Background People experiencing homelessness suffer significant morbidity and significantly higher standardised mortality rates compared to the general population (Aldridge, Story, Hwang, et al., 2018. The Lancet. 391:241). People experiencing homelessness worry about their death, dying alone and where they will die. Previous bad experiences of healthcare may also lead to fear that they will not be offered symptom control at the end of life (Song, Bartels, Ratner, et al., 2007. J Gen Intern Med. 22: 435; Ko, Kwak & Nelson-Becker, 2015. Death Stud. 39:422; Krakowsky, Gofine, Brown, et al., 2012. Am J Hosp Palliat Med. 30: 268). Engagement with palliative care of people experiencing homelessness is poor due to late recognition of ill-health, unpredictable disease trajectory and complex care (de Veer, Stringer, van Meijel, et al., 2018. BMC Palliat Care. 17).
Aims To observe whether the introduction of a Homeless-Palliative Care MDT could improve recognition, engagement and discussions of end of life care.
Methods A two-year audit (Audit 1: 2017-19) was carried out looking at deaths of people experiencing homelessness registered with a GP practice providing specialist primary care for this group. A re-audit covering two years (Audit 2: 2020-2022) was conducted following the introduction of a Homeless-Palliative Care MDT comprising Homeless GPs, Homeless Outreach Nurses, Consultants in Palliative Medicine and a Palliative Care-Homelessness Nurse. The following were used as markers of recognition of ill-health and engagement with end of life discussions: Patient included on the Gold Standards Framework (GSF) register, review by specialist palliative care professional, documented discussions of Preferred Place of Care or Death (PPC/D) and whether a DNACPR was issued.
Results Recognition of dying and anticipatory planning improved following the introduction of the Homeless-Palliative Care MDT. The proportion of patients who died that were included on the GSF register increased from 31% to 90%; the proportion who had a specialist palliative care review increased from 13% to 90% and the proportion of patients with a recorded PPC/D and DNACPR increased from 19% for each to 70% and 75% respectively.
Conclusion Establishing a Homeless-Palliative Care MDT drawing on specialist knowledge of homeless healthcare and palliative care reduces barriers to access and allows engagement, choice and empowerment for people experiencing homelessness at the end of their lives.
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