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Palliative or end-of-life care is an approach to improve a person’s quality of life when they are diagnosed with a life-limiting illness. (Gap, 2019) Support is provided to the person and their families to alleviate pain and suffering while addressing the condition's physical, psychosocial, practical, and spiritual side. (Gap, 2019) Palliative support can be provided by family or a support worker in the hospital or home and is used during the disease progression. (Gap, 2019) Individuals plan and discuss with their family members and a healthcare team and require OHIP qualification, detailed medical documents, and health network referrals. (Gap, 2019) Some questions include considering what the person wants, the nature of their illness, and what options are available. (Gap, 2019) The questions and support seem appropriate for a certain percentage of the population, specifically, those of a certain level of socioeconomic class with access to certain privileges, such as having a place to call home.

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What happens to the percentage of people living with different social determinants in palliative care decision-making? Particularly people who live on the streets or sleep in their car or a friend’s couch. The people who do not have family or were disowned. The people who may never have received appropriate medical care, do not have a doctor, have lost faith in the medical system or do not trust people with a perceived level of authority. The people who do not have anyone to help or take care of them. The people who are randomly attacked at night because of where they are resting their head. The people who would say their only need is to alleviate traumatic pain and manage their mental health conditions. The people who believe they do not exist because they do not have a stable place to exist and answer the question that all they want is a place to feel safe and call home. These are the people who are more worried about the virtues of homelessness rather than the virtues of their illness. These are the people who may die without dignity on the street because they do not have a place to call home or are otherwise homeless.

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            The city of Toronto is faced with a multifaceted ethical dilemma of bridging the gap between homelessness and palliative care. Homeless rates continue to increase with each year in Toronto, with an average life expectancy of 50-years-old. (Stroh, 2018) Systemic homeless problems arise through government policies and inadequacies in service delivery compounded with an increased population. Dying with dignity seems like a possibility for someone who does not have to worry about the multitude of problems that come with being homeless. Journey Home Hospice provides ethical palliative care by supporting and addressing the multitude of needs of being homeless while dying. An integrative team provides end-of-life care to support this marginalized population while aspiring to the standards of autonomy, justice, beneficence, and non-maleficence.  

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Journey Home Hospice provides palliative care and end-of-life support for homeless individuals in Toronto. (Stroh, 2018) The rates of people experiencing homelessness or a lack of stable and safe permanent, appropriate housing in Toronto have exceeded 10,000 people in 2021. (Victor, 2021) Those who are considered homeless, either living on the streets or invisible homeless, those without a permanent home, are at a much higher disadvantage in meeting basic living needs. Often, these individuals are met with harsh conditions that propel them into survival mode, which prevents them from thinking about taking care of their health conditions. Shelters are overrun, have seen a 200 percent increase in violence, a 125 percent increase in deaths, higher drug use, overdoses, and infections. (Neufeld, 2021) Users of Toronto’s shelters feel that there is nowhere to go to calm down in the shelter setting as they are surrounded by tensions and violence amongst other users. (Neufeld, 2021) Shelter users are also more likely to choose to live on the streets because they often feel that they are not treated humanely in shelters. (Neufeld, 2021)

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Becoming homeless in Toronto can happen for various reasons, including substance abuse, loss of employment, family issues, poor mental and physical health, and physical, sexual, or emotional abuse. (Victor, 2021) Similar to poor health conditions or prognosis, homelessness can affect any person at any age. Journey Home Hospice provides a place for homeless individuals who require end-of-life care in Toronto. Users are given a place to calm down, heal, reduce pain, rest, resolve family issues, have family visits, and receive medical care and food. (Stroh, 2018) The hospice currently has ten beds available, and their goal is to provide hospice quality care, safety, and end-of-life experience for those who have barriers accessing healthcare. Their work addresses the ethical dilemma of providing a home palliative care environment to people who would not otherwise have access to a home to die peacefully. Their goal is to provide equitable access of hospice care by providing a safe, welcoming, and caring home for end-of-life care while working within the ethical framework of autonomy, justice, beneficence, and non-maleficence. (Hospice, About Us, 2021)

