Death Is a Social Justice Issue: Perspectives on Equity-Informed Palliative Care

Race and Ethnicity Are Related to Undesirable Home Health Care Outcomes in Seriously Ill Older Adults

OBJECTIVES

Medicare Home Health Care (HHC) services are integral to the care of homebound seriously ill older adults requiring ongoing specialized medical care. Although disparities in health outcomes are well documented in inpatient and primary care, disparities experienced by historically marginalized racial and ethnic groups underrepresented in HHC are understudied. This study aimed to examine the relationship between individual characteristics and differences in HHC health outcomes for seriously ill older adults.

DESIGN

Secondary data analysis, repeated measure.

SETTING AND PARTICIPANTS

Seriously ill older adults who received HHC in 2016 in the HHC Outcome and Assessment Information Set (OASIS).

METHODS

Start of care and discharge data from the 2016 HCC OASIS were used to examine the relationship between individual characteristics and differences in HHC health outcomes identified by the Centers for Medicare and Medicaid Services as key indicators of quality in HHC, including dyspnea, pain frequency, cognitive functioning, and presence of unhealed pressure ulcer stage II or higher. A generalized ordered logit model with partial proportional odds was used for the ordinal categorical outcomes and a logistic regression was used for the binary dependent variable.

RESULTS

Findings indicated that of 227,402 seriously ill individuals with an HHC episode in 2016, those from underrepresented racial and ethnic groups had between 14% and 57% higher odds of worse health outcomes compared with non-Hispanic white patients with the exception of pain frequency.

CONCLUSIONS AND IMPLICATIONS

For people living with serious illness, there are significant differences in Medicare HHC health outcomes when comparing underrepresented racial or ethnic beneficiaries with white counterparts. More research is needed to understand how health care processes such as referral patterns or time to care initiation, and structural factors such as HHC agency quality and neighborhood social deprivation are related to health differences observed in the population.

"The great escape": how an incident of elopement gave rise to trauma informed palliative care for a patient experiencing multiple disadvantage

BACKGROUND

This case report from Scotland, UK illustrates how unresolved traumatic experiences across the life course can affect a patient's engagement with palliative care and offers insights into the flexibility and adaptations necessary for taking a trauma informed approach to care for an individual experiencing multiple disadvantage. Trauma informed care is a cornerstone in the pursuit of equitable palliative care, particularly for those facing multiple disadvantage, as it acknowledges the impact of past traumas on current healthcare experiences, and fosters an environment of understanding, acceptance, and tailored support to alleviate suffering in the final stages of life.

CASE PRESENTATION

"M" was a veteran with a history of homelessness, living with end stage anal cancer and symptoms consistent with post-traumatic stress disorder, although he never received a formal diagnosis. M exhibited complex behaviours perceived to be related to his history of trauma, including his decision to elope from the hospice, reluctance to accept personal care from nurses, and unpredictability. These behaviours posed a significant challenge to his palliative care team, both in the hospice and at home. An individualised and flexible approach to care delivery was eventually adopted, which included a 'safety-netting' approach and care delivery outside of the hospice. M was ultimately supported to remain at home until a week before he died.

CONCLUSION

M's case underscores the necessity of adopting a trauma informed approach to palliative care, particularly for patients with a history of trauma and multiple disadvantage. The case highlights the importance of understanding and respecting a patient's past traumas, promoting safety and autonomy, and ensuring flexibility in care delivery.

"You can't die here": an exploration of the barriers to dying-in-place for structurally vulnerable populations in an urban centre in British Columbia, Canada

BACKGROUND

One measure of quality in palliative care involves ensuring people approaching the end of life are able to receive care, and ultimately die, in the places they choose. Canadian palliative care policy directives stem from this tenet of autonomy, acknowledging that most people prefer to die at home, where they feel safe and comfortable. Limited research, however, considers the lack of 'choice' people positioned as structurally vulnerable (e.g., experiencing extreme poverty, homelessness, substance-use/criminalization, etc.) have in regard to places of care and death, with the option of dying-in-place most often denied.

METHODS

Drawing from ethnographic and participatory action research data collected during two studies that took place from 2014 to 2019 in an urban centre in British Columbia, Canada, this analysis explores barriers preventing people who experience social and structural inequity the option to die-in-place. Participants include: (1) people positioned as structurally vulnerable on a palliative trajectory; (2) their informal support persons/family caregivers (e.g., street family); (3) community service providers (e.g., housing workers, medical professionals); and (4) key informants (e.g., managers, medical directors, executive directors). Data includes observational fieldnotes, focus group and interviews transcripts. Interpretive thematic analytic techniques were employed.

RESULTS

Participants on a palliative trajectory lacked access to stable, affordable, or permanent housing, yet expressed their desire to stay 'in-place' at the end of life. Analysis reveals three main barriers impeding their 'choice' to remain in-place at the end of life: (1) Misaligned perceptions of risk and safety; (2) Challenges managing pain in the context of substance use, stigma, and discrimination; and (3) Gaps between protocols, policies, and procedures for health teams.

CONCLUSIONS

Findings demonstrate how the rhetoric of 'choice' in regard to preferred place of death is ethically problematic because experienced inequities are produced and constrained by socio-structural forces that reach beyond individuals' control. Ultimately, our findings contribute suggestions for policy, programs and practice to enhance inclusiveness in palliative care. Re-defining 'home' within palliative care, enhancing supports, education, and training for community care workers, integrating palliative approaches to care into the everyday work of non-health care providers, and acknowledging, valuing, and building upon existing relations of care can help to overcome existing barriers to delivering palliative care in various settings and increase the opportunity for all to spend their end of life in the places that they prefer.

Nonphysical Suffering: An Under-Resourced and Key Role for Hospice and Palliative Care Social Workers

This article highlights recent research findings that have significance for hospice and palliative care social work in Canada, and for the field of hospice and palliative care more broadly. A 2020 discourse analysis study examined the experiences of 24 interdisciplinary palliative care clinicians across Canada in their work with patients' nonphysical suffering. Nonphysical suffering is suffering that may be emotional, psychological, social, spiritual and/or existential in nature. The study found an absence of specialist social workers on hospice and palliative care teams or limited time for specialist social workers to address patients' nonphysical suffering due to high caseloads and complex practical needs. While the study recognizes social workers have expertise in supporting patients' nonphysical suffering, a competency and skill that has not been sufficiently captured in the existing literature, the systemic barriers they face in providing care may leave patients' needs unmet. The study also highlights the unique pressure social workers may feel to relieve patients' nonphysical suffering due to the psychosocial focus of their role. The need for specialist social workers to be included and adequately resourced on hospice and palliative care teams across diverse settings in Canada is evident.

