Research focus

Research focus: end of life care for homeless people

Homeless people have a shortened life expectancy (Crisis 2012). This digest summarises three recent research studies relating to end of life care among the homeless population

Homeless people have a shortened life expectancy (Crisis 2012). This digest summarises three recent research studies relating to end of life care among the homeless population

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Challenges to discussing palliative care with people experiencing homelessness: a qualitative study

The views and experiences of people who are homeless and those supporting them regarding conversations about and approaches to palliative care were explored in this study.

The study was conducted in three London boroughs with a range of participants, including 28 people experiencing homelessness, ten formerly homeless people, 48 health and social care providers, 30 hostel staff and 10 outreach staff. It involved 28 focus groups and ten semi-structured interviews. Data were analysed thematically.

Participants reported that conversations about future care and dying were rare. Four key themes emerged as challenges to these conversations:

  • Attitudes to death.
  • Recovery focus.
  • Fear of impact on homeless person and staff.
  • Uncertainty.

The authors argue that people who are homeless and nearing the end of life need an approach to advanced care planning that incorporates uncertainty and complexity, and promotes well-being, dignity and choice.

They propose a three stage strategy that involves identifying people who could be approaching the end of life; gathering information, exploring wishes, insights, options and concerns; and multidisciplinary support and reviewing plans.

Hudson B, Shulman C, Low J et al (2017) BMJ Open. 7, 11.


End-of-life care for homeless people: a qualitative analysis exploring the challenges to access and provision of palliative care

The purpose of this research was to explore the views and experiences of current and formerly homeless people, front-line staff and health and social care providers regarding challenges to supporting people with advanced ill health. This was a qualitative descriptive study using the same dataset as Hudson et al (2017).

Data were analysed thematically focusing on challenges to access and provision of palliative care.

Three themes

The first was complex behaviours in mainstream services, particularly behaviours related to complex trauma and substance misuse, and the inexperience of many professionals in working with these behaviours.

The second was gaps in existing systems, which included the lack of appropriate alternatives to hospices and care homes, the need for a holistic approach to care and support, and conceptualising the hostel as a place of care and death.

The final theme was uncertainty and complexity, which related to difficulty predicting illness trajectories, and advance care planning. The authors recommend greater multidisciplinary team working, extended in-reach into hostels, training and support for all professional groups, and the establishment of palliative care coordinator roles.

Shulman C, Hudson B, Low J et al (2018) Palliative Medicine. 32, 1, 36-45.

Homeless individuals approaching the end of life: symptoms and attitudes

The authors of this study examined the symptoms experienced by homeless people approaching the end of life, and explored their social background, attitudes and experiences.

The study was conducted in a medical respite centre in the US. People experiencing homelessness where eligible to participate if they had a major medical condition that caused their healthcare professional to answer no to the question: Would you be surprised if this patient were not alive in one year?

Structured interviews explored symptoms using the Memorial Symptom Assessment Survey. Symptoms were compared with those of comparator groups in other studies.

Common diagnosis

Twenty people, with a median age of 58 years, took part. The most common diagnosis was cancer. There were high levels of mental illness and substance use disorders.

Symptom frequency was high, especially in relation to pain and psychological symptoms. Mistrust of others’ decisions about end of life care was common, as was concern about receiving too little or too much care. The frequency of symptoms was higher than in the comparator studies.

The authors conclude that people who experience homelessness require a tailored approach to end of life care provision.

Tobey M, Manasson J, Decarlo K et al (2017) Journal of Pain and Symptom Management. 53, 4, 738-744.


Implications for practice

  • People who are homeless experience high symptom frequency at the end of life.
  • They also experience barriers to end of life care provision.
  • They require bespoke interventions at the end of life.


Compiled by Caroline McGraw, lecturer at City, University of London


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