When dying at home is not an option: exploration of hostel staff views on palliative care for homeless people.

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When dying at home is not an option: exploration of hostel staff views on palliative care for homeless people Wendy Ann Webb

Background: The Department of Health in the UK suggest that hostel staff are the most appropriate key workers for their dying homeless residents and that hostel-based palliative care may be the best way forward. However, little is known about the views of hostel staff with regard to this. Methods: Semi-structured qualitative interviews were conducted with seven participants from hostels distributed across three counties. A total of 37 specific case studies were discussed involving homeless residents with a wide range of life-limiting or palliative conditions. Findings: Eight main themes emerged: understanding palliative care; working with limited medical information; taking responsibility; building rapport; upholding residents’ dignity; recognising physical deterioration; managing environmental challenges; role limitations and support needs of hostel staff. Conclusion: Discussion centred around the following four topics: policy, principles and practice of palliative care; professional boundaries as a threat to holism and a hindrance to dignity; the social undesirability and invisibility of homeless people; ‘community living’ as a barrier to hostel-based palliative care and a new concept of family. Key words: Homeless l Palliative care l Dying l Marginalised l Hostel This article has been subject to double-blind peer review.

T Wendy Ann Webb, Palliative and Medical Advanced Nurse Practitioner, Evesham Community Hospital, Worcestershire Health and Care Trust, UK Correspondence to: wendy@registerednurses. com

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he Department of Health (DH) in the UK asserts that palliative and end-of-life care (EoLC) should be available at the point of need (DH, 2009). This care should also be universally accessible and inclusive, ‘wherever the person may be’ and ‘irrespective of socioeconomic deprivation’ (DH 2008: 2). Widening access to palliative care services has consequently received much political interest and government funding (DH, 2008; Help the Hospices, 2012). Nevertheless, the fact remains that some of the more vulnerable and marginalised groups of society, including the homeless population, still fail to access the palliative and end-of-life care services they need (Help the Hospices, 2012; Nyatanga, 2012).

Dying and homeless: doubly disadvantaged? There are some people who face the end of their life with a sense of peace and with calm acceptance, yet there are many others who experience vulnerability, fear and anxiety (DH, 2011). Dying people have therefore been specifically described as a vulnerable population. The homeless population could also be described as a vulnerable population (Collier, 2011). Indeed, many homeless people have grappled daily with issues of vulnerability and powerlessness, having faced each day of life without the most basic security of a safe and stable home (Song et al, 2007a). Homeless people who are also dying are therefore arguably a doubly disadvantaged and the doubly vulnerable group in society (DH, 2010a), who probably need even greater support at the end-of-life than other groups of people. Yet homeless people continue to experience greater difficulty than other groups of society in accessing palliative and EoLC services (Help the Hospices, 2012; Nyatanga, 2012).

The dying homeless: a hidden social problem Official statistics report that homelessness is officially on the increase in the UK (Department for Communities and Local Government, 2013). Homelessness is considered to be a complex and ever-increasing social problem which, in these times of economic recession, is likely to persist. It is in fact a global problem. However, despite rising statistics, homeless people are still described as ‘a hidden population’ (DH 2010a: 3), who also ‘often report feeling invisible’ (DH 2010b: 12). It is difficult to calculate the exact figures in the UK, however, it is estimated that approximately 40 500 homeless individuals are in the UK hostel system at any given time (DH, 2010a). In the UK, hostels exist to provide temporary accommodation for homeless people; usually in the form of a small, basic bedroom within a large purpose-built or specifically-adapted building. However, there

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Abstract

International Journal of Palliative Nursing 2015, Vol 21, No 5

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are many more homeless people living in squats and sleeping rough on the streets. A further interesting statistic is the average age of death among people known to be homeless. In the UK, this was found to be somewhere between 40 and 44 years of age (DH, 2010c). Mortality rates are higher among homeless people than in the general population and yet they generally live in environments which are not considered to be ‘conducive to palliative care’ (Podymow et al, 2006: 81). It is therefore quite reasonable to suspect that such individuals may be in greater need of hospice in-patient facilities than the general population. However, homeless people are definitely under-represented in UK hospices and Specialist Palliative Care (SPC) units; this is evidence that they are failing to access these inpatient services (DH, 2010a).