Finding the Hidden Professional Culture of Mental Health Nursing-Spiritual Care for Individuals with a Co-morbid Life-Limiting Illness

People with severe mental illness are dying up to thirty years earlier than the general population. The limited literature on their experience of dying indicates that they often suffer from inequities in their access to healthcare services, and further, what care they do receive is frequently poor. Living with both a mental illness and facing death can engender spiritual concerns and dying at a younger age is a risk factor for spiritual despair. Hence, addressing spiritual concerns can be an important dimension of mental health nursing care. The aim of this ethnographic study of 11 senior and experienced mental health nurses was to determine if the culture of the mental health service impacted their spiritual care for those patients who were facing death. The data highlighted that the nurses felt comfortable in providing spiritual care when the person was suffering from psychosis. Yet, the results also revealed that nurses felt disempowered by the dominance of the biomedical culture, in which they felt unable to articulate their care. However, it was identified that their spiritual care was inherent within the professional values, knowledge, and skills of mental health nursing and framed through their therapeutic relationships. Therefore, strategies need to be used by the organization to assist nurses to reclaim their power and assist the mental health service to further develop and engage in spiritual care practices.

From Cultural Safety to Anti-Racism: Reflections on Addressing Inequities in Palliative Care

The purpose of palliative care is to ease the suffering of individuals with a serious and often life-limiting illness throughout the course of their disease by providing holistic care that considers the physical, spiritual, and psychosocial dimensions of health and well-being. Research shows that a palliative approach to care is cost-effective for the healthcare system and results in improved quality of life for patients and their loved ones. However, it is well-documented in the literature that structurally vulnerable populations have greater difficulty accessing equitable and culturally safe palliative care. Several domains are identified as contributing factors to the disparities seen in the literature, including systemic racism, cultural differences around death and suffering, and language barriers. Although Canada has had a national palliative care framework since 2018, ongoing issues of access and equity continue to disproportionately impact certain groups, including racially marginalized, immigrant, and low-income communities. In this commentary, successes and ongoing gaps in providing culturally safe and anti-racist palliative care are explored. In these proposed interventions, we advocate for a palliative approach to care that is grounded in equity, justice, and human rights.

Reflecting on choices and responsibility in palliative care in the context of social disadvantage

There is a need to understand how to improve palliative care provision for people impacted by social inequity. Social inequity, such as that related to socioeconomic circumstances, has profound impacts on experiences of death and dying, posing personal and professional challenges for frontline professionals tasked to ensure that everyone receives the best standard of care at the end of their lives. Recent research has highlighted an urgent need to find ways of supporting healthcare professionals to acknowledge and unpack some of the challenges experienced when trying to deliver equitable palliative care. For example, those involved in patient or person-centred activities within health settings often feel comfortable focusing on individual choice and responsibility. This can become ethically problematic when considering that inequities experienced towards the end of life are produced and constrained by socio-structural forces beyond one individual's control. Ideas and theories originating outside palliative care, including work on structural injustice, cultural safety and capabilities approach, offer an alternative lens through which to consider roles and responsibilities for attending to inequities experienced at the end of life. This paper draws upon these ideas to offer a new way of framing individual responsibility, agency and collective action that may help palliative care professionals to support patients nearing their end of life, and their families, in the context of socioeconomic disadvantage. In this paper, we argue that, ultimately, for action on inequity in palliative care to be effective, it must be coherent with how people understand the production of, and responsibility for, those inequities, something that there is limited understanding of within palliative care.

Total pain and social suffering: marginalised Greenlanders' end-of-life in Denmark

With a focus on socially marginalised Greenlanders in Denmark, this study explores the significance of the concept of social suffering for the concept of total pain. Greenland is a former Danish colony and Greenlanders retain the right to Danish citizenship with all the benefits of access to the resources of Denmark as any other Danish citizen. However, Greenlanders are overrepresented amongst the most socially disadvantaged in Denmark. They have a disproportionately high risk of early death, often undiagnosed and untreated. This study reports on research conducted with socially marginalised Greenlanders and some of the professionals who work with them. It interrogates the concept of total pain as developed by Cicely Saunders, the founder of modern palliative care. Saunders noted that pain at the end-of-life was not adequately explained by symptoms of a disease process because it was more like a situation that engulfed every aspect of the patient and those close to them; it included physical, psychological, spiritual, and social dimensions. We agree with other scholars that the social dimension of the total pain experience is underexplored. By drawing on the theoretical and methodological lens of intersectionality, our work with marginalised Greenlanders has enabled us to describe the multiple and intersecting social forces that create social suffering for this group. This leads us to conclude that social suffering is not entirely an individual experience but a product of social harm and disadvantage, poverty, inequality, and the various legacies of colonialism, which combine to place some citizens in a harmed condition. Our findings also draw us into a discussion with the concept of total pain and its neglect of the socially constructed nature of social suffering. We conclude by indicating ways in which the concept of total pain can be informed by a more thoroughgoing concept of social suffering. We conclude, with others, that there is a problem of inequity in the way that end-of-life care is currently distributed. Finally, we point to ways in which an understanding of social suffering can help to address the exclusion of some of the most vulnerable citizens from appropriate end-of-life care.

The 2023-2026 Hospice and Palliative Nurses Association Research Agenda

The Hospice and Palliative Nursing Association established the triannual research agenda to ( a ) provide focus for researchers to conduct meaningful scientific and quality improvement initiatives and inform evidence-based practice, ( b ) guide organizational funding, and ( c ) illustrate to other stakeholders the importance of nursing research foci. HPNA Research Agendas are developed to give direction for future research to continue advancing expert care in serious illness and ensure equitable delivery of hospice and palliative care.