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Homeless individuals are likely to lack autonomy when thinking about their health and healthcare decisions for various reasons. Some of these include that they are likely to be victims of abuse and trauma, have undiagnosed and untreated mental health conditions, have weakened immune systems, have barriers in accessing healthcare, have a loss of faith in healthcare systems, have likely faced barriers in accessing supports and services, are thinking about today and not the future or long-term, prioritize finding a safe space to sleep, are in survival mode, have a diminished capacity, and possibly battling substance abuse addictions. Homeless individuals may feel despair and face disparities when thinking about their future and their health and may see ending their life as a way to reduce their pain and burdens. They may also lack the appropriate resources of understanding their health conditions or access to appropriate medical interventions.

One of the first users, a victim of sexual abuse and family discord, was given a place to call home at Journey Home Hospice. (Stroh, 2018) Pandora became homeless and developed a heart condition called infective endocarditis, which required regular care and oxygen. (Stroh, 2018)  Pandora’s journey led her to temporary shelters, and she was assigned a caseworker, where she connected with Dr. Dosani. (Stroh, 2018) By virtue of circumstance, Pandora lacked self-determination, and autonomy, a principle in ethical healthcare. (Europe, Respect for autonomy, 2009) Pandora was unable to determine her destiny with her family, living condition, and heart condition. Through Journey Home Hospice, Pandora was given the option to make an autonomous decision of where she would spend her last days. She had a place to call home and was given hope to reconnect with her family and change her destiny. Dr. Dosani, working within the autonomy principle of John’s ethical framework, provided Pandora, and other homeless individuals, a place that would minimize harm, provide community and equity, and give them power over their end-of-life journey. (Europe, Respect for autonomy, 2009)

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  Journey Home Hospice's goals are to provide justice for palliative care in homeless individuals. The Canadian Medical Association code of ethics for medical professionals highlights the virtues of compassion, honesty, humility, integrity and prudence. (Association, 2018, p. 2) Dr. Dosani mentions that providing care humanely requires recognizing privilege to build trust, rapport, and empathy. (Stroh, 2018) The CMA describes trust as the highest standard of ethical practice and standard of care between the physician and patient. (Association, 2018, p. 2) Dr. Dosani builds trust and rapport by acting truthfully, consistently, and with good conscience in clinical and moral reasoning and judgement. (Association, 2018, p. 2) His ethical practice allows him to recognize suffering, vulnerability and alleviate pain while acknowledging the user’s personal, medical or circumstantial limits (Association, 2018, p. 2)

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Journey Home Hospice meets the moral obligation of providing a fair distribution of scarce resources, particularly a palliative care home for homeless individuals in Toronto. (Europe, Justice , 2010) Users of the hospice are given the right to be treated equally and to receive equal access to treatment regardless of their place of residence, social status, disability, insurance coverage, and prognosis. (Europe, Justice , 2010) In Pandora’s case, she was treated with indifference and lack of concern while living on the streets and in shelters. She was unable to receive regular care such as oxygen because the shelters could not accommodate the equipment needed. (Stroh, 2018) Journey Home Hospice provides justice and fair distribution of resources for the vulnerable homeless population. They share resources, such as medical care, a private room and a washroom, to those who lack personal autonomy or have a lower moral claim by virtue of homelessness. (Europe, Justice , 2010)

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Ethical care extends further from autonomy, justice, and fair distribution. It involves balancing the risks, costs and lessening harm while providing appropriate care within the ethical framework. (Europe, Justice , 2010) Recently, Toronto spent close to two million dollars removing homeless encampments in three parks. (Staff, 2021) City funds were allocated to removing trespassers and debris, hiring security, erecting fences, making the park grounds usable, and other operational costs such as personal protective equipment and buses. (Staff, 2021) Josh Matlow mentions in the CityNews article that the costs used could have provided stable housing for 58 homeless individuals. (Staff, 2021) Mayor John Tory stated that the parks needed to be repaired from the encampment damages and that Toronto residents ‘sacrificed’ by being denied access to the parks. (Staff, 2021) Between April 2020 to August 2021, 1898 homeless encampments users were referred to safe inside spaces, and close to 6640 homeless were moved from the shelter to permanent housing. (Staff, 2021)