Barriers to receiving end-of-life care services The literature surrounding palliative care for homeless people to date concentrates predominantly on both the perceived and the actual barriers to receiving such care. However, a detailed exploration of these identified barriers is clearly beyond the scope of this paper. Table 1 summarises the wide range of barriers identified in the current literature.

Choice, dignity and respect: the foundations of effective end-of-life care


Choice is central to the ethos of palliative and EoLC (National Council for Palliative Care (NCPC), 2011a). For most people, the idea of a good death involves being pain-free and being free from other distressing symptoms (DH, 2008; 2009). However, a good death also involves having the freedom to make certain fundamental choices and being cared for with respect and dignity (DH 2008; 2009) and in familiar home surroundings (DH, 2008). The wide range of barriers, highlighted in the literature (Table 1), severely compromise the choice, dignity and respect that is offered to homeless people (DH 2010b). This means that the core foundations of palliative care provision are missing for this particular population group, hindering access to optimal palliative and EoLC services (Lewis et al, 2011).

Hostel-based palliative care: the way forward? Creative solutions and innovative service developments are desperately needed (Help the Hospices, 2012), possibly imitating the crucial coordinator role pioneered by St Mungo’s hostel


Table 1. Barriers identified in the literature Barrier identified

Reference

Competing priorities

DH, 2010b, Collier, 2011; McNeil and Guirguis-Younger, 2011

Complexity of need

Podymow et al, 2006; DH, 2010c; McNeil et al, 2012

Negative previous experience

DH, 2010b

Lack of trust in authority/ health-care providers

DH, 2010b; Collier, 2011; McNeil and Guirguis-Younger, 2011

Lack of continuity and interruptions to care

DH, 2010b, McNeil and Guirguis-Younger, 2011

High levels of drug/substance abuse

DH, 2010c, McNeil and Guirguis-Younger, 2011, McNeil et al, 2012

Mental illness

DH, 2010b; 2010c

Inflexible processes/appointment systems/non-attendance

DH, 2010c; DH, 2010b; Dorney-Smith, 2011; McNeil and Guirguis-Younger, 2011

Prognosis driven, referral based system of access to specialist palliative care in the UK

McNeil et al, 2012

Professionals’ poor understanding of the specific needs of homeless people

Song et al, 2007b; DH, 2010b; 2010c

Transport and other costs

DH, 2010b

Communication, language and literacy

DH, 2010b

Discrimination/myth that hospices are for ‘middle class’

Ahmed et al, 2004; DH, 2010b; McNeil et al, 2012

in London, UK (Nyatanga, 2012). Traditional, existing models wrongly assume that all people have a number of fundamental resources such as relatives and a roof over one’s head (Song et al, 2007b). However, homeless people often do not have access even to these basic resources. The DH has therefore suggested that hostel-based palliative care is the obvious way forward (DH, 2010a). The DH also suggests that hostel staff are not only the most appropriate people to provide advocacy and support for a homeless person who is approaching the end of life, but also that hostel staff are the people who are most likely to recognise when a homeless person’s health is deteriorating (DH, 2010a). However, little is known about the perceptions of the staff at such hostels regarding palliative and EoLC for the homeless population. In fact, there have been no published research articles to date, in the UK or internationally, on the views and perceptions of hostel staff concerning the provision of hostelbased palliative care to homeless people. A ‘CINAHL Plus’ and ‘MEDLINE’ database search which was conducted, using the terms ‘palliative care OR dying OR end of life’ AND ‘homeless’ in the abstract, and the search uncovered only 11 results. A comprehensive ‘Summon’

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●●The participant must work in a second-stage (intermediate/long stay) hostel for homeless people in one of the three counties ●●The participant must work at the hostel in a position that requires regular face-to-face contact with the homeless people who live there ●●The participant must be over 18 years of age ●●The participant must be able to articulate their perceptions and their experiences of working with and caring for homeless residents ●●The participant must have the permission of the hostel manager to be involved in the study.

search carried out using the same terms uncovered a small number of relevant government policy documents and many short reports and commentaries. However, very few original research papers were found concerning palliative or EoLC for homeless people and none at all were found on the subject of hostel-based palliative care to homeless people.

