PC for People Experiencing Homelessness: Naheed Dosani

Eric 00:00

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:05

And Alex, who do we have with us today?

Alex 00:07

Today we are honored to welcome Naheed Dosani, who is a palliative care doc and health justice advocate. He’s assistant professor at the University of Toronto. He’s the founder and leader of the Palliative Education and Care for the Homeless program in Toronto, Palliative care physician at St. Michael’s Hospital in the Department of Family and Community Medicine. Naheed, welcome to the GeriPal Podcast.

Naheed 00:31

Thanks so much for having me here. Really looking forward to the conversation.

Eric 00:34

I’m excited for this. So we did a podcast on aging and homelessness with Margot Kushel in 2023. So we’re going to be today talking about serious illness palliative care in the homelessness population. I’m also wondering how I should be calling that. So we’ll talk about how should we be thinking about even the label, the name homelessness. But before we do that, Naheed, do you have a song request for Alex?

Naheed 00:58

I do. I thought long and hard about this one and I’m going to request the song Blinding Lights by The Weeknd.

Eric 01:06

Why did you choose Blinding Lights?

Naheed 01:08

Well, first of all, I’m a proud Canadian and the Weeknd is from Canada. But not just that, the Weeknd is actually from the same borough that I’m from in Toronto, Ontario. And from a medical historical perspective, you might say that it just seemed fitting because when it comes to palliative care for people experiencing homelessness, we’re really trying to shine a light on the issues that often get overlooked. And I gonna choose Bryan Adams, summer of 69. But let’s be real, it’s super cold in Toronto in January. It’s nowhere near summer right now. So let’s go with Blinding Lights.

Eric 01:39

Awesome.

Alex 01:50

(singing)

Eric 02:55

Thank you, Alex.

Naheed 02:57

Dude, I was over here head banging. That was amazing. [laughter]

Alex 03:00

That was so fun song. Thank you for that request. Thank you so much.

Eric 03:07

Naheed, I’m going to start off with this question. I’ve seen you answer this question a lot. So I’ve just listened to a podcast that you did with End of Life University Podcast, which we’ll have a link to in our show notes too, because I just, I’ve never heard of that podcast before, but I love it now. But the question that I see you answering a lot is what inspired you or what motivated you to focus and it seems like a big focus of your career has been around delivering palliative care for people experiencing homelessness.

Naheed 03:48

Yeah, for sure. An important question and it certainly wasn’t a linear trajectory. I was born and raised in Toronto, Canada, the son of two refugees and growing up is a first generation Canadian born in that kind of household. The social determinants of health and what community well being was a big part of. I always knew that I wanted to get into healthcare, to use healthcare as a springboard for social change in our communities. But as a first year resident trainee at the University of Toronto, I cared for a young man in his early 30s while working in a shelter. Who, his name was Terry. He was a person with schizophrenia, he was a person who used drugs and he presented in pain crisis to our shelter.

He had this disseminated head and neck cancer and he had tried to get care before and due to his mental illness, he couldn’t follow up for cancer care. By the time he got into us, the tumor grew, he had experienced, he was experiencing significant pain and so trauma, informed care and building a relationship with him was such a big part of the care. And I remember getting to the shelter the next day after meeting him early and not finding him anywhere and learning later that he had died overnight. He had overdosed due to a combination of alcohol and street drugs. And this is really traumatic event for his street family and the street community that he knew. But it was really traumatic for me as a trainee living in Toronto.

We have world class primary care, cancer care, palliative care. And it just really upset me internally that we were living in a society where we were letting people fall through the cracks again, again, again and again at the end of life. And I just had this theory that if we can’t get it right from a humanity perspective at the end of life, like what? What are we doing? And so Terry’s been a real inspiration for me and carrying him in my heart everywhere I go every single day.

Eric 05:34

Let me ask you this, is that probably every one of us and every intern and resident has cared for a Terry. That story is not a unique story, unfortunately. What about that particular case? Is there something about that particular case that motivated you or is it just the culmination of Terry’s that you’ve had to care for, where this was just like the last straw? Have you thought about that?

Naheed 06:01

Yeah, I mean, so a little bit of both. Right. So in Terry, I saw a person who was literally trying to connect to a healthcare system that he couldn’t find a connection to. I saw a person who needed humanitarian care. I saw a person who couldn’t access the social determinants of health. And yet in my other rotations and experiences, it was so clear that we were resourcing people with palliative care resources very well. You didn’t have to walk many blocks down the street to a hospital or another facility where people were getting world class care. So for me, it was the inequ of it in many countries around the world. In Canada, we’re pretty good at delivering equality based health care where people get the same things to be happy and healthy.

