We agree with Dr Lakhani's assessment that people with advanced progressive disease who are admitted to hospital are not always identified as being at the end of life and in need of palliative care. Marie Curie in partnership with St Mungo's, a charity working with homeless people, recently undertook work to try to improve care for homeless people around the time that they were dying. The work was funded by a 3 year grant from the Department of Health (http://www.mariecurie.org.uk/Documents/HEALTHCARE-PROFESSIONALS/Innovati…). Advanced liver disease was identified as one of the most common conditions amongst hostel residents that existed with other co-morbidities in conjunction with substance abuse. Residents had multiple physical symptoms in the last 6 months of life alongside psychological distress. Admissions to hospital were frequent and lengthy and a number of sudden deaths occurred in hospital and hostels. The average age was 55 years. Despite increasing admissions to secondary care in the last 6 months of life for management of acute episodes lasting an average of 18 days, no evidence was found of any referrals to palliative care. Communication between secondary care and hostel staff was limited due to issues of disclosure, despite some residents regarding hostel staff as their next of kin in the absence of family or alternative supportive networks. This lack of sharing of information meant that hostel staff were often ill informed or unaware of the severity of a resident's medical condition when they were discharged from hospital. Consequently staff working with residents in hostels found difficulties linking the signs and behaviours associated with advanced liver disease with possibilities for palliative care interventions such as exploring choices, future needs and wishes, or agreeing a suitable plan for care. This also prevented opportunities for residents to reconnect with estranged family members. Symptoms at the end of life were frequently distressing for residents with the majority dying in hospital, an environment that they had previously resisted and in which many did not feel comfortable. Deaths that occurred suddenly had not usually been anticipated and were therefore perceived to be unexpected. This resulted in some distress to other residents and staff as well as to family members that were still in contact – no one was prepared. People who are homeless have a right to be informed about their medical condition and prognosis and offered a chance to express their wishes for care at the end of life. Recommendations following this work include training for hostel staff in palliative care issues to enable them to recognise and therefore act on key signs and symptoms and offer psychological support as a resident's condition deteriorates. The palliative care coordinator at St Mungo's has started to involve staff in end of life care training and encouraged them to adopt an advocacy role on behalf of residents when interacting with health professionals and planning services. Improvements in communication between hostel staff and health professionals are necessary to provide residents with the relevant information to facilitate discussions about the choices available to them for care. Communication materials have also been developed in partnership with the National Council for Palliative Care as part of their Dying Matters series to help people who are homeless inform others of what matters to them as they approach the end of life, and for hostel staff and healthcare professional when initiating conversations about their end of life care (http://www.dyingmatters.org/page/homeless-people). Future in-depth qualitative work with hostel residents will help us to explore their wishes and needs for care at the end of life and will provide information on the environment and services they find most acceptable.
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