Palliative Care Pilot Project for the Homeless

The Community and Neighbourhood Services Committee recommends the adoption of the following report (June 4, 1998) from the Commissioner of Community and Neighbourhood Services subject to amending Recommendation No. (3) by deleting the words "about a year's", and inserting in lieu thereof the words "six months", so that such recommendation reads as follows:

"(3) a progress report be submitted to the Community and Neighbourhood Services Committee in six months' time on the outcome of this pilot program and any research data developed; and":

Purpose:

This report seeks Committee approval to set up a pilot project to provide palliative care to homeless men staying at the Seaton House Annex.

Funding Sources, Financial Implications and Impact Statement:

None.

Recommendations:

It is recommended that:

(1) the Department be authorized to set up a palliative care pilot program at the Seaton House Annex;

(2) this program be conditional on the appropriate support being provided by the Coroner's Office and Mount Sinai Hospital;

(3) a progress report be submitted to the Community and Neighbourhood Services Committee in about a year's time on the outcome of this pilot program and any research data developed; and

(4) the appropriate City officials be authorized to take the necessary action to give effect thereto.

Council Reference/Background/History:

The former Metropolitan Council authorized the opening of the Seaton House Annex two years ago. This was in response to one of the recommendations of the Coroner's Jury which investigated the freezing deaths of three homeless men. The palliative care pilot program now being proposed is a natural extension of the work of the Annex.

Comments and/or Discussion and/or Justification:

The Seaton House Annex has been referred to as a "wet hostel" and the service is based on a harm reduction approach. It has 51 beds which are consistently filled. By all measures, this program has been exceptionally successful in reaching a group of severely alcoholic men who were living outside.

Tragically, many of our clients are in the last stages of life and need our help and care more than ever. Turning our backs on these men at this stage leaves them without acceptable options. Helping them to the end is the ultimate act of our harm reduction approach.

An abbreviated copy of the palliative care proposal developed by Annex staff is attached and provides a good overview. A more detailed background report is available upon request.

Staff have had a number of meetings with the Coroner's Office, Mount Sinai Hospital, and other agencies. The pilot program will only proceed when appropriate arrangements are in place with these other organizations.

Because palliative care is an emerging field and because this may be the first homeless shelter to include this service, a research feature will be included. If the service is successful, then this research may be extremely valuable to other organizations working with the homeless in Toronto, as well as other cities in North America.

Conclusions:

This proposal is realistic and is intended to alleviate human suffering. It is a frightening experience for these men to go into hospitals, or to be removed from friends and familiar surroundings. The palliative care proposal by the Annex staff should be supported.

Contact Name:

John Jagt

Director of Hostel Services Division

Tel: (416) 392-5358/Fax: (416) 392-8876

E-mail: john_jagt@metrodesk.metrotor.on.ca

--------

Seaton House Proposed Protocol for

Palliative Care Pilot Project

(1) Definition of Palliative Care and its Implementation at Seaton House:

In the first twelve months of operation in the Annex, three clients died on the premises. Two of these deaths were foreseeable. We must recognize that the health realities of our clients, whose bodies have worn down after decades of the effects of poverty and chronic substance use, are not currently being addressed. While they died in a place where they felt at home, their deaths lacked the dignity that any person deserves. Palliative care is built on the foundation of acknowledging the dying process, and honouring the choices an individual who is going through that process, makes. One of the most important elements of palliative care is the successful management of physical, psycho-social, and spiritual pain. Palliative care aims to reduce the harm to an individual within the final months, weeks or hours of their lives.

It is our intention to implement this program at the Seaton House Annex harm reduction facility. Currently there are ten men residing in the Annex's 24-hour program whose age and chronic health concerns make them likely candidates for this new initiative. The small size of the Annex combined with the high staff-to-client ratio enables the Annex staff to work closely with the clients in a therapeutic fashion. It is important to acknowledge that the clients in the Annex have developed a sense of ownership and belonging making the Annex the ideal environment to initiate this program.

(2) Objectives of the Pilot Project:

One of the foundations of palliative care is providing a "death with dignity" approach to client service. Another goal of the program is to reduce pain and suffering for the client during the final stages of life. This model would meet a need not currently being met in the community. Systemic benefits of this model would provide palliative clients with a sense of purpose, as well as the knowledge that they had friends and people who will miss them.

This program will provide an excellent opportunity to forge partnerships with health care providers in the community, building links with other agencies to better serve our clients. We will be developing the program with an eye towards its implementation at other facilities serving the homeless in Toronto.

(3) Description of Program:

We intend to initiate the program within our current 24-hour facility. The staff will assess potential clients and, if concerned about their health, consult with the visiting doctor to the Annex. When a serious health concern is recognized, a doctor from the Temmy Latner Centre for Palliative Care (TLCPC) at Mount Sinai hospital will be asked to make a palliative assessment. A case plan will then be formulated with the palliative care doctor, the staff at the Annex and the presenting client. The case plan will include long-term treatment decisions, pain management protocol, issues involving a living will, including "Do not resuscitate" (DNR) orders if deemed appropriate. A DNR order by a client is their informed, stated choice to not be resuscitated in the event of a catastrophic occurrence (such as cardiac or respiratory arrest). It is hoped that when a client gives his informed consent, it will allow him to die where he is most comfortable and in a dignified fashion. Comfort measures will be implemented using available resources within the Annex, Seaton House, TLCPC and Community Care Access Centres (CCAC) for nursing and homemaking resources. Careful and thorough documentation will be necessary to follow the client's progress and document success indicators for further clients.

All program co-ordination will take place from the Annex, liaising between all health care initiatives and the Annex clientele.

(4) Staff's Role:

One of the main aspects of the Annex staff's role will be to assist health care professionals in understanding and dealing with the unique problems and circumstances of our clientele. Providing on-site support and counselling for the residents who are dying, as well as providing bereavement counselling for their fellow residents and staff is also an important function of the model. We will be responsible for the day to day operation of the program including assisting the clients with their functional daily activities. If, during the course of a shift, our non-medical staff notice that a client is in distress, they will contact the on-call physician as opposed to contacting 911 if indicated in the case plan.

This model will be implemented by a program co-ordinator and facilitated by all staff in the Annex. The co-ordinator will be responsible for dealing with the community health care agencies, co-ordinating communication between the various agencies involved, including TLCPC, CCAC and St. Michael's Hospital. Educating members of the community and other service providers will be an important facet of the program that will be managed by staff at the Annex. As well as our regular operations, research into the effects of the program and assessing the needs of this population will be vitally important for any future applications of this pilot project. Ultimately, it is the responsibility of the co-ordinator to ensure that clients are receiving appropriate health care within this new program.

(5) Health Care Professional's Role:

Medical assessment of the clients will be provided by one of the visiting physicians that tend to the Annex clients on a bi-weekly basis. They are also available on-call 24 hours per day. When appropriate, this physician will refer clients to be assessed by one of the doctors from the TLCPC. Subsequent to the assessment of the client, the palliative care doctor will tend to the needs of the client, including regular visits and medical case planning with their new patient. TLCPC, in concert with the visiting doctor, will help to guide Annex staff in the provision of the appropriate health care for the clients. Weekly clinical consultation with the Annex staff and the TLCPC team to ensure that the client is receiving the most beneficial service available to him.

As the need arises for extended care, CCAC will be involved in providing nursing and homemaking support. Since Annex staff will be primarily involved in the day-to-day care of the clients, TLCPC team will provide palliative care training. "Care for the caregiver" will also be included in this training.