But what Terry needed was equity based health care. He, he needed what he needed to be happy and healthy. And it was different and perhaps a little bit more, but we just couldn’t get it to him. And so, you know, you’re right, like Terry wasn’t the only case. And I went through my training and I’d see more people, people experiencing mental illness, people who use drugs, racialized folks, people who are at or below the poverty line, seem to never get into our palliative care systems that you and I work in, or they get into those systems at a lower rate. And that really, really bothered me, still bothers me to this day.

Eric 07:22

So at what point did you decide to create this PEACH program? The Palliative Education and Care for the Homeless program?

Naheed 07:33

Yeah. So I pursued further training in palliative care at the University of Toronto. And during my residency training, upon myself to explore every social determinant of health. And everywhere I rotated. Ask the question, who are you seeing and who are you not seeing? To medical directors, chiefs, and some were really cool to talk to me. And I think I annoyed a lot of my future colleagues along the way and started to pitch what we thought was a best practice, which eventually became the PEACH program, to different organizations. And one of those organizations, Inner City Health Associates, which is a large network of health care professionals who provide health care for people experiencing homelessness, took me up on the offer and basically said, you know, we have some resources. We just hired a nurse. If you can convince her, her name is Namreg, to work with you on this project, you know, we’ll give you a year’s worth of funding to make it work. And we were off to the races.

Eric 08:29

So this is straight out of fellowship?

Naheed 08:31

That’s right. Yeah. We launched like the day after I graduated. True story. And out the back of my Honda Civic, actually driving around the streets, you know, seeing folks. And after one year we saw 42 people. The peach program and our mobile palliative care program for people experiencing structural vulnerabilities. You know, we found that 64% of the people we cared for never went to the hospital or ER. 80% died exactly where they wanted to and 83% were reconnected to family or friends through a psychosocial support system that we put into place. And so the metrics kind of spoke for itself.

And yeah, Fast forward to 10 years later, literally. We’re celebrating our 10 year anniversary. The Peach program has cared for over 1,000 clients. We have 120 to 140 clients on caseload at any given time. The team has grown to a team of seven palliative care doctors, two nurses, two social workers, a peer worker, a psychiatrist, and an interprofessional roster of home care professionals who are working in non traditional home settings to deliver palliative care. It’s been quite a ride.

Eric 09:39

So I wonder if you can just paint a picture for our audience who probably the majority have never done palliative care or even hospice care in a homeless population. People who. Wait, can I ask, but even before I say, am I using the right word? Homeless, Is that what term?

Alex 09:59

Before we use the wrong term or whatever. Is there a wrong term? Is there a right term?

Naheed 10:06

I really appreciate you asking because I think that these kinds of conversations are really important and our words matter and language matters and I know that that’s where this is coming from. And so whenever I’m asked this question, I always think it’s important to speak to the population we aim to serve and have their input because it’s really about them. What we hear is that it is more trauma informed in many contexts to have people first language. And so saying people experiencing homelessness or a person experiencing homelessness is often how we use the lingo more recently in our political discourse because it’s all connected, right?

Health and health justice. We talk a lot about people being unhoused, which I think takes the blame away from the individual and kind of de. Stigmatizes this population that is often stigmatized and puts more of the onus on society and large systems, political systems, economic systems, that there should be an adequate supply of affordable, high quality housing for people. And no person should actually be experiencing homelessness. So, you know, I just wanted to present a couple options and give you a sense of, you know, the background for both.

Alex 11:17

Thank you. If you ask people who are homeless or houseless or unhoused, what term do they prefer? Do you have a sense?

Naheed 11:26

No. I’ve met many people who are very okay with, you know, being described as homeless, but then there are probably more people than that who say, I’m not. Like when you call me homeless, I’m much more than that. It’s intersectionality. Right. There’s so many identities like, I’m a person, I’m a human, I’m a man, I love music. We start to be really reductive in our discourse when we kind of just identify people with one label. And so that’s where person first language can be helpful or even starting to make it a little bit more political in nature and kind of progressing the language to even call folks who are experiencing homelessness actually saying they’re unhoused.

Eric 12:08

Yeah.

Alex 12:09

And for the purposes of this podcast, how do you suggest we talk? What words do you suggest we use going forward? People with. I’ll just throw out there people with serious illness experiencing homelessness.

