Advance care planning, palliative care, and end-of-life care interventions for homeless people: A systematic review.
Homeless individuals have a high prevalence of multiple chronic comorbidities and early mortality compared to the general population. They also experience significant barriers to access and stigmatization in the healthcare system. Providing advance care planning, palliative care, and end-of-life care for this underserved population is an important health issue.



To summarize and evaluate the evidence surrounding advance care planning, palliative care, and end-of-life care interventions for homeless persons.



A systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.



Articles from MEDLINE, EMBASE, CINAHL, PsycINFO, Social Work Abstracts, Cochrane Library, Web of Science, and PubMed databases were searched through 13 June 2015. Peer-reviewed studies that implemented advance care planning, palliative care, and end-of-life care interventions for homeless populations were included. Data from studies were independently extracted by two investigators using pre-specified criteria, and quality was assessed using modified Cochrane and Critical Appraisal Skills Programme tools.



Six articles met inclusion criteria. Two studies were randomized controlled trials involving advance directive completion. Two cohort studies investigated the costs of a shelter-based palliative care intervention and predictors for completing advance directives. These studies were rated low to fair quality. Two qualitative studies explored the interface between harm-reduction services and end-of-life care and the conditions for providing palliative care for homeless persons in a support home.



The effectiveness of advance care planning, palliative care, and end-of-life care interventions for homeless individuals is uncertain. High-quality studies of interventions that reflect the unique and complex circumstances of homeless populations and investigate patient-related outcomes, caregiver burden, and cost-effectiveness are needed.
1 Faculty of Medicine, University of Toronto, Toronto, ON, Canada.|2 Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
Rafael
R
Sumalinog
2 Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
Katy
K
Harrington
3 Inner City Health Associates, Toronto, ON, Canada.|4 Department of Family and Community Medicine, St Michael's Hospital, Toronto, ON, Canada.|5 Division of Palliative Care, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.|6 Division of Palliative Care, William Osler Health System, Brampton, ON, Canada.
Naheed
N
Dosani
1 Faculty of Medicine, University of Toronto, Toronto, ON, Canada.|2 Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.|7 Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada.
Stephen W
SW
Hwang
D032722:Advance Care Planning / Q000458:organization & administration / Q000592:standards; D017048:Health Care Costs; D006297:Health Services Accessibility / Q000592:standards; D006703:Ill-Housed Persons; D006801:Humans; D010166:Palliative Care / Q000191:economics / Q000458:organization & administration / Q000592:standards; D013727:Terminal Care / Q000191:economics / Q000458:organization & administration / Q000592:standards
Advance care planning; end-of-life care; homeless persons; palliative care; systematic review; terminal care