In Australia on any given night, 1 in 200 people are homeless. Young Australians make up the largest proportion (46 percent of the homeless are younger than 25), but nearly one quarter are older than 45. A significant number of homeless people have significant, complex needs.
Five months ago, Neil, a 46-year-old male, presented to the emergency department with significant weight loss and increasing chest pain. Extensive investigation revealed he had stage 4 lung cancer. When Neil was asked his current address, he said he had been "living near the river." He had family members living in another state, but he hadn't had any contact with them in years. At the same time, the local newspaper had reported that a homeless shelter place had been closed in the area.
While we were discussing the diagnosis and treatment options with Neil, he was using the hospital as a site of care. He would leave the hospital (to "take care of business") without informing the nurses of considering his medical priorities. The oncology social worker (OSW) became involved and tried to find an adequate site to receive care. Neil made the OSW assessment very difficult by giving conflicting information about his own arrangements with his family. He refused to give health professionals the details of the person to contact. That made it very difficult for health professionals to identify his next of kin. We also had to determine who would make the decisions regarding his care after death. Prompting a homeless person to make a will that will provide information about funeral arrangements is important.
Neil had behavioral problems that made professional care very difficult at times. He would become verbally aggressive in situations where he found it difficult to cope. In the homeless population, alternative lifestyles such as illicit drug use and alcoholism greatly impact a person's ability to cope with life-changing situations.
Deciding on treatment was another challenge for Neil. There were issues such as appropriate storage for medications and theft of opioids. He may have also been tempted to sell opioids for food or other needs. Besides this, compliance can be very low, and lack of finances may complicate matters. Patients sometimes need to bear a small amount of the chemotherapy costs, and radiotherapy is delivered within a private model of care; patients need to pay the gap fee not insured by Medicare. Neil had no treating GP, either, raising the issue of opioid prescribing in the community setting.
Involving community palliative care and district nursing services is a challenge in the homeless population. In Australia, before the initial assessment of a community patient, it is mandatory for community nurses to screen the patient's environment for safety. High-risk screening mainly results in the refusal of community teams to be involved in the patient's care.
The oncology team always had an open and honest line of communication with Neil. As a team, we identified triggers for discussion and left it up to Neil if he wanted to discuss an issue or not. We agreed on a discharge plan and anticipated discharge time, and we assessed the care needs on a daily basis.
Strategic coordination of care was needed, with the main focus on discharge planning from the hospital to the community. Neil decided to rekindle his relationship with his family and to receive high-level professional care from appropriate community services. He agreed to see a Cancer Council-funded solicitor, and a will was documented with his preferences for place of death and funeral arrangements. A very difficult discussion was held about DNR and was documented in case of an emergency event in hospital.
Sadly, Neil died before he was discharged from the hospital. DNR documentation was imperative in making his end of life as peaceful as possible. In a discussion I had with him a day earlier, he said he had come to terms with his end-of-life situation and was not afraid of dying. Emotional support was provided to his grieving family.
How well is your organization prepared for managing the needs of a homeless cancer patient? What policies and referral pathways are in place in America? Does anyone have any advice on how I can improve cancer care for the homeless population?