Introduction
Thousands of homeless Canadians are suffering unnecessarily each year because they lack access to palliative end of life care. In Canada, the number of hospital admissions and A&E visits are reported to be three times higher for homeless people compared to other citizens (Canadian Hospice Palliative Care Association, 2013). Challenges to access of healthcare services among the homeless population are varied and multifaceted. Like many countries in the United States, Canada is a developed country with a stable healthcare system, however, there are disparities in just access to healthcare. The inequality is most notable in undeserved group such as the homeless population (Pineau, 2015). New policies such as palliative care need to be implemented to allocate resources more effectively and to maintain the quality of the healthcare system. Palliative care is a fundamental resource for homeless people in Canada because most of them do not have insurance cover. However, lack of palliative end of care for homeless people in Canada makes many hospices to refuse caring people without a permanent address. Most homeless shelters in Canada do not have equipment or skills to care for homeless individuals. According to Pineau, (2015) lack of palliative care leads to upstream health services which ultimately place a huge burden on the healthcare system, take away resources from others, and augment healthcare cost. Therefore, new policies such as provision of palliative care to undeserved population should be made that brings palliative care to homeless individuals in Canada to ensure equity in provision of healthcare in the country. (Canadian Hospice Palliative Care Association, 2013).
Palliative and end-of-life care services continue to be in great demand with increasing Canada’s aging population of about 35% and as the rates of terminal and chronic diseases rise (Crane & Joly, 2014, p.258). However, palliative care services such as shelter based and mobile programs are being provided to homeless population in Canada with an ultimate goal of address health needs of sick and aged individuals (Crane & Joly, 2014, p.259). The shelter-based program usually provided by the Canadian Alliance to End Homeless involves the use of hostels and shelters provided by medical staff and organizations to cater for these patients (Crane & Joly, 2014, p.259). Mobile programs are rare due to inadequate facilities. However, these programs are convenient because they can reach people irrespective of the location. They have been used to provide care to patients who may be housed in the streets. This paper seeks to discuss lack of palliative end of life care for individuals experiencing homelessness in Canada.
Literature Analysis of Lack Palliative End of Life Care
Thousands of Canadian homeless citizens are suffering unnecessarily every due to lack of palliative care which prompts the government to consider end-of-life care as a priority in a new federal, provincial accord. There are disparities in access of palliative care in Canada. A person’s housing in Canada can not only predetermine access to basic healthcare services but also the degree to which they are treated. According to Morgan, (2016), about 16%-30% receive palliative care near the end of the life. However, reluctance of patient to be referred, lack of resources to refer to, and program eligibility criteria will continue to create barriers to implementing palliative care in Canadian healthcare system (Morgan, 2016).
In Canada, palliative end of care is being provided in the last days of life, but majorly to cancer patients. Therefore, there has been a clear call by the underserved population for the implementation of palliative care alongside accessible healthcare services for homeless people (Argintaru et al.2013, p.577). The lack of palliative end of life care among homeless population significantly impacts the health status of these individuals. About 70% of the homeless population lose their lives due to lack of palliative care and this decreases their life span. Lack of palliative care implies that a lot of effort has to be put in ensuring that the palliative end of life care meets the expectations of these patients. The Canadian Homeless Research Network (CHRN) advocates that a big percentage of homeless population should be receiving palliative care in the hospitals and at homes (Fazel, Geddes, & Kushel 2014). The provincial government is being criticized by CHRN for little funding for the palliative funding as well as general support for the program. The situation is further affirmed by the fact that only a small fraction of the Canadian provinces have put up palliative care as critical service the under their provincial health plan which further contributes to lack of palliative care among the homeless population(Fazel, Geddes, & Kushel 2014). However, the Canadian government has put in place strategies to address lack of palliative care among homeless population (Hudson et al. 2016). Hudson et al. (2016) states that the federal government donated $3million in 2014. This money was as used to finance research study and create a framework of integrative community models of the palliative care hospices. The initiative did come up with two documents namely, The Way Forward National Framework and the Palliative Care in the Community (Hudson et al. 2016).
