use a GP who specializes in the care of the homeless [32]

Involvement of family

 • Some of the homeless persons want family nearby, others (often a majority) do not want to burden their families [28, 38]

 • Requests for some form of social contact with family and friends and resolving remaining issues and disagreements before dying even if they were estranged [24, 32]

 • Participants who are not in contact with their family desire to be placed in a familiar environment where they could be surrounded by a social support network [24]

Treatment/care options

 • Spirituality and religion are important components in defining life and death [23, 24, 33, 34]

 • Desire for advance care planning/documentation; this relates to several concerns (anonymity, estrangement, maintaining control, discussion with significant others), with trust as an important condition [28, 29, 33, 39]

 • Requests for detoxification [32]

 • Patients predominantly interact with GPS for prescriptions [32]

 • End-of-life care focus on pain control [28]

 • Asking how they would like to be remembered, including post-death wishes [31]

After death

 • Explicit and detailed desires that homeless people’s bodies be laid to rest in a personally and culturally acceptable manner (due to the misconceptions and fears about body disposal) [28]

Treatment preferences

 • Resuscitation:

 - Almost all homeless persons expressed a preferences to receive cardiopulmonary resuscitation (CPR) in the event of cardiorespiratory arrest if there was a chance of returning to their current state of health^a [41]

 - Homeless people want resuscitation more than physicians and patients with COPD [40]

 - Homeless men are more likely to want resuscitation than homeless women [40]

 - Non-white homeless people are more likely to want resuscitation or life-sustaining treatment than white homeless people [40, 42]

 • Life sustaining treatment:

 - Nearly half of the homeless participants (8/17) indicated that they would want all measures taken, a smaller proportion (7/8) would prefer limited treatment [31]

 - Between 20% and 37% want life-sustaining treatment depending on condition (lowest in case of dependence, highest for unconsciousness [42]

 - 31% desired no life-sustaining treatment if dying [42]

 - In the scenario of a permanent coma or severe dementia, homeless people are more likely to want CPR or mechanical ventilation than physicians [40]

Wishes for the dying process

 • A natural death (dying in sleep, no artificial medical interventions to prolong life, avoiding heroic measures such as prolonged life support without hope of functional recovery) [24, 33, 38]

 • Homeless people want to have their wishes represented when they become incompetent and/or dying [23, 39]

 • Dying peacefully, taking care of inner conflicts, being able to express love, apologizing to family and others [24]

 • Death without suffering [24]

Proxy decision-makers

 • A significant proportion of homeless people named a proxy decision-maker^a [41]

 • Nearly all chosen surrogate decision-makers were not related; most often they were service providers, friends or (occasionally) romantic partners [28]

 • 29% to 34% of homeless participants showed a (written) preference for surrogate decision-making [42]

 • 87% of homeless participants named a family member as a surrogate decision-maker in their completed advance directives [42]