Essay: Homelessness – palliative care

Introduction
Whether we like to admit it or not, homelessness is a prevalent issue within our Canadian society. According to statistics Canada, approximately 13% of the Canadian population earns what is considered a ‘low-income’ salary and estimates 150,000-300,000 Canadians experience homeless annually per year (retrieved from https://www150.statcan.gc.ca/n1/pub/75-006-x/2016001/article/14678-eng.htm).
Homelessness is a state where an individual or family does not have a stable, permanent or appropriate housing environment or an immediate prospect or means of obtaining it (Veer, Stringer, Meijel & Verkaik, 2018). Individuals with poor economic status continue to have inadequate or absence of palliative care services resulting in poorer outcomes (Huynh, Henry & Dosani, 2015).
It is important to address this issue as palliative care is a human right. Throughout this paper we will analyze each aspect of palliative care promoted in the Canadian healthcare system such as; relief of suffering, psychosocial/socioeconomic support, treatment of medically active issues, appropriate care (Howell & Syme, 2015). We will end the discussion with suggestions on how we can improve the current hospice palliative care delivery system.
Relief of Suffering
“Hospice and Palliative care is aimed at relief of suffering and improving the quality of life of persons who are living with or dying from advanced illness” (Howell & Syme, 2015). The goal is to promote a holistic approach in caring for terminally ill and dying patients in all care settings in order to reduce and alleviate pain and suffering to the best of the health professional’s abilities. This includes administering care is a non-judgemental and genuine manner.
Homeless individuals often live in an unstable environment and have previously endured both physical and psychological traumas. These wrongs leave these vulnerable individuals to turn to inappropriate coping mechanisms such as solicit drug and alcohol use. Another devastating result of these individuals’ past is the overall distrust in people, including those in the health care system (Shulman, Hudson, Lew, Hewett, Daly, Kennedy & Stone, 2017). Health care professionals who are inexperienced with caring for this population often contribute to the stress and affliction felt by these individuals by have pre-empt assumptions that contribute the stigma surrounding homelessness. The mistrust in this particular population results in confusing the individuals reports of pain and symptoms with drug seeking behaviour therefore not providing the optimal care as intended (Hudson, Flemming, Shulman & Candy, 2016).
Homeless individuals are unfortunately left in fear of dying alone and in pain. Palliative care protocols used in the hospital setting often do not take into consideration the homeless populations previous medical history such as past self-medication. Some examples of the self-medication methods possibly used are cocaine, heroin, methadone etc. that are not exactly equivalent to standardized institutional dosages. This unfortunately leads to subtherapeutic pain management leading to a high incidence of adverse symptoms that includes pain, fatigue and psychological distress (Veer et al., 2018).
Psychosocial/Socioeconomical Support
“Hospice and Palliative care strive to help patients and families address physical, psychological and social, spiritual and practical issues and their associated expectations, needs, hopes and fears” (Howell and Syme, 2015). Economically deprived populations such as the homeless are less likely to have access to individualized hospice and palliative care services and will often die in the hospital setting (Lavergne, Lethbridge, Johnston, D-Intino & McIntyre, 2015). When planning hospice and palliative care for an individual the expectation is that the person will have some sort of support system and a stable environment in which the care can be received. due to a lack of support from family or friends combined with an unstable residence and low economic status they do not uphold the same opportunities to these services as others in society (Henry, Dosani, Huynh, & Amirault, 2017).
Many homeless individuals have little to no familial support to advocate for them as their health deteriorates. Past encounters have led to strained relationships and in many cases the homeless individual is unwilling to open these painful wounds (Shulman et al., 2017). This unfortunately leaves these individuals facing their deteriorating illness alone with support of their healthcare providers.
Homeless individuals often have chaotic and unstable lifestyles and ‘home’ environments. These outstanding circumstances make it very difficult to deliver proper hospice and palliative care in the community setting as mainstream settings are not always accommodating to the homeless person’s needs. Shelters and hostels throughout the community do not have the requires services and training to deliver proper care when traditional settings are not possible for the homeless individual (Klop, Donger, Frake, Rijens & Onwuteaka-Pimpsen, 2018).
Treatment of Medically Active Issues
“Hospice palliative care aims to treat all active issues, prevent new issues from occurring and promote opportunities for meaningful and valuable experiences, personal and spiritual growth and self-actualization” (Howell and Syme, 2015). This goal becomes difficult in the homeless population as many do not have a clearly recorded medical history due to their unstable lifestyle. According to recent research as many as 50% of homeless individuals do not have a primary caregiver such as a family physician or nurse practitioner resulting in an increased use of hospital emergency services as the primary care location (Klop et al., 2018). This population tends to go multiple hospital emergencies, receiving short term treatment with no follow leaving no timeline of the injury or illness and treatment plan (Veer et al, 2018).