Effectiveness of Skill-Building Interventions for Informal Caregivers of Adults with Cancer: a Systematic Review

Over 19 million people worldwide were diagnosed with cancer in 2020. Informal caregivers of adults with cancer play an important role in helping their loved ones with cancer yet often receive little support in developing the necessary skills for caregiving. A systematic review of skill-building interventions for informal caregivers of adults with cancer was conducted across three electronic databases for academic articles published through February 2022. PRISMA reporting guidelines were followed throughout this review, the Mixed Methods Appraisal Tool was used to assess study quality, and results were summarized in a narrative synthesis. The main components of skill-building interventions examined include caregiving preparedness, communication, and self-care. Nine of the 11 included articles showed that interventions effectively built skills for informal caregivers. The articles reviewed had a wide variety of intervention strategies, outcome measures, and study designs. Two of the 11 articles mentioned vulnerable and key groups, and no studies were performed in low- and middle-income countries. Findings generally support implementing skill-building interventions for informal caregivers of adults with cancer; however, further research is necessary to determine the most effective approaches for improving caregiver skills and reaching vulnerable and key populations.

Barriers to cancer treatment and care for people experiencing structural vulnerability: a secondary analysis of ethnographic data

BACKGROUND

A key pillar of Canada's healthcare system is universal access, yet significant barriers to cancer services remain for people impacted by structural vulnerability (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing structural vulnerability within a Canadian context.

METHODS

We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 h of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers.

RESULTS

Our analysis identified four themes presenting as 'modifiable' barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) impact of lower health literacy (3) addressing social care needs is a pre-requisite for treatment (4) intersecting and compounding barriers reinforce exclusion from cancer care. These inter-related themes point to how people impacted by health and social inequities are at times 'dropped' out of the cancer system and therefore unable to access cancer treatment.

CONCLUSION

Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publically funded healthcare system. Identifying people who experience structural vulnerability, and approaches to delivering cancer services that are explicitly equity-oriented are urgently needed.

Assessing the impact of a health navigator on improving access to care and addressing the social needs of palliative care patients experiencing homelessness: A service evaluation

BACKGROUND

Health navigators are healthcare professionals who specialize in care coordination, case management, navigating transitions, and reducing barriers to care. There is limited literature on the impact of health navigators on community-based palliative care for people experiencing homelessness.

AIM

We devised key performance indicators in nine categories with the aim to quantify the impact of a health navigator on the delivery of palliative care to patients experiencing homelessness.

DESIGN

Data were collected prospectively for all patient encounters involving a health navigator from July 2020 to 2021 and reviewed to determine the distribution of the health navigator's role and the ways in which patient care was impacted.

SETTING AND PARTICIPANTS

This study was conducted in Toronto, Ontario with the Palliative Education and Care for the Homeless (PEACH) Program. At any one time, the PEACH health navigator served a total of 50 patients.

RESULTS

We identified five key areas of the health navigator role including (1) facilitating access (2) coordinating care (3) addressing social determinants of health (4) advocating for patients, and (5) counselling patients and loved ones. The health navigator role was split evenly between activities pertaining to palliative care for structurally vulnerable populations and community-based palliative care for the general population. To achieve high impact outcomes, a considerable investment of time and energy was required of the health navigator, speaking to the importance of adequate and sustainable funding.

CONCLUSIONS

These findings underscore the potential for health navigators to add value to community-based palliative care teams, especially those caring for structurally vulnerable populations.

Palliative care for people who use drugs during communicable disease epidemics and pandemics: A scoping review on access, policies, and programs and guidelines

BACKGROUND

People who use drugs with life-limiting illnesses experience substantial barriers to accessing palliative care. Demand for palliative care is expected to increase during communicable disease epidemics and pandemics. Understanding how epidemics and pandemics affect palliative care for people who use drugs is important from a service delivery perspective and for reducing population health inequities.

AIM

To explore what is known about communicable disease epidemics and pandemics, palliative care, and people who use drugs.

DESIGN

Scoping review.

DATA SOURCES

We searched six bibliographic databases from inception to April 2021 as well as the grey literature. We included English and French records about palliative care access, programs, and policies and guidelines for people ⩾18 years old who use drugs during communicable disease epidemics and pandemics.

RESULTS

Forty-four articles were included in our analysis. We identified limited knowledge about palliative care for people who use drugs during epidemics and pandemics other than HIV/AIDS. Through our thematic synthesis of the records, we generated the following themes: enablers and barriers to access, organizational barriers, structural inequity, access to opioids and other psychoactive substances, and stigma.

CONCLUSIONS

Our findings underscore the need for further research about how best to provide palliative care for people who use drugs during epidemics and pandemics. We suggest four ways that health systems can be better prepared to help alleviate the structural barriers that limit access as well as support the provision of high-quality palliative care during future epidemics and pandemics.

"Once you open that door, it's a floodgate": Exploring work-related grief among community service workers providing care for structurally vulnerable populations at the end of life through participatory action research

BACKGROUND

At the end of life, people experiencing structural vulnerability (e.g. homelessness, poverty, stigmatization) rely on community service workers to fill gaps in access to traditional palliative services. Although high levels of burnout are reported, little is known about these workers' experiences of grief.

AIM

To explore community service workers' experiences of grief to identify ways of providing more tailored, meaningful, and equitable supports.

DESIGN

A community-based participatory action research methodology, informed by equity perspectives, was employed.

SETTING/PARTICIPANTS

In an urban center in western Canada, community service worker (primary) participants (n = 18) were engaged as members of an action team. A series of 18 action cycles took place, with secondary participants (n = 48) (e.g. palliative, social care, housing support, etc.) being recruited throughout the research process. Focus groups (n = 5) and evaluative interviews (n = 13) with participants were conducted. Structured observational field notes (n = 34) were collected during all team meetings and community interventions. Interpretive thematic analysis ensued through a collaborative and iterative process.

RESULTS

During initial meetings, action team participants described experiences of compounding distress, grief, and multiple loss. Analysis showed workers are: (1) grieving as family, not just providers; (2) experiencing complex layers of compounded grief; and (3) are fearful to open the "floodgates" to grief.

CONCLUSIONS

Findings contribute to our understanding on the inequitable distribution of grief across society. A collective and material response is needed, including witnessing, acknowledging and valuing the grief process; facilitating community wellness, collective grieving, and advocacy; and providing training and tools in a palliative approach to care.