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There is a linear progression and apparent systemic flaws within Toronto’s homeless population and service provision. It is unknown how many of those referred found a home, if the safe inside spaces were a shelter, or if any of those homeless were diagnosed or could potentially be seriously ill or have an unknown, foreseeable death. Through Dr. Dosani’s and his teams' work, it is obvious that there is a social, empathic need to provide palliative care or hospice solutions for Toronto’s homeless population. For Pandora, her greatest scare and concern was not necessarily being homeless but what could happen when she was homeless. (Stroh, 2018) The ethical dilemma of providing palliative hospice care to homeless people can be a concern to those who were living in the encampments. Those affected were shuttered into the shelter system without considering the possibility of medical intervention, such as palliative care.

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From a cost perspective, Journey Home Hospice collaborates with alliances and associations, including Saint Elizabeth Health, Hospice Toronto, Inner city Health Associates, and Homes First Society. (Hospice, About Us, 2021) They are a non-profit organization comprised of employed clinical staff and volunteers and rely on the government to fund fifty percent of their budget. (Hospice, About Us, 2021) The hospice also relies on charitable and fundraising donations through private, community, and corporate sponsors. Recently, they received a one million dollar donation from the Iacobelli family of Primo and Unico. (Hospice, About Us, 2021) Dr. Dosani works alongside people with lived homeless experience, physicians, allied health professionals, and clinical staff. (Hospice, About Us, 2021) Their work strives to promote excellence in homeless palliative care by measuring key indicators of quality, safety, patient satisfaction, and systemic impacts. (Hospice, About Us, 2021) The hospice dually operates within the ethical framework standard of beneficence even though they may face budgeting and financial concerns while implementing a medical professional code of ethics.

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The CMA’s code of ethics describes the physician's role within society as contributing to improving health care service and delivery to address systemic issues that particularly affect disadvantaged, underserved, and disadvantaged communities on a systemic level. (Association, 2018, p. 7) The hospice team provides quality medical services within society while recognizing social determinants of health within the homeless population. (Association, 2018, p. 7) They responsibly work alongside the public population by supporting healthcare through promoting equitable access to health care resources. (Association, 2018, p. 7) Their team is diverse with staff and volunteers, which allows them to work within a cohesive and integrated health system amongst inter-professionals by collaborating models of care. (Association, 2018, p. 7)

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Journey Home Hospice works within John’s framework of ethical principles of beneficence and non-maleficence. Their palliative care provides support that a homeless person would not receive in a shelter. Hospice users can gain a sense of control of their treatment and prognosis through their relationship with the staff and actively participating in their decision-making process. (Europe, Beneficence and non-maleficence, 2009) Pandora was given an environment that resembled a home as the hospice did not look like streets, shelters, or even hospitals. (Stroh, 2018) Her last two days of living were in a place to call home as it provided her hope, comfort, and a place where friends or family could visit or send a card. (Stroh, 2018) She had full-time medical care, meals, a bedroom and a washroom. (Stroh, 2018) In her short stay, she received treatment that focused on the beneficence of the treatments instead of the costs involved. (Europe, Beneficence and non-maleficence, 2009) She was treated with non-maleficence as she had a private space to rest and receive medical treatment, which reduced her harm. (Europe, Beneficence and non-maleficence, 2009) Pandora was described as someone who gained hope and joy because she felt alive, simply because she took up a place. (Stroh, 2018)

