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“Everybody in this community is at risk of dying”: An ethnographic exploration on the potential of integrating a palliative approach to care among workers in inner-city settings

Published online by Cambridge University Press:  07 May 2020

Kelli I. Stajduhar ,
Melissa Giesbrecht Open the ORCID record for Melissa Giesbrecht [Opens in a new window] ,
Ashley Mollison  and
Margo d'Archangelo
Kelli I. Stajduhar*
Affiliation:
Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada School of Nursing, University of Victoria, Victoria, BC, Canada
Melissa Giesbrecht
Affiliation:
Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
Ashley Mollison
Affiliation:
Institute on Aging and Lifelong Health, University of Victoria, Victoria, BC, Canada
Margo d'Archangelo
Affiliation:
Victoria Hospice, Education and Research, Victoria, BC, Canada
*
Author for correspondence: Kelli I. Stajduhar, Institute on Aging and Lifelong Health, University of Victoria, 3800 Finnerty Road, Victoria, BC, CanadaV8P 5C2. E-mail: [email protected]
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Abstract

Objective

At the end of life, the need for care increases. Yet, for structurally vulnerable populations (i.e., people experiencing homelessness and poverty, racism, criminalization of illicit drug use, stigma associated with mental health), access to care remains highly inaccessible. Emerging research suggests that enhancing access to palliative care for these populations requires moving care from traditional settings, such as the hospital, into community settings, like shelters and onto the street. Thus, inner-city workers (ICWs) (e.g., housing support and community outreach) have the potential to play pivotal roles in improving access to care by integrating a “palliative approach to care” in their work.

Method

Drawing upon observational field notes and interview data collected for a larger critical ethnographic study, this secondary thematic analysis examines ICWs’ (n = 31) experiences providing care for dying clients and garners their perspectives regarding the constraints and facilitators that exist in successfully integrating a palliative approach to care in their work.

Results

Findings reveal three themes: (1) Approaches, awareness, and training; (2) Workplace policies and filling in the gaps; and (3) Grief, bereavement, and access to supports. In brief, ICWs who draw upon harm reduction strategies strongly parallel palliative approaches to care, although more knowledge/training on palliative approaches was desired. In their continuous work with structurally vulnerable clients, ICWs have the opportunity to build trusting relationships, and over time, are able to identify those in need and assist in providing palliative support. However, despite death and dying is an everyday reality of ICWs, many described a lack of formal acknowledgement by employers and workplace support as limitations.

Significance of results

Findings contribute promising practices for enhancing equitable access to palliative care for society's most vulnerable populations by prioritizing front-line workers’ perspectives on how best to integrate a palliative approach to care where structurally vulnerable populations live and die.

Keywords

Critical ethnographyHealth disparitiesMarginalized populationsPalliative approachStructurally vulnerable populations
Type
Original Article
Information
Palliative & Supportive Care , Volume 18 , Issue 6 , December 2020 , pp. 670 - 675
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Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

