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James R, Flemming K, Hodson M, Oxley T. Palliative care for homeless and vulnerably housed people: scoping review and thematic synthesis. BMJ Support Palliat Care 2023; 13:401-413. [PMID: 33941575 DOI: 10.1136/bmjspcare-2021-003020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION People who are homeless or vulnerably housed are subject to disproportionately high risks of physical and mental illness and are further disadvantaged by difficulties in access to services. Research has been conducted examining a wide range of issues in relation to end-of-life care for homeless and vulnerably housed people, however, a contemporary scoping review of this literature is lacking. OBJECTIVES To understand the provision of palliative care for people who are homeless or vulnerably housed from the perspective of, and for the benefit of, all those who should be involved in its provision. DESIGN Scoping review with thematic synthesis of qualitative and quantitative literature. DATA SOURCES MEDLINE, Embase, PsycINFO, Social Policy and Practice and CINAHL databases were searched, from inception to May 2020. Citation chasing and manual searching of grey literature were also employed. RESULTS Sixty-four studies, involving 2117 homeless and vulnerably housed people were included, with wide variation in methodology, population and perspective. The thematic synthesis identified three themes around: experiences, beliefs and wishes; relationships; and end-of-life care. CONCLUSION Discussion highlighted gaps in the evidence base, especially around people experiencing different types of homelessness. Existing evidence advocates for service providers to offer needs-based and non-judgemental care, for organisations to use existing assets in co-producing services, and for researchers to address gaps in the evidence base, and to work with providers in transforming existing knowledge into evaluable action.
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Affiliation(s)
- Richard James
- Public Health, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Flemming
- Department of Health Sciences, University of York, York, UK
| | | | - Tammy Oxley
- Palliative Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Rollans C, Baek J, Bloch G, Nyhof-Young J, Morey T, Dosani N, Spaner D. Exploring the Barriers and Facilitators Experienced by Palliative Health Care Providers Working with Patients Experiencing Homelessness during the COVID-19 Pandemic. Palliat Med Rep 2023; 4:3-8. [PMID: 36743340 PMCID: PMC9892914 DOI: 10.1089/pmr.2022.0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 01/19/2023] Open
Abstract
Background Patients experiencing homelessness not only have higher rates of medical complexity, comorbidity, and mortality, but also face barriers to accessing palliative care services. In structurally vulnerable populations with palliative care needs, these barriers are compounded, creating significant challenges for both patients and providers that have important health equity implications. Objective The aim is to explore the experiences of palliative care providers working with patients experiencing homelessness during the COVID-19 pandemic and understand the barriers they faced in providing care, as well as facilitators that aided in the success of their teams. Methods Seven health care providers from two Canadian palliative outreach teams involved in delivering palliative care services to patients experiencing homelessness during the COVID-19 pandemic participated in audio-recorded and transcribed videoconferencing interviews. Analysis was completed using generic descriptive thematic analysis. Results Five key themes were identified: (1) factors negatively impacting patient health, (2) use of technology, (3) care provider emotions, (4) care provider education and advocacy, and (5) outreach team factors. Conclusion Identified barriers during the pandemic included worsening of existing patient vulnerabilities, as well as challenges incorporating technology into care. Providers faced increased emotional burden, with a rise in workload, stress, fear, and grief. However, several facilitators allowed teams to provide high-quality care to this vulnerable population, including team support, interprofessional collaboration, and advocacy and education initiatives. The outreach model also proved to be a highly flexible, resilient, and adaptable model for providing care during the COVID-19 pandemic.
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Affiliation(s)
- Claire Rollans
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Justine Baek
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Address correspondence to: Justine Baek, MD, CFPC, Department of Family and Community Medicine, Mount Sinai Hospital, 60 Murray Street, L4-000 Box #13, Toronto, Ontario M5T 3L9, Canada.
