TORONTO -- They're too often the forgotten people -- or the ones many of us turn a blind eye to as we pass a street corner where they might implore us for extra change: the homeless living rough outside through all kinds of weather or those precariously housed in a cot-for-the-night shelter or a decaying rooming house.
But what happens when these people are dying? Where do they find care in their final days?
"Being sick is hard. Being sick and homeless can be even harder," Dr. Naheed Dosani, a palliative care specialist at St. Michael's Hospital in Toronto, says with obvious understatement.
Dosani, a member of a large network of inner-city health physicians, is part of a new program that takes end-of-life care to the homeless and vulnerably housed wherever they are situated.
Called PEACH -- for Palliative Education and Care for the Homeless -- the watchword of the mobile program is to give individuals the dignity of choosing where they receive medical and supportive care, and hopefully where they will able to die.
"Most people want to pass away at home with family around them," says Dosani. "That sentiment is no different for the patients PEACH aims to treat. The only difference is that our patients' homes are often a shelter and their families may be other shelter clients and staff."
A visit to one of his patients brings home that desire with poignant clarity: Dan Thibideau has two wishes -- he wants to live out his final days in his furnished unit at the Fred Victor transitional housing centre in downtown Toronto, close to the people who share his world, and to reconnect with the children he hasn't seen for almost 20 years.
"They made me an offer of going into a hospice, but I said I had my own friends and people to support me," says Thibideau, who at 59 has advanced lung cancer and at about 100 pounds, is less than half the weight he once was.
"My wishes are I didn't want to be alone. I didn't want to spend what I have left alone," he says softly weeping, sitting on a sagging brown couch that has seen better days.
"There's some people I've known for years, they keep an eye out for me and they're there when I need help," Thibideau explains, adding that the nurses who check on him and give him his medications are "kind to me."
"I'm happy they gave me a place to come to that's close to the people I know. I don't know any other people that love me."
Life wasn't always like this for the New Brunswick native, who has lived in Toronto for the last two decades.
Back then, the father of two young daughters worked for the Ontario government in the ministry of skills development as a senior purchasing officer.
"Then I became addicted to drugs. I became addicted to life itself, I guess," he says wistfully of getting hooked on heroin and cocaine, and ultimately losing his family, job and home.
Thibideau admits he's still on and off the drugs, and his partly filled ashtray is a testament to an ongoing tobacco habit. And although the PEACH program operates on the principle of harm-reduction, its practitioners take a non-judgmental approach to their clients.
"Good palliative care takes a holistic view of the person who is receiving that care," says Dosani. "And it's truly meeting all the biological, psychosocial needs that a patient really requires along their disease journey.
"Sometimes when I'm speaking to patients, I describe it as the mind-body-soul specialty."
Besides being treated for cancer-related symptoms -- shortness of breath, nausea and pain -- Thibideau is on blood thinners for a severe blood clot in one leg, which Dosani was able to get diagnosed at a local ultrasound clinic, thereby honouring his wish to stay out of the ER and the hospital.
The program also helps people like Thibideau, who may have had little or no regular contact with doctors for years, to navigate the health system at a time of greatest need.
"It's hard for ordinary, housed Canadians, it's hard enough for them to understand, for example, the cancer system and how to access a tertiary palliative care clinic," say Dosani.
"Can you imagine how hard that might be for someone who is vulnerably housed or homeless? For someone who might have co-morbid mental illness or substance use?
"It's a huge issue."
Indeed, many of those who end up on the street are there because of a psychiatric disorder or substance abuse, or both.
While life expectancy for the average Canadian is about 81, for the homeless it's estimated at 34 to 47. The rate of premature death among this population is roughly four to seven times higher than that of the general population.
Dr. Jeff Turnbull, medical director of the Inner City Health Project for the homeless in Ottawa, says the likelihood of living to age 75 in a shelter is a dismal 25 per cent.
"They die of problems that are generally a consequence of addiction and mental health," says Turnbull, who is also chief of staff at the Ottawa Hospital.
"For example, if you're addicted to alcohol, you may die of end-stage liver disease; if you're a smoker, you're going to die of lung cancer; if you're an IV drug user, you may die of HIV or hepatitis C."
In Ottawa, an 18-bed hospice at the Union Mission provides palliative care for the homeless, who may be transferred there from another shelter or brought in by friends on the street or even the police.
Turnbull says many of the people who come to the hospice are lonely and afraid, worried about whether they will linger and die in pain and who will be there to care for them.
"To take somebody and say, 'We will always look after you. We will always be here and you will not be in pain and we will support you,' most of the time, that's all you have to say," he said.
"And the sense of relief that they get from just that is dramatic -- just the fact that they know that somebody they trust will say, 'Fine, you're ours. You will always be ours."'
Besides providing medical care and a home where individuals can be supported by staff and others in the homeless community, programs such as the Ottawa hospice and PEACH in Toronto will also try, if asked, to connect patients with family from whom they may have been estranged for many years.
That's Thibideau's other dying wish -- to see his two now-grown daughters, who each have children of their own. One lives in Calgary,the other in Shanghai.
"I haven't seen my family, my girls, for 19 years and then we got in touch," he says, racked by quiet sobs, as Dosani lays a comforting hand on his shoulder.
"My brother came from New Brunswick and my other brother from Oshawa (Ont.). And my kids are supposed to come.
"My girls finally got in touch with me," says Thibideau, pointing out a photo of the daughters he regrets leaving "when they were babies" and the grandchildren he has never met. "They love me. I want to see them, that's all.
"That would mean my life would be complete."