Methods

Qualitative design

A qualitative approach was adopted for this study, exploring the perceptions and lived experiences of people working in hostels where the homeless ‘residents’ may be approaching end of life. More specifically, after careful consideration of the many and various qualitative frameworks and methodological approaches, a descriptive phenomenological approach was found to be the ‘best fit’ for this study because descriptive phenomenology involves deep exploration of lived experience and careful portrayal of these experiences, ultimately leading to deeper understanding and fresh insights (Polit and Beck, 2010).

Ethical approval Careful plans were made to address ethical issues and safeguarding study participants. Informed consent was obtained from each participant prior to the interview. Unconditional ethical approval for this study was granted from the Worcester University Research Ethics Committee before data collection began.

Study participants In order to offer an adequate, appropriate and diverse sample of study participants and to help to capture a more complete picture of the phenomenon under study (Polit and Beck, 2010), this was a multi-site study, recruiting participants from the staff of homeless hostels across the three counties in Central England. Initially, telephone and email contact was made with Homeless UK (the national charity supporting homeless organisations in the UK). Their data-

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base highlighted all hostels providing temporary accommodation to adults over 25 years (rather than 18–25 year olds). The managers of these hostels were then contacted individually in writing to seek preliminary support for the study. Those who responded were later contacted again with more formal information about the study, inviting their hostel staff to participate. Support for the study was initially secured from the managers of seven hostels across these regions. However, due to workload pressures and service redesign, some managers later opted not to participate. Finally, seven participants, who had experience of working with dying homeless people within the hostel environment and who met the eligibility criteria in Box 1, were recruited to participate in the study. The participants worked in four different hostels across the three counties.

Data collection The narrative data for this study was collected through semi-structured, in-depth, face-to-face interviews. The seven participants shared their experiences of working with homeless people who have been approaching the end of life while living within a hostel environment. Each interview lasted between 32 and 55 minutes and a total of 37 specific case studies were discussed across the seven interviews. The case studies involved homeless residents with a wide range of life-limiting or palliative conditions. The interviews took place at each participant’s place of employment (hostel) during their paid working hours as this was believed to be most convenient for the participants and would thereby encourage consent to take part. The discussions were intentionally relaxed and loosely structured, following a written topic guide and using just nine open questions to encourage free and open expression of the study participants’ relevant experiences and perceptions. The written topic guide or interview schedule (Box 2) contained some further possible prompts, but this was available as a useful aid during the interviews, rather than a rigid, prescriptive tool. All participants gave consent for the interviews to be audio-recorded and then transcribed, however, a technical glitch prevented the audio-recording of one interview. For that interview, handwritten notes were made both during and immediately after the interview. Data were collected over a 4-month data period (November 2013 to March 2014) with the study having a cross-sectional rather than a longitudinal perspective. This means that there was one single data-collection point (one interview date) for each study participant. Data triangulation (space trian-


Box 1. Eligibility criteria for inclusion in study



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gulation) between the multiple sites and counties enables the study to capture a more complete picture of the phenomenon under study and test for cross-site consistency (Polit and Beck 2010).

Data analysis Several interpretations of the data analysis process exist for this type of study (Colaizzi, 1978; Giorgi, 2009). However, Giorgi’s (2009) four-stage phenomenological method of data analysis was adopted for this study for its simplicity and its clarity. These four stages are summarised as follows: 1. Developing a total impression 2. Identifying meaning units 3. Articulating the insights in each individual meaning unit 4. Summarising their importance. This four-stage process took place after each interview had been transcribed. The transcripts of the interviews were then scrutinised to identify important phrases used, ideas expressed and major themes identified, all of which were allocated codes. This process of coding qualitative data is extremely involved and time-consuming and analysis of the whole process itself is beyond the scope of this report. After coding, the computer-assisted qualitative data analysis software package, NVivo, was used to further explore the data and to facilitate data management, creating both ‘text word frequency’ queries, which allow the use of a particular word such as ‘vulnerable’ to be viewed in context (Figure 1) and also creating ‘tag clouds’ which focus the attention of the analyst and highlight frequently used words in diagrammatic form (Figure 2).