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References

Bagget, T, O'Connell, J, Singer, D, et al. (2010) The unmet health care needs of homeless adults: A national study. American Journal of Public Health 100, 1326–1333.CrossRefGoogle Scholar
Bourgois, P (1998) The moral economics of homeless heroin addicts: Confronting ethnography, HIV risk, and everyday violence in San Francisco shooting encampments. Substance Use & Misuse 33(11), 2323–2351.CrossRefGoogle Scholar
Cagle, J (2009) Weathering the storm: Palliative care for the elderly homeless. Journal of Housing for the Elderly 23, 29–46.CrossRefGoogle Scholar
Canadian Hospice Palliative Care Association (2012) Fact Sheet – Hospice Palliative Care in Canada. Available at: http://www.chpca.net/media/7622/fact_sheet_hpc_in_canada_may_2012_final.pdf.Google Scholar
Centre for Urban Health Solutions Survey Research Unit (2017) Palliative Care Services for People Experiencing Homelessness in Toronto: A Preliminary Needs Assessment. Toronto, ON: Centre for Urban Health Solutions Survey Research Unit.Google Scholar
Collier, R (2011a) Access to palliative care varies widely across Canada. CMAJ: Canadian Medical Association Journal 183(2), E87–E88. doi:10.1503/cmaj.109-3763.CrossRefGoogle Scholar
Collier, R (2011b) Bringing palliative care to the homeless. CMAJ: Canadian Medical Association Journal 183(6), E317–E318.CrossRefGoogle Scholar
Commission on Social Determinants of Health (2008) Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization.Google Scholar
Fereday, J and Muir-Cochrane, E (2006) Demonstrating rigor using thematic analysis: A hybrid approach of inductive and deductive coding and theme development. International Journal of Qualitative Methods 5(1), 1–11.10.1177/160940690600500107CrossRefGoogle Scholar
Ferrell, BR, Twaddle, ML, Melnick, A, et al. (2018) National consensus project clinical practice guidelines for quality palliative care guidelines, 4th edition. Journal of Palliative Medicine 21(12), 1684–1689. doi:10.1089/jpm.2018.0431.CrossRefGoogle Scholar
Giesbrecht, M, Stajduhar, K, Mollison, A, et al. (2018) Hospitals, clinics, and palliative care units: Place-based experiences of formal healthcare settings by people experiencing structural vulnerability at the end-of-life. Health & Place 53, 43–51.CrossRefGoogle ScholarPubMed
Håkanson, C, Sandberg, J, Ekstedt, M, et al. (2016) Providing palliative care in a Swedish support home for people who are homeless. Qualitative Health Research 26(9), 1252–1262. doi:10.1177/1049732315588500.CrossRefGoogle Scholar
Hankivksy, O, Grace, D, Hunting, G, et al. (2014) An intersectionality-based policy analysis framework: Critical reflections on a methodology for advancing equity. International Journal for Equity in Health 13(1), 50–78. doi:10.1186/s12939-014-0119-x.Google Scholar
Henry, B, Dosani, N, Huynh, L, et al. (2017) Palliative care as a public health issue: Understanding disparities in access to palliative care for the homeless population living in Toronto, based on a policy analysis. Current Oncology 24(3), 187–191.10.3747/co.24.3129CrossRefGoogle ScholarPubMed
Hudson, BF, Flemming, K, Shulman, C, et al. (2016) Challenges to access and provision of palliative care for people who are homeless: A systematic review of qualitative research. BMC Palliative Care 15(96). doi:10.1186/s12904-016-0168-6.CrossRefGoogle ScholarPubMed
Huynh, L, Henry, B and Dosani, N (2015) Minding the gap: Access to palliative care and the homeless. BMC Palliative Care 14, 62.10.1186/s12904-015-0059-2CrossRefGoogle ScholarPubMed
Hwang, S (2001) Homelessness and health. CMAJ: Canadian Medical Association Journal 164(2), 229–233.Google ScholarPubMed
Khandor, E, Mason, K, Chamgers, C, et al. (2011) Access to primary health care among homeless adults in Toronto, Canada: Results from the street health survey. Open Medicine 5(2), e94–e103.Google ScholarPubMed
Klop, HT, Evenblij, K, Gootjes, JRG, et al. (2018) Care avoidance among homeless people and access to care: An interview study among spiritual caregivers, street pastors, homeless outreach workers and formerly homeless people. BMC Public Health 18, 1095. doi:10.1186/s12889-018-5989-1.CrossRefGoogle ScholarPubMed
Ko, E, Kwak, J and Nelson-Becker, H (2015) What constitutes a good and bad death?: Perspectives of homeless older adults. Death Studies 39(7), 422–432.CrossRefGoogle ScholarPubMed
Krakowsky, Y, Gofine, M, Brown, P, et al. (2013) Increasing access—A qualitative study of homelessness and palliative care in a major urban center. American Journal of Hospice & Palliative Care 30(3), 268–270.CrossRefGoogle Scholar
McNeil, R, Guirguis-Younger, M and Dilley, L (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. BMC Palliative Care 11(1), 14.CrossRefGoogle ScholarPubMed
Moller, DW (2012) Dancing with Broken Bones: Poverty, Race, and Spirit-Filled Dying in the Inner City (Rev. & expand ed.). New York: Oxford University Press.10.1093/acprof:osobl/9780199760138.001.0001CrossRefGoogle Scholar
Moller, DW (2019) Dying at the Margins: Reflections on Justice and Healing for Inner-City Poor. New York, NY: Oxford University Press.Google Scholar
Nolte, AGW, Downing, C, Temane, A, et al. (2017) Compassion fatigue in nurses: A metasynthesis. Journal of Clinical Nursing 26(23–24), 4364–4378.CrossRefGoogle ScholarPubMed
Palepu, A, Gadermann, A, Hubley, AM, et al. (2013) Substance use and access to health care and addiction treatment among homeless and vulnerably housed persons in three Canadian cities. PLoS ONE 8(10), e75133.CrossRefGoogle ScholarPubMed
Pauly, B (2014) Close to the street: Nursing practice with people marginalized by homelessness and substance use. In Hwang, S and Younger, M (eds.), Homelessness and Health in Canada. Ottawa: University of Ottawa University Press.Google Scholar
Reimer-Kirkham, S, Stajduhar, K, Pauly, B, et al. (2016) Death is a social justice issue: Perspectives on equity-informed palliative care. Advances in Nursing Science 39(4), 293–307.CrossRefGoogle ScholarPubMed
Savage, J (2000) Ethnography and health care. BMJ 321(7273), 1400–1402.CrossRefGoogle ScholarPubMed
Sawatsky, R, Porterfield, P, Lee, J, et al. (2016) Conceptual foundations of a palliative approach: A knowledge synthesis. BMC Palliative Care 15, 5.10.1186/s12904-016-0076-9CrossRefGoogle Scholar
Schulman, C, Hudson, BF, Low, J, et al. (2018) End-of-life care for homeless people: A qualitative analysis exploring the challenges to access and provision of palliative care. Palliative Medicine 32(1), 36–45.CrossRefGoogle Scholar
Song, J, Bartels, D, Ratner, E, et al. (2007) Dying on the streets: Homeless persons’ concerns and desires about end of life care. Journal of General Internal Medicine 22, 435–441.10.1007/s11606-006-0046-7CrossRefGoogle ScholarPubMed
Stajduhar, K (2011) Chronic illness, palliative care, and the problematic nature of dying. The Canadian Journal of Nursing Research 43(3), 7–15.Google ScholarPubMed
Stajduhar, KI, Mollison, A, Giesbrecht, M, et al. (2019) “Just too busy living in the moment and surviving”: Barriers to accessing health care for structurally vulnerable populations at the end-of-life. BMC Palliative Care 18(1), 11. doi:10.1186/s12904-019-0396-7.CrossRefGoogle ScholarPubMed
Statistics Canada (2014) Portrait of caregivers, 2012. Retrieved from: http://www.statcan.gc.ca/pub/89-652-x/89-652-x2013001-eng.htm (accessed November 26, 2015).Google Scholar
Stern, PN (2008) Constant comparison. In Given, LM (ed.), Sage Encyclopedia of Qualitative Research Methods. Thousand Oaks, CA: SAGE, pp. 114–115.Google Scholar
Wen, C, Hudak, P and Hwang, S (2007) Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters. Journal of General Internal Medicine 22, 1011–1017.CrossRefGoogle ScholarPubMed