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Table 1 Characteristics of papers included in review

From: Challenges to access and provision of palliative care for people who are homeless: a systematic review of qualitative research

Reference Author Title Setting N Participants Data collection methods Analytical approach Main findings Critical appraisal score
[39] Tarzian, Neal & O’Neil (2005) Attitudes, Experiences, and Beliefs Affecting End-of-Life Decision-Making Among Homeless Individuals USA 20 Homeless people Focus groups Thematic analysis Five main themes:
1) Valuing an individual’s wishes;
2) Acknowledging emotions
3) The primacy of religious beliefs and spiritual experience;
4) Seeking relationship-centred care
5) Reframing advance care planning.
[36] Song et al. (2007) Dying on the streets: homeless persons’ concerns and desires about EoLC USA 53 Homeless people Focus groups “Consensual qualitative research” 3 step inductive analytic process Personal themes:
1) Experience of EoLC
2) Fears and uncertainties around lack of dignity and dying anonymously
3) Preferences wishes and
4) Advance care planning
5) Spirituality & religion
6) Veteran status
Relational themes:
1) Relationships with known people/burden to others
2) Relationships with strangers
3) Communication tools
Environmental factors
1) Barriers and facilitators to good EoLC
2) Participant suggested interventions
[37] Song et al. (2007) Experiences with and attitudes toward death and dying among homeless persons USA 53 Homeless people Focus groups “consensual qualitative research” 3 step inductive analytic process Personal themes:
1) Early loss
2) Experience with death
3) Personal life threatening experiences
4) Fears and uncertainties
5) Coping strategies
6) Approach to risk, risk management and risky behaviours
Relational themes:
1) Relationships with strangers
[29] Ko, Kwak & Nelson-Becker (2015) What constitutes a good and bad death?: perspectives of homeless older adults USA 19 Homeless people (aged 60+) Semi structured individual interviews Grounded theory A good death
1) Dying peacefully
2) Not suffering
3) Experiencing spiritual connection
4) Making amends with significant others.
A bad death
1) Experiencing death by accident or violence
2) Prolonging life with life supports
3) Becoming dependent while entering a dying trajectory
4) Dying alone
[30] Ko & Nelson-Becker (2014) Does end-of-life decision making matter? Perspectives of older homeless adults USA 21 Homeless people (aged 60+) Semi structured individual interviews Grounded theory 1) EOL topic is uncomfortable
2) God plans EoLC
3) Physicians are preferred as decision makers
4) EoLC is not a priority
5) need for sensitivity
[39] Davis – Berhman (2016) Serious Illness and End-of-Life Care in the Homeless: Examining a Service
System and a Call for Action for Social Work
USA 14 Homeless people, hostel staff, outreach staff and health and social care professionals Interviews Grounded theory Lack of services for serious, chronic
and life threatening illness,
Barriers to access to services
End-of-life care.
[6] Hakanson et al. (2015) Providing palliative care in a Swedish support home for people who are homeless Sweden 12 Hostel staff Group and individual discussions Interpretive description 1) Conditional factors framing palliative care
2) Building trustful- family like relationships
3) Re-dignifying the person
4) Re-defining flexible and pragmatic care solutions
[38] Webb (2015) When dying at home is not an option: Exploration of hostel staff views on palliative care for homeless people UK 7 Hostel staff Semi structured individual interviews Four stage phenomenological method 1) Understanding of palliative care
2) Working with limited medical information
3) Taking responsibility
4) Building rapport
5) Upholding residents dignity
6) Recognising physical deterioration
7) Managing environmental challenges
8) Role limitations and support needs of hostel staff
[33] McNeil & Guirguis-Younger (2011) Illicit drug use as a challenge to the delivery of end-of-life care services to homeless persons who use illicit drugs: Perceptions of health and social care professionals Canada 50 Canadian Health care professionals and hostel workers Semi structured individual interviews Grounded theory Barriers to EoLC services:
1) Competing priorities
2) Lack of trust of healthcare providers
3) Exclusion from traditional end-of-life care settings
Challenges to EoLC service delivery:
1) Non-disclosure of illicit drug use
2) Pain and symptom management
3) Interruptions in care as a result of illicit drug use policies
4) Lack of understanding of addictions and palliative medicine
[34] McNeil, Guirguis Younger & Dilley (2012) Recommendations for improving the end-of-life care system for homeless populations: A qualitative study of the views of Canadian health and social services professionals Canada 54 Canadian health and social care professionals Semi structured individual interviews Grounded theory Perceived barriers to the EoLC system:
1) Availability of end-of-life services and supports
2) operating policies that exclude homeless populations
3) lack of continuity of care
Participant recommendations to improve the EoLC system.
1) Low threshold strategies
2) Partnering community agencies with EoL services
3) Strengthening training for EoLC professionals
[35] McNeil et al. (2012) Harm reduction services as a point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs: a qualitative analysis Canada 54 Canadian health and social care professionals Semi structured individual interviews Grounded theory Harm reduction services as a point of entry to EoL services.
1) Increasing engagement with this population
2) Engaging with clients over time
3) Maintaining relationships with EoLC providers
Harm reduction outreach services as a source of EoLC:
1) Providing EoLC for those unable to access services
2) Providing EoL support for clients who wished to die at home
Residential harm reduction services as a source of EoLC.
1) Providing culturally competent care.
2) Providing EoLC in a home setting
3) Implications of EoLC for regular services
[31] Krakowsky et al. (2012) Increasing access—A qualitative study of homelessness and palliative care in a major urban center Canada 7 Registered nurses (n = 3) & outreach workers (n = 4) Semi structured individual interviews Thematic analysis 1) Homeless persons’ access to palliative care compromised due to previous negative experiences of Homeless people with the health care system.
2) Staff training needed
3) Palliative services must respect the individual’s habits, friends, and preferred surroundings.
4) Diversity needed in vehicles used to deliver palliative care.
[32] Macwilliams et al. (2014) Reaching out to Ray: delivering palliative care services to a homeless person in Melbourne, Australia Australia 6 Managers from hospitals, palliative care services & residential shelters. Semi structured individual interviews Thematic analysis Key concerns from health care providers
1) Late stage presentation and multiple admissions
2) Safe use of drugs
3) Non compliance
4) Staff stress