Facilitating equitable access to hospice care in socially deprived areas: A mixed methods multiple case study

BACKGROUND

There is uncertainty about the factors influencing inequities in access to palliative care in socially deprived areas, including the role of service models and professional perceptions.

AIM

To explore the relationship between social deprivation and access to hospice care, including factors influencing access and professional experiences of providing care.

DESIGN

A mixed-methods multiple case study approach was used. Hospice referrals data were analysed using generalised linear mixed models and other regression analyses. Qualitative interviews with healthcare professionals were analysed using thematic analysis. Findings from different areas (cases) were compared in a cross-case analysis.

SETTING

The study took place in North West England, using data from three hospices (8699 hospice patients) and interviews with 42 healthcare professionals.

RESULTS

Social deprivation was not statistically significantly, or consistently, associated with hospice referrals in the three cases (Case 1, Incidence Rate Ratio 1.04, p = 0.75; Case 2, Incidence Rate Ratio 1.09, p = 0.15, Case 3, Incidence Rate Ratio 0.88, p = 0.35). Hospice data and interviews suggest the model of hospice care, including working relationship with hospitals, and the local nature of social deprivation influenced access. Circumstances associated with social deprivation can conflict with professional expectations within palliative care.

CONCLUSION

Hospice care in the UK can be organised in ways that facilitate referrals of patients from socially deprived areas, although uncertainty about what constitutes need limits conclusions about equity. Grounding professional narratives around expectations, responsibility, and choice in frameworks that recognise the sociostructural influences on end-of-life circumstances may help to foster more equitable palliative care.

Bureaucracy and burden: An Intersectionality-Based Policy Analysis of social welfare policy with consequences for carers of people with life-limiting illness

BACKGROUND

For informal carers of people with life-limiting illness, social welfare policy related to income support and housing has been associated with varied psychosocial issues, yet remains relatively under-explored. An intersectional approach offers potential to illuminate diverse experiences and implications.

AIM

To explore the way in which caring in the context of life-limiting illness is framed within welfare policy, to articulate inequities encountered by carers, and to identify policy and practice recommendations.

DESIGN

The Intersectionality-Based Policy Analysis (IBPA) Framework was used to situate findings of a broader qualitative study.

SETTING/PARTICIPANTS

Data were collected via semi-structured interviews with participants who were bereaved carers (n = 12), welfare workers (n = 14) and palliative care workers (n = 7), between November 2018 and April 2020, in an Australian region associated with socioeconomic disadvantage. Five elements of IBPA were applied to the products of analysis of this data.

RESULTS

Use of the IBPA Framework revealed that representations of carers and causes of their welfare needs in policy were underpinned by several assumptions; including that caring and grieving periods are temporary or brief, and that carers have adequate capacity to navigate complex systems. Policy and processes had differentiated consequences for carers, with those occupying certain social locations prone to accumulating disadvantage.

CONCLUSIONS

This intersectional analysis establishes critical exploration of the framing and consequences of welfare policy for carers of people with life-limiting illness, presented in a novel conceptual model. Implications relate to intersectoral development of structural competency, responsiveness to structurally vulnerable carers in clinical practice, and needed policy changes.

Promoting Health Equity: Palliative Nurses on the Frontlines

In May 2021, the National Academies of Sciences, Engineering, and Medicine released the Future of Nursing 2020-2030-Charting a Path to Health Equity. The report provides an in-depth analysis of the history and evidence of structural racism, the role of social determinants of health, and the role of nurses improving health equity in times of conventional care, disasters and crises, and public health emergencies. Palliative nurses are integral to impacting health equity for individuals with serious illness. Three strategies can help palliative nurses provide more equitable palliative care: 1) develop a more culturally sensitive practice and communication skill; 2) learn about the elements of social determinants of health to perform a simple Social Determinants of Health assessment as part of every patient's assessment; and 3) gather a list of community resources to help direct patients to resources.

Extending Palliative Approaches to Care Beyond the Mainstream Health Care System: An Evaluation of a Small Mobile Palliative Care Team in Calgary, Alberta, Canada

Background:

People experiencing houselessness (PH) endure worse health outcomes than their housed counterparts and often have inadequate care when nearing end of life. Innovative palliative care approaches are necessary when considering socially vulnerable populations.

Aim:

Evaluate the implementation and early outcomes of the Calgary Allied Mobile Palliative Program (CAMPP) after the first four years of servicing people experiencing extreme social marginality.

Setting/Participants:

Participants include CAMPP clients and service providers (SPs) who work adjacently to CAMPP in the social services/health sectors.

Design:

This is a mixed-methods evaluation, including an SP survey (n = 31); client interviews (n = 5); collection of program metrics; and case note reviews.

Results:

The CAMPP has served 128 clients to date. The CAMPP supported clients by connecting them to 62 services, programs, agencies, and/or resources totaling 485 connections. The most referred-to resource was for social support in the community for PH at 61 referrals. The second was for transportation with 57 referrals, followed by referrals to palliative and Home Care programs (n = 53 referrals). Another common referral was for food assistance with 30 referrals. The survey showed that 97% of SPs agreed that CAMPP is “an essential service in the area of palliative care.” Twenty-six of 30 (87%) “Strongly Agreed” or “Agreed” that their knowledge in working with people with life-limiting illnesses has improved since working with CAMPP. The SPs suggested that the team should focus on referral clarity and improved communication with the wider health care team. Finally, clients reported high levels of satisfaction with CAMPP services. Clients also reported challenges navigating the complexity of care in the social/health services sector.

Conclusions:

The CAMPP bridges the gap in care between health/social services. The CAMPP connects clients to community resources and is effective in adapting to client needs. This evaluation provides four recommendations to improve and build on the existing program.

Equity-Oriented Healthcare: What It Is and Why We Need It in Oncology

Alarming differences exist in cancer outcomes for people most impacted by persistent and widening health and social inequities. People who are socially disadvantaged often have higher cancer-related mortality and are diagnosed with advanced cancers more often than other people. Such outcomes are linked to the compounding effects of stigma, discrimination, and other barriers, which create persistent inequities in access to care at all points in the cancer trajectory, preventing timely diagnosis and treatment, and further widening the health equity gap. In this commentary, we discuss how growing evidence suggests that people who are considered marginalized are not well-served by the cancer care sector and how the design and structure of services can often impose profound barriers to populations considered socially disadvantaged. We highlight equity-oriented healthcare as one strategy that can begin to address inequities in health outcomes and access to care by taking action to transform organizational cultures and approaches to the design and delivery of cancer services.

