Tens of thousands of people in North America experience homelessness every year [1, 2]—that is, live in conditions unfit for human habitation or temporary or emergency accommodations without housing alternatives —and many thousands more are at risk of homelessness at any given time [1, 2]. Homeless populations in North America, while highly heterogeneous in terms of age, gender, sexuality, and ethnicity, suffer disproportionately from poor health in comparison to housed populations . Chronic health conditions that are common among the homeless include chronic lung diseases , circulatory diseases , and diabetes . Homeless persons also experience higher incidences of substance use [8, 9], severe mental illness [10, 11], and infectious diseases such as HIV/AIDS [12, 13] and Hepatitis C . Daily challenges associated with homelessness (e.g. food insufficiency, exposure, etc.) [4, 15, 16] and barriers to accessing health care services (e.g. discrimination, lack of insurance, etc.) [4, 17, 18] make it difficult to manage medical needs, leading to further deteriorations in overall health. Homeless populations subsequently have among the highest all-cause mortality rates of any population in North America [19–23].
Homeless persons have a high level of need for end-of-life care services [24, 25] and these needs may be increasing due to the steady growth in the number of homeless older adults [26, 27]. It is estimated that more than 58,000 seniors (i.e. 62 years or older) will experience homelessness annually in the US by 2020  and, while estimates are not available for Canada, researchers in various cities have observed upward trends . High levels of morbidity among homeless older adults , in combination with the natural progression of health challenges common among this population (e.g., HIV/AIDS, HCV, etc.), suggest that the end-of-life care system will likely see an increased demand for its services among the homeless in the immediate future.
While the demand for end-of-life care services may be growing among the homeless in North America, this population faces many barriers to accessing end-of-life care services [24, 25, 29, 30]. In North America, the end-of-life care system is largely premised on a series of assumptions that do not reflect the experiences and circumstances of homeless populations. Specifically, the end-of-life care system generally assumes that prospective clients are housed, supported by family and friends, and able to pay for supplementary care. In Canada, where our research was conducted, hospice and palliative care services are underdeveloped  and are structured in ways that limit access for homeless populations. For example, existing service structures emphasize family caregivers and dying-in-place (i.e., the home) [31, 32]. Accordingly, in many regions, end-of-life care services are oriented toward providing home care support and potentially limit access for homeless or precariously housed persons. Hospice and hospital-based end-of-life care services are also available to provide an additional source of care in many communities, especially in urban centres . However, homeless populations are often unable to access hospice or hospital-based end-of-life care due to rules and regulations (e.g. anti-drug policies, codes of behaviour, etc.) that exclude substance-using populations [29, 30]. For example, research suggests that, among those who continue to use alcohol or illicit drugs at end-of-life, abstinence-only policies and discrimination within hospice and palliative care settings serve as a significant barrier to care [29, 30]. Furthermore, homeless persons who use alcohol or drugs may also refuse referrals to hospice and palliative care services due to a range of factors, including real or perceived discrimination in these settings or the preference to die in a familiar environment (e.g., emergency shelter, hostel, etc.) .
Due to these barriers, homeless persons often die with poor health care support  and without accessing the end-of-life care system . Song et al.  have reported that these barriers may serve as a source of anxiety among homeless persons—namely, that they might have poor access to necessary care (e.g., pain and symptom management) due to financial barriers. Several ways to improve end-of-life care services delivery to homeless populations have been previously identified, and have included individual-level and environmental recommendations. For example, researchers have recommended that advance care planning be undertaken with homeless persons and noted that this population is willing to document its end-of-life care preferences [35–39]. Researchers have also documented the benefits of emergency shelter-based end-of-life care services delivery, including cost savings  and cultural competence [24, 30, 40]. And yet, research has not been conducted that has explored ways to improve the end-of-life care system as a whole for homeless populations. Research providing systems-level recommendations is urgently needed to identify structural changes that have the potential to increase access and equity in end-of-life care services for homeless populations.
This article presents recommendations for improving the end-of-life care system for homeless persons based on research conducted in six Canadian cities as part of a national study of homelessness and end-of-life care. The main objectives of this study were to identify barriers to end-of-life care services delivery to homeless persons and identify recommendations to improve the end-of-life care system for this population. The findings presented here take into account the perspectives of health and social services professionals providing care to homeless persons at end-of-life. While this study was carried out in a country with universal health insurance, our findings provide insights that may strengthen end-of-life care services delivery to homeless persons elsewhere given the barriers they face to accessing care even when healthcare coverage is available .