Reaching out to Ray: delivering palliative care services to a homeless person in Melbourne, Australia

Abstract

Most terminally ill people express a preference for dying at home. Within established models of palliative care, achieving death at home is a particular challenge for homeless people. This paper describes a quality-improvement project undertaken by a community-based palliative care service in Melbourne, Australia, to understand homeless people's palliative care needs and the challenges that workers face. Six semi-structured interviews with workers in hospital and community-based settings were undertaken and a case study documented. The results were used to initiate discussion about how policy and protocols for the community-based palliative care service might serve this population more effectively. The findings confirmed that homeless people have complex psychosocial and medical needs. They may be periodically uncontactable or living in unsafe settings, experience isolation from social support networks, and have issues of compliance with treatment protocols exacerbated by mental health problems and/or substance abuse. Service providers had particular challenges in meeting the palliative care needs of homeless people. A flexible, compassionate, and coordinated response is required, and more work is needed to explore how the needs of this particular group can be met.

Challenges to access and provision of palliative care for people who are homeless: a systematic review of qualitative research

“…This is less likely to be possible for homeless people [6, 32–35, 39–41]: “It makes a difference when you’re homeless and you’re dying…You’re here by yourself…” Homeless person [40] …”

“…Perhaps as a result, avoidance of thinking or talking about death and dying was common, which acts as a barrier to the establishment of palliative discussions [6, 33, 35–37, 39, 40, 42].

“Everybody wants to live you know ….I find if I dwell on it, it gets depressing … I get depressed enough you know” – Homeless person [33]

…”

“…From the review it was clear that homeless people often generally avoided health care facilities, and crisis presentations of complex symptoms directly to emergency services were common [35]: “People who are living on the street…it’s much harder to access them. They don’t come to us and they don’t go anywhere for help until they’re so sick that they’re picked up by an ambulance” – Health care professional …”

“…Being unable to store or administer medication (particularly opioids) safely in a hostel environment may in itself necessitate transfer to hospital [35], which a homeless person may prefer to avoid [9]. :…”

“…Hostel staff also may not have accurate or adequate information about residents [6, 9, 41] making the acquisition of the necessary support harder still [6, 35]. This could be because of homeless people’s reluctance to share this information [6, 41] or inadequate information sharing between medical services and hostels [9].…”