| | - Gary Bloch
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Primary Care, Inner City Health Associates, Toronto, Ontario, Canada
| | - Joyce Nyhof-Young
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Academics Program, Women's College Hospital, Toronto, Ontario, Canada
| | - Trevor Morey
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Palliative Education and Care for the Homeless, Inner City Health Associates, Toronto, Ontario, Canada
| | - Naheed Dosani
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Palliative Education and Care for the Homeless, Inner City Health Associates, Toronto, Ontario, Canada
| | - Donna Spaner
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Palliative Education and Care for the Homeless, Inner City Health Associates, Toronto, Ontario, Canada.,Palliative Care, Toronto Grace Health Centre, Toronto, Ontario, Canada
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Reilly J, Ho I, Williamson A. A systematic review of the effect of stigma on the health of people experiencing homelessness. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:2128-2141. [PMID: 35762196 DOI: 10.1111/hsc.13884] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/10/2022] [Accepted: 05/27/2022] [Indexed: 06/15/2023]
Abstract
Experiencing homelessness is associated with poor health, high levels of chronic disease and high premature mortality. Experiencing homelessness is known to be socially stigmatised and stigma has been suggested as a cause of health inequalities. No previous review has synthesised the evidence about stigma related to homelessness and the impact on the health of people experiencing homelessness. The present mixed-methods review systematically searched four databases and retrieved 21 original articles with relevant data around stigma, homelessness and health. Across all studies, there was broad agreement that some people experiencing homelessness experience significant stigma from providers when accessing health care and this impacts on general health and service access. There is also evidence that perceived stigma related to homelessness correlates with poorer mental and physical health.
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Bérubé A, Tapp D, Dupéré S, Plaisance A, Bravo G, Downar J, Couture V. Do Socioeconomic Factors Influence Knowledge, Attitudes, and Representations of End-of-Life Practices? A Cross-Sectional Study. J Palliat Care 2022:8258597221131658. [PMID: 36237145 DOI: 10.1177/08258597221131658] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Access to palliative and end-of-life (EOL) care might be influenced by knowledge, attitudes, and representations of these practices. Socioeconomic factors might then affect what people know about EOL care practices, and how they perceive them. This study aims to compare knowledge, attitudes, and representations regarding EOL practices including assisted suicide, medical assistance in dying, and continuous palliative sedation of adults, according to socioeconomic variables. METHODS A cross-sectional community-based questionnaire study featuring two evolving vignettes and five end-of-life practices was conducted in Quebec, Canada. Three sample subgroups were created according to the participants' perceived financial situation and three according to educational attainment. Descriptive analysis was used to compare levels of knowledge, attitudes, and representations between the subgroups. RESULTS Nine hundred sixty-six (966) people completed the questionnaire. Two hundred and seventy participants (28.7%) had a high school diploma or less, and 42 participants (4.4%) were facing financial hardship. The majority of respondents supported all end-of-life options and the loosening of eligibility requirements for medical assistance in dying. Differences between subgroups were minor. While respondents in socioeconomically disadvantaged subgroups had less knowledge about EOL practices, those with lower educational attainment were more likely to be in favor of medical assistance in dying, and less likely to favor continuous palliative sedation. CONCLUSIONS People living with situational social and economic vulnerabilities face multiple barriers in accessing health care. While they may have poorer knowledge about EOL practices, they have a positive attitude towards medical assistance in dying and assisted suicide, and a negative attitude towards continuous palliative sedation. This highlights the need for future research and interventions aimed at empowering this population and enhancing their access to EOL care.
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Affiliation(s)
- A Bérubé
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - D Tapp
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - S Dupéré
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
| | - A Plaisance
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - G Bravo
- Faculty of Medicine and Health Sciences, Sherbrooke University, Sherbrooke, QC, Canada
| | - J Downar
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - V Couture
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Axis, Research Center of the CHU de Québec-Université Laval, Quebec, QC, Canada
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Vihvelin C, Rupasinghe V, Hughes J, Karabanow J, Weeks LE. A first voice perspective of people experiencing homelessness on preferences for the end-of-life and end-of-life care during the COVID-19 pandemic. BMC Res Notes 2022; 15:142. [PMID: 35428317 PMCID: PMC9012062 DOI: 10.1186/s13104-022-06025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
People experiencing homelessness often encounter progressive illness(es) earlier and are at increased risk of mortality compared to the housed population. There are limited resources available to serve this population at the end-of-life (EOL). The purpose of this study was to gain insight into preferences for the EOL and end-of-life care for people experiencing homelessness. Utilizing an interpretive phenomenology methodology and the theoretical lens of critical social theory, we present results from 3 participants interviewed from August to October 2020, with current or previous experience of homelessness and a diagnosis of advanced disease/progressive life-threatening illness.
Results
A key finding focused on the existential struggle experienced by the participants in that they did not care if they lived or died. The participants described dying alone as a bad or undignified way to die and instead valued an EOL experience that was without suffering, surrounded by those who love them, and in a familiar place, wherever that may be. This study serves to highlight the need for improvements to meet the health care and social justice needs of people experiencing homelessness by ensuring equitable, humanistic health and end-of-life care, particularly during the context of the COVID-19 pandemic.
