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Culturally Acceptable Advance Care Planning and Advance Directives for Persons Experiencing Homelessness

Stone, Whitney BSN, RN; Mixer, Sandra J. PhD, RN, CTN-A; Mendola, Annette PhD

Journal of Hospice & Palliative Nursing: October 2019 - Volume 21 - Issue 5 - p 350–357
doi: 10.1097/NJH.0000000000000530
Ethics Series

Although the process of dying is a universal human experience, it often magnifies individuals’ unique cultural differences. Persons experiencing homelessness (PEHs) have unique barriers, challenges, and wishes for end-of-life care. There is insufficient evidence about how to provide culturally congruent advance care planning (ACP) through advance directive (AD) completion for PEHs. This study addressed this knowledge gap, and its findings serve as the basis for developing additional strategies to promote a satisfying ACP experience for this population when they complete an AD. The purpose of this study was to discover if an AD form recreated for PEHs would positively affect their completion of the AD as well as their overall experience with ACP. Guided by the culture care theory and qualitative ethnonursing methodology, 38 individuals (30 PEHs and 8 student nurses) were interviewed. Data were analyzed using the 4 phases of ethnonursing analysis. The 3 themes abstracted were (1) “it needs to be done,” (2) the presence or absence of trusted family support, and (3) ACP for PEHs is facilitated by an AD workshop. Nursing interventions based on study findings can be used to help promote a dignified, meaningful ACP experience for vulnerable populations.

Whitney Stone, BSN, RN, is staff nurse, Intensive Care Unit, East Tennessee Children’s Hospital. She was former honors student nurse at The University of Tennessee, Knoxville, College of Nursing.

Sandra J. Mixer, PhD, RN, CTN-A, is associate professor, College of Nursing, University of Tennessee, Knoxville.

Annette Mendola, PhD, is assistant professor and chief, Division of Clinical Ethics, University of Tennessee, Graduate School of Medicine, and The University of Tennessee Medical Center, Knoxville.

Funding was received from The University of Tennessee, Knoxville, Office of Undergraduate Research Undergraduate Summer Research Internship.

Address correspondence to Whitney Stone, BSN, RN, 8529 Knoll Pines Lane, Powell, TN 37849 (

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Online date: March 6, 2019

© 2019 by The Hospice and Palliative Nurses Association.