Table 3 The care provided care: barriers relating to homeless people, interaction between homeless people and healthcare professionals, and healthcare professionals

In relation to receiving healthcare

 • End-of-life care is not a priority; to obtain the basic necessities of survival and living on a day-to-day basis takes precedence over efforts to obtain health and/or end-of-life care [23, 26, 34, 38, 43]

 • Drug and/or alcohol dependence and non-disclosure of illicit drug use may lead to decreased opportunities for persons to remain in their usual abode or to receive and/or adhere to treatment at traditional end-of-life services due to anti-drug policies [26, 27, 34, 47]

 • Planning care activities and attending for hospital appointments is often difficult: patients frequently do not adhere to expected routines, arrangements for health service activities, GP and hospital appointments and often have to be reminded about their condition, homeless people are reluctant due to a long waiting time and/or they self-discharge [32, 34, 37]

 • Very late stage of seeking help and thus medical problems that are difficult to handle and multiple admissions before death [37, 43, 47]

 • A lot of homeless people are unwilling to accept the recommended treatment [44, 47]

 • Pain and symptom management of homeless persons who use illicit drugs (high levels of opioid tolerance) and specialists who are unable or unwilling due to fears that they would be liable for adverse reactions [26]

 • Lack of health insurance [43]

In relation to social relationship

 • No support from family members or relatives and small networks and many without trusted peers [30, 33, 37]

 • A lot of homeless people who have psychiatric illness and are paranoia, refuse multiple offers of housing [44]

 • Travel and access to transport when living in a rural area [34]

 • Relationships between healthier and sicker patients are complex and sometimes manipulative to gain access to further alcohol [32]

 • Death and dying does affect other homeless patients [32]

In relation to (health) behaviour

 • Limited insight into their condition or unable to acknowledge illnesses [32, 44]

 • Problems relating to alcohol and/or drug addiction, such as denial of addiction, bingeing, ignoring of risks of overdose [32]

 • Aggressive or changing behavior [32]

 • Unwillingness to pay attention to their personal hygiene [32]

• Feelings of being ignored, discriminated and disrespected by healthcare providers and a lack of trust and suspicion (e.g. shown disrespect, withholding of pain medication, inappropriately short hospital stays, not respecting wishes) that initially has to be overcome before any treatment could be started [26, 33, 35,36,37,38, 45]

• End of life is an uncomfortable topic; some homeless persons do not want to know about their own diagnoses, do not want to talk about their health concerns or are incapable of talking comfortably about death and dying [23, 35, 36]

• Barriers to achieving the level of communication and connections homeless people desired, e.g. too little time to chat with staff and volunteers because they were busy [34, 39]

• Patients engage with internal services such as key and substance misuse workers but rarely with mental health or social workers [32]

• Homeless people express many misperceptions and uncertainties about surrogate decision-making [28]

• Homeless persons often describe their problems in a jumbled manner, understanding the most prioritized needs is thus not always easy [37]

Knowledge and skills

• It is difficult for staff to determine when a patient is nearing the dying phase and to establish palliative care needs; staff members’ notions of palliative care vary and opportunities to prevent deaths are being missed [32, 33, 35, 37, 43]

• Deaths of homeless patients are often sudden, staff were often upset [32, 33]

• Hostel staff are often not able to plan for end-of-life care with patients [32]

• Medical intake personnel (in hospital) do not know how to deal with a homeless person 47]

• Little opportunity for funding or training shelter staff in palliative care [45]

• Working with limited medical information [35]

• Staff of healthcare services not being knowledgeable about the unique issues facing the homeless [36]

• Often difficult to interpret reaction of patients suffering from mental illness and/or illicit drug use [37]

• Trying to solve all of a patient’s problems at once is seldom successful [37]

Organization

• Access to palliative care, primary care and/or preventive services is minimal (due to competing priorities, attitude of healthcare professionals, anti-drug policies, not conforming to procedures, healthcare system’s nonadherence to harm reduction strategies, a lack of caregiver support and/or financial resources) and a significant proportion of homeless persons may be underusing healthcare [25, 27, 28, 32, 36, 38, 43, 47]

• Lack of appropriate housing, beds, respite or hospice facilities and programmes and care sites for homeless people at the end of life and limited resources for providing end-of-life care [25, 28, 44, 45, 49]

• Poor coordination and/or communication between secondary care and hostel staff or homeless programmes and end-of-life programmes [32, 35, 49]

• Setting treatment goals according to routine guidelines were often regarded as unrealistic in this context [37]

• In-shelter palliative care means more work for staff and a greater burden for a workforce already thinly stretched [45]

• Cost of medications that was not covered by the benefits and had to be paid for in cash [30]