Homelessness and palliative care Michael Bramwell August 2014

Overview Definition of homelessness is difficult. Prevalence of homelessness is significant in Australia (1.1M experienced homelessness over past 10 years). Most homeless are young people, people displaced by domestic and family violence/abuse and ATSI. Emerging group of aged people within Australia facing homelessness.

Overview Collier (2011) reviewed resident notes in a accommodation service of a hostel for homeless people in UK. –Symptoms at end of life are distressing –Staff, health professionals and residents found it difficult to link the signs and behaviours of advanced liver disease with possibilities for palliative care interventions. –Reluctance by residents to access hospital because of restrictions placed on their behaviour. –Appropriate pain relief was often not received and the resident relied on self-medication. –Most deaths occurred suddenly and unanticipated by staff in hostel AND hospital.

Overview Dosani (2014) from Canada formed PEACH (Palliative Education & Care for the Homeless) to address issues of: –Average life expectancies for homeless persons are estimated to be between years. –Mortality rates among homeless populations are 2.3 – 4 times higher than general population. –Homeless people do not receive end-of-life care because of their immediate environment. –Many healthcare services feel that mainstream PC services are generally inaccessible to homeless populations. –34-59% of homeless people die in acute care settings.

Assessment Vulnerability Index (Hwang et al, 1998) –More than 3 hospitalisations or emergency visits in a year –More than 3 emergency room visits in previous 3 months –Aged 60 years or older –Cirrhosis of liver –End-stage liver disease –History of frostbite or hypothermia –HIV/AIDS –Tri-morbidity: co-occurring psychiatric problems, substance abuse, and chronic medical condition.

Recommendations A lead worker role is essential. Relationship with the homeless person is essential. Consequently, a specialist homeless person’s agency should take the lead role with palliative care services working in collaboration and consultation with other providers of care. Regular case conferences/meetings are core to effective communication. Advanced care planning is possible and essential. Access to after-hours meds should be negotiated with acute care facility.