Caring and Grieving in the Context of Social and Structural Inequity: Experiences of Australian Carers With Social Welfare Needs

Caring for and bereavement following the death of someone with a life-limiting illness may precipitate social welfare needs related to income support and housing. Nevertheless, carer experiences of welfare policy and institutions have not received significant attention. This qualitative study explored experiences of carers who navigated social welfare policy while caring for someone with a life-limiting illness, and in bereavement. In-depth interviews were conducted with 12 bereaved carers in an area associated with socioeconomic disadvantage. Carers differentially encountered precariousness, with some experiencing structural vulnerability. These positionalities appeared to be shaped by policy and process-related burdens, perceptions of the welfare state, and degrees of legitimisation or disenfranchisement of forms of capital and coping orientations. Recommendations that may improve carer experience were identified. Implications relate to the need for an expanded conceptualisation of vulnerability in health and welfare practice, policy that authentically validates caring and grieving, and upstream strategies that address inequity.

Exploring socioeconomic inequities in access to palliative and end-of-life care in the UK: a narrative synthesis

BACKGROUND

Efforts inequities in access to palliative and end-of-life care require comprehensive understanding about the extent of and reasons for inequities. Most research on this topic examines differences in receipt of care. There is a need, particularly in the UK, for theoretically driven research that considers both receipt of care and the wider factors influencing the relationship between socioeconomic position and access to palliative and end-of-life care.

METHODS

This is a mixed studies narrative synthesis on socioeconomic position and access to palliative and end-of-life care in the UK. Study searches were conducted in databases AMED, Medline, Embase, CINAHL, SocIndex, and Academic Literature Search, as well as grey literature sources, in July 2020. The candidacy model of access, which describes access as a seven-stage negotiation between patients and providers, guided study searches and provided a theoretical lens through which data were synthesised.

RESULTS

Searches retrieved 5303 studies (after de-duplication), 29 of which were included. The synthesis generated four overarching themes, within which concepts of candidacy were evident: identifying needs; taking action; local conditions; and receiving care.

CONCLUSION

There is not a consistent or clear narrative regarding the relationship between socioeconomic position and receipt of palliative and end-of-life care in the UK. Attempts to address any inequities in access will require knowledge and action across many different areas. Key evidence gaps in the UK literature concern the relationship between socioeconomic position, organisational context, and assessing need for care.

"Everybody in this community is at risk of dying": An ethnographic exploration on the potential of integrating a palliative approach to care among workers in inner-city settings

OBJECTIVE

At the end of life, the need for care increases. Yet, for structurally vulnerable populations (i.e., people experiencing homelessness and poverty, racism, criminalization of illicit drug use, stigma associated with mental health), access to care remains highly inaccessible. Emerging research suggests that enhancing access to palliative care for these populations requires moving care from traditional settings, such as the hospital, into community settings, like shelters and onto the street. Thus, inner-city workers (ICWs) (e.g., housing support and community outreach) have the potential to play pivotal roles in improving access to care by integrating a "palliative approach to care" in their work.

METHOD

Drawing upon observational field notes and interview data collected for a larger critical ethnographic study, this secondary thematic analysis examines ICWs' (n = 31) experiences providing care for dying clients and garners their perspectives regarding the constraints and facilitators that exist in successfully integrating a palliative approach to care in their work.

RESULTS

Findings reveal three themes: (1) Approaches, awareness, and training; (2) Workplace policies and filling in the gaps; and (3) Grief, bereavement, and access to supports. In brief, ICWs who draw upon harm reduction strategies strongly parallel palliative approaches to care, although more knowledge/training on palliative approaches was desired. In their continuous work with structurally vulnerable clients, ICWs have the opportunity to build trusting relationships, and over time, are able to identify those in need and assist in providing palliative support. However, despite death and dying is an everyday reality of ICWs, many described a lack of formal acknowledgement by employers and workplace support as limitations.

SIGNIFICANCE OF RESULTS

Findings contribute promising practices for enhancing equitable access to palliative care for society's most vulnerable populations by prioritizing front-line workers' perspectives on how best to integrate a palliative approach to care where structurally vulnerable populations live and die.

'Bare-bones' to 'silver linings': lessons on integrating a palliative approach to care in long-term care in Western Canada

Background

‘Whole-person’ palliative approaches to care (PAC) are important for enhancing the quality of life of residents with life-limiting conditions in long-term care (LTC). This research is part of a larger, four province study, the ‘SALTY (Seniors Adding Life to Years)’ project to address quality of care in later life.

A Quality Improvement (QI) project to integrate a PAC (PAC-QI) in LTC was implemented in Western Canada in four diverse facilities that varied in terms of ownership, leadership models, bed size and geography. Two palliative ‘link nurses’ were hired for 1 day a week at each site over a two-year time frame to facilitate a PAC and support education and training.

This paper evaluates the challenges with embedding the PAC-QI into LTC, from the perspectives of the direct care, or front-line team members. Sixteen focus groups were undertaken with 80 front-line workers who were predominantly RNs/LPNs (n = 25), or Health Care Aides (HCAs; n = 32). A total of 23 other individuals from the ranks of dieticians, social workers, recreation and rehabilitation therapists and activity coordinators also participated. Each focus group was taped and transcribed and thematically analyzed by research team members to develop and consolidate the findings related to challenges with embedding the PAC.

Results

Thematic analyses revealed that front-line workers are deeply committed to providing high quality PAC, but face challenges related to longstanding conditions in LTC notably, staff shortages, and perceived lack of time for providing compassionate care. The environment is also characterized by diverse views on what a PAC is, and when it should be applied. Our research suggests that integrated, holistic and sustainable PAC depends upon access to adequate resources for education, training for front-line care workers, and supportive leadership.

Conclusions

The urgent need for integrated PAC models in LTC has been accentuated by the current COVID-19 pandemic. Consequently, it is more imperative than ever before to move forwards with such models in order to promote quality of care and quality of life for residents and families, and to support job satisfaction for essential care workers.

