Homeless Palliative Care in Liverpool

Background - Need and Service Provision

Brownlow Health is a large city centre GP providing specialist healthcare for people experiencing homelessness. An audit of deaths of people experiencing homelessness was undertaken over a two year period which found that on retrospective review a significant number of patient deaths could be expected and that there was a low level of palliative care support provided.

In response, Brownlow Health collaborated with Marie Curie Hospice in Liverpool to establish a Homeless Palliative Care Multi-Disciplinary Team. This team:

• Secured funding for a Palliative Care Nurse to lead on care for people experiencing homelessness and people using substances.
• Established a Homeless-Palliative Care MDT. This team meets once per month and discusses patient management and care.
• Focused on early identification of people with deteriorating ill-health before they reach the dying phase.
• Undertook out-reach work to review and manage individuals at the end of their life where they live and in an appropriate setting to them.
• Provided education to support workers and hostel teams and offered structured reflective practice to teams after death.
• Created links with hospital based palliative care teams to ensure smooth transition of care into or out of hospital.

A subsequent audit of deaths was carried out after the team had been active for two years. The following improvements were found:

• 90% of patients were on the practice palliative register when they died opposed to 31% before.
• Some level of end of life discussion/advanced care planning happened in 85% of cases increased from 19%.
• A preferred place of care & death was recorded for 70% of patients an increase from 19%.
• 90% of patients received a medical palliative care review prior to death, an increase from 13%.

During our work it was identified that patient's preferred place of care and death was most commonly the hostel where they lived. The team worked hard to support end of life plans for patients to allow them to die in hostels, linking in with allied professionals and homeless/hostel staff. Despite some resistance from other professionals we have managed to utilise syringe drivers in the hostel setting successfully at the end of life, achieving a number of planned deaths in homeless hostels. As far as I am aware we are the only service which has been able to utilise syringe drivers in the hostel setting. Below is a case study of one such patient's experience.

Case Study - Mark (name changed)

Mark, a resident at a hostel in Liverpool had a history of alcohol dependence and heroin and crack misuse. He was managed on a methadone script which was delivered daily to the hostel. Whilst an inpatient he was reviewed by the Homeless Palliative Care Team as he had developed liver failure and was given less than three months to live. At this time, he suffered from encephalopathy and did not have capacity. Brownlow Homeless Team, who knew Mark well, decided that his preferred place of care would be the hostel he had lived at for the last four years. The Homeless Palliative Care Team worked with the hospital and hostel staff to arrange a rapid discharge to the hostel for end-of-life care.

On discharge there was a marked improvement as Mark regained cognition and capacity and some functional ability. He confirmed at this time that it was indeed his wish to be cared for and to die at the hostel as he regarded this as his home. The team regularly reviewed Mark in the hostel and developed a trusting relationship with him.

Around six weeks after his discharge Mark developed ascites, jaundice and was sleeping more and more. He developed nausea and vomiting and abdominal pains. The team managed this with oral morphine and metoclopramide (anti-sickness medication). He continued to deteriorate, and a syringe driver was commenced to manage pain, distress, and nausea which provided good symptom control. Concerns were raised by staff and the district nursing team as to the appropriateness of using a syringe driver with controlled drugs in this setting. Through remote and face to face meetings with staff, the team were able to answer questions and ease concerns about the use of a syringe driver in the hostel setting.

The team arranged for a package of care to support staff with Mark’s personal care.

Mark died peacefully at the hostel, with staff and friends around him, with dignity, in a setting he regarded as his home.

The Homeless Palliative Care Team met with the hostel staff after Mark’s death to complete reflective practice, offer emotional and spiritual support and learn from this new experience of providing end of life care in a hostel setting.

Feedback:

Following Mark’s death, the Homeless Palliative Care Team received the following feedback:

From the District Nursing Team:

“Just a thank you from the district nursing team to all attached to this email for the care of [Mark] in single men’s hostel.

Thank you for the compassionate holistic care provided and ensuring Mark’s wishes were met, thank you [Hostel Managers] who advocated for Mark, he felt safe and supported by yourselves.

Thank you especially [GP] and [Palliative Care Consultant] for the regular reviews, communication with DNs and synergy between Marie Curie, DNs, GP and hostel in this complex situation. Thank you for ensuring his care and comfort”.

From the Hostel Manager:

“I would just like to take the opportunity to thank everyone for their contributions towards granting [Mark] his final wishes to have his end of life be at [Hostel]. I am so glad he got to die with dignity and choice. The team have been amazing and I am so proud to be part of it”.

From the Service Manager:

“Notwithstanding the central efforts to support [Mark], this is a superb example of services working together, supporting each other to get the best outcome for someone in a difficult situation. The sum is certainly greater than the parts and your involvement has been an inspiration to our team”.

From Housing Commissioner:

“It’s really heart-warming to see how you are all working together to provide the best possible support for [Mark] and that the level of support for [Mark] and staff is so high”.

Extra Information

Permissions from partner organisations and from myself and Brownlow Health to share the case study.

Permission to share logos for Brownlow Health, Marie Curie Liverpool and Whitechapel.

Services Involved: Brownlow Health (Homeless Team), Marie Curie Liverpool, Whitechapel Centre & SHAP (run 2 Aigburth Drive Hostel, mentioned in case study).

Tips for success: It is vital for healthcare staff to have regular and open conversations with allied health providers and homeless service providers. Regular contact can alleviate concerns and empower other providers to offer care in the most challenging of scenarios. Early planning is vital and reflective practice and learning is vital to continue to improve. Each case is a new challenge and will be different.

Next Steps: We are looking to share our experiences on a wider scale and offer support for those wishing to replicate elements of our service. At a local level we are looking to offer specialist advice around managing end of life care for people experiencing homelessness and people who suffer addictions who are not registered at Brownlow to support other services to achieve similar outcomes.