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Gievers L, Khaki S, Dotson A, Chen Z, Macauley RC, Tolle S. Social Determinants of Health May Predict End of Life Portable Orders for Life Sustaining Treatment Form Completion and Treatment Selections. Am J Hosp Palliat Care 2021; 39:678-686. [PMID: 34569256 DOI: 10.1177/10499091211041566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND End of life (EOL) care planning is important for aging adults given the growing prevalence of chronic medical conditions in the US. The Portable Orders for Life Sustaining Treatment (POLST) program promotes communication between clinicians and patients with advanced illness about EOL treatment preferences. Despite growing resources for EOL care, utilization remains unequal based on social determinants of health (SDOH), including race, language, urbanization, and education. We evaluated the relationship between POLST form selections and completion rates and SDOH. METHODS Oregon POLST Registry and American Community Survey data from 2013 to 2017 were analyzed retrospectively. POLST form completion rates and selections, and various SDOH, including age, income, insurance status, urbanization, etc. were recorded. Data were merged based on ZIP codes and analyzed using χ2 or Wilcoxon-Mann-Whitney tests. Logistic regression was performed. RESULTS 127,588 POLST forms from 319 ZIP codes were included. POLST form completion rates were highest among urban ZIP codes, and urban registrants more often selected CPR and full treatment. ZIP codes with higher incomes tended to select CPR. ZIP codes with higher rates of private insurance completed POLST forms, and selected CPR and full treatment more frequently. ZIP codes with higher rates of Bachelor's degrees (or higher) completed POLST forms and selected full treatment more frequently. CONCLUSIONS Various SDOH-specifically, urbanization, insurance status, income level and educational level achieved-may influence POLST form completion rates and selections. The expanding socioeconomic diversity and growth of urban communities, highlight the need for broader access to EOL planning and POLST.
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Affiliation(s)
- Ladawna Gievers
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Sheevaun Khaki
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Abby Dotson
- Oregon POLST Registry, Department of Emergency Medicine, Portland, OR, USA
| | - Zunqiu Chen
- Department of General Internal Medicine, External Consultant, Portland, OR, USA
| | - Robert C Macauley
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Susan Tolle
- Division of General Internal Medicine and Geriatrics, Center for Ethics in Health Care, Oregon Health and Science University, Portland, OR, USA
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Purkey E, Davison C, MacKenzie M, Beckett T, Korpal D, Soucie K, Bartels S. Experience of emergency department use among persons with a history of adverse childhood experiences. BMC Health Serv Res 2020; 20:455. [PMID: 32448175 PMCID: PMC7245948 DOI: 10.1186/s12913-020-05291-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/04/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Adverse childhood experiences (ACEs) are associated with increased morbidity and mortality, lower levels of distress tolerance, and greater emotional dysregulation, as well as with increased healthcare utilization. All these factors may lead to an increased use of emergency department (ED) services. Understanding the experience of ED utilization among a group of ED users with high ACE scores, as well as their experiences as viewed through the lens of a trauma and violence informed care (TVIC) framework, could be important to their provision of care. METHODS This is the qualitative portion of a larger mixed methods study. Twenty-five ED users with high ACE scores completed in depth interviews. Thematic analysis of the interview transcripts was undertaken and directed content analysis was used to examine the transcripts against a TVIC framework. RESULTS The majority of participants experienced excellent care although challenges to this experience were faced by many in the areas of registration and triage. Some participants did identify negative experiences of care and stigma when presenting with mental health conditions and pain crises, as did participants who perceived that they were considered "different" (dressed differently, living in poverty, young parents, etc.). Participants were thoughtful about their reasons for seeking ED care including lack of timely access to their family doctor, perceived urgency of their condition, or needs that fell outside the scope of primary care. Participants' experiences mapped onto a TVIC framework such that their needs and experiences could be framed using a TVIC lens. CONCLUSIONS While the ED care experience was excellent for most participants, even those with a trauma history, there existed a subset of vulnerable patients for whom the principles of TVIC were not met, and for whom implementation of trauma informed care might have a positive impact on the overall experience of care. Recommendations include training around TVIC for ED leadership, staff and physicians, improved access to semi-urgent primary care, ED patient care plans integrating TVIC principles, and improved support for triage nurses and registration personnel.
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Affiliation(s)
- Eva Purkey
- Queen's University Department of Family Medicine, 220, Bagot street, Kingston, Ontario, K7L 5E9, Canada.
| | - Colleen Davison
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | | | - Tracey Beckett
- Family Violence and Crisis Team, Department of National Defense, Kingston, Ontario, Canada
| | - Daniel Korpal
- Department of Emergency Medicine, Western University, London, Ontario, Canada
| | - Katherine Soucie
- Department of Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Susan Bartels
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
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