Dying on the streets

U professors gather homeless people's thoughts on death and dying

In 1997, there were approximately 15,000 homeless people in Minnesota; by 2003, the number had risen to over 20,000.

by Kristi Goldade

July 24, 2007

"I've had a lot of tragedy. My girlfriend died in my arms with my baby."

"Me? I'd just like to be remembered by somebody."

"The only thing I'm worried about is that I don't want to die on the streets."

"...They'll throw you in a pauper's grave someplace and nobody's going to mourn you."

Listen to them. Hear the concerns of the homeless, the disenfranchised, the hopeless. These voices come from people around the Twin Cities included in a study by the Center for Bioethics called Dying on the streets: homeless persons' concerns and desires about end of life care. Researchers John Song, Edward Ratner, and Dianne Bartels combined their experience in ethics, clinical work, and end of life issues to answer questions such as, "What do homeless people think about the end of life?" and "What barriers to a dignified death do they face?"

The investigators began their study by first speaking with people at shelters and meal programs, and then by hosting a community-wide meeting of service providers, end-of-life care professionals, and homeless people. They wanted to see if death indeed was an issue that this community wanted addressed. The groups responded vigorously. Yes, they all agreed, this was an issue, and one that especially needed attention from the medical community.

Homeless people suffer disproportionately high rates of illness and death, and the National Institute of Health (NIH) funded the study to explore further this public health crisis. The average age of death for a homeless person is 40, often due to lack of basic human needs such as food and shelter. And the prevalence of homelessness is growing. In 1997, there were approximately 15,000 homeless people in Minnesota; by 2003, the number had risen to over 20,000.

Song, Ratner, and Bartels carried out the study as a series of interviews at several homeless programs. They asked about health, what makes a good death, about trusting family and friends, service providers and social workers, and, perhaps most importantly, how the problem might be amended.

The average age of death for a homeless person is 40, often due to lack of basic human needs such as food and shelter.

The results were surprising. Because homeless people are faced with death more often than the average citizen--due to lack of health care, exposure to the elements, and a daily struggle to survive--they voice unique concerns.

They fear not being found or recognized, and dying anonymously without any memorial. They favor advance care planning like appointing surrogate decision-makers and creating living wills. And they note barriers to respectful care among the very poor and estranged.

"They think because we live on the streets, we're all junkies that don't feel no pain," one person said.

They also echoed many people's concerns when facing the end of their life: not wishing to be a burden, wanting to avoid "heroic measures" like life support, and needing to reconnect with family members.

So, how can we, the public, be sensitive to this issue?

Ratner suggests "recognizing that there are significant numbers of homeless people, even in the winter. This is a real problem with real people. The public must overcome the presumption that all homeless people are lazy, dangerous, or mentally impaired." Of homeless people involved in a one-day study by the Wilder Center, 26 percent were full-time workers.

Simple acts, like the promise of a memorial service, provided much comfort. The Minnesota Coalition for the Homeless annually hosts a memorial, march, and vigil on December 21, the national Homeless Person's Memorial Day to honor those who have died during the year.

Ratner, Bartels, and Song are testing a written tool to aid the elderly in end-of-life issues. "The importance of our research extends beyond issues of the homeless," says Ratner. "We are trying to understand attitudes and issues among the disadvantaged, and especially, the estranged. Looking at extreme examples helps us to understand end-of-life care for broader populations."

Visit the Web site of the Minnesota Coalition for the Homeless.