Naheed 12:21

I think that’s a really, like. If I heard that, I would feel that’s trauma informed. I would feel that you’re being insightful and reflecting on. On bias and trauma as you. As you say that phrase. And I think that would work. A lot of people talk about experiencing homelessness as a sort of standard term in our sector.

Eric 12:38

Okay. So I’m going to get back to the question. So I imagine. So you’re straight out of fellowship. Did you say you’re going around in your Camry or Corolla? Which car was it again?

Alex 12:49

Civic.

Eric 12:49

Honda Civic. Driving around your Civic. What challenges did you encounter in delivering palliative care.

Naheed 13:01

Yeah.

Eric 13:02

To people experiencing homelessness?

Naheed 13:04

Yeah, it’s an important, fair question. I think actually it’s the crux of the whole theory here. Right. Is identifying those challenges and removing barriers for people to get the care they need. I think the first is trauma and trust. The raw reality is that the many of the people we care for do not trust the healthcare system. And as a result of that, do not trust me and my colleagues who work in healthcare because many of Them have experienced trauma. Yes, the world, but often at the hands of health care. And so going out there and connecting with people. We have many, many PEACH clients who are kind of almost like, like can’t believe they’re, they’re receiving good care. That like, you’re a doctor, you spent an hour with me to hang out sitting on this curb, just kind of like connecting and talking about sports and, you know, the sunsets and like, really, what’s the catch here? Like, what’s the catch? They can’t believe it, but we come back again and again and again gently to provide that support. And that’s kind of that trauma informed care.

The next thing is like, just the obvious logistics of like, where do you receive care when you do not have a home? And I often say this in conversations like this, but like, you know, we’ve gone out, like, we being the palliative care community, depending on where you are, we’ve gone out and like, we designed this like, robust home palliative care system. But like, what about people who don’t have homes? Like, like we literally created a system that structurally excluded people who don’t have homes. And like, I know it’s semantics and it’s words, but we just agreed words matter. Right. And so we’ve designed really robust home palliative care systems, but as soon as they don’t have a roof over their head or a phone number, we don’t know how to serve them. Right.

Eric 14:41

We exclude them often.

Naheed 14:43

Right, Exactly.

Alex 14:44

It’s in the name home based palliative care. Right, right.

Naheed 14:47

Words.

Eric 14:48

And even at hospice, a lot of hospices will not. Like some of them will, but majority won’t care for people experiencing homelessness.

Naheed 14:56

You got it. And so the attitude has unfortunately become like, we just don’t provide care to folks. And then it’s like some like, advanced logistics, like where do you put medications? Like if, you know, if you have a procedure the next day and you’re going for a colonoscopy, like, where do you use the bathroom? And we know a lot of the folks we care for need care and access to supports and services. And that’s really difficult to do in a shelter, respite, drop in an encampment, in a park. Like, these are challenging things. And so these were some of the challenges. I think another piece that is important for the palliative care community to talk about, and I’m glad you’re having conversations around substance, substance use health on the podcast is the concept of how do we care for people who use drugs through a palliative care approach. And again, not everyone who’s unhoused uses drugs, but there is a proportion of people who do, and harm reduction was a huge strategy that we used to overcome that.

Eric 15:51

Can I ask specifically about that question?

Naheed 15:53

Yeah, yeah.

Eric 15:54

What year did you start peach?

Naheed 15:56

2014.

Eric 15:57

2014. How much of your training was focused on managing substance use disorder training and palliative care?

Naheed 16:05

Yeah, you know. Yeah, yeah. So.

Eric 16:08

And how did you. I’m guessing, like here, especially in 2014, almost none of it was. Although thankfully that’s, that’s changing, I think, in a lot of fellowships. How did you build up that competence if that was the case?

Naheed 16:20

Yeah. You know, I think the key thing is that, yes, things are definitely changing back then. I, I gotta say I’m lucky to have trained at the University of Toronto where, you know, there, there, there, there is some good foundational training for the trainees to go through in use health, opioid agonist therapy, et cetera. But for me to really get comfortable in palliative practice, I had to go book like other rotations and spend some, some extra time with people who do addiction health, people who, you know, I spent time with the outreach nurses who are doing, you know, street outreach visits. I spent time with harm reduction workers at overdose prevention sites. And even then, you know, to say that I, I’m confident. I think you have to have a sense of humility when you do this work. I don’t think I’ll ever say I’m confident.