Recommendations to Improve Palliative Care Provision for Marginalized Populations: Summary of a Roundtable Discussion

Palliative care is increasingly recognized as fundamental to health and human dignity. However, a growing body of evidence highlights the variations in access to palliative care based on personal characteristics, belonging to a certain group, and socioeconomic background. Discriminatory attitudes and behaviors and lack of legal reform protecting the rights of marginalized populations are still common, particularly across Lebanon and the Middle East and North Africa region. This article presents a summary of a roundtable discussion organized by the Lebanese Medical Association for Sexual Health in collaboration with the Lebanese Center for Palliative Care-Balsam, focusing on improving palliative care provision for the following populations: prisoners; lesbian, gay, bisexual, and transgender people; refugees; migrant domestic workers; and people with substance use disorder. It also offers recommendations based on the key themes identified from the discussion, in the hope that they will guide the development of guidelines and policy to advance equity in palliative care provision for marginalized populations.

Social welfare needs of bereaved Australian carers: Implications of insights from palliative care and welfare workers

An individual and psychological emphasis has influenced practice and research on bereavement following informal care provision in the context of life-limiting illness. Consideration of the potential for bereavement to be shaped by intersecting social and structural inequities is needed; and should include an understanding of interactions with government institutions and social policy. This qualitative study employed interpretive description to explore the way in which palliative care workers and welfare sector workers perceive and approach experiences and needs of bereaved carers receiving government income support or housing assistance in Western Sydney, an area associated with recognised socioeconomic disadvantage. A total of 21 palliative care workers within a public health service and welfare workers from two government social welfare services participated in in-depth interviews. Data were analysed using framework analysis. Participants highlighted social welfare policy and related interactions that may impact bereavement, potentially related to financial, housing and employment precariousness. Personal, interpersonal and structural factors perceived to shape the navigation of welfare needs were explored, alongside needed professional and structural changes envisioned by workers. With limited forms of capital, vulnerably positioned carers may encounter difficulties that heighten their precariousness in bereavement. Transactional organisational cultures alongside health and welfare agencies that function in a siloed manner appear to contribute to structural burden for carers, following death due to life-limiting illness. Palliative care and welfare workers also associated elements of their work with bereaved carers with their own experiences of helplessness, frustration and distress. Findings point to a need for the development of interagency strategies in addition to policy underpinned by more nuanced understandings of vulnerability in bereavement, post-caring.

Caring precariously: An interpretive description of palliative care and welfare worker perspectives on end of life carers navigating social welfare

BACKGROUND

Caring at end-of-life is associated with financial burden, economic disadvantage, and psychosocial sequelae. Health and social welfare systems play a significant role in coordinating practical resources and support in this context. However, little is known about social policy and interactions with public institutions that shape experiences of informal carers with social welfare needs at end-of-life.

AIM

To explore ways in which palliative care and welfare sector workers perceive and approach experiences and needs of the carers of people with life-limiting illnesses who receive government income support or housing assistance, in an area of recognised socioeconomic disadvantage.

DESIGN

An interpretive descriptive study employed in-depth, qualitative interviews to explore participants' reflections on working with carers of someone with a life-limiting illness. Data were analysed using the framework approach.

SETTING/PARTICIPANTS

Twenty-one workers employed within three public services in Western Sydney were recruited.

RESULTS

Workers articulated understandings of welfare policy and its consequences for carers at end-of-life, including precariousness in relation to financial and housing circumstances. Identified resources and barriers to the navigation of social welfare needs by carers were categorised as personal, interpersonal and structural.

CONCLUSIONS

Caring at end-of-life while navigating welfare needs was seen to be associated with precariousness by participants, particularly for carers positioned in vulnerable social locations. Findings highlighted experiences of burdensome system navigation, inconsistent processes and inequity. Further exploration of structural determinants of experience is needed, including aspects of palliative care and welfare practice and investment in inter-agency infrastructure for supporting carers at end-of-life.

Caregiving at the margins: An ethnographic exploration of family caregivers experiences providing care for structurally vulnerable populations at the end-of-life

BACKGROUND

People experiencing structural vulnerability (e.g. homelessness, poverty, racism, criminalization of illicit drug use and mental health stigma) face significant barriers to accessing care at the end-of-life. 'Family' caregivers have the potential to play critical roles in providing care to these populations, yet little is known regarding 'who' caregivers are in this context and what their experiences may be.

AIM

To describe family caregiving in the context of structural vulnerability, to understand who these caregivers are, and the unique challenges, burdens and barriers they face.

DESIGN

Critical ethnography.

SETTING/PARTICIPANTS

Twenty-five family caregivers participated. Observational fieldnotes and semi-structured interviews were conducted in home, shelter, transitional housing, clinic, hospital, palliative care unit, community-based service centre and outdoor settings.

RESULTS

Family caregivers were found to be living within the constraints of structural vulnerability themselves, with almost half being street family or friends. The type of care provided varied greatly and included tasks associated with meeting the needs of basic survival (e.g. finding food and shelter). Thematic analysis revealed three core themes regarding experiences: Caregiving in the context of (1) poverty and substance use; (2) housing instability and (3) challenging relationships.

CONCLUSION

Findings offer novel insight into the experiences of family caregiving in the context of structural vulnerability. Engaging with family caregivers emerged as a missing and necessary palliative care practice, confirming the need to re-evaluate palliative care models and acknowledge issues of trust to create culturally relevant approaches for successful interventions. More research examining how 'family' is defined in this context is needed.

Ethics of Finitude: Nursing and the Palliative Approach in Geriatric and Forensic Psychiatry

There is a called-for shift to an upstream provision of palliative care as an overall care approach within a health equity perspective. Our research explored how nurses in psychiatry engage with aging patients and mortality to discern enactment of ethical dimensions of care. Drawing from tenets of interpretative phenomenological analysis, forensic and geriatric psychiatry registered nurses working at a mental health facility in eastern Ontario completed interviews for analysis. Nurses engaged with mortality through a process of recognition and through the affirmation of their values. The affirmed values are aligned with the palliative care approach and within an ethics of finitude lens in that their enactment is partly premised on the recognition of patients’ accumulated losses related to human facticities (social, temporal, mortal). This research underscores preliminary insights on a process identifying care practices aligned with the palliative approach and possibilities for expanding upon an ethics of finitude lens.

