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Seven ways to provide better care to homeless individuals at end-of-life

Toronto, December 23, 2013

By Naheed Dosani

Naheed Dosani
Naheed Dosani, Palliative Medicine Fellow, Department of Family and Community Medicine, University of Toronto

At the end of November, the Good Neighbours Club hosted an event that brought together more than 50 stakeholders who work with homeless people to focus on future directions for palliative care for Toronto's homeless population.

As a palliative care fellow, it was an inspiring day for me because, as many stakeholders in the city have noted, much more thought is required to figure out the ways to best serve this population, especially since currently existing frameworks do not seem to be meeting their needs. As Dr. Bruno Scorsone, executive director of the Good Neighbours Club, said, “The system is not there yet to care for homeless individuals at end-of-life."

Dr. Stephen Hwang presented some unsettling numbers:

  • There are about 5,200 homeless in Toronto, with around 450 who sleep in our city’s streets
  • The average duration of homelessness among these individuals is three years
  • 10 per cent of Toronto's homeless are over the age of 60
  • For every homeless individual in Toronto's shelter system, there are 23 who are vulnerably housed
  • Homeless individuals are nearly twice as likely to die of cancer and 3.7 times more likely to die of cirrhosis than the average person

So, how can we – health care providers whose inner city patient populations often include homeless individuals at end-of-life – provide better and more compassionate care to these folks?

We spent the afternoon discussing the seven best practices for end-of-life care for homeless and marginalized individuals, recently developed by social worker Kailee MacDonald, Sabastian Glass and David Bruce from the Good Neighbours Club:

  1. Maintain flexible eligibility and admission criteria to meet the unique and complex needs of this population. They already face a ton of barriers – including mental health and addiction issues, limited social support, housing instability, transient lifestyle and lack of proper personal ID – let’s be a little more flexible in helping them access health care services.

  2. Offer consistent and continuous case management which would ensure comprehensive discharge planning, follow-up care and communication amongst professionals – essential components for providing continuity of care.

  3. Maximize flexibility of program policies. Basically, homeless and marginalized persons are likely to develop irregular or unhealthy coping mechanisms to deal with the stress of their daily uncertainties (e.g. alcohol and/or drug use, gambling). Providing there is no risk to others, can we be a little more flexible towards what would ordinarily be excluded behaviours (e.g. smoking, recreational drug use, etc.)?

  4. Foster peer-support networks. The most common fear around dying is that of dying alone: community building at this critical stage of life is an effective means of bridging meaningfulness to the process of dying. We need to encourage socialization through congregate dining, recreation, collective decision making and communal expressions of celebration and grief.

  5. Employ diverse and holistic care models to address a heightened need for philosophical and spiritual reflection as people look for comfort in their final days.

  6. Prioritize client dignity. Most homeless and marginalized persons have had families of their own, gainful employment, respectable positions in the community, and have been forced into marginalization through mental illness, job loss, breakdown of family circumstances, poor physical health, amongst others. Let’s remind ourselves to acknowledge the full dignity of the person beyond the stigma of their marginalization.

  7. Provide palliative care within intensive supportive housing so that a patient’s designation can be changed without the disruption of physical relocation. Rooms or beds could be designated as supportive/respite or palliative based on their occupancy rather than their location.

The infrastructure required to support such a system may not be there yet, but these seven best practices sure are a great place to start.

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.