Illicit drug use as a challenge to the delivery of end-of-life care services to homeless persons: Perceptions of health and social services professionals

Abstract

Homeless persons tend to die younger than the housed population and have complex, often unmet, end-of-life care needs. High levels of illicit drug use among this population are a particular challenge for health and social services professionals involved in end-of-life care services delivery. This article explores the challenges of end-of-life care services to homeless illicit drug users based on data collected during a national study on end-of-life care services delivery to homeless persons in Canada. The authors conducted qualitative interviews with 50 health and social services professionals involved in health services delivery to homeless persons in five cities. Interviews were transcribed verbatim and analysed thematically. Themes were organised into two domains. First, barriers preventing homeless illicit drug users from accessing end-of-life care services, such as competing priorities (e.g. withdrawal management), lack of trust in healthcare providers and discrimination. Second, challenges to end-of-life care services delivery to this population in health and social care settings, including non-disclosure of illicit drug use, pain and symptom management, interruptions in care, and lack of experience with addictions. The authors identify a need for increased research on the role of harm reduction in end-of-life care settings to address these challenges.

Achieving Drug and Alcohol Abstinence Among Recently Incarcerated Homeless Women

“…Among homeless parolees, multiple challenges with mental health issues, substance use addiction, unemployment, and unstable housing conditions impact successful re-entry (Binswanger et al, 2011). Illicit drug use is a contributing factor to incarceration as well as homelessness (McNeil & Guirguis-Younger, 2012; Tsai, Kasprow, & Rosenheck, 2013). However, recently released offenders continue to have unmanaged drug issues, with probationers and/or parolees affected four to nine times higher when compared to their non-supervised counterparts (Fearn et al, 2016).…”

Challenges to access and provision of palliative care for people who are homeless: a systematic review of qualitative research

“…No additional studies were found through contacting authors of eligible studies. The study by Neil et al [36–38] was reported in more than one paper focusing on different aspects of the data, as was the study by Ko et al [32, 33] and also by Song et al [39, 40]. No studies were excluded following quality assessment because none were found to be of very poor standard (Table 3 of Appendix 1).…”

“…Often shaped by discrimination, disrespect [6] and disempowerment [42]. As a result, expectations and conceptualisation of health care, including of palliative care, described by homeless people appear different to those perhaps commonly shared by the housed population [6, 33, 34, 36, 40]. This contributes to the difficulty homeless people had in trusting or engaging with health and social services [6, 9, 34–37, 39] as outlined in the quote below:

“There is a lot of shame….low self-esteem, horrific histories of trauma and abuse, mistrust of caregivers.

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Homelessness & Health in Canada

“…Furthermore, while homeless populations have high levels of alcohol and/or illicit drug use, palliative care services typically operate under abstinence-only policies that constrain access to care (McNeil and Guirguis-Younger 2012). Accordingly, homeless persons are typically unable to access much needed care at the end of life, often dying alone and unsupported .…”

“…Recently, Canadian researchers have advanced a definition of homelessness that recognizes this diversity by situating homelessness along a continuum of living arrangements, including: (1) living outside or in places not fit forin-patient care (Hwang et al 2011;Palepu et al 1999), they frequently have unmet health needs due to the barriers that they face to accessing care and adhering to treatment (Hwang et al 2010;Khandor et al 2011;McNeil and Guirguis-Younger 2012). The reasons for this are complex and, to a great extent, largely the product of the challenges experienced by homeless persons.…”