Social Work Practice with LGBT Elders at End of Life: Developing Practice Evaluation and Clinical Skills Through a Cultural Perspective

Applied patient-level palliative care interventions designed to meet the needs of sexual and gender minorities: A scoping review and qualitative content analysis of how to support sexual and gender minorities at end of life

BACKGROUND

Sexual and gender minorities experience considerable health disparities across the life span. End of life presents unique challenges for this population, further exacerbating existing disparities.

AIM

We aimed to identify applied patient-level palliative care interventions for sexual and gender minorities and describe how said interventions met the needs of these populations at end of life.

DESIGN

We conducted a scoping review in keeping with the updated Arksey and O'Malley Framework. All included reports were analyzed qualitatively to describe the intervention and summarize thematically how it met the needs of sexual and gender minorities at end of life.

DATA SOURCES

We conducted searches in MEDLINE, EMBASE, PsychInfo, and CINAHL from 1946 to June 10, 2023. Reports were eligible for inclusion if they described a palliative care intervention delivered to sexual and gender minorities, and if the palliative care intervention responded to at least one specific need of the sexual and gender minority population(s) in question.

RESULTS

We included and summarized 27 reports. We identified three overarching themes describing how palliative care interventions responded to the needs of sexual and gender minorities at end of life.

CONCLUSIONS

This review responds to a need to improve palliative care delivery for sexual and gender minorities. Recommendations derived from these interventions, including how to center and advocate for sexual and gender minorities at end of life, can be applied by any interdisciplinary palliative care provider.

LGBTQ+ Loss and Grief in a Cis-Heteronormative Pandemic: A Qualitative Evidence Synthesis of the COVID-19 Literature

LGBTQ+ people are no stranger to loss and grief, particularly during times of pandemic such as the 1980s-90s HIV/AIDS pandemic and now, the COVID-19 pandemic. Current COVID-19 loss and grief research remains relatively silent on LGBTQ+ peoples' loss and grief experiences. The aim of this research was to conduct a qualitative evidence synthesis of LGBTQ+ people's COVID-19 loss and grief experiences reported in the literature. A systematic search and inclusion strategy identified 22 relevant articles for review. Inductive thematic synthesis resulted in five loss-focused themes across the articles: (1) loss of work and livelihood, (2) loss of social and kinship connection, (3) loss of LGBTQ+ community connection, (4) loss of physical and mental health supports and (5) loss of LGBTQ+ identity authenticity, affirmation and visibility. Discussion of these themes highlights the many layered and often disenfranchised nature of LGBTQ+ people's loss during the COVID-19 pandemic.

Lesbian, gay, bisexual, transgender and gender diverse and queer (LGBTQ) community members' perspectives on palliative care in New South Wales (NSW), Australia

Lesbian, gay, bisexual, transgender and gender diverse people, and queer people (LGBTQ people) are at increased risk of some chronic diseases and cancers. NSW Health palliative care health policy prioritises equitable access to quality care, however, little is known about community members' perspectives on palliative care. This study aimed to understand LGBTQ community views and preferences in palliative care in NSW. A community survey and follow-up interviews with LGBTQ people in NSW were conducted in mid-2020. A total of 419 people responded to the survey, with 222 completing it. Six semi-structured phone interviews were conducted with participants who volunteered for follow-up. The sample included LGBTQ people with varied levels of experience in palliative care. Thematic analysis was conducted on survey and interview data, to identify perceived barriers and enablers, and situate these factors in the socio-ecological model of health. Some perceived barriers from community members related to considering whether to be 'out' (i.e., making one's sexual orientation and gender known to services), knowledge and attitudes of staff, concern about potential substandard care or mistreatment (particularly for transgender health), decision making, biological family as a source of tension, and loneliness and isolation. Perceived enablers related to developing and distributing inclusive palliative care information, engaging with community(ies), fostering inclusive and non-discriminatory service delivery, ensuring respectful approaches to person-centred care, and staff training on and awareness building of LGBTQ needs and issues. Most of the participants who had experienced palliative care recounted positive interactions, however, we identified that LGBTQ people require better access to knowledgeable and supportive services. Palliative care information should be inclusive and services respectful and welcoming. Particular consideration should be given to how services respond to and engage with people from diverse population groups. These insights can support ongoing policy and service development activities to further enhance palliative care.