1. Can you tell me about your current role and how long you have worked with homeless people? 2. What do you think of when you hear the terms ‘palliative care’ and ‘end-of-life care’? 3. Can you think of any past residents who seemed to be approaching the end of their life while they were at the hostel? 4. In your current role, in what ways do you (or could you) offer support to a resident who is approaching the end of their life? What do you think your role involves (or could involve)? 5. The Department of Health has produced a document (show a copy) about improving end-of-life care for homeless people in hostels. Has anyone shown it to you or sent you a copy? 6. How would you feel personally about being a key worker for a resident who was approaching the end of life? 7. What aspects of such a role might be difficult for you? Can you think of anything that might hinder your ability to support dying residents? 8. Is there any extra support or training would you like to receive?

(four of the seven participants) articulated a broad, holistic understanding of palliative care and the principles behind it: ‘It’s about giving dignity and choice ... palliative care can happen anywhere, in a variety of settings not just in hospices.’

Discussion

The other three participants expressed either very limited understanding or even confusion concerning what actually constitutes palliative care and concerning their own role in providing it, but when questioned specifically about people in their hostel accommodation, they all spoke freely about individuals who were approaching the end of life and needed care. The phrase ‘palliative care’ can be vague and open to interpretation, which needs careful clarification (National Institute for Health and Care Excellence (NICE), 2004) and as such appears to have the potential to create confusion in both health-care and nonhealth-care circles. However, the term ‘end-of-life care’ is one that is more simply defined in the literature as being care provided during the last year of life (NCPC, 2011b: 4) and is a term that was also immediately recognised by all participants in this particular study. Interestingly, the term ‘life-limiting illness’ was understood in very broad terms with one participant, expressing the interesting view that mental illness is a significantly life-limiting condition. This same participant concluded the interview by posing the challenging question of whether acute crisis intervention (in successful suicide attempts) also constitutes EoLC:

Participants demonstrated variable understanding of the concept of palliative care. The majority

‘End-of-life care, in my experience here, can be minutes, or days, or weeks ... we have sent people to the hospital who have committed cata-

Recurrent themes Detailed analysis of the interview data allowed identification of eight recurrent themes: ●●Understanding palliative care ●●Working with limited medical information ●●Taking responsibility ●●Building rapport ●●Upholding residents’ dignity ●●Recognising physical deterioration ●●Managing environmental challenges ●●Role limitations and support needs of hostel staff. The discussion section of this article will be presented under four sub-headings that explore the deeper issues behind these eight themes. © 2015 MA Healthcare Ltd

Box 2. Interview schedule

Palliative care: policy, principles and practice



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Figure 1. NVivo text search query

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Participants pointed out that the homeless residents do sometimes share relevant and accurate information about their diagnoses with their key worker at the hostel, but that this does not happen until a rapport of trust has been established. ‘You have to build a relationship with these people before they will say “I’ve got leukaemia and I’ve got 6 months left.”’

Participants explained that some homeless people themselves do not want to know about their own diagnoses or do not want to talk about their health concerns. Fear was highlighted as the cause of this avoidance behaviour:

Figure 2. NVivo word frequency query strophic acts and you are aware as they are going out the door that there is a very high likelihood that this person will not survive this event. Is that end-of-life care?’

Further exploration of this interesting question is beyond the scope of this paper, but has been included in the findings as it challenges the

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‘Well we don’t know because people don’t tell us what the diagnoses are …’

‘There’s a massive fear ... they’re not getting investigated … they’re not getting a diagnosis.’

Participants expressed that lack of medical information presents a significant challenge to hostel staff who are trying to support dying residents. Clearly this is an issue that still needs to be


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widely accepted and current thinking within palliative care (DH, 2009; NCPC, 2011a). Participants clearly expressed frustration at the lack of access to any specific medical or healthrelated information, other than that which the homeless residents choose to share.

