Consent, dementia, and surrogate decision-making: Ethical challenges in the context of homeless health care

Like all other patients, homeless patients can develop dementia or other conditions that limit their ability to provide informed consent for shared medical decision-making. However, many homeless patients have lost contact with family or close friends and can have difficulty appointing a surrogate decision maker if needed. This interactive workshop will use the case of an 85-year-old male from Puerto Rico with advanced dementia and likely rectal cancer to address issues of consent and surrogate decision-making in the context of health care for homeless persons. The workshop will incorporate a series of small-group discussions to promote participant engagement in an iterative analysis of emerging issues as the case unfolds. Brief didactic summations of key points will be provided to highlight ethical principles and core concepts arising in the context of health care for persons experiencing homelessness. The workshop will be led by a team of clinicians active in homeless health care, including a medicine-pediatrics physician, a family medicine physician, and a clinical social worker. This team also brings additional training in bioethics, public health, and law. The case will be presented in three segments with each segment addressing a different ethical concern. After each segment, the workshop participants will be divided into small groups to discuss the ethical concerns raised during that segment for 15-20 minutes. The group will then reconvene to discuss how the general principles of ethics apply to the questions raised by the case. The goal of this workshop is to help practitioners working with patients experiencing homelessness who lack capacity for aspects of medical decision making understand how to ethically and legally provide care for these patients who need special assistance.