Right. Just I feel that it’s necessary to step in and to care for folks in this way. And if we don’t, people will really suffer and they’ll die. And on the topic of death, and then I’ll just kind of like pass it back to you is just to say that I think a major challenge is our health system and our palliative care systems often project what a good death is on people. And a lot of the time when our palliative care community in the past has tried to, to provide palliative care for, for people who are unhoused or experience homelessness, they’ve, they’ve projected what they think a good death is. You know, that deluxe death, you know, in a place with a marble floor and the music in the background, that’s not, that’s not typically what people that I care for on the streets and in shelters actually want.

Eric 17:52

What do you hear?

Naheed 17:53

Yeah, they want connection, they want relationship, they want, meaning. They want to feel like they’re supported. They’re more, more interested in relationship centered care than the fancy medicines that you’re. They want you to recognize their pain, not just their physical pain, but their trauma that they’ve experienced as a, as a, as a result of being on the streets. They want a care model that’s flexible, not rigid. Right. So yeah, those are some of the things that I hear and I keep.

Eric 18:25

On hearing back to trauma informed care. So we just did a podcast on trauma informed care. We’ll have a link to our show Notes. When you think about delivering trauma informed care to people experiencing homelessness, are there things that you think palliative care providers, people who are. Anybody caring for people with serious illness in this population should really be mindful of?

Naheed 18:48

Yeah, absolutely. When I talk to palliative care providers about how they can care for this population, I recognize that not everyone’s in a position to start a, a PEACH program or especially with the current political landscape and funding schemes, it’s really difficult to move those pieces of work. But that doesn’t mean we can’t care for people in trauma informed ways. One of the first things I’ll say is to actually really see the social determinants of health and treating those as a palliative care intervention, we’re really focused on pain, nausea, constipation stuff is important, don’t get me wrong. But when someone comes in and has insecure housing, that is a really important moment that can really change someone’s life. To connect them with a housing worker, fill in an application, you know, food security, you know, all of the social determinants that someone could present with. That’s, that’s one of the things that I say.

Eric 19:43

How much of that do you think is, you know, it’s so much easier just to focus on the things that we can write a prescription for versus addressing social determinants of health, which in some ways feels overwhelming and daunting, especially if you don’t have a big interprofessional team or a system that actually would support that.

Naheed 20:04

And you know, the key to this conversation is not to put the onus on individuals. We are having a systemic conversation here. We’re talking about systems like. I agree with you that we need changes in our systems that support clinicians to be able to make that change. But I will have you know that there is a movement in the UK and Canada and many places, places around the world called social prescribing, where the concept of writing a prescription and writing housing or food is not a, is not or is not a wild concept. Actually, it’s being talked about a lot, so.

Eric 20:35

Well, it’s fascinating because we, at least in the US we’re okay giving writing prescription for a $300,000 a year drug that has marginal, if any, benefit, especially some of these cancer drugs. But you can’t write that prescription for an apartment for the next three months while they’re getting treatment, even though it’s, you know, on the single digit, percentage wise amount of money. So like $1,000 or $2,000 make a.

Naheed 21:05

Huge point like what’s more cost effective? We now have lots of research in the realm of housing first. The idea that instead of making people jump through hoops to get a home, if we just gave them housing first, that would just be cheaper. There’s lots of evidence to support what you’ and yeah, I agree that it’s a little bit of a twisted system that prioritizes sometimes the wrong things.

Eric 21:27

Yeah.

Alex 21:28

One of the things we talked about in the podcast we recorded yesterday or two days ago on substance use disorder, when we were talking about trauma informed care, one of the terms that kept coming up was accountability without termination. Or as we said in the podcast, abandonment. Non abandonment is a core principle of palliative care. And I wonder if that is key in patients, people who are experiencing homelessness as well.

Naheed 21:58

Absolutely. A lot of the principles that are talked about in core topics in substance use health, I definitely do extend. I would agree that a lot of the time the people we care for have been abandoned previously by the health systems around us. They have been let down. And that when they slip up or make a mistake, it’s more punitive than it is. Let’s talk about what happened and let’s figure out a way forward that might be better.

And so we try to move away from a punitive approach to when people maybe use a few more of their opioids than they should have, or there might be a reason for that, or if people don’t show up for an appointment or we do all this work to get an outreach visit at a shelter and they’re not there, it’s, there’s possibly a reason maybe they were out panhandling because they ran out of money, because it’s really difficult out there on the streets, especially, you know, in the winter in Canada. And so, you know, a sprinkle of humanity with some of those concepts definitely in combination are vital.