The government also introduced advanced care planning to address lack of palliative care among the homeless population. The care planning strategy involves a health profession engaging in the plan for making health care decisions in case the patient is unable to make an informed decision regarding his or her health condition (Morgan, 2016). The healthcare professionals involved in the advanced care planning include physicians, nurses and other healthcare providers involved in direct care of patients. Such cases have been witnessed in advanced serious illness. The government has also rolled out awareness programs to emancipate the public on the value of supporting the palliative end of life care facilities. The CHPCA hosts the National Hospice Palliative Care Week in the first week of May of each year to raise funds for supporting the program. The themes of this event are extracted from the World Hospice Palliative Care theme. The sole mandate of CHPCA is to create an awareness campaign for informal caregivers among the homeless population. This was an awareness campaign that was launched in 2012 (Morgan, 2016). One of the partnerships involved in the launch cared homeless while the rest provided end of life care to the homeless patients.
Palliative care programs in Canada are created to solve the needs of mainstream society. While these systems attempt to accommodate every individual in Canada, the unique challenges of serving underserved populations make this difficult. Perhaps, it is believed that the most challenging population to assist is the homeless. Jaworsky et al. (2016) argue that the homeless population need support more than most of others. However, it is challenging to take the values of palliative healthcare and apply them in to the homeless population. Since most of the palliative services are provided in the hospitals, the homeless are unlikely to benefit from them. According to Jaworsky et al. (2016) the homeless fear that they will be treated harshly by hospital staff and misunderstood by other patients. The author also states that most healthcare providers for the homeless are ill-equipped to take care for the homeless people and this prompts the high demand for palliative care services for this population. No matter the location, most provision of palliative care services to the homeless people in Canada is fraught with challenges (Jaworsky et al. 2016).
How Lack of Palliative Care among homeless Population can be addressed
In the shelter-based program, organizations and medical staff with hostels and shelter providers can take the initiative to provide palliative care. This program is very instrumental and cost-effective in the provision of palliative among the homeless population. The model helps in reducing pain and providing comfort to homeless individuals. Research in 2015 reveals that $ 1.39 million was saved since the commencement of patient care in hospices in comparison with other locations (Mundt-Leach, 2016). The disadvantages of the shelter-based programs are that there is usually conflicts between the health professionals and the shelter providers. There is also an enormous burden of work placed on the staff managing the shelter. The problem of unpaid overtime and emotional stress cannot be underestimated.
Mobile based programs are rare due to limited resources but is more convenient and flexible because they can reach all residents irrespective of the locations. The program targets the homeless individuals who take their shelter in the streets. A perfect example is that of Toronto, PEACH (Palliative Education and Care for the Homeless). This program in Toronto gives homeless patients the dignity of alleviating their ill health conditions. It is noted that both mobile-based and shelter-based programs are accessible to the urban population and in much smaller supplies in rural or remote areas (Morgan, 2016, p.36).
Impact of Lack of Palliative End of Life Care on the Client and Family
The effects of lack of palliative care are far reaching with most concern being an increased rate of depression and continued suffering among homeless patients and their families. Coping with death of a loved one can be a challenging experience for the family members (Webb, 2016). Complicated grief is identified by disinterest in personal activities, distressing yearnings, preoccupied with thoughts of the deceased, and symptoms of intrusive thoughts. Lack of palliative care services leads to increased pain symptoms, and poor patient satisfaction with care as well as increased costs of treatment. Furthermore, lack palliative care may decrease a patient survival besides affecting mood and quality of life (Webb, 2016).
Lack of palliative care services has significant impacts to family members as well. For instance, poor communication creates a barrier between the family members and healthcare providers. Poor communication prompts a risk factor for depression and post traumatic disorder in patient’s family members post death. Experiencing a loved one’s death can distressing. Qualitative research has shown that family members of those who die in their homes due to lack of palliative care services have increased risk for poorer mental health, bereavement outcomes and quality of life compared to those whose loved ones dies in hospice care (Tobey et al. 2017, 738). Other impacts on family members resulting from lack of palliative care services include financial difficulties associated with medical expenses, absenteeism from work to stay with their sick loved one as well as lack of information.
Impact of Lack of Palliative End of Life Care in the Nursing Profession
Nurses are likely to encounter ethical dilemma resulting from the need to care for homeless patients who are in need of palliative end of life care. Ethical dilemmas subject nurses and other members of healthcare staff in complex situations. These professionals are faced with contradicting situations that are to be met at the same time. For instance, homeless patients may lack legal access to palliative end of life care services. In a palliative care setting, it becomes more controversial because the homeless patient may be in the final trajectory of illness and facing death. The homeless patient can be denied access to palliative end of services on the basis of temporary home addresses and other restrictions which have been implemented by the government.
