Homelessness, Ageing and Dying 55 Appendix 3. Six key steps for end of life care for people who are homeless (From: End of Life Care: Achieving quality in hostels and for people who are homeless- a route to success (NHS) 1. Discussions as the end of life approaches The only way to find out someone’s wishes for end of life care is to ask them. But how do you begin that conversation? ‘This is perhaps one of the most challenging steps,’ says Tes Smith, the guide’s author and social care lead within the NHS programme. ‘People wonder if it’s the right time, and if they are the right person. The answer is, why should it not be you?’ Ms Smith suggests that hostel workers ask themselves what they already know about the person and what the person knows about themselves. ‘Do they know they are unwell and that they have a life-threatening illness? If they don’t, you could ask generally about their health. If someone says, “I’m not feeling so well, but I don’t know why”, you can ask a simple question: “What can I do to help you find some answers?”. But if someone says “I’m fine”, you can’t push that.’ As for spotting that someone is close to the end of their life, even health workers struggle with this. Ms Smith offers some general signs to look out for: ‘When somebody is in the dying phase, they sleep more. They’re less inclined to eat or drink or to engage either socially or generally in life. For example, if someone’s habit has always been to go out at 9am and suddenly they stop, that could be a sign.’ 2. Assessment, care planning and review As a person approaches the end of their life, it is vital to establish their needs and wishes as early as possible and identify any areas of unmet need. The report recommends a care plan assessment should take into account all aspects of end of life care - social, emotional and spiritual, as well as physical. But Ms Smith warns against becoming fixated with the process of assessment itself. ‘A conversation can be an assessment,’ she says. ‘You don’t have to sit in front of someone with loads of forms.’ 3. Care coordination As many clients not only suffer from chronic physical illnesses but have mental health and substance abuse issues, a coordinated approach to care is essential. But it can be very difficult for hostel staff to know who to turn to and what services are out there. At the simplest level, Ms Smith recommends getting in touch with social services and GPs, who will be an invaluable source of information. 4 High-quality services in different settings Hostel residents are entitled to the same high level of care, no matter where they are dying, and they should be able to choose where that is. If they regard a hostel as their home, it is understandable that they would want to stay there. ‘People who are homeless don’t like being in hospital - that’s why they have health problems,’ says Peter Cockersell, director of health and recovery at St Mungo’s. ‘But they often end up dying in hospital by default. They spend their last days somewhere they would actively avoid.’ Whether or not a hostel is an appropriate place will depend on the services and space available - single rooms, for example. Ms Smith says that it is a misconception that people need 24-hour nursing care when they’re dying. ‘Hostels don’t have to offer services themselves, they can benefit from support from community health services. No hostel can do this in isolation,’ she says.
Homelessness, Ageing and Dying
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