Palliative and End-of-Life Care for Unhoused Individuals: Provider Approaches to Care amidst an "Inhumane Lack of Resources"

Background and Purpose:

Palliative and end-of-life (PEOL) care offer many benefits to those with life-limiting illness; however, older unhoused individuals face several structural barriers in accessing such care. The purpose of this study was to explore healthcare and social service providers’ approaches to addressing PEOL needs among unhoused individuals in Colorado amidst dehumanizing systems and a lack of resources.

Methods:

Using an exploratory-descriptive qualitative approach, in-depth semi-structured interviews were conducted over Zoom with a convenience and snowball sample of healthcare and social service providers in Colorado who provided direct care/services to adults. Several strategies were incorporated to address qualitative rigor and trustworthiness, including ongoing reflexivity among the research team, and the use of triangulation, audit trails, peer debriefing, and member checking. An iterative thematic analysis approach was used to inductively analyze qualitative data using the following phases: 1) familiarizing with the data; 2) generating initial codes; 3) searching for themes; 4) reviewing themes; 5) defining and naming themes; and 6) producing the report (Braun & Clarke, 2006).

Findings:

Seventeen healthcare and social service providers participated in interviews between June-September 2022. Interviews lasted an average of 54 minutes. The sample was primarily white (n=16, 94%), most identified as women (n=11, 65%), with a mean age of 42 years (SD=11.37). Healthcare and social service providers were represented relatively evenly, with 10 participants in healthcare settings (primary care, hospitalist specialty service, hospice, and respite care) and seven in social services (housing/homeless services, aging services, community mental health, non-hospice EOL care). Interviews highlighted a number of challenges in providing complex care to unhoused individuals in the context of an inhumane lack of resources, including a lack of resources to support PEOL needs for unhoused individuals, stigmatized attitudes towards unhoused individuals that impact care, and siloed and overextended services. Amidst these challenges, providers highlighted person-centered and holistic approaches to care that prioritize building rapport and trust-building and challenging the culture of stigma towards homelessness within and across organizations. Participants emphasized the importance of organizational commitment to support these holistic approaches. Participants also discussed potential solutions to improve PEOL care for unhoused individuals, including specialized PEOL interventions such as street-based palliative care and social model hospice homes, and transforming our culture surrounding poverty, homelessness, and end-of-life.

Conclusions and Implications:

This study highlights humanizing approaches within structural challenges to providing PEOL care for unhoused individuals. The findings highlight the importance of organizational leadership to support and encourage efforts to provide person-centered care to unhoused individuals, including specialized PEOL services such as street-based palliative medicine and social model hospice homes. Additionally, this study further supports the need for policy reform in housing and healthcare (e.g., better housing solutions and more robust hospice reimbursement), as well as addressing and disrupting poverty and homelessness stigma.