Taking Hospice to the Unhomed

Imagine a disease.

Imagine a disease that doesn’t just affect your body. It affects your dignity and your sense of self-worth.

Imagine a disease that predictably cuts a person’s lifespan by 30 years.

I’m not talking about heart disease. I’m not talking about diabetes. And I’m not talking about cancer.

I’m talking about a social disease.

Homelessness.

The vast majority of what makes us sick may not actually be what you think. Biology, genetics, and access to clinics and hospitals are relatively minor factors in our overall health.

In fact, more than 60 percent of what makes us sick in our communities comes from social factors: how we live, learn, work, and play.

Homelessness isn’t only about not having a roof over your head. It isn’t only about not having a home.

Homelessness is deadly.

I learned about the devastating impact of homelessness on health when I first met Terry, and it changed my life forever.

Spending even one night on the streets can cause trauma that lasts a lifetime.

Terry had spent 15 years living on the streets while dealing with complex mental illness and a substance use disorder.

As I examined him, I gained a better understanding of what was causing him so much distress.

There was a large mass on Terry’s tongue.

Advanced cancer.

It was bad.

I learned that he had been diagnosed a year earlier. Terry had started isolating himself because he felt sad, angry, frustrated, and embarrassed about how he looked.

As time went on, he began to experience pain.

So he did what any one of us would do. He went from urgent care center to urgent care center, emergency department to emergency department, hospital to hospital, seeking the kind of pain control that any of us would expect to receive.

Sadly, Terry was denied access to medications that could have improved his quality of life.

He had no support system. No family. No friends. No medication to treat his pain.

He had no one to trust, and understandably, he trusted no one.

Over the next few days, I started to build a trusting relationship with Terry.

He agreed to a plan to start medication and treat his pain.

With that breakthrough in mind, I arrived at the shelter early the next morning, so excited to see him.

But I couldn’t find Terry anywhere.

His body had been found in the early hours of the morning by a commuter on her way to work.

Despite our best efforts, Terry had turned to the best pain relief he knew.

He had overdosed on a combination of alcohol and street drugs.

As the Canadian-born son of two refugee parents, I grew up learning about injustice, inequality, and poverty.

But this was Canada.

How was it possible that we could allow someone so vulnerable, someone so in need, to fall through the cracks again and again and again?

Consider this.

On any given night, more than half a million people in the United States are living on the streets or in shelters. In Canada, it’s more than 35,000.

For every one person we see in a shelter or on the street, there are 23 others we don’t see with the naked eye. People who are struggling to make ends meet. People who are on the verge of homelessness.

So what is the connection between homelessness and health?

Compared with the general population, people experiencing homelessness are 28 times more likely to have hepatitis C, five times more likely to have heart disease, and four times more likely to have cancer.

So what’s the bottom line?

Homelessness cuts a person’s life expectancy by 20 to 30 years. In many cases, it cuts it in half.

Homelessness is a life-limiting illness.

Homelessness is a terminal diagnosis.

Terry’s death made more sense to me now. I understood that the odds had been stacked against him from the very start.

With an incredible team at Inner City Health Associates in Toronto, Canada, we worked to build a bold new program, a new model of care.

We called it PEACH: Palliative Education and Care for the Homeless.

It’s a mobile healthcare team that meets people’s healthcare and social service needs wherever they are: on the streets, in shelters, or under bridges.

The PEACH program started in 2014 with the goal of making sure no person falls through the cracks.

We do this by removing barriers to healthcare and social services.

We connect, and we educate.

Some people ask me, “Why palliative care? What is palliative care?”

Palliative care is about relieving suffering.

Palliative care is about improving quality of life for people with serious illness.

Palliative care is the perfect intersection between healthcare and humanity.

What started with me and a teammate, a street nurse, driving around and supporting people has blossomed into a 24/7 interprofessional care team.

Even better, the PEACH program has inspired other programs across Canada, the United States, and Australia.

I’ve spent several years on the streets, in shelters, under bridges, and in rooming houses, providing palliative care to people experiencing structural vulnerabilities like homelessness, poverty, mental illness, and substance use.

What have I learned?

Stories like Terry’s are so important because they vividly depict the inequities that exist in healthcare.

They show us how our systems fail to address the non-healthcare causes of poor health.

These stories matter.

And if we care to address them, palliative care needs to become more accessible.

That means we need to break the mold.

To truly meet people where they are, we need to take palliative care to the people. Out of our clinics. Out of our hospitals. Into our communities.

Meeting people where they are means supporting them in the ways they need.

Harm reduction for people who use drugs is an evidence-based approach that saves lives. Yet in palliative care, we rarely talk about harm reduction.

Amid an opioid epidemic that is literally killing thousands of people, this is more important than ever.

I’ve learned that Black people, Indigenous people, and other people of color face distinct barriers to accessing palliative care and healthcare more broadly.

Those barriers include racial bias in pain medicine, a lack of cultural safety, and underrepresentation in the healthcare workforce.

The future of equitable access to palliative care lies in anti-racism.

One of the most profound things I’ve learned from working with people is that they can heal even when they are sick.

That moment when a person is truly heard can be life-changing.

It can be transformational.

This is what trauma-informed care is all about.

Trauma-informed care is about learning how to pronounce a person’s name.

It’s about sitting at eye level so you can connect with someone.

It’s about caring without judgment.

It’s about learning what someone has lived through so that, when we offer treatment, we don’t cause more trauma.

Regardless of where you live, healthcare is a social justice issue.

We need to work together to move our healthcare systems from equality to equity to justice.

In equality-based healthcare systems, people receive the same things to help them become happy and healthy.

In equity-based healthcare systems, people receive what they need to become happy and healthy.

In justice-based healthcare systems, there are no barriers to health. People receive the support and resources they need to make their own healthy choices.

You see, it all comes down to a few crucial questions.

What is a life worth?

How do we value dignity at the end of life?

Is it the same for everyone?

Was Terry’s life worth as much as my life?

Is my life worth as much as yours?

I’d like to think that we live in a world where all of our lives are worth the same.

Yet social factors, how we live, learn, work, and play, are clearly making a difference in how we live.

But should they really make a difference in how we die?

It is often said that the best way to judge a society is by how it treats its most vulnerable people.

If we truly want to live in a world where no one dies the way Terry did, then let’s ensure that all of us can live well and die well.