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addressed. One of the most serious consequences of this phenomenon is that hostel workers usually have inadequate or inaccurate medical information about their residents. It could be suggested that if the DH is advocating and endorsing ‘hostel-based palliative care for homeless people’ (DH, 2010a), as a solution to the documented inequalities in access to palliative care, and if the DH is expecting hostel staff to ‘engage with key professionals and palliative care professionals’ on behalf of the residents they support (DH, 2010a: 5), then hostel staff, like other social care agencies, must be permitted access to accurate, up to date medical information. A further interesting and yet disappointing finding of this study is that none of the participants were aware of the practical guidance document produced by the DH (2010a), which was intended to be a practical guide specifically aimed at helping hostel staff to achieve quality EoLC for homeless people living in hostels. Not one single participant had seen it. Several participants demonstrated genuine surprise that they had not even heard of such a document, as the following comment demonstrates: ‘Not that I’ve seen and I probably would have because ... I used to be deputy manager and have been very involved.’

This finding casts serious doubt over whether the document was disseminated and intended to be used in practice, or whether it was in fact merely a paper exercise, representing another example of the prolific policy–practice gap (Hunter and Killoran, 2004).

Professional boundaries: a threat to holism and a hindrance to dignity Participants highlighted the extra work created for them as they advocate for the homeless and attempt to persuade other professionals to accept responsibility for meeting the complex care needs of homeless people with palliative conditions:


‘It was really hard trying to get someone on the side with us … It was so negative the responses we were getting.’

Specific case studies where homeless residents were referred from one service to another with no one service provider taking responsibility for the provision of care was outlined by five of the seven participants. ‘But again it was about trying to get someone to take responsibility for his care ...’.


Concerning professional jurisdiction and boundaries, all seven participants drew attention to the boundaries and limitations of their particular role and recognised themselves as support workers rather than personal care workers. One participant expressed it in the following way: ‘At the end of the day I’m not a personal carer. My job is not personal care.’

❛None of the participants were aware of the practical guidance document produced by the DH.❜

Difficulties accessing personal care for homeless people which then compromises the dignity of homeless people nearing the end of life, is an issue that has not been documented previously in the literature and appears to represent new information. Participants explained that personal care is generally not part of the role of key workers within hostel settings and that this type of carerelated task crosses the boundaries of their support and advocacy role. There were also issues surrounding the administration of medicines, as hostel staff members have not had training in this. Such adherence to professional jurisdictions and role boundaries represents a genuine threat to holism, a basic tenet of palliative care (NICE, 2004) and also a fundamental principle of wider nursing and social care philosophies. There is also arguably a need for ‘flexible, boundary-blurring professionals’ to collaborate and plan palliative and EoLC services for this vulnerable, marginalised population (Collier, 2011).

No choice or voice: the social undesirability and invisibility of the dying homeless The homeless residents in the case studies often had limited, if any, choices made available to them regarding care options, despite ‘choice’ being central to the ethos of palliative care (NCPC, 2011a; 2011b). Their dignity is also a concern to hostel workers. Indeed, most participants identified dignity as a specific concern in the care of their residents, even though there were no specific prompts or questions surrounding dignity and this word was intentionally not used by the interviewer. ‘These people have not had much dignity—it’s about giving that back to them.’

The same participant also made the following observation: ‘Everyone here is someone’s son and deserves dignity.’

Participants identified a number of sub-themes,


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relevant to upholding the dignity of dying homeless residents. This included enabling choice regarding care options and advocating for residents as they attempt to access relevant services.

‘The resources thing is—are we really an appropriate environment? Do we have rooms that are equipped for people who are reaching the end of their life?’

‘Advocating for the resident and helping them to have a say in what happens.’

In addition to these practical concerns regarding facilities, participants drew particular attention to issues of community living and the vulnerability of all other residents in the hostel environment. They expressed particular concerns regarding the emotional burden and stress placed on other residents who sometimes feel they need to look out for their sick co-residents in the way one would for a close family memb e r, a s t h e f o l l o w i n g t w o c o m m e n t s illustrate clearly:

The paramount importance of helping residents to have a voice that is heard and therefore undertaking an advocacy role was readily acknowledged by six of the seven participants in the study. However, participants expressed that the dying homeless residents were frequently referred from one service provider to the next with no single organisation taking responsibility for organising care provision for this vulnerable, disadvantaged, marginalised, invisible, stigmatised and essentially socially undesirable population (DH, 2010b; 2010a). Participants sometimes felt they were actually battling with health care staff and expressed significant concerns about the way that some health care staff had treated homeless people. Concerns were expressed that the homeless people they had supported seemed to be treated differently to other sick people: ‘I think it’s difficult to be taken seriously, you know. They can access medical services but I think it’s that … they’re not listened to. Yeah that seems to be the problem.’