Addressing Social Determinants of Health in the Care of Patients With Heart Failure: A Scientific Statement From the American Heart Association

Heart failure is a clinical syndrome that affects >6.5 million Americans, with an estimated 550 000 new cases diagnosed each year. The complexity of heart failure management is compounded by the number of patients who experience adverse downstream effects of the social determinants of health (SDOH). These patients are less able to access care and more likely to experience poor heart failure outcomes over time. Many patients face additional challenges associated with the cost of complex, chronic illness management and must make difficult decisions about their own health, particularly when the costs of medications and healthcare appointments are at odds with basic food and housing needs. This scientific statement summarizes the SDOH and the current state of knowledge important to understanding their impact on patients with heart failure. Specifically, this document includes a definition of SDOH, provider competencies, and SDOH assessment tools and addresses the following questions: (1) What models or frameworks guide healthcare providers to address SDOH? (2) What are the SDOH affecting the delivery of care and the interventions addressing them that affect the care and outcomes of patients with heart failure? (3) What are the opportunities for healthcare providers to address the SDOH affecting the care of patients with heart failure? We also include a case study ( Data Supplement ) that highlights an interprofessional team effort to address and mitigate the effects of SDOH in an underserved patient with heart failure.

Disadvantaged and disenfranchised in bereavement: A scoping review of social and structural inequity following expected death

An emphasis on individual intervention and psychological complexity has characterised research on bereavement following an experience of life-limiting illness. Exploration of "structural vulnerability" as a positionality produced by social and structural inequity could provide insights into areas of practice and policy in need of development. This scoping review sought to summarise published research on experiences of social and structural inequities in the context of bereavement due to life-limiting illness. Underpinned by recognised methodological frameworks, systematic searches were conducted of four electronic databases. Eligible studies attended to bereavement experience following the death of an adult due to life-limiting illness, included consideration of social and structural inequities, and were undertaken in high income countries between 1990 and 2018. Following thematic analysis, a conceptual framework was developed. Of 322 records, 62 full text articles were retrieved and 15 papers met inclusion criteria. Studies highlighted unequal social status in bereavement related to gender, class, sexuality, ethnicity and age, with structural inequity experienced in interactions with institutions and social networks. Studies also identified that the experience of bereavement itself may be accompanied by exposure to disenfranchising systems and processes. Structural vulnerability appeared to be associated with outcomes including psychological distress, social disenfranchisement and practical concerns such as financial strain, housing insecurity and employment issues. Social and structural inequities potentially contribute to layered and patterned experiences of disadvantage and disenfranchisement following expected death, with implications for individual agency. Findings point to the need for consideration of socio-ecological approaches within and beyond specialist palliative care, involving development of more responsive social policy, coordinated advocacy, and systemic capacity building regarding experiences of grief, to better support populations positioned as structurally vulnerable in bereavement.

Towards a Guiding Framework for Prison Palliative Care Nursing Ethics

The number of people aging and dying behind bars is growing, bringing greater attention to the need for prison palliative care. While this trend has rightly led to increased scholarship, a focus on understanding the most effective way to deliver prison palliative care has overshadowed thinking about why the need itself has arisen, as well as deeper ethical thinking about how the nursing profession should respond. This article interweaves 4 strands of analysis-contextual, relational, social, and political-to produce a framework to guide ethical action in prison palliative care nursing, relevant to practice, research, policy, and education.

Social Processes Affecting the Workforce Integration of First-Generation Immigrant Health Care Professionals in Aging Citizens in the Netherlands

Introduction: Within a Dutch nursing home, the prevailing workforce culture was challenged by new personnel, which caused institutional change, which in turn, affected workforce integration. The purpose of this study was to examine social processes affecting workforce integration of first-generation immigrant health care professionals in aging citizens in a Dutch health institution in the Netherlands. Method: A purposive sample of 10 immigrants and 10 established nurses was recruited. Ethnography was used to guide this study. 105 hours of participant observation, 8 semistructured interviews with 4 immigrants and 4 established nurses, and 2 focus-group discussions with 8 immigrants and 6 established nurses. Results: The study identified various processes that affect culturally congruent care in the nursing home, like the imposing professional norms, the use of "weapons of the weak," mutual suspicions of indifference, and collective images of "us" versus "them." Both groups conceived the "others" as the source of their discomfort, however, both had pain of not mattering. Discussion: When recruiting international educated nurses "all nursing staff" face difficulties when going through the precarious process of mutual integration in daily care practices. We recommend that nurse leaders facilitate positive intergroup interactions that promotes reciprocity for all groups of nurses for better health care outcomes for all.

Providing Data-Driven Equitable Palliative and End-of-Life Care for Structurally Vulnerable Populations: A Pilot Survey of Information Management Strategies

BACKGROUND

Considerable gains are being made in data-driven efforts to advance quality improvement in health care. However, organizations providing hospice-oriented palliative care for structurally vulnerable persons with terminal illnesses may not have the enabling data infrastructure or framework to derive such benefits.

METHODS

We conducted a pilot cross-sectional qualitative study involving a convenience sample of hospice organizations across North America providing palliative care services for structurally vulnerable patients. Through semistructured interviews, we surveyed organizations on the types of data collected, the information systems used, and the challenges they faced.

RESULTS

We contacted 13 organizations across North America and interviewed 9. All organizations served structurally vulnerable populations, including the homeless and vulnerably housed, socially isolated, and HIV-positive patients. Common examples of collected data included the number of referrals, the number of admissions, length of stay, and diagnosis. More than half of the organizations (n = 5) used an electronic medical record, although none of the record systems were specifically designed for palliative care. All (n = 9) the organizations used the built-in reporting capacity of their information management systems and more than half (n = 6) augmented this capacity with chart reviews.

DISCUSSION

A number of themes emerged from our discussions. Present data collection is heterogeneous, and storage of these data is highly fragmented within and across organizations. Funding appeared to be a key enabler of more robust data collection and use. Future work should address these gaps and examine opportunities for innovative ways of analysis and reporting to improve care for structurally vulnerable populations.

Living, loving, dying: Insights into rural compassion

OBJECTIVE

To improve understandings of the enablers and barriers to maintaining good quality of life for people dying, caring and grieving in rural areas.

DESIGN AND SETTING

In-depth interviews designed on participatory research principles were held with bereaved carers living in a small community in rural Tasmania. Participants had cared for someone until their death within the 3-year period prior.