Alex 23:02

And how do you find people who are experiencing homelessness given that there’s, you know, it’s if somebody has a home and you’re doing home based care, you go to that home. If somebody is, is experiencing homelessness, how do you locate them?

Naheed 23:16

Yeah, you know, I would say that we’re really grateful to have a wide and deep seated network of people who are deeply supportive of the PEACH program. As you can imagine, get referrals from healthcare workers, emergency departments, primary care, cancer care hospital, you know, internal medicine to our service. And that’s about half of our referrals. But did you know that half of our referrals actually come from non healthcare workers, social care workers, housing workers, harm reduction workers, people who are like PSWs in community, other people with lived experiences. And we’ve trained this community over the years to identify what a palliative care approach can look like and who may need a palliative care approach. And it’s worked.

Alex 24:03

What’s a psw?

Naheed 24:05

A personal support worker. Sorry about that. That’s the phrase for care aides in Canada.

Eric 24:11

And then Alex’s question too. I’m hearing like, if they’re homeless, sometimes they’re in particular spots, but in some places they get moved, they’re forced to relocate. That’s a question too, Alex. How do you actually physically find them if that’s the case?

Naheed 24:31

So especially with the referrals that we get and the calls that we get from our non healthcare colleagues, they tend to be folks who are case managing people on the streets and supporting them. So actually we often our initial visit will be with those folks. So it could be a case manager at a shelter or an outreach worker who works in the encampment areas of Toronto. And so we work with our trusted partners. And because we’re part of a network of people caring for people experiencing homelessness, we get to the shelters, respites, drop ins, the encampments, the rooming houses, and we’re able to find where people go, are coming from and where they’re going to. This is a transient population and sometimes we show up and they’re not there. And so the attitude isn’t like, you know, oh, like they missed an appointment, like, okay, like this is so annoying.

No, it’s more like they must have been really busy. There must be a good reason why, you know, they miss this appointment because they value this, but they have a lot of other things on their plate. And we recognize that when people are unhoused, people are busy. It’s a difficult existence to maintain sustenance and dignity and, and food and, and resources and perhaps the roof over your head. So we’ll go back and we call it a door knock. We’ll go back and kind of check, check on them. Or maybe we should ask, you know, the peer worker who’s on our team or maybe we should ask one of the housing managers to go and check on them. And it’s kind of like, you know, a cycle of figuring out where people are. And most of the time we find people, most of the time we connect with them and it works.

Eric 25:59

Who’s eligible for.

Naheed 26:01

Yeah, we have very broad definitions, you know, and it’s purposely broad because we don’t want to be so rigid from a, for example, from a prognosis perspective that the homelessness sector, so the non healthcare folks who care for people in the homeless sector don’t get confused. I think broadness is an important principle. One of the big ones is you need to meet the Canadian definition of homelessness, which is an established definition. The second is that that there needs to be a reason you might not be able to connect with mainstream palliative care services. So the obvious one is like not having a home, but it could actually be if someone has tried and wasn’t able to, if someone has serious mental illness, if the person’s drugs and then they have to have a serious life limiting illness on top of that.

And those are really our three categories just to put out there. Not everyone dies in the program. While palliative care has a focus on serious ill and the end of life journey, people get better. Like, like a lot of people get, you know, a compassionate care approach, get some medicine, some food, some social determinants of health optimized and then, and then all of a sudden they bounce back and we’ve actually discharged people to primary care and that happens too. And we celebrate that when that happens. It’s appreciating how it can go and not like having a rigid trajectory. That’s really important.

Eric 27:26

I love the PEACH program. I love it and, but I just wondering as I’m doing inpatient consults or people are doing outpatient care or you’re caring for people and you don’t have this program, let’s say you can advocate for. But right now, boots on the ground, are there pearls that you’ve learned in the last decade that would be helpful for me to know as I care for people experiencing homelessness who are also having a serious illness.

Alex 27:57

Who are hospitalized, for example?

Eric 27:59

Yeah, let’s say who are hospitalized for sure.

Naheed 28:02

I mean I, I think the first thing is, is you know, one of the first things I do before I go see someone when I’m working on inpatient hospital service, like the consult team is I actually look up their address and their postal code and if I don’t know about the area of Toronto, I learn about it. Just to understand what their environment is like. You can’t make assumptions, but it gives you a sense of where they might be coming from. The second thing is to really adopt a trauma informed approach. You know, recognize that this person may have experienced trauma at the hands of health care. You don’t need to know about it, but then really like wear your trauma informed hat when you are interacting with them. Ask them in their preferred names, sit at eye level, use the appropriate pronoun, you know, those kinds of things.