Participants in this study found that the homeless person’s symptoms and distress were not always taken seriously by health professionals who seemed to have very limited understanding of the specific needs of this population. These findings are consistent with previous research describing health professionals’ poor understanding of the needs of the dying homeless (Song et al, 2007b; DH, 2010b; 2010c) and would seem to suggest that health professionals would benefit from training to recognise and address the specific needs of this client group, who ‘often report feeling invisible’ (DH 2010b: 12).

Community living: the biggest barrier or a new concept of family? While the issue of unsuitable temporary accommodation is mentioned in the literature (Nyatanga, 2012), it is not given huge significance. However, one theme articulated frequently by participants in this study is that of the challenges the hostel environment itself presents when trying to support homeless residents whose condition is rapidly deteriorating.

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‘You’d also have other residents who were really worried. You know and it’s not appropriate for them to start caring for people and so it’s really difficult, really difficult.’

Participants described instances of other residents calling ambulances and even finding the person dead in the morning: ‘He was found dead [by other residents] in the early hours of the morning.’

Participants explained that hostel staff members also often function as a family to the homeless residents, sharing a deep and genuine rapport. In fact, every single one of the seven participants referenced instances where hostel staff had acted above and beyond the call of duty for a resident in need of palliative care. ‘That weekend when I spent 17 hours at the hospital it was in my own time.’

Participants had even visited dying residents while they were off duty in order to meet their emotional needs. Two had worked unpaid in order to be there for the resident’s final moments of life and one staff member described a scenario where she took complete responsibility for arranging the resident’s funeral. Participants readily identified that they carry a huge emotional burden for residents dying in their hostels and described personal feelings of guilt, trauma, sadness, upset, worry, devastation and stress. The word ‘horrendous’ was used on three occasions by two different participants to describe situations they had faced. Other powerful words used were ‘traumatic’ and ‘devastated’. However, in spite of these comments, most participants described feeling very well


❛Hostel workers in this study demonstrated incredible resilience, compassion and creativity in the face of challenging palliative and EoLC situations.❜



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supported from within their hostel-based team and received excellent peer support from within their employing organisation. Participants acknowledged both the importance and the necessity of this peer support: ‘I think in this line of work, you have to be very resilient ... if you are not, then potentially some of the things you are going to come across in this job, and deal with, some of the stuff you deal with is going to take you to some very dark places.’

Hostel workers in this study demonstrated incredible resilience, compassion and creativity in the face of challenging palliative and EoLC situations. Nevertheless, they still have their own support and learning needs which must not be overlooked if hostel-based palliative care really is the way forward and if hostel staff will be the key workers for homeless people approaching the end of life.


Strengths and limitations of the study The major strength of this study lies in the methodological approach adopted. The author offers clear justification for the choice of methodology and for the methods used and has worked to maintain congruence throughout the study. Furthermore, this is a multi-site study, recruiting participants from hostels across three counties in England. Such data triangulation means that the diverse sample of participants captures a more complete picture of the phenomenon under study and tests for cross-site consistency. This in turn enhances the transferability of the findings of this study to the general population of hostel workers. The ethical issues surrounding this study were carefully considered and clear steps were taken to minimise any potential risks. There are, however, several limitations of this study. Firstly, there are obvious limits to the generalisability of this study as participants were included from only four hostels. Given that staff roles tend to be moulded by specific features of the organisation they work in (Hannigan and Allen, 2011), it is not really possible to generalise the findings of this study to the workers of hostels across other parts of the UK. Nevertheless, it is hoped that the findings of this study will still be of benefit to health and social care professionals who work with homeless people or in palliative care. A further limitation of the study is the lack of availability of evidence concerning researcher reflexivity. However, while it has not been possible to


include the researcher’s reflexive journal in this paper, the full research report includes many appendices which contain extracts of interview transcripts and NVivo reports which enhance the overall quality and trustworthiness of this qualitative study.