During their clinical practice nurses usually find themselves at the center of conflict involving patients, family members and other members of the staff on the use of palliative care services. Nurses may be forced to continue aggressive provision of care deemed futile thus denying the patient the benefits of palliative care. According to Sumalinog et al. (2017) nurses constantly consider palliative care as an area of practice where they spend more time with patients and their families. It has been argued that lack of palliative care does not allow nurses to do real nursing (Tobey et al. 2017, 739).
Evidence-based nursing strategies used to address lack of palliative care among homeless individuals
Shelter-based Programs
New policies have been developed that bring palliative care to the homeless. For instance the Ottawa Inner City Health Project reported that embracing a shelter-based palliative care model would realize a daily healthy cost of $165 instead of $675 for tertiary hospital care and $687 for traditional palliative care (Crane, & Joly, 2014). For the last two decades, numerous interventions and strategies to solve homelessness have emerged. While each intervention model is aimed towards transitioning people out of homelessness and providing palliative care, different approaches are informed by different theoretical frameworks (Sumalinog et al. 2017). Some of the current models used to address the issue of lack of palliative care among homeless population include shelters and housing first.
The housing first strategy perceives housing as an important intervention to lack of palliative end of life care while the treatment first model views it as a desirable outcome among the homeless population. There are studies which associate treatment first model with increased treatment compliance of palliative services, however, there exists a considerable body of research showing a greater efficacy with the housing first strategy (Pineau, 2015). For instance, the housing first model has been associated with a reduced prevalence of stress symptoms among the homeless population in Canada. Besides, the housing first model has been linked with housing stability and higher retention rates for disorders associated with age especially among the homeless population. One study on the effectiveness of housing first model confirmed that the approach is effective in reducing consumption among homeless persons with substance use disorders (Pineau, 2015). Also, studies have suggested that the housing first model more suitable for the homeless population.
Shelter and Hospice
Shelter and hospices for the homeless population correspond with the patient’s dignity and humanity. Crane & Joly, (2014) propose that in order to ensure that humanity and dignity of a patient is upheld, there need to be health facilities, sleeping and personal hygiene facilities, a chapel, laundry, and a welcoming a conducive environment with dignity and privacy. Shelters play a significant role in alleviating homeless and form essential transitional spaces because they facilitate interactions between homeless population and resources. In 2010, the number of registered shelters in Canada was 1128 most of which were collected in large urban centers (Sumalinog et al. 2017). These roles were categorized into the following: specialized services for women and children, services enhancing self-sufficiency, treatment services, and services meeting basic needs. Shelters have a significant potential to help the transition of individuals out of homelessness. However, shelters have recently been criticized for not addressing lack of palliative care among homeless individuals. Sumalinog et al. (2017) argue that the current models have changed and became more like long-term solutions to homelessness and less transitional spaces.
Implementation of End-of-life Care Services
The Canada Health Act (CHA) has expanded its definition for “medical necessities” to include end-of care services. Death is a common phenomenon and therefore every individual should have access to end-of-life care services that help them through this experience. The CHA strives to ensure that palliative care services are administered according to its five principles. The facilities which comply to these regulations benefit from federal contributions. Besides, palliative care has been integrated within the whole health system in Canada to increase access to services, ensure downward substitution, use resources more efficiently, reduce cost, and promote continuity of care (Canadian Hospice Palliative Care Association, 2013).
Funding for Palliative care Programs
Palliative care programs such as The Hospice have been established to provide palliative to underserved population such as the homeless in Canada. These programs use their savings and aides from the government to fund their activities. Besides, the earmarked taxes have been to fund this program and this protects it from the federal government who wish to reallocate budget expenditures.
Conclusion
Thousands of homeless Canadians are suffering unnecessarily each year because they lack access to palliative end of life care. Homeless people in Canada are faced with complex and unique advanced ill health conditions due to lack of palliative end of life care services. Flexible services are therefore important in promoting coordinated and compassionate care among this population. Provision of the palliative end of life care for homeless population requires a joint approach from social, housing, and health services. At a minimum, this should include support from all professional groups, provision of treatment and housing models and greater training, as well as increased collaboration between services. Palliative and end-of-life care services continue to be more in demand with increasing Canada’s aging population and as the rates of terminal and chronic illness rise. Provision of palliative end-of-life care is faced with different barriers such as lack of sufficient access to medical professionals and negative experiences in healthcare by homeless population. Individuals experiencing homeless can get palliative care based on where they are located in various ways such as shelter-based programs and mobile programs.
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