Living Without Dignity But Trying To Die With It

Dr. Soraya Mumtaz, reviewed the struggles and importance of delivering palliative care to the homeless at the Grand Rounds held at Ontario Shores on May 7.

Dr. Mumtaz began by noting the staggering statistics surrounding morbidity and mortality in the homeless population. In Toronto, the homeless are four times more likely to die of cancer and five times more likely to die of heart disease than the general population. The life expectancy for a homeless person is half that of the general population at just 37 to 43 years old. Dr. Mumtaz also stated that people who suffer from mental illness die 25 years earlier than the general population, on average – meaning people who are homeless and also suffer from a mental illness (approximately 50 per cent of the homeless population) have an even lower life expectancy.

It’s a tough topic to talk about, but the importance of palliative care is indisputable. With an aging population and increased rates of homelessness, the need for proper end-of-life care is growing quickly. Traditional palliative care programs are developed based on the assumptions that individuals are housed, supported by family/friends and have resources for supplementary care. These assumptions are generally not true for the homeless population.

“How are we going to be able to serve this population?,” asked Dr. Mumtaz.

There are many barriers preventing access to proper palliative care for the homeless. These barriers include previous negative experiences and mistrust of healthcare providers, fear of stigma/judgement which can lead to a lack of respect for the individuals’ habits and friends, exclusionary operating practices (such as anti-drug policies) and insufficient knowledge and training of staff to provide care.

Dr. Mumtaz stressed the importance of developing palliative care programs for the homeless population. If these patients are able to forego emergency rooms and hospital visits, replacing them with palliative care programs in shelters or hospices, the health care system can save up to $1.39 million per person.

Dr. Mumtaz cited advice from the homeless population and care providers outlining what they would like to see in these programs. Clients want health care providers to listen to them, increase their own awareness of stigma and biases and transform advanced care planning into a goal setting process centred on human understanding and respect. Health care providers recommended flexible behavioural policies and harm reduction strategies, as well as linking their services with population-specific health and social workers to increase understanding.

The presentation cited the Palliative Education and Care for the Homeless (PEACH) program as a model for future palliative care programs in this field. PEACH is a mobile program that stresses early intervention and can go wherever the individual needing help is – whether it is on the streets or in a shelter. It is the first program of its kind and operates out of St. Michaels Hospital in Toronto. Since its establishment in July of 2014, PEACH has taught health care providers that care coordination is possible, advanced care planning for the homeless is needed, and delivery of its services needs to be customized to each individual they serve.

Moving forward, PEACH will act as a model for future programs with goals centred on advocacy, research, communication, collaboration and clinical care. Mumtaz stressed that more research is needed on this topic and hopes PEACH will be studied as a model for future palliative care programs and moved across the country and into the United States.