PARTICIPANTS

Nineteen participants comprising 18 bereaved former carers and one person with a life-limiting illness, and all but four were over retirement age.

STUDY AIM

To explore experiences of end-of-life care in a rural community.

RESULTS

Participants discussed the challenges they experienced during end-of-life caring, including transport into the city for treatment, and access to basic and specialised services. However, they also reported positive aspects of formal and informal palliative care, and described experiences of personable, expert, flexible and innovative caregiving.

CONCLUSIONS

The rural location enabled personalised and innovative expressions of care. This research adds new insight into rural end-of-life palliation, as a complex intersection of supererogation, innovation and place-driven care.

A scoping review of palliative care for persons with severe persistent mental illness

Objective

People with severe persistent mental illness (SPMI) experience a greater burden and severity of chronic disease, late diagnosis, and premature death compared with the general population. Those with SPMI also receive fewer medical treatments, poor quality of care, and are less likely to receive palliative care. A systematic scoping review was undertaken to determine the extent, range, and nature of research activity about people with SPMI requiring palliative care, and to identify gaps and opportunities for future research.

Method

A systematic scoping review was undertaken in September 2017 and updated in May 2018 to map literature on this topic, determine the extent and range of what has been published, and report the findings. This five-stage framework was conducted by (1) identifying the research question; (2) identifying relevant studies; (3) determining study selection; (4) charting the data; and 5) collating, summarizing, and reporting the results. A narrative approach to analysis was used to synthesize and interpret findings. A search of multidisciplinary healthcare databases resulted in 46 included articles.

Result

Four major themes were identified from the included studies: complexity of care; limited access to care (both through systems and healthcare providers); competence and autonomy; and the potential for relationships between mental health and palliative care.

Significance of results

This review reveals a highly vulnerable population with complex needs that are not reliably being met by the healthcare system and providers. Research in this area must continue to develop using rigorous qualitative and quantitative study designs, and interventions should be developed and tested based on existing knowledge to inform care. The voices of people with SPMI in need of palliative care must be represented in future studies to address gaps. To expand a body of literature addressing mainly individuals, system perspectives and sociocultural analysis can bring much to contextualizing the experience of living with SPMI in the palliative phase of care. Adoption of a palliative approach, which promotes the principles of palliative care across nonspecialized care settings provided by nonspecialist palliative providers, has the potential to increase access to high-quality palliative treatment for people with SPMI.

"Just too busy living in the moment and surviving": barriers to accessing health care for structurally vulnerable populations at end-of-life

BACKGROUND

Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL.

METHODS

Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently.

RESULTS

Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers.

CONCLUSIONS

Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.

Delay in commencement of palliative care service episodes provided to Indigenous and non-Indigenous patients: cross-sectional analysis of an Australian multi-jurisdictional dataset

Background

Rapid effective responsiveness to patient needs is pivotal to high quality palliative care. Aboriginal and Torres Strait Islander (Indigenous) people are susceptible to life-limiting illnesses at younger ages than other Australians and experience inequity of health service provision. The Palliative Care Outcomes Collaboration collects Australia-wide health service data on patient care, and has established performance benchmarks for specialist palliative care services. We investigated whether the benchmark for timely commencement of palliative care episodes (occurrence of delay >1 day after being designated ‘ready for care’ in <10% instances) is being met for Indigenous Australians in participating services. Additionally, we investigated the association between identification as Indigenous and delay.

Methods

Using multi-jurisdictional Palliative Care Outcomes Collaboration data, this cross-sectional analytical study investigated all episodes of care (n = 84,238) provided to patients ≥18 years (n = 61,073: Indigenous n = 645) in hospital and community settings commenced and completed during the period 01/07/2013–30/06/2015. Proportions of episodes resulting in delay were determined. Crude and adjusted odds of delay among Indigenous compared with non-Indigenous patients were investigated using multiple logistic regression, with missing data handled by multiple imputation.

Results

The benchmark was met for both Indigenous and non-Indigenous patients (delay in 8.3 and 8.4% episodes respectively). However, the likelihood of delay was modestly higher in episodes provided to Indigenous than non-Indigenous patients (adjusted odds ratio [aOR], 1.41; 95% confidence interval [CI] 1.07–1.86). Excess delay among Indigenous patients was accentuated in first episodes (aOR, 1.53; 95% CI 1.14–2.06), in patients aged < 65 years (aOR, 1.66; 95% CI 1.14–2.41), and among those residing in Inner Regional areas (aOR, 1.97; 95% CI 1.19–3.28), and also approached significance among those in outer regional, remote and very remote areas collectively (aOR, 1.72; CI 0.97–3.05).

Conclusions

Although the timeliness benchmark is being met for Indigenous Australians in palliative care, they may experience delayed initiation of care episodes, particularly if younger, and especially at first encounter with a service. Qualitative research is required to explore determinants of delay in initiating palliative care episodes. The timeliness of initial referral for specialist palliative care in this population remains to be determined.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0380-7) contains supplementary material, which is available to authorized users.

Discourses Reproducing Gender Inequities in Hospice Palliative Home Care

BACKGROUND

As home is a site where gendered attitudes, beliefs, and practices are reproduced, it is imperative that policies and practices promote gender equity in end-of-life care at home.

PURPOSE

The purpose of this study was to critically analyze gender relations in the sociopolitical context of hospice palliative home care.

METHODS

Using a critical feminist perspective, we examined gender relations between and among clients with cancer, their family caregivers, and nurses in hospice palliative home care. Ethnographic methods of in-depth interviews (n = 25), observations of home visits (n = 9), and review of documents (n = 12) were employed to expose gender (in)equities.

FINDINGS

This critical analysis sheds light on institutional discourses that reproduce gender inequities: discourses of difference and denial; discourses of individuality, autonomy, and choice; and discourses of efficiency, objectivity, and rationality. Although gender was discounted, these neoliberal discourses reinforced traditional gender relations.

DISCUSSION

Neoliberal discourses frame health and health-care experiences as resulting primarily from individual behaviors and biomedical factors, permitting health-care providers and policy makers to overlook power relations and the sociopolitical forces that obscure gender inequities. A critical perspective is needed to consider how social structures significantly shape everyday gendered experiences in hospice palliative home care.

When cancer hits the streets

Toby died 5 October 2015. [...]