White Coat, Black Art

Palliative care team helps the homeless die 'with dignity,' a healing circle helps them grieve

After a homeless woman died of breast cancer, the doctors, nurses and shelter workers who helped to ease her final days gathered to remember her.

How this 'street family' relies on each other to recover after losing patients

Standing from left: Lazar Kakkasery (program manager, Good Shepherd Non-Profit Homes), Sadia Urooj (trustee, Good Shepherd), Tanya Doucette (program manager, Good Shepherd), Brian Goldman, Bianca Yau (support worker, Good Shepherd), Mike Finlay (superintendent, Good Shepherd), Marion Harris (home visiting nurse, Spectrum Healthcare). Seated: Naheed Dosani (Lead Palliative Care Physician, PEACH), Sasha Hill, (nurse coordinator, PEACH) (Jeff Goodes/CBC)
Listen to the full episode26:29

It was an unremarkable venue for an extraordinary gathering: A drab, windowless staff room in the basement of a Toronto homeless shelter in mid-February.

Doctors, nurses and shelter workers sat on well-worn chairs around a coffee table displaying a framed photo of the woman — who is being called Ruth to protect her privacy — beside a flickering candle.

Hoping to find better care in a larger centre, Ruth arrived in Toronto from Saskatchewan with a dire cancer prognosis, no family and no place to live.

The team at Palliative Education and Care for the Homeless (PEACH), which had cared for the 56-year-old woman through her metastatic breast cancer for two years, were mourning in a "healing circle" to help process her death.

Hoping to find better care in a larger centre, "Ruth" arrived in Toronto from Saskatchewan with a dire cancer prognosis, no family and no place to live. (Submitted by Dr. Naheed Dosani)

"She just always had such a beautiful smile on her face," said Sasha Hill, a co-ordinator with PEACH, which provides end-of -life care to those who are homeless or have precarious housing in the Greater Toronto Area.

"The one thing we could learn from her was how to have so much grace in such a difficult situation. I never heard her complain," the nurse told White Coat, Black Art's Dr. Brian Goldman, who was invited to observe the healing circle.

An estimated 235,000 Canadians experience homelessness each year, including 35,000 on any given night. How many die homeless is largely unknown because it's so difficult to track. The City of Toronto estimated 91 such deaths last year and 101 in 2017 due to a variety of causes, including drug overdoses, heart disease and suicide

A 'sweet angel amongst us'

When someone dies with no fixed address, those who aided in their care may share the experience of grieving in a group.

Dr. Naheed Dosani, the lead palliative care physician with PEACH, guided the healing circle, using what he calls the "4Rs": remember, reflect, recover and plan to reinvest.

He asked the group — which calls itself Ruth's "street family" — to recall what was both "beautiful" and "difficult" about her death.

"When she showed up, I absolutely knew we had a sweet angel amongst us because of her wonderful tenacity … her energy spoke volumes," said Tanya Doucette, a program manager at Good Shepherd Non-Profit Homes, where Ruth stayed in a palliative care room.

"What you saw blossom — those smiles, that energy — that was human connection. It was love," said Dosani.

Dosani first came up with the idea of providing palliative care to marginalized people during his medical training. He opened PEACH the day he graduated in 2014.  

"When a woman is dealing with metastatic breast cancer by herself in a shelter and doesn't have health insurance and has no one to help her ... that's really where this started."

"That's the bottom line. Like, really? We can do better."

'They say the best way to judge a society is how we treat our most vulnerable citizens and so we need to get that right,' said Dr. Naheed Dosani. (CBC)

Dosani was also instrumental in setting up a Journey Home Hospice, an end-of-life centre for people who are homeless, which opened last year in Toronto.

"Death is a social justice issue and as we begin to unravel that more and more, we're beginning to ask ourselves questions about what kind of a society we want to live in," he said.

"They say the best way to judge a society is how we treat our most vulnerable citizens and so we need to get that right."

Healing circles can tackle burnout

Dosani has been a part of more than 100 healing circles. He believes it's one way to guard against burnout, an increasing danger, when you add the opioid crisis to high rates of homelessness.

Marion Harris, Ruth's palliative care nurse, admitted she was sometimes frustrated at her resistance to accept medication, such as taking an anti-nauseant.

What gives me comfort, is that everyone in our program, whether they've rejected us a thousand times and not wanted to see us, they died with dignity and in their final moments, they knew they were cared for.- Sasha Hill

"You feel helpless," she said. "But at the same time, I realize I'm doing as much as she'll let me do," she said.

Health-care professionals can experience a type of stress called moral distress when someone believes they know what's right to do, but institutional or other constraints make it difficult to do so.

Speaking to the circle, Dosani acknowledged they would have to prepare themselves to return to the streets and the shelters to treat more patients.

"Because each and every time we deal with a case like this … there is always that process where you [are] expected to go out and do it again," he said, asking them to share their plan for recovery.

Hill said she holds fast to one thought: "What gives me comfort, is that everyone in our program, whether they've rejected us a thousand times and not wanted to see us, they died with dignity and in their final moments, they knew they were cared for."