The other thing I think is like to, to, to move them forward in their care. And often this involves, you know, disposition, planning and community, is to better understand their community. And you may not have a PEACH program or one of our cousin programs that have, it’s been established across Canada and many places around the world. But there are definitely health care workers who are providing care for the unhoused in your community, and there are definitely housing workers who would love to get a call from you to hear more. And so one of the best things that my colleagues in the homelessness sector say is when, when a health care worker, like a physician or a nurse calls them and says, your client is admitted and we’re having a family meeting and we’d love for you to be there. Like, that goes so far. Right. And can really go the extra mile to connecting people and making them, making them feel heard.

Eric 29:26

That’s a great pearl.

Naheed 29:28

That’s a big one, right?

Eric 29:29

That’s a big one. Often forgotten about.

Naheed 29:31

Yeah, for sure. And, and I think the biggest thing is just recognizing that the systems that have been designed to deliver healthcare for people were not designed with the, the interests and needs of people experiencing homelessness in mind. The, the system isn’t broken. It was built this way. It was built this way in a way that doesn’t keep in mind the needs of people experiencing homelessness. So that might, that might emanate in different ways under your care. It might have to do with drug policy and harm reduction. It might have to do with a sensitivity around mental health. It might have to do with more resources at the time of discharge. So being aware of those holes, it’s a paradigm shift. It makes you think differently of your care.

Eric 30:16

Does it shift how you think about managing symptoms at all? Because I can imagine, like managing dyspnea, like we’ll often use, we’ll think about opioids, we’ll think about oxygen. I Can imagine both of those sometimes may be challenging. Like, worried about what’s going to happen to those opioids? Is it in a safe place? How are you actually going to do oxygen in somebody who is experiencing homelessness? How do you think about symptoms? Differently. Differently. And maybe I’ll just start off with, like, dyspnea. Do you think about it differently?

Naheed 30:48

Yeah, definitely. All the symptoms. And I think the key step before any step is actually just not to make any assumptions and to be open to learning about what that person’s environment is going to look like. You know, oxygen actually works in a lot of different spaces in the homelessness sector. It doesn’t in others. I think some of the lessons from our colleagues in substance use health, and again, I understand a podcast coming out probably are really parallel to discussions here. In some cases, if appropriate, we will, you know, dispense opioids on in a daily dispense format for folks. Sometimes we’ll do it weekly. Sometimes we’ll, you know, we’ll. We’ll kind of like do it for two weeks at a time and see how it goes.

Or sometimes it’s important to have our home care colleagues be part of the circle of care to monitor and just make sure there’s, there’s safety and that symptoms are being managed at the same time. So. So don’t assume anything and have the curiosity to learn about a person’s environment. I know it takes an extra moment or two, but as you go forward in your practice, over time you’ll see patterns. Actually, you’ll feel more comfortable with it.

Eric 31:55

Yeah. So, like, for example, if you’re dealing with somebody with heart failure, severe heart failure, and, you know, you’re ramping up those diuretics, I’m guessing spending some time to figure out, like, what is their access to. To. To bathrooms. If you’re going to be prescribing these. And does that shift how often you prescribe and when you prescribe them during the day?

Naheed 32:16

Yeah, I liken it to, like, detective work or some, like, really good problem solving. You really have to think this through. Like, I’m prescribing this medicine. Where are they getting it from? Do they have coverage? You know, when they take that diuretic and they need a bathroom access, how far is it? Is it a communal bathroom? Is it individual? You know, every step of the way? And what I think sometimes clinicians struggle with, and I totally understand this, is, you know, that negotiation of, like, what’s best practiced in the, in the medicine world. And then what’s realistically possible for the person in front of you. And that’s a difficult, like, you know, balance to strike. And I just think that if people are just thinking through that second piece, you’ll find a way to strike that balance, like, over time.

Alex 33:01

In many ways, the work you’re doing, which is incredible, inspiring to us and to our listeners, is the apotheosis of great palliative care. You know, I remember Ashwin Kutwal in a presentation shared one of Cicely Saunders early drawings of the total pain concept. Right. And it included the social factors. Right. And so your work is like the culmination of so many of these different elements of addressing that total pain concept. And I’m thinking of, you know, prior podcasts that we’ve done recently and how it’s also the culmination of many of the podcasts. As we’ve talked about substance use disorder, we talked about harm reduction on that podcast. We talked about trauma informed care recently on a different podcast.