Barriers to LGBTQIA-Inclusive Palliative Care

Along the continuum of care, the transition towards end of life often provokes anxiety and requires medical assistance from palliative care providers. Unfortunately, historical, legal and medical barriers often prevent lesbian, gay, bisexual, transgender, queer, intersex and asexual patients from receiving essential palliative services. This article seeks to explain currently known barriers faced by these patients in obtaining palliative care, and offer preliminary solutions that can be implemented by all providers.

How can social workers be meaningfully involved in palliative care? A scoping review on the prerequisites and how they can be realised in practice

Palliative care is a holistic practice using a multidisciplinary approach in addressing multidimensional needs. Although the social aspects surrounding the end-of-life phase suggest a place for social work in it, the profession is often inadequately involved in daily practice. This contrasts strongly with the potential meaningful contributions of social workers in this field. To date, no comprehensive list of prerequisites for meaningful social work involvement in palliative care exists. This review aims to gain more insight on the prerequisites for meaningful social work involvement in palliative care and how to realise them in practice. It could therefore provide pathways for future intervention development in enhancing the involvement of social workers and maximising their contributions in palliative care. A scoping review methodology was used. A systematic selection of peer-reviewed articles ranged from 2000 to April 2021 – out of the electronic databases Web of Science, Scopus and Pubmed – was conducted. The 170 articles that met the eligibility criteria were analysed for relevant content using open and axial coding processes. The findings are reported according to the PRISMA-ScR checklist. The nine prerequisites listed in this review concern the level of individual social work capacities and the level of contextual factors structuring social work practices. A majority of articles have, however, focused on the level of individual social work capacities in a rather specialist view on palliative care. Future research should further address the contextual level of social work involvement in the broader practice of death, dying and bereavement.

Palliative care needs, concerns, and affirmative strategies for the LGBTQ population

The Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning population, also known as sexual and gender minorities, are an incredibly marginalized and vulnerable population that have been disproportionately affected by the provision, delivery, and optimal access to high-quality medical care including palliative, hospice, and end-of-life care. The long-standing and unique experiences shaped by positive and negative historical events have led to a better understanding of significant barriers and gaps in equitable healthcare for this population. The intersection of both internal and external stressors as well as minority identities in the context of discriminatory political and societal infrastructures have resulted in variable health outcomes that continues to be plagued by economic barriers, oppressive legislative policies, and undesirable societal practices. It could not be more urgent and timely to call upon the government and healthcare systems at large to execute reforms in policies and regulations, engage in cultural competency training, and promote cultural shifts in beliefs, attitudes, and practices that will ultimately recognize, prioritize, and address the needs of this population. After all, health care access is a universal right regardless of personal, social, political, and economic determinants of comprehensive medical care.

Demand for Space: Elderly Transgender and Gender Nonconforming People, Healthcare, and Theological Ethics

Visibility for transgender and gender nonconforming people and the elderly is growing; however, thus far the overlap of the two groups has rarely been considered. Trans persons therefore remain largely invisible in the context of older people's care and medicine. The discrimination faced by this group is at least twofold: they are the targets of aggression incited by transphobia, and also by ageism. Although older trans and gender nonconforming people exist as a greatly marginalized group within another already marginalized group, even the field of theological ethics has neglected to grant them ethical attention. This leads to especially harsh consequences for elderly transgender and gender nonconforming people due to their specific vulnerabilities. There are reports from trans persons who have resolved never to make use of health services again due to regular experiences of transphobia in medical settings. There are religious components within transgender and gender nonconforming issues that should not be overlooked in this context. On the one hand, medical staff, in the name of their Christian beliefs, have refused to provide trans persons with basic medical care. On the other hand, demands for places of visibility, and spaces for the individual, are regularly made in trans-positive studies, and can be linked to discussions within theological ethics about giving space. Some ethical formulas within the Hebrew and Christian traditions focus on the creation of space in which other beings may exist, as found in concepts like brother-sisterhood, friendship, and Sabbath. By casting light on elderly trans and gender nonconforming people, and on their demands for space, via reflections on ethical concepts of space-making, this study develops a specific understanding of space for elderly trans persons. The paper aims to develop an understanding of trans-positive spaces within theological ethics and applied ethics. Spaces that assume a withdrawal or contraction by all those who have previously taken up trans spaces through ignorance, contempt, or violence, should not thereby become spaces of absence: indeed, elderly trans and gender nonconforming people might be in need of both kinds of spaces, those where otherness enables withdrawal, and those where the helping presence of others continues.

