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Adults experiencing homelessness face significant symptom burdens and inequalities due to life-limiting illnesses and loss of rootedness. Lack of adapted palliative and end-of-life care worsens their illness and quality of life.
Coverdale and colleagues (2024) conducted a review to identify interventions and models of care used to address the palliative and end of life care needs of adults experiencing homelessness, and to determine their effectiveness.
This systematic review included research articles describing palliative care and end-of-life interventions for adults experiencing homelessness. Case series and case reports, commentary, review and opinion pieces were excluded. A quality assessment of individual studies was conducted and a narrative synthesis summarizing the main findings was assembled.
After a review of 5,487 studies that were initially identified, nine studies were included in the review. Of the included studies, three were qualitative, one was mixed methods, three were service evaluations/improvements, one was a retrospective cohort study and one was a randomised control trial.
Nine studies were identified that focused on: education and palliative training for support staff; advance care planning; a social model for hospice care; and the creation of new roles to provide extra support to homeless adults through health navigators, homeless champions or palliative outreach teams. The table below summarizes the interventions, key components and effectiveness of the model.
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| ·Duties included signposting and assisting homeless adults with multiple activities of daily living, including attending medical appointments, referring to hostels, accessing food banks. ·Advocating for these marginalised individuals when appropriate including instigating advance care planning | ·One social worker assisted a maximum of 50 homeless adults within their service at any one time.
·2007 activities completed by the healthcare navigator for adults experiencing
homelessness and needing palliative care support.
·A focused approach to the social determinants of health was undertaken to facilitate
equitable care at the end of life |
| ·Residents received personalised 24-hour care and support.
·Living within a social environment united residents and created a shared sense of belonging. This enhanced social interaction and emotional well-being | ·Patient reported outcomes assessed including: physical location to receive care;
community involvement in care; spiritual needs addressed via access to a chaplain.
·Allowed to bring pets on site.
·Family re-connected with residents.
·Residents felt ‘at home’ and cared for by staff and other residents.
·Harm reduction strategy allowed residents to die with dignity in a comfortable, peaceful location.
·Healthcare needs and medication was provided by certified nurse’s assistants.
·Certified nurse assistants (CNAs) were onsite 24/7 and befriended residents; this
created a sense of community and connection which made residents feel more
confident in their caregivers |
The Palliative Education and
Care for the Homeless (PEACH) programme | ·Four key domains were addressed when engaging with homeless adults (harm reduction, trauma informed care, intersectionality and
antioppression, interprofessional approach to care).
·Involvement within education and research on reducing inequalities of this marginalised population was also a key component | ·Social service workers and community workers could directly refer to the PEACH model and at the earliest opportunity.
·Education was a priority—active role in teaching and offering electives to medical
students.
·Reflective practice was encouraged for all professionals involved which helped them to explore ways in reducing barriers faced by clients in their practice and beyond.
·Advocacy was a key component of the PEACH programme- high quality, early and integrated palliative care for vulnerable patients. ·Advocating for food, housing, healthcare.
·Advocating at the population level to call for societal change was undertaken via
teaching and engagement with local government to tackle the issues arising around homelessness and poverty.
·Focused on research on the palliative needs of homeless individuals.
·Support was provided on funeral arrangements, leisure activities and reconnecting
homeless adults with family members.
·Grief circles encouraged all professionals involved in the programme to come together
and support one another in grieving a client’s death |
Shelter based hospice for the
homeless | ·Patients resided within a designated 15 bed area and received comprehensive 24/7 healthcare and palliative care consultation to optimise symptoms.
·Religious needs were addressed, end of life issues were discussed and
continuity of care was maintained during the terminal phase of life.
·Patients were reunited with family when and where possible | ·Hostel staff were responsible for supervised provision of medication which improved
compliance in the homeless population.
·No increase in substance abuse.
·Continuity of care in the terminal phase was achieved.
·Homeless adults were reunited with family when wanted, and where possible.
·57% had palliative care consult.
·82% died in hospice; 18% of homeless adults transferred to the emergency department
for further symptom control at their request.
·End of life issues were discussed, and religious needs met |
| ·2-day educational course implemented to train and support hostel staff in their duties when working with homeless adults requiring palliative care | ·All sections of the course were interesting and useful according to hostel staff.
·Knowledge of palliative care and services available was most improved among hostel
staff.
·Staff gained confidence in supporting their clients; also gained knowledge on how to
access support, and how to give support to residents.
·Hostel staff more open to confront ill health and talk about it with the clients.
·Enhanced self-awareness of staff to support their own health and well-being. Work
related stress was also slightly improved.
·Improved attitudes and openness of hostel staff to supporting dying patients and
accepting of these dying patients remaining in the hostel. However, some staff did not want the hostel to turn into a hospice environment |
| ·Programme which trained staff how to provide outreach support to
homeless individuals needing palliative and end of life care.
·This was achieved through improved awareness of the early identification of patients with deteriorating health, signposting to relevant agencies for additional support, and initiating advance care
planning discussions | ·Front line staff were engaged to deliver advance care planning with homeless adults; they were understanding of the importance of advance care planning and increased its
uptake and completion.
·Increased number of homeless individuals dying with dignity in preferred place of care with the right support.
·Three patients died in preferred place of care; four patients were supported in
accommodation.
·Improved front line staff knowledge on the identification of deteriorating patients, palliative and end of life care |
| ·Homeless champions were appointed to work within four hostels and contracted to attend the hostels for two half days per month.
·Homeless champions were tasked with multiple responsibilities including supporting hostel staff and residents through providing
bereavement support, implementing multidisciplinary working
into routine practice, signposting to external agencies and directly
meeting with residents of concern when needed.
·The new role of a homeless champion was directly incorporated into the job specification in replace of previous duties
| ·Hostel residents reported positively feeling cared for by staff.
·Staff felt empowered following introduction of homeless champions; there was a shift in mindset on the development of holistic palliative ethos within their practice.
·Homeless champions improved interagency and multiagency communication and collaboration.
·Mental health was addressed through the introduction of a death cafe and vigil.
·Residents were less inclined to blame staff for deaths of their peers; staff and residents
supported each other through the grieving process |
Advance directive completion | ·Counsellor directed completion of an advance directed versus self-directed completion of an advance directive.
·The advance directive form was specifically designed to address the end-of-life needs of homeless adults.
·Participants were provided with documentation detailing what advance care planning is following enrolment | ·Primary outcome: completion of an advance directive within 3months of enrolment into
the study.
·Advance directives were assessed for their legibility and legality status by multiple
independent investigators who were blinded to intervention groups.
·70/262 completed the advance directive. 2 were not counted due to illegibility.
·Higher completion rate in the counsellor guided intervention group: 37.9% compared with the self-directed group:12.8%. P value <0.001. |
Medical student led intervention on the completion of advance
directives | ·Free assistance in the completion of an advance directive, with prior
in person counselling on what an advance directive entails.
·The provision of written information for reference was also given to
participants | ·9/10 homeless adults who attended focus groups signed up to complete an advance
directive.
·88.8% completion rate |
Source: Coverdale, M. R., & Murtagh, F. (2024). Destitute and dying: interventions and models of palliative and end of life care for homeless adults–a systematic review. BMJ Supportive & Palliative Care.
