Table 4 The care provided care: facilitators relating to homeless people, interaction between homeless people and healthcare professionals, and healthcare professionals

• Primacy of religious beliefs and spiritual experience or connection; religious beliefs are a core component of homeless people’s end-of-life beliefs and experiences; it provides comfort and solace through spirituality/religion [24, 28, 39]

• Allow for patients to have “unscheduled” space to share their life stories and to acknowledge those stories [37]

• Freedom is essential to homeless people [33]

• Other homeless patients could become involved in the care of fellow residents who are unwilling to work with services [32]

• Among homeless people who filled out an AD, there were increasing in plans to write down end-of-life wishes, plans to talk about these wishes with someone and less worrying about death [46]

Attitude towards homeless people

• Building and establishing trusting and/or family-like relationships and contact by interacting with patients in everyday situations and staff taking a supportive and/or advocating role in encounters with other health providers [25, 32, 35, 37]

• Upholding homeless residents’ dignity and maintaining pride by showing human kindness, respect, love, comfort and to name accomplishments and elements of character [29, 31, 35, 37]

• Staff must never judge a homeless person as impossible, or in terms of failure, and always patiently give them a new chance [37]

• Persistence to engage the patient and to keep them engaged, with a constant effort required for effective follow-up [47]

Treatment of homeless people

• A pragmatic approach by staff, facilitating flexible care solutions, such as the choice where to die and accepting that planned activities may not happen or need to be cancelled [25, 37, 45]

• Compassionate healthcare providers who are present (e.g. not leaving the individual alone during or after death [25, 28, 37]

• Staff can respect individual’s habits and needs (also if rather unconventional, friends and preferred surroundings (e.g. stay in the hostel) when they are at the end of life [32, 36]

• Staff only contacting family members at the end of life if the patients so request [37]

• Formulating simple messages towards patients about death and dying [37]

Activities/therapies

• Advance directive completion rate is higher when counsellor guided that compared to no counsellor guidance [41, 42, 46]

• Low-threshold strategies have an increased capacity to deliver end–of-life care services [26, 27]

• Harm reduction services (e.g. clean needle exchange, medically prescribed alcohol) are a critical point of entry to and source of end-of-life care and support for homeless people who use alcohol and/or illicit drugs and are unable to access services [25, 48]

• Physical contact can enable feelings of safety and appreciation in patients (not all patients) [37]

• Memorial services held by staff to give staff members and other patients or visitors a moment to remember and say farewell [37]

Knowledge and skills

• Optimizing management of pain, symptoms and functional decline, e.g. by palliative care consultations [48, 49]

• End–of-life care and addiction training [26]

• To preserve integrity in being close to patients [37]

• Treatment for symptoms and distress is often provided simultaneously with the use of illicit drugs and/or alcohol, this necessitates special skills for identification of signs and symptoms and treatment regimens [37]

Organization

In-shelter hospice care; without it, a large part of homeless patients might not have sought care or received services and died homeless with no pain and symptom management [48]

• Costs of in-shelter hospice care are substantially less than the estimated costs of traditional care for the same patients [48]