‘I'm going to live my life for me’: trans ageing, care, and older trans and gender non-conforming adults’ expectations of and concerns for later life

While research on the health and wellbeing of older lesbian, gay and bisexual adults is gradually expanding, research on older trans and gender non-conforming (TGNC) adults lags behind. Current scholarship about this group raises important questions about the intersection of ageing and gender identity for enhancing care and support for older TGNC adults and the lack of preparedness of health and social professionals for meeting these needs. In this paper, we examine the accounts of 22 TGNC individuals (50–74 years) on the topic of ageing and unpack their concerns for and expectations of later life. We present qualitative findings from a study of gender identity, ageing and care, based in Wales, United Kingdom. Data were generated from two-part interviews with each participant. Four key themes are identified: (a) facilitative factors for transitioning in mid- to later life; (b) growing older as a new lease of life; (c) growing older: regrets, delays and uncertainties; and (d) ambivalent expectations of social care services. We argue that growing older as TGNC can be experienced across a multitude of standpoints, ranging from a new lease of life to a time of regret and uncertainty. We critically discuss emergent notions of trans time, precarity and uncertainty running across participants’ accounts, and the implications for enhancing recognition of gender non-conformity and gender identity in social gerontology.

Cultural Humility: A Way to Reduce LGBTQ Health Disparities at the End of Life

Sexual and gender minorities experience disparities throughout the life course. These are especially detrimental at the end-of-life and can include disenfranchised grief, homophobia and transphobia from medical staff, and forced outing. The best healthcare training approach to ameliorate health disparities is debated. Cultural competency trainings for clinicians have been commonly proposed by major medical institutions and certifying bodies to ameliorate lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) health disparities. However, cultural competency trainings have limitations, including (1) false competence, (2) measurement issues, and (3) ecological fallacy (i.e., assuming individuals conform to the norms of their cultural group). The purpose of this commentary is to describe the limitations of cultural competency training and argue for healthcare systems to implement cultural humility trainings as a way to reduce LGBTQ health disparities at the end-of-life. The strengths of cultural humility training include focus on (1) individuals instead of their cultural groups, (2) self-reflection, and (3) active listening. While there are challenges to implementing cultural humility trainings in the health-care system, we assert that these trainings align with the aims of healthcare systems and can be an essential tool in reducing LGBTQ health disparities. We suggest practical components of successful cultural humility trainings including leadership buy-in, appropriate outcome measurements, multiple training sessions, and fostering a safe reflection space.

Care and LGBT Aging in Canada: A Focus Group Study on the Educational Gaps among Care Workers

OBJECTIVES

Educational interventions have the potential to equip healthcare providers to support diverse aging populations. The purpose of this research was to identify educational gaps hindering the provision of person-centered care to older adults who identify as LGBT.

METHODS

Three focus groups were conducted in urban centers in northern, southern, and eastern Ontario with healthcare professionals and frontline staff. Semi-structured focus group discussion guides were developed based on the literature identifying some of the knowledge gaps, attitudes, challenges, and barriers around providing care for older LGBT adults.

RESULTS

The focus group data revealed several key findings related to 1) lack of curricula within formal education; 2) the need to create safer physical and social environments; and 3) the need to build relationships with LGBT-focused groups/organizations.

CONCLUSIONS

Care providers want to provide open space for sexual and gender diverse older adults but lack the knowledge to do so.

CLINICAL IMPLICATIONS

There is an ongoing gap within formal education systems such that historically marginalized populations who are now aging may be systemically neglected within formal curricula.