And we also talked with Vicki Jackson and colleagues about tele palliative care. And I remember on a prior podcast, I think this was the one with Margot Kuchel. You know, lot of people experiencing homelessness now have cell phones, which is different from, you know, 10, 20 years ago. And so I wonder if there is a potential for delivering telepalliative care to people experiencing homelessness.

Naheed 34:13

Yeah, you know, just first, I just want to say, really agree with your comments about this just being good palliative care. Palliative care is grassroots, it’s community minded. It’s meeting people where they’re at and it’s addressing total suffering. Fully agree. And when I met Balfour Mounts, who was the founder of palliative care in Canada, and you know, you know, he said, he told me, like, what, what, what you’re doing in Toronto, this is what palliative care was originally meant to do. And that meant a lot to me to hear that from him on the topic of digital health. You know, I think sometimes when people hear about digital health, they think, oh, people experiencing homelessness, they’re not going to have access to that.

And while some people don’t, you, you know, mobile technologies are getting cheaper. At least SMS technology is more readily available. We ran a pilot during the COVID 19 pandemic. One of our mobile carriers actually gave us a bunch of phones. And it was really nice to be able to communicate through SMS technology with our clients. And there is evidence to show that unhoused people are really benefiting from access to mobile phones and that they’re able to coordinate their care better. And so our health navigators, our nurse coordinators, are literally texting our clients on the PEACH program, reminding them of appointments that they have, communicating about a food bank delivery or their next PEACH visit.

And it can make a really real big difference. I think the biggest area of impact is care coordination. And it feels to me like as the years go on that we’re leaning more into the coordination of care than the actual care resources. Like, there’s a lot of resources of people to provide care. It’s getting the care to the people we care for. That’s. And I think digital technology is going to be a big part of that. And so I totally agree.

Alex 35:55

Yeah. One of the issues that we’re facing now as we’re recording this podcast, and I’m sure is still happening when this podcast comes out, is that many of the initiatives, funding sources for diversity, equity, inclusion, and potentially social determinants of health are under threat. And given that there’s been so much broken trust because the health system has failed people experiencing homelessness so many times, I wonder if there’s a concern about that in Canada, which of course is different from the US is different. Government is not the 51st state. But I wonder if, you know, you have to be stable, you have to have confidence that you can be stable, and your program has grown tremendously over the last 10 years.

How are you funding this? How do you feel secure that you’ll be able to come through for these people you’ve built relationships with and that trust that you’ve built which is so essential to the care you provide for people experiencing homelessness?

Naheed 36:55

Yeah. This is a really deep question and one that, you know, we’re thinking about a lot. And a lot of the storylines you are experiencing and reading about in in the United States are very much storylines we’re seeing here in Canada. And that it’s a sign of the changing political times. You know, we are grateful to receive in our public health care system public health care dollars to deliver this care. And we’ve innovated within the public health care system, which I think is a nod to public health care and our system in Canada, if you don’t mind me saying. But when I think about how to protect these models so that we can continue to have trust with communities who have historically had a lack of trust in healthcare, I’ve thought of some really important pearls.

The first is to be evidence based and we’ve spent a lot of time doing research and evaluation to give this work the rigor it deserves, whether it’s retrospective chart reviews, you know, service evaluations, developing key performance indicator frameworks like, we are working at multiple levels to show that what we’re creating works from a scientific and evidence based perspective. I think the second thing is we need to build more services that empower people with, with lived experiences of homelessness to be part of the care. And like one of the best things that we’ve done the last two years is created a new role on our team called the PEACH Peer Worker. You know, we have a peer worker, a person with lived experiences of homelessness. We’ve hired her because she’s lived on the street and can support our clients.

And that has allowed us to build trust in a way that we were not able to previously. And we’ve been using some federal funding and grants to be able to prove that that’s successful. We’ve been able to even move that into our radical Love Hospice program at Kensington Hospice at Kensington Health, where we have a peer worker on site at the hospice providing psychosocial and emotional support to PEACH clients and others who’ve experienced structural vulnerability in really unique ways. And then I think the third piece is that to be able to keep that trust going, we need to support each other. And I just want to give a shout out to so many people across America, Canada, all over the world who are caring for people experiencing homelessness, whether through the healthcare side, the social side, or administration, or policymaking. There’s not enough support that goes out to you and there’s a lot of grief, bereavement and loss that is unaddressed.

