Recommendations for improving the end-of-life care system for homeless populations: A qualitative study of the views of Canadian health and social services professionals

McNeil, Ryan; Guirguis-Younger, Manal; Dilley, Laura B

doi:10.1186/1472-684x-11-14

Cited by 45 publications

(91 citation statements)

References 41 publications

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“…In addition to mental health issues, 62% have addictions to alcohol, and 58%, to other forms of drugs 1 . Homeless men have a life expectancy of only 42-52 years, and their mortality rate is 3-4 times the national average 1,2 . Given the high mortality rate in the population, it is not surprising that only 2%-28% of homeless individuals are elderly (65 years of age and older) 5 .…”

Section: Quantifying the Problem: Demographic And Epidemiologic Datamentioning

confidence: 99%

“…As previously noted, homeless individuals have a heavy disease burden and higher levels of psychiatric conditions and addictions; many are also chronic smokers 17 . Any attempt to envision a palliative care service that truly meets a patient-centred philosophy of care will require a re-exploration of known barriers to equitable service provision: exclusionary policies, poor continuity and episodic care, prohibitive low-threshold policies for behaviors and attitudes toward progressive harm-reduction strategies, and ineffective linkages between the various service agencies currently mandated to provide support to the homeless population 2 . In that light, addressing the adoption of harm reduction or identifying that the "street" itself should be added as a potential site for the delivery of palliative care services could be appropriate avenues of exploration to generate sustainable change.…”

Section: Moral Claims Of the Stakeholdersmentioning

confidence: 99%

“…Currently, the palliative care system continues to be challenged by suggestions of those middle-class underpinnings 18 . Similarly, many in the palliative care community champion death at home and provide services structured to limit access to homeless people (abstinence policies and so on) 2 , which is structurally a challenge for that population.…”

Section: Justice: When the Palliative Care System Is The Problemmentioning

confidence: 99%

“…Even in a developed country such as Canada, a person's housing status can predetermine not only the degree to which they are treated with respect and dignity, but also their access to basic health care services 1 . Regrettably, the word "homeless" has become both a negative descriptor and a stereotype in our society 2 .…”

Section: Introductionmentioning

confidence: 99%

“…The daily lived experience of many homeless individuals is filled with exposure to social discrimination, stigmatization, and poor access to support services and health care 1,2,18 . Many people who are homeless have developed an inherent distrust of most authority-based institutions, and the health care system is not an exception 5,17 .…”

Section: Impaired Trust and Individual Respectmentioning

confidence: 99%

See 4 more Smart Citations

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

et al. 2017

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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.

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Section: Quantifying the Problem: Demographic And Epidemiologic Datamentioning

confidence: 99%

Section: Moral Claims Of the Stakeholdersmentioning

confidence: 99%

Section: Justice: When the Palliative Care System Is The Problemmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Impaired Trust and Individual Respectmentioning

confidence: 99%

See 3 more Smart Citations

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

et al. 2017

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PROTOCOL: A comprehensive review of prioritized interventions to improve the health and wellbeing of persons with lived experience of homelessness

Pottie

Mathew

Mendonca

et al. 2019

Campbell Systematic Reviews

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Worldwide, over 1.8 billion people lack adequate housing and almost 25% of the world's urban population reside in informal accommodation (United Nations Human Rights Council, 2019). "People with a lived experience of homelessness" is a term coined to describe individuals who are, have been, or at risk of becoming homeless. This population lacks stable, permanent, appropriate housing, or may be without immediate prospect, means and ability to acquire it. Such physical living situations can include emergency shelters or provisional accommodations (Canadian Observatory on Homelessness, 2017). This population continues to grow, giving rise to a major international clinical and public health priority. Homelessness is strongly associated with high levels of morbidity (Hwang, Wilkins, Tjepkema, O'Campo, & Dunn, 2009) and mortality (Nordentoft & Wandall-Holm, 2003). People with lived experience of homelessness are at an increased risk for acute illnesses, such as traumatic injury

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The Effect of Advance Directive Completion on Hospital Care Among Chronically Homeless Persons: a Prospective Cohort Study

Leung

Luong

et al. 2016

J Urban Health

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Advance care planning is relevant for homeless individuals because they experience high rates of morbidity and mortality. The impact of advance directive interventions on hospital care of homeless individuals has not been studied. The objective of this study was to determine if homeless individuals who complete an advance directive through a shelter-based intervention are more likely to have information from their advance directive documented and used during subsequent hospitalizations. The advance directive included preferences for life-sustaining treatments, resuscitation, and substitute decision maker(s). A total of 205 homeless men from a homeless shelter for men in Toronto, Canada, were enrolled in the study and offered an opportunity to complete an advance directive with the guidance of a trained counselor from April to June 2013. One hundred and three participants chose to complete an advance directive, and 102 participants chose to not complete an advance directive. Participants were provided copies of their advance directives. In addition, advance directives were electronically stored, and hospitals within a 1.0-mile radius of the shelter were provided access to the database. A prospective cohort study was performed using chart reviews to ascertain the documentation, availability, and use of advance directives, end-of-life care preferences, and medical treatments during hospitalizations over a 1-year follow-up period (April 2013 to June 2014) after the shelter-based advance directive intervention. Chart reviewers were blinded as to whether participants had completed an advance directive. The primary outcome was documentation or use of an advance directive during any hospitalization. The secondary outcome was documentation of end-of-life care preferences, without reference to an advance directive, during any hospitalization. After unblinding, charts were studied to determine whether advance directives were available, hospital care was consistent with patient preferences as documented in advance directives, and hospital resource utilization during admission. During the 1-year follow-up period, 38 participants who completed an advance directive and 37 participants who did not complete an advance directive had at least one hospitalization (36.9 vs. 36.2 %, p = 0.93). Participants who completed an advance directive were significantly more likely to have documentation or use of an advance directive in hospital, compared to participants who did not complete an advance directive (9.7 vs. 2.9 %, p = 0.047). Without reference to an advance directive, documentation of end-of-life care preferences occurred in 30.1 vs. 30.4 % of participants, respectively (p = 0.96), most often due to documentation of code status. There were no significant differences in resource utilization between admitted patients who completed and did not complete an advance directive. In conclusion, homeless men who complete an advance directive through a shelter-based intervention are more likely to have their detailed care preferences document...

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Recommendations for improving the end-of-life care system for homeless populations: A qualitative study of the views of Canadian health and social services professionals

Cited by 45 publications

References 41 publications

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

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

PROTOCOL: A comprehensive review of prioritized interventions to improve the health and wellbeing of persons with lived experience of homelessness

The Effect of Advance Directive Completion on Hospital Care Among Chronically Homeless Persons: a Prospective Cohort Study

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