Dying in Long-Term Care: Perspectives from Sexual and Gender Minority Older Adults about Their Fears and Hopes for End of Life

As lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities age, many individuals expect a need to enter the long-term care system toward the end of life. Not unlike most aging Canadians, this anticipation is met with concern and fear. However, previous research suggests that older LGBTQ + individuals have unique fears often related to personal safety and discrimination. This qualitative study examined the hopes and fears of older LGBTQ + adults considering long-term care as they face end of life. Data were collected from three focus groups in Ontario, Canada, and analyzed using inductive thematic analysis. Specific and frequent reference to fear of entering long-term care homes was common across all focus groups, as participants anticipated: social isolation, decreased independence and capacity for decision-making, increased vulnerability to LGBTQ+-related stigma as well as exposure to unsafe social and physical environments. The results from this study, therefore, emphasize the need for palliative care specialists and long-term care home staff to address the unique health needs of older LGBTQ + adults nearing the end of life in order to work toward allaying fears and creating supportive and inclusive long-term care environments.

Palliative and End-of-Life Care for Lesbian, Gay, Bisexual, and Transgender (LGBT) Cancer Patients and Their Caregivers

OBJECTIVE

To identify the unique needs of lesbian, gay, bisexual, and transgender (LGBT) cancer patients and caregivers, and review recommendations supporting more effective and inclusive palliative and end-of-life care.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Transitions in care raise particular challenges for LGBT patients, including provider communication, perceptions of safety and acceptance, and assessing and respecting patients' definitions of family and spirituality.

IMPLICATIONS FOR NURSING PRACTICE

LGBT patients and their caregivers need competent nurses to support them, especially during transitions. Implementing LGBT-inclusive education, training, and practice will improve outcomes for LGBT cancer patients and their caregivers - and potentially all patients.

Staying Out of the Closet: LGBT Older Adults’ Hopes and Fears in Considering End-of-Life

Le vieillissement de la population canadienne et l’hétérogéneité des aînés amène une diversité accrue en fin de vie. L’objectif de cette étude était d’aider à combler les lacunes présentes dans la recherche du vieillissement et la fin de vie des personnes LGBT. À l’aide des groupes de discussion, nous avons tenté de mieux comprendre les expériences vécues des individus LGBT plus âgés, afin de mettre en évidence leurs inquiétudes associés aux dernières phases de la vie. Notre analyse démontre que l’identité LGBT est déterminante lorsqu’on considère le vieillissement et les soins en fin de vie. En particulier, l’identité de genre et l’orientation sexuelle sont des facteurs importants par rapport aux liens sociaux, influençant les attentes des individus envers les soins qu’ils reçoivent, à la crainte unique associée à la révélation de son homosexualité et le maintien de l’identité tout au long du vieillissement et des dernières phases de la vie. Cette étude souligne le besoin de considérer l’identité du genre et l’orientation sexuelle en fin de vie. En particulier, la reconnaissance de l’intersectionnalité et des lieux sociaux est essentielle afin de faciliter des expériences positives par rapport au vieillissement et des soins en fin de vie.

Healthcare and End-of-Life Needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) Older Adults: A Scoping Review

Lesbian, gay, bisexual, and transgender (LGBT) older adults face a number of challenges with respect to access to healthcare especially towards end-of-life. Through a systematic search and scoping review of the literature, we sought to answer two related research questions. In particular, the purpose of this scoping review was to determine the healthcare needs of LGBT older adults nearing end-of-life as well as the factors that contribute to a good death experience among older adults who identify as LGBT. A systematic search of electronic databases for articles published between 2005 and 2016 as well as screening for relevance resulted in 25 results. The data were charted and grouped according to the themes of: social support and chosen family, intimacy, health status, fear of discrimination and lack of trust, lack of knowledge and preparedness, and cultural competence in the healthcare system. The results suggest a role for health and social service workers in contributing to a positive care experience for LGBT older adults by becoming knowledgeable about the unique needs of this population and being unassuming and accepting of individuals' sexuality. Many of the articles reviewed collected data outside of Canada, limiting generalizability and highlighting a need for Canadian data on LGBT aging and end-of-life.