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Dr. Dosani and his colleagues provide formal education and mentorship opportunities in health system delivery within their community work and hospice services. (Association, 2018, p. 7) He often lectures in Toronto on the topic of providing medical support to the homeless population. (Stroh, 2018) His work, alongside Nancy Lefebre from Saint Elizabeth’s Healthcare, aims to provide homeless people with dignity in their end-of-life by providing a safe, supportive and warm place to call home. (Stroh, 2018) Journey Home Hospice answers and provides ethical and compassionate care to the members of society who are vulnerable and marginalized. They close the gap by providing community-based programs that focus on bereavement, spiritual care, complementary therapies, psychosocial services, and even therapy dog support. (Hospice, Our Programs, 2021)

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Most people think of palliative care and end-of-life planning when they are in the situation, and their basic needs are already being met. Social determinants can affect planning, especially for the person facing homeless disparities. Journey Home Hospice provides access and service provision of palliative care to homeless individuals by ensuring they maintain autonomy and are treated with fairness, kindness, and without discrimination. Dr. Dosani mentions in the article that Journey Home Hospice is a testament to community and compassion for end-of-life care for the marginalized and vulnerable population. (Stroh, 2018) Dr. Dosani and his team are motivated to continue to provide palliative care to people like Pandora while working within the medical profession's code of ethics and John’s ethical framework. Their work through the hospice is provided by people who care and understand the value of all human life regardless of the status of residency or their social determinants. (Stroh, 2018) Journey Home Hospice provides ethical palliative care by solving the problem of how a person can die with dignity at home when they do not have a place to call home.  

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References

Association, C. M. (2018, December 1). CMA Code of Ethics & Professionalism PD19-03.pdf. Retrieved from Canadian Medical Association: https://policybase.cma.ca/en/viewer?file=%2fdocuments%2fPolicyPDF%2fPD19-03.pdf#phrase=false

Europe, A. (2009, October 9). Beneficence and non-maleficence. Retrieved from Alzheimer Europe: https://www.alzheimer-europe.org/Ethics/Definitions-and-approaches/The-four-common-bioethical-principles/Beneficence-and-non-maleficence

Europe, A. (2009, October 9). Respect for autonomy. Retrieved from Alzheimer Europe: https://www.alzheimer-europe.org/Ethics/Definitions-and-approaches/The-four-common-bioethical-principles/Respect-for-autonomy

Europe, A. (2010, March 29). Justice . Retrieved from Alzheimer Europe: https://www.alzheimer-europe.org/Ethics/Definitions-and-approaches/The-four-common-bioethical-principles/Justice

Gap, C. T. (2019, April 29). Palliative Care in Ontario: Everything You Need To Know. Retrieved from Closing The Gap : https://www.closingthegap.ca/palliative-care-in-ontario-everything-you-need-to-know/

Hospice, J. H. (2021, October 5). About Us. Retrieved from Journey Home Hospice: https://journeyhomehospice.ca/about-us/

Hospice, J. H. (2021, October 5). Our Impacts . Retrieved from Journey Home Hospice: https://journeyhomehospice.ca/our-impacts/

Hospice, J. H. (2021, October 5). Our Programs. Retrieved from Journey Home Hospice: https://journeyhomehospice.ca/our-programs/

Neufeld, A. (2021, July 15). 'Like a rat cage': Toronto’s homeless describe packed shelters, surge in violence and death. Retrieved from CTV : https://toronto.ctvnews.ca/like-a-rat-cage-toronto-s-homeless-describe-packed-shelters-surge-in-violence-and-death-1.5471155

Staff, N. (2021, September 17). City of Toronto spent almost $2M clearing homeless encampments. Retrieved from CityNews: https://toronto.citynews.ca/2021/09/17/toronto-homeless-encampments-funding/

Stroh, P. (2018, July 5). Life on streets 'a killer': New hospice offers end-of-life care to the homeless. Retrieved from CBC: https://www.cbc.ca/news/health/journey-home-hospice-toronto-homeless-end-of-life-care-1.4715540

Victor, F. (2021, October 5). Facts about Homelessness in Toronto. Retrieved from Fred Victor: https://www.fredvictor.org/facts-about-homelessness-in-toronto/

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