Palliative Care as a Public Health Issue: Understanding Disparities in Access to Palliative Care for the Homeless Population Living in Toronto, Based on a Policy Analysis

Abstract

Even in a developed country such as Canada, there are disparities in just access to adequate health care-and, more specifically, palliative care. That inequality is most notable in an underserved group such as the homeless population. Even the word "homeless" has become both a negative descriptor and a stereotype in our society. We posit that the provision of hospice palliative care is structured on several problematic assumptions: an expectation that patients will have an informal support network (family and friends), a stable and secure residence, a predictive terminal illness trajectory, and reasonable access to health care. Those assumptions create structural inequality within the system.Homeless individuals have considerable experience with death and dying, and qualitative research has shown them to hold the expectation that their death will be both sudden and violent. Here, we look at the current data concerning known disparities in access to good palliative care services experienced by the homeless population, based on a stakeholder analysis of the available literature. That information, coupled with the use of a public health ethics decision-making tool, such as the Good Decision Making in Real Time framework, is used to explore the common ethics challenges that can arise in public health interventions aimed at the provision of end-of-life care to homeless adults. A broad exploration of the system that underlies our care is critical to the proper and appropriate provision of care for homeless individuals.

Experiences of Palliative Health Care for Homeless and Vulnerably Housed Individuals

“…This recommendation is also consistent with the literature. 10,25 Data in this study outlines services often used by clients, which could inform locations for outreach as well as targets for education and intervention around palliative care for people experiencing homelessness.…”

Palliative care and public health: an asymmetrical relationship?

“…This would mean a genuine acceptance of the complex nature of the association 91 and the possibility of divergent or even conflicting perspectives within public health. It would also involve some classification and accommodation, for example, between those who advocate for a public health approach to palliative care service development within the wider health and social care system, compared to those who see the public health approach through a much wider lens incorporating multi-faceted actions and perspectives, as well as community and lay viewpoints.…”

Bearing Witness: Exploring the End-of-Life Needs of Homeless Persons and Barriers to Appropriate Care

“…Several papers discussed homeless persons’ lack of trust in health providers (Cagle, 2009; Collier, 2011; Davis et al., 2011; Hakanson et al., 2016; B. Henry, Dosani, Huynh, & Amirault, 2017; Ko & Nelson-Becker, 2014; Krakowsky et al., 2012; Lewis, DiGiacomo, Currow, & Davidson, 2011; McNeil & Guirguis-Younger, 2012; Shulman et al., 2018; Song, Bartels, et al., 2007; Tarzian et al., 2005; Webb et al., 2018) primarily as a result of past experiences with, or internalized, stigma and discrimination. Some papers also cited lack of awareness of or misconceptions about hospice (Hindmarch, 2012; Lewis et al., 2011) as possible barriers to accessing appropriate end-of-life care.…”

“…Barriers related to negative attitudes and behaviors of health providers toward homeless persons were reported in several papers (Davis et al., 2011; Davis-Berman, 2016; B. Henry et al., 2017; Ko & Nelson-Becker, 2014; Lewis et al., 2011; NHS Improving Quality, 2014; Nyatanga, 2012; Song, Bartels, et al., 2007; Webb, 2015; Webb et al., 2018). According to Cagle (2009), health professionals may hold tacit stigmatizing beliefs about homeless persons that may impede access to appropriate end-of-life care.…”