Complex health needs of unhoused populations are preventing palliative care access, Lakehead U. review finds

Individuals experiencing homelessness are facing sustained barriers to accessing palliative care, largely stemming from stigmas associated with previous experiences with healthcare providers. That's according to a new scoping review from Lakehead University, published in the journal BMC palliative care on July 18.

The review examined 45 studies on palliative care within unhoused populations, including 18 from Canada. It is part of a broader study funded by Health Canada looking into palliative care access among vulnerable populations, said Ravi Gokani, an associate professor at Lakehead University's School of Social Work, and a co-author of the study.

The complexities of healthcare needs for unhoused individuals can create barriers to the kind of care available, as well as an ongoing lack of the healthcare professionals qualified to provide the necessary care, the study says.

"One of the key findings is that there is a need for a focus on the relationship between the healthcare providers and the people seeking access," Gokani says.

Palliative care is aimed at improving the quality of life for patients experiencing serious illness, often towards the end of their lives. 

Across Canada, palliative care services have been rising over the past few years. According to Health Canada, 58% of Canadians who died in 2021-2022 had accessed palliative care, while seniors aged 65 to 84 were the most likely to receive this type of care.

However, when it comes to unhoused populations in North America, the review points out the average age of death is 34 to 47.

Many times, unhoused individuals may not know that they need end-of-life care until it is too late.

"They're seeing doctors very intermittently," said Brendan Carlin, executive director of Shelter House in Thunder Bay. "By the time it gets to that point, it's too late or they just say 'why would I get this care? I'm gonna pass away anyway.'"

One of the biggest barriers restricting access to palliative care for unhoused individuals is the lack of trust they themselves may hold against healthcare providers, feelings originating from previous negative experiences, the review says. 

Carlin says negative interactions can include cases of mistreatment due to stigmas surrounding homelessness, or racism that they've experienced at the hands of healthcare providers.

The review also points out organizational policies are the most common palliative care provider-related barrier for unhoused individuals.

Policies that may be put in place to protect staff, such as ensuring the safety of their working environment and substance use polices can prove to be prohibitive to allowing unhoused individuals access to care, Gokani says.

"Generally, the findings suggest harm reduction policies don't impede access, but abstinence-based policies do impede access to palliative care."

Another organizational policy that can be prohibitive is the definition they may have for family, potentially restricting patients from seeing some of the individuals to whom they are closest. 

"Some of our clients don't have a lot of family support, if any at all, and when you're unhoused, you tend to spend your time with lots of people," Carlin said. "When you're going to a hospital and it has to be blood relatives or whatever, you just think, well why would I want to go there?"

Seeking collaborative solutions

Integrated models combining palliative care with shelter support services or a system navigator can prove to be beneficial in improving access to palliative care, the review says. In these instances, individuals most in need of end-of-life support can get the care they need from staff and individuals they feel comfortable with. 

The review also noted embedding palliative care specialists within shelters made it easier for the subject to be discussed between unhoused individuals and medical professionals.

Thunder Bay's Shelter House is making progress in integrating palliative care within its own services. Beginning this fall, the shelter will offer a pair of palliative care units within its expanded Kwae Kii Win Managed Alcohol Program.

Carlin says the palliative care units will be bigger than the standard rooms offered to clients in the program, making room for visitors and medical equipment. He says the new palliative care program will be jointly managed by NorWest Community Health Centres.