On Lok, The Gold Standard for End-of-Life Care

On Lok's 30th Street Senior Center in San Francisco

On Lok Senior Health Services started in 1971 in San Francisco Chinatown by a group of Chinese elders who wanted an alternative to nursing homes. The founders believed that traditional models of care were not adequately meeting the needs of the elderly. Today, the majority of On Lok’s seniors are low-income Chinese and Latinos living in three Bay Area counties. On Lok provides low-income frail seniors with comprehensive services that allow them to stay at home. These services include home visits and clinical care, meal deliveries, transportation, and adult day care.

Dr. Alana Shpal, primary care physician at On Lok

“Even though it’s taboo, I usually say ‘I’m your doctor and this is my job and I need to know what you want or what you don’t want,’ ” said Dr. Alana Shpal, a primary care physician at On Lok in San Francisco. “And I also bring up that if we don’t discuss this now, it’ll put their family in a harder place later on and that often helps because they see their family struggling to make a decision and they don’t want to be a burden.” She added, “I remind them that telling me is a gift they’re giving their family members.”

Shpal, who mostly works with Spanish-speaking patients, says conversing with them can often be challenging, especially if cultural norms prohibit patient autonomy and discussing death.

But thanks to the efforts of Shpal and other staff members, almost all of On Lok’s participants have completed advance directives. “It’s a crusade of mine, to have everyone document their end-of-life preferences,” said Shpal.

On Lok currently serves over 1,500 frail elders and, at the end of life, provides seniors with comfort care similar to hospice. On Lok’s innovative program has now been replicated in thirty states. The goal is helping seniors age in place and live independent, active lives until the end.

Hope for the Future

Dr. Julie Thai,
medical school graduate

Julie Thai and her mother are still recovering from the shock of her grandfather’s painful and protracted death. Thai is encouraging her parents to plan for the end of their lives and complete their advance directives, to avoid repeating the mistakes of her grandfather. She recently asked her mother about how she wants to die. “She’s pretty comfortable talking about it,” said Thai, “She says ‘Just let me go.’ ”

Following the death of her grandfather, Thai graduated from medical school. She’s now a doctor in Flint, Michigan, specializing in family medicine and geriatrics and is trained to help seniors plan for the end of their lives. By having open, honest conversations, Thai hopes to honor her patients’ wishes. In particular, she wants to reach out to patients bound by culture who can’t talk openly about death. Efforts like Thai’s could have a big impact some day on reducing racial disparities in end-of-life care.


This is one in a two-part series examining racial disparities in accessing comfort care at the end of life.

JoAnn Mar’s two-part report was produced as a project for the USC Annenberg Center for Health Journalism’s 2018 California Fellowship.

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