Low economic status is frequently associated with poor access, and more advanced disease that is extremely problematic in the homeless population as there are many additional co-morbidities present in conjunction with the terminal prognosis (Huynh et al., 2015). There is a high prevalence of untreated mental health and addiction issues within the homeless population resulting in limited insight into their state of both physical and psychological health (Klop et al., 2018). Many suffer from addiction, psychosis and other psychiatric illnesses that affect adherence to treatment plans and how they overall prioritize their health. The presence of substance abuse can also mask or exacerbate symptoms making it increasingly difficult to perform accurate assessments and give accurate prognosis (Hudson et al., 2016).
Apart from mental health issues, many suffer from physical illness co morbidities such as chronic obstructive pulmonary disease, liver cirrhosis and human immunodeficiency virus. Health care professionals misinterpret the up and downs of these illness trajectories as improvements without taking into consideration that environment has an effect of symptoms and exacerbations (Veer et al., 2018). These diseases not only exacerbate the new prognosis but also alter the trajectory of the illness significantly (Klop et al., 2018).
Appropriate Care
“Hospice Palliative care is appropriate for any patient and/or family unit to or at risk for developing a life-threatening illness due to any diagnosis, with any prognosis regardless of needs and prepared to accept care” (Howell & Syme, 2015). Palliative care is inherently a human right and is inscribed in our constitution. Palliative care must always be made available and accessible to citizens regardless of sex, race or socioeconomic standing in all settings (Brennan, 2014). The current health care system involved in the administration of palliative is not equipped to deliver equitable access such as alterations to care practices to ensure care is appropriate and individualized to any and all citizens (Henry et al., 2017).
Many palliative care services and institutions are built on the premise that is prohibitive of the homeless population’s co-morbidities and psychosocial circumstances. Within these institutions, operational policies of many palliative care programs and services such as anti-drug policies, conduct and behavioural codes create a barrier for the homeless population to be included in the care being offered (Huynh et al., 2017). These strict gatekeeping policies make these mainstream institutions who offer the best care possible for palliative care recipients inaccessible to the homeless population who are in need and who have higher incidence of untreated terminal illness than any other population within Canada.
Palliative care becomes problematic when delivered in the non-traditional setting as shelters and hostels are not equipped to deliver the appropriate and necessary palliative care to these individuals. This particular population at the end of life deal with a high burden illness especially towards the end stages which requires extensive and demanding care that is not possible or available outside the hospital or specialized tertiary setting (Henry et al, 2017).
Ways for Improvement
As demonstrated, there are many disparities in the delivery of hospice and palliative care for the homeless population. There are many ways as health care professionals to promote and initiate accessible and appropriate resources for these individuals. It is important that we start at the health care professionals themselves who are the first line caregivers. It is imperative that they adopt a ‘harm reduction strategy’ which fosters a trusting therapeutic relationship between the homeless individuals and the health care providers through demonstration of awareness of their current situation and psychosocial circumstances (Huynh et al., 2015). Pre- conceived notions and stigma towards homelessness must be removed from any and all interactions for this therapeutic relationship to be started and maintained (Hudson et al., 2016).
Health care professionals must use a non-biased, patient centered approach by setting goals that are realistic and attainable in the context homelessness. There is a need for more flexibility, conducive conversations and collaboration between homeless individual and the treating professional (Hudson et al., 2016). Awareness and understanding are required of the treating health care professionals as the goals and expectations of a homeless individual may greatly differ from those of a non-homeless individual. For example, the emphasis of advanced care planning must be implemented as many homeless individuals lack the social support to make decisions on their behalf as their physical and mental state deteriorates. This can also further encourage autonomy and control over their health and remainder of their life which has been previously absent in their life (Klop et al., 2018).
Another aspect that requires for attention is the integration of community and institutional services for the homeless population. Specialized palliative care implemented by trained health care professionals with a well-rounded understanding of the complex and unique physical, mental and psychosocial issues within the homeless population is required in all settings (Brennan, 2014). This can be achieved through integration and partnerships between health care institutions and its professionals and local homeless community services so care can be delivered to these individuals in the setting of their choice, whether it be in a hospital setting or in the shelter where they feel most comfortable (Henry et, al., 2017).
Conclusion
The models that currently exist to provide assessment, consultation, support and knowledge regarding the delivery of palliative care do not promote equitable access and opportunity to promote a palliative care approach (Lavergn et al., 2015). In order to provide the highest quality of care for the Canadian population we must accommodate special populations. The goals and standards we promote are not always applicable to the homeless population.
We must be more flexible and accommodating with the homeless population through compromise and accommodations with the more rigid policies. Through initiatives and proper communication between hospital and community resources this can be attainable. We can only hope that every Canadian has equitable access to their right to health care resources and services.