Palliative care for the homeless: complex lifes, complex care.

Background: Homeless people often encounter multiple problems and have a shorter life- expectancy. Little is known about how palliative care for this group is organized and can be improved. Aim: To explore and describe aspects of the palliative care for homeless people in The Netherlands from the perspectives of the patients, their relatives and professionals. How do they perceive the provided care and what care is needed? Methods: In this qualitative study nineteen cases of homeless people needing palliative care were studied. Eight persons were identified as in need of palliative care (using the ‘surprise question’) and eleven persons recently died. Semistructured interviews were held in 2014–2016. For each case we interviewed on average 3 people: the homeless person (where possible), doctors, nurses and/or social workers (number of interviews = 55). All interviews were transcribed verbatim and analyzed inductively, using thematic analysis. Open coding, memo writing and constant comparison were supported by MaxQDA software. Results: From the analysis three main themes were derived: ‘access’, ‘capricious trajectory’ and ‘complex care’. The first theme refers to the often limited access to palliative care, e.g. because people are ambivalent regarding accepting care. The second theme refers to the illness trajectory, which is often capricious and non-predictable. The third theme refers to the specific challenges in caring, for instance, with regard to pain and symptom management. This is often complex because of a history of addiction and the often severe physical, psychosocial and cognitive problems. Conclusion: The life of homeless people is often hard, resulting in complex care needs at the end of their life. Cooperation between palliative care professionals and mental health professionals, is needed to improve care for homeless people at the end of life and to realize better access to palliative care