NEWS

What happens at the end?

BY HANNAH HERNER

The end of a year is a time to reflect on those lost. For those experiencing homelessness and poverty, end of life care can be fraught.

Death comes up more often than average for those experiencing homelessness. According to the National Coalition for the Homeless, the life expectancy for those experiencing homelessness is as low as 50 years old. In an informal count by Open Table Nashville, the city lost 166 people who had experienced homelessness in 2021.

For people experiencing homelessness, who often don’t get the medical care they need, they end up in the emergency room and into hospice for just a few days at the very end of life. Hospice is something that’s for people who have six months or less to live, not just mere days or weeks, says Alive Hospice social worker Shannon Ripani. When someone is in hospice care, they have their medical needs taken care of, so they have more opportunity to have quality time with family members, she adds.

“I feel like when people elect hospice, they sometimes struggle with — families or the patient —feeling like they've given up but it's really not about that,” Ripani says. “It's not failure to die. We're all gonna do it. And it can be very peaceful. There's a lot of joy and laughter, way more laughter and hospice than I ever expected. Like every visit, people are laughing about something, so that's a good thing.”

Jim Powers, head of Vanderbilt Geriatrics, says compared to other states, Tennessee ranks low in many areas around senior care, including 49th out of 50 in support for caregivers, but Tennessee’s Medicaid program, Tenncare, does provide for end of life care, which isn’t required.

Alive Hospice, the only nonprofit hospice in Middle Tennessee, and the only one with its own residential units, raises money to cover the gaps. The issue is, TennCare will cover hospice care, but often not room and board — which comes into play a lot with those who don’t have their own home.

Nationally, about 80 percent of hospice care takes place in the person’s home. Powers says when people experiencing homelessness need somewhere to receive such care, it can be a challenge to find a place to admit them. Nursing homes are even less likely to take in a person if they aren’t on government insurance. It tends to fall on private, faith-based organizations to take those who are homeless at the end of life, Powers says. He also works with the Veterans Affairs hospital in Murfreesboro, and says out of its 24-bed unit, at any given time about 10 percent of those staying there are homeless.

“Medicare generally thinks that those people are going to go home cared for by their family. That's why the homeless are particularly affected because they don't have a home to go to where they can get that care,” Powers says.

Social workers like Ripani help apply for insurance, and if there’s a family member involved, they can even complete that application posthumously. When no direction is given or there’s no money to pay for burial and services, the social worker will then apply for indigent burial, which is covered by state funds and takes place at The Hills of Calvary Memorial Park.

Even if there isn’t a lot of money involved, there are still ways to get affairs in order. Powers says when families get together for the holidays, it’s a good time to talk to loved ones about making such a plan. It’s a hard conversation to start, but an important one, Powers says. It's a reality that we’ll have to face eventually, and getting some directives on file can help ensure your wishes are honored.

There are three main documents to fill out. A living will, also known as an advance healthcare directive, indicates care preferences. He also recommends appointing a healthcare agent who is trusted to make medical decisions when the patient is no longer able to. And the third form is a portable directive or medical order which provides information to medical personnel regarding the patient’s wishes around resuscitation and intubation.

These are the kinds of documents that would be wise to keep on you at all times, Ripani says. But those documents can also be given to a doctor, or stored in an online cloud via mydirectives.com.

The pandemic has exacerbated the shortage of people taking care of our aging and dying populations. The job does not pay well and is hoping for its first raise in 14 years through the American Rescue Plan, Powers says. But a shortage has been real since the 1980s, and the Department of Health and Human Services has invested in workforce development programs since then. Vanderbilt is the site of one of them.

“We find that those who did accept that challenge, who do work with older adults find that it is one of the most gratifying areas of medical care, nurses, social workers, physical therapists, physicians as well. All across the board. And when you survey these trainees, they say ‘I just never knew I would like to so much,’” Powers says. “The gratefulness, the appreciation, the life stories you can hear the personalities are just incredible. And if you like people, you will like working with older adults.”

For those who don’t have anyone to sit with them as their life comes to a close — a volunteer will likely be filling that role. Alive has a roster of 400 volunteers.

“I've gotten to meet hundreds of patients that either don't have insurance or are low income, or have no income or lost their income when they got sick.” Ripani says. “It's been really eye opening. I just learned a lot in all those encounters. And it just makes me kind of sad, really, that those are the financial things that they have to focus on at the end of life… It's just a sad, sad thing. So I'm glad and honored to be able to help.”

The goal is to not let anyone die alone.