Palliative care among the homeless

04 July 2018

Dr. Naheed Dosani is a palliative care physician with Inner City Health Associates, working in street and shelter-based settings in Toronto, and founder and project lead of PEACH (Palliative Education and Care for the Homeless). The EFC interviewed him in June 2018 in conjunction with our Palliative Care Toolkit, a practical booklet you can download for free.

Below you'll find:

  • a video excerpt from the interview
  • text from the full interview conducted by EFC staff Joel Gordon (JG)
  • questions for personal or small-group reflection

ND: I thought we’d start today’s discussion here at the Church of the Holy Trinity where the homeless memorial is held once a month to commemorate the lives of those who are our neighbours, our brothers, our sisters, our aunts, our uncles, our friends and family who have been lost in the city and in our streets.

Many don’t realize that the average life expectancy of the homeless population in a city like Toronto is 34 to 47 years old. They die at a rate that is 2.3 to 4 times higher than you and me. And while many do think of palliative care as involving a biological, terminal diagnosis, it’s interesting because research has shown that homelessness itself cuts a person’s life span by 50 per cent. And so many are now thinking that homelessness or a lack of stable housing is itself a terminal diagnosis.

Dr. Dosani went on to tell how the story for him really began when he was a first year trainee at the University of Toronto doing an informational rotation at a men’s shelter. He met a man in his mid-thirties named Terry who was experiencing significant pain and distress due to advanced cancer without medical care. Dr. Dosani came back to the shelter the next day to help Terry begin treatment, only to discover that Terry had died in the night. He had overdosed on a combination of alcohol and street drugs. Dr. Dosani was very troubled and asked himself, “How is it possible that someone so vulnerable, so in need, could fall through the cracks again and again and again in a city like Toronto?”

JG: As we look across the country, we know that many Canadians don’t have access to good quality palliative care. What are additional barriers that are faced by those who are homeless?

ND: That’s a great point. I think one of the things that I’ll zone in on is you can’t really deliver community-based palliative care without good access to what we call home care. When you have a home, you can put in nursing and supports and equipment. But when you don’t, how do you address that? And that’s one thing the PEACH program aims to do as a partnership between InnerCity Health Associates and Toronto Central Local Health Integration Network’s home care team, we actually do provide home care for the homeless. That’s one [barrier] that’s really important to consider.

Another [barrier] is the impact addictions can have and that mental health issues can have on getting access to basic health care, but also palliative care. And in a field where we often use opioids and other controlled substances to treat symptoms, there’s often a sense that it might not be appropriate or it may not be safe to provide these medications or prescribe them – but yet this patient population is suffering, and so that makes it so difficult.

The other thing is the difficulties in navigating the health care system when you are struggling to have a roof over your head. You’re spending your days trying to maintain sustenance and keep a sense of dignity within yourself. And then you’re also dealing with your disease in addition to mental health or addictions issues. How do you get to your clinic appointments? How do you meet the home care coordinator who’s aiming to support you in the community when you don’t have a phone, for example?

The social determinants of health become very real, and there is so much health navigation required to interact with a palliative care system. So, really, you need an intensive support system to address and support people in that way. So those are just a few factors that I think are important to consider.

One of the sad things we learn quickly when we meet patients is that they feel they’re not deserving of the support that they’re receiving.

JG: Are your clients grateful and appreciative of the care that your team provides?

ND: Most definitely. Every day working with this population is truly a privilege, an honour, a gift that just keeps on giving not just to us, but obviously to the clients and the patients who themselves feel so grateful for the support they’re receiving. And often, society has kind of said, Well, these are folks who didn’t care about themselves or they did it to themselves. I’ve never met a patient where that’s actually true. There’s often – [no] always – structural socio-economic determinants that have contributed to a person’s place in society and where they are today. Sure, have some of our patients made bad decisions from time to time? For sure, absolutely, but never in isolation. So we do find when we break through some of those barriers around stigma and discrimination that the population is very grateful, and it’s an honour and a pleasure to work with them.

JG: What are some common elements of providing palliative care to someone who is homeless or street-involved or anyone who is terminally ill?

ND: The elements are not that different from supporting housed Canadians. There are still pain and symptoms. They’re sometimes more complicated, sometimes the pain is not physical pain, it’s emotional pain, it’s trauma, it’s discrimination, it’s racism, it’s oppression, and that’s the kind of pain we’re dealing with. The same resources are needed, it’s just the resources that have been kind of defined for the housed population need to be reworked, refitted, so they can work in a boarding house, a shelter, on the streets, whatever that might mean. And the loss and the grief that people experience during their dying process, those psycho-social concerns that we see among housed Canadians, are very similar in this population, just often associated with mental health, with addictions, with colonial histories in some cases, and it’s a bit more complicated. So, really, the issues are the same, our approach might need to be different. And that’s the customized approach for a population that needs that little bit of support to get to the same level of well-being as other housed Canadians. Equity is the name of the game.

Speaking about young adults who may be interested in becoming involved in frontline care, Dr. Dosani encouraged them to approach this service with humility, aware of the power imbalance that exists. He recommended volunteer training, like the training offered at Hospice Toronto. After telling the story of a volunteer who reached out to connect with a dying man, Dr. Dosani ended the interview with these words:

At the end of the day, that’s what it’s all about, a compassionate community. Because that’s what really is the focus and goal of the work we’re trying to do, to showcase that everybody deserves dignity as they approach end of life and deal with disease.

Discussion questions:

  1. Dosani mentions emotional pain, loss and grief, and psycho-social concerns at the end of life. Sometimes as Christians, we’d like to think we have the answer for every question or concern. Loss and grief may not require answers, but they almost always require compassion and support. How can you resist offering “easy” answers and offer practical help instead?
  2. Dosani talks about an approach of humility. Read and consider Philippians 2:3-11. Why is humility so important? How can we follow Jesus’ example in this area?
  3. What does it mean to be a compassionate community where you live? Who needs compassion?
  4. In what ways could you, your family or your church show compassion? What are the barriers to becoming a compassionate community? What changes are possible? Where do you think God may be leading in this area?

Author: Joel Gordon

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