Conclusion This study demonstrates that there is still much work to be done in terms of making high-quality palliative care truly accessible for homeless people. Hostel workers in this study demonstrated incredible resilience, compassion and creativity in the face of challenging palliative and EoLC situations. In addition to this they genuinely care about the residents with whom they have built trusting family-type relationships and they already work to promote dignity and choice. These findings clearly lend support to the suggestion that hostel workers probably are indeed the most appropriate people to support a dying homeless person. However, enhanced collaborative working, access to accurate and up-to-date medical information and clearer lines of communication between health professionals and hostel workers could result in better outcomes for this population in terms of having a voice that is heard, being offered choices regarding care options, and being treated with the same dignity and respect that the rest of the population has come to expect at the end of life.

❛Participants drew particular attention to issues of community living and the vulnerability of all other residents in the hostel environment.❜

Recommendations for future research This study suggests the need for further research in the following areas: ●●The concept of palliative care, particularly in relation to mental illness and whether certain individuals with ‘life-limiting’ mental illness could meet the criteria for accessing specialist palliative care services ●●The impact of ‘hostel-based palliative care’ initiatives on other vulnerable residents in the hostel ●●The potential benefit of ‘palliative care family support’ interventions for both hostel staff and co-residents of dying homeless people ●●The perception of hostel staff regarding the value of a local Palliative Care Coordinator role specifically for homeless people. Declaration of interests The author has no conflicts of interest to declare. Ahmed N, Bestall J, Ahmedzai S et al (2004) Systematic review of the problems and issues of accessing specialist palliative care by patients, carers and health and social care professionals. Palliat Med 18(6): 525–42 Collier R (2011) Bringing palliative care to the homeless.


Research

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Call for peer reviewers International Journal of Palliative Nursing is very grateful for the advice provided by its pool of dedicated volunteer peer reviewers and always appreciates new offers from experienced clinicians and academics interested in helping out. If you would like to be considered for the peer review team, please send a brief CV and details of your particular areas of expertise or interest to the Editor: [email protected]

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Guidelines for reviewers are available.



Transition to palliative care when transcatheter aortic valve implantation is not an option: opportunities and recommendations.

Providing Palliative Care in a Swedish Support Home for People Who Are Homeless.

Dying homeless receiving little palliative care, study finds.

Is home-based palliative care cost-effective? An economic evaluation of the Palliative Care Extended Packages at Home (PEACH) pilot.

Dying at home: a qualitative study of family carers' views of support provided by GPs community staff.

One in five dying people do not receive the palliative care they need.

[Palliative care practices at home: instead of social exclusion of older people in later life?].

An exploration of NHS staff views on tuberculosis service delivery in Scottish NHS boards.

Grief and the experiences of nurses providing palliative care to children and young people at home.

Providing end-of-life care in care homes for older people: a qualitative study of the views of care home staff and community nurses.

First-Line Nursing Home Managers in Sweden and their Views on Leadership and Palliative Care.

Ignorance is not an option.

When vision is not an option: children's integration of auditory and haptic information is suboptimal.

Homeless people and psychiatric care.

Caring for Dying Patients in the Nursing Home: Voices From Frontline Nursing Home Staff.

The challenges of dying: lessons for palliative care.

Futile Education: When Graduation Is Not the Best Option.

End of the Road: Diabetes Care When Insulin May Not Be an Option.

The Use of Emergency Medication Kits in Community Palliative Care: An Exploratory Survey of Views of Current Practice in Australian Home-Based Palliative Care Services.

Physician-assisted death is not palliative care.

Paediatric palliative care at home: a single centre's experience.

Nursing Home Staff Palliative Care Knowledge and Practices: Results of a Large Survey of Frontline Workers.

Is effective, person-centred, home-based palliative care truly achievable?

Patient-centered care or cultural competence: negotiating palliative care at home for Chinese Canadian immigrants.