Harm reduction services as a point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs: a qualitative analysis

Abstract

BackgroundHomeless and marginally housed persons who use alcohol and/or illicit drugs often have end-of-life care needs that go unmet due to barriers that they face to accessing end-of-life care services. Many homeless and marginally housed persons who use these substances must therefore rely upon alternate sources of end-of-life care and support. This article explores the role of harm reduction services in end-of-life care services delivery to homeless and marginally housed persons who use alcohol and/or illicit drugs.MethodsA qualitative case study design was used to explore end-of-life care services delivery to homeless and marginally housed persons in six Canadian cities. A key objective was to explore the role of harm reduction services. 54 health and social services professionals participated in semi-structured qualitative interviews. All participants reported that they provided care and support to this population at end-of-life.ResultsHarm reduction services (e.g., syringe exchange programs, managed alcohol programs, etc.) were identified as a critical point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs. Where possible, harm reduction services facilitated referrals to end-of-life care services for this population. Harm reduction services also provided end-of-life care and support when members of this population were unable or unwilling to access end-of-life care services, thereby improving quality-of-life and increasing self-determination regarding place-of-death.ConclusionsWhile partnerships between harm reduction programs and end-of-life care services are identified as one way to improve access, it is noted that more comprehensive harm reduction services might be needed in end-of-life care settings if they are to engage this underserved population.

Homelessness & Health in Canada

“…Specifically, the Ottawa Mission Hospice identified a need to combine compassionate palliation and harm reduction strategies (i.e., providing managed alcohol consumption services, providing harm reduction paraphernalia and allowing off-site illicit drug use) and situate this service within a larger network of homeless health care services. Participants believed that this was necessary to facilitate access to services and ensure continuity of care, echoing the findings of other studies emphasizing the important role that public health services should play in palliative care services delivery to underserved populations (McNeil et al 2012b;McNeil, Guirguis-Younger, Dilley 2012a).…”

“…Previous research has noted that the palliative care system has largely been developed in accordance with a series of assumptions (i.e., that prospective clients are housed, supported by caregivers and, in many cases, have the financial resources to pay for supplementary care) that do not reflect the circumstances of homeless populations (Cagle 2009;McNeil, Guirguis-Younger and Dilley 2012a;McNeil et al 2012b). 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).…”

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).…”

“…Despite a lack of date parameter, no eligible studies published before 2005 were identified. As outlined in Table 1 semi-structured interviews [9, 32–38, 41] and focus groups [39, 40, 42] were the most common methods of data collection.…”

“…: perspectives of homeless older adultsUSA19Homeless people (aged 60+)Semi structured individual interviewsGrounded theoryA good death1) Dying peacefully2) Not suffering3) Experiencing spiritual connection4) Making amends with significant others.A bad death1) Experiencing death by accident or violence2) Prolonging life with life supports3) Becoming dependent while entering a dying trajectory4) Dying alone28/29[30]Ko & Nelson-Becker (2014)Does end-of-life decision making matter? Perspectives of older homeless adultsUSA21Homeless people (aged 60+)Semi structured individual interviewsGrounded theory1) EOL topic is uncomfortable2) God plans EoLC3) Physicians are preferred as decision makers4) EoLC is not a priority5) need for sensitivity28/30[39]Davis – Berhman (2016)Serious Illness and End-of-Life Care in the Homeless: Examining a ServiceSystem and a Call for Action for Social WorkUSA14Homeless people, hostel staff, outreach staff and health and social care professionalsInterviewsGrounded theoryLack of services for serious, chronicand life threatening illness,Barriers to access to servicesStigma,End-of-life care.24[6]Hakanson et al (2015)Providing palliative care in a Swedish support home for people who are homelessSweden12Hostel staffGroup and individual discussionsInterpretive description1) Conditional factors framing palliative care2) Building trustful- family like relationships3) Re-dignifying the person4) Re-defining flexible and pragmatic care solutions33/34[38]Webb (2015)When dying at home is not an option: Exploration of hostel staff views on palliative care for homeless peopleUK7Hostel staffSemi structured individual interviewsFour stage phenomenological method1) Understanding of palliative care2) Working with limited medical information3) Taking responsibility4) Building rapport5) Upholding residents dignity6) Recognising physical deterioration7) Managing environmental challenges8) Role limitations and support needs of hostel staff26/28[33]McNeil & Guirguis-Younger (2011)Illicit drug use as a challenge to the delivery of end-of-life care services to homeless persons who use illicit drugs: Perceptions of health and social care professionalsCanada50Canadian Health care professionals and hostel workersSemi structured individual interviewsGrounded theoryBarriers to EoLC services:1) Competing priorities2) Lack of trust of healthcare providers3) Exclusio...…”