So we run grief circles to support our colleagues. Anytime there’s a death or a tragedy or a loss, the PEACH program descends on a shelter respite. Drop in and we will create a circle and we will grieve together and we’ll cry together and we’ll laugh together, and we’ll remember what it’s like to care for these folks and think about ways we can renew and reinvest in each other. That’s just one small way that we can support each other. But if we don’t support this workforce that is supporting people experiencing homelessness and structural vulnerability, it’s going to start to break down and degrade over time. And so I’m really thankful for that question because it really allowed me to think deeply about the ways that we can continue to build trust and sustain trust despite the changing political times around us.

Alex 40:07

Thank you.

Eric 40:08

Okay, right after this podcast, I gotta go back to the inpatient consult service so you can see I’m focused on this issue. We are caring for people, people who are experiencing homelessness. Any other pearls, like for advanced care planning? Is there anything that I should be thinking about in particular that’s different about this population or should I have a heightened awareness about.

Naheed 40:33

Yeah, you know, there’s been a lot of research actually on the topic of advanced care planning and serious illness conversations with people experiencing homelessness. It’s probably, probably because when this population shows up in acute care, they tend to choose more aggressive healthcare decisions like pursuing ICU, full code or they don’t.

Eric 40:54

Even have a surrogate, like there’s nobody to turn to. So you just do this default medicine.

Naheed 40:59

You got it. And I think that’s why there’s been a lot of research and focus in this area. Rightfully so. It turns out that people experiencing homelessness have very strong thoughts about their futures and their end of life journeys. Contrary to what many people might think, they think a lot about being alone. They don’t want to be alone. The research says that they think a lot about their bodies, their bodily remains, like what will happen and that they would actually choose full code and ICU for their goals of care because they don’t trust that even if they said something different, that anyone would actually listen to them.

And so the best advice around advanced care planning is to make it, rather than filling out like a paperwork or a toolkit, make it more about the relationship, focus on the connection. It also is helpful to have serial discussions over time. So we work with our colleagues in the homelessness sector, the homelessness case managers and outreach workers, to do these discussions in a serial fashion over time and do it in chunks so that it’s less traumatic and it’s easier to digest. Be wary of trauma because these are heavy and difficult situations and try to be a little bit more concrete about what the outcomes will be. You might choose to be a little bit more direct in these kinds of discussions than you might be with other folks.

And I think a lot of the time the population I care for, people who are on the streets and in shelters just often want the goods. They want it to be delivered in a clear way, not this jargon that we sometimes use in medicine and healthcare to dance around things. So yeah, there’s a huge area of work and I think we have a lot more to learn. But those are some of the pearls that we’ve talked about along the way.

Eric 42:42

Oh, that’s fantastic. My last question for you, when you’re thinking about the future of palliative care for people experiencing homelessness. If you had a magic wand, what would you use that on? What are you hoping for?

Naheed 42:57

If I could be really frank, I would use that one to end homelessness through radical, upstream, really progressive housing policy that provides high quality supportive housing for people that’s affordable. In the absence of that, I would really put it out to the palliative care community that I would ask that our colleagues and friends see this population and this work equity oriented palliative care as part of their work. You know, I would ask that, you know, it may take a little bit more time, it may be a little bit more complicated, but never under underestimate the impact you can have when you see, you know, addressing total suffering, pain associated with homelessness, addressing housing, food security and poverty, or just taking an extra few moments to be with someone who doesn’t have a lot and the impact that can have. I just want. I just want this to be part of the work, right? Not on the side. Like, this is part and parcel of who we are and I have faith that we can definitely do that.

Eric 43:57

Naheed, I just love how inspiring you are. I can listen to you all day, tackle this incredibly hard subject. You are really inspiring. We’ll have a bunch of links to the stuff that you’re doing, but maybe we can just end with a little bit more of the weekend.

Alex 44:14

Alex, before the weekend, I’m just going to point out I’m wearing my warriors jersey, which has GeriPal and the number 85 on the back. I’ll show people on YouTube real quick. Hey. And one of my more painful memories is the Golden State warriors is losing to the Toronto Raptors in the playoffs.

Naheed 44:32

Will always be the champ.

Alex 44:34

So, yeah, congratulations. Thanks to your team for that. And here’s a little bit more of The Weeknd.

Alex 44:50

(singing)

Eric 45:55

Thank you for joining us on this GeriPal podcast.

Naheed 45:58

Thanks so much. It was such an honor. Really appreciate it.

Eric 46:01

And thank you to all of our listeners for your continued support.

This episode is not CME eligible.