They would qualify except for behavioural issues and they have no family support. I don’t know what the issues are but they obviously have no money to pay to get in. They have no family to advocate [for them]. (Emergency Shelter Director)” “We kind of rightly or wrongly think palliative care and hospices are for the middle class. We never think about the poor. We are assuming the poor will automatically get in but because there is often a cost component, sometimes the homeless are left to die on the streets. (Emergency Shelter Director)” Operating

policies that Inhibitors,research,lifescience,medical exclude homeless populations Participants noted that end-of-life care providers in their communities had largely adopted operating policies that excluded homeless populations from accessing Mdm2 inhibitor services (e.g., anti-drug policies, codes of conduct, etc.). Participants felt that these operating policies privileged ‘normative patients’

(e.g., persons who were housed, had family, Inhibitors,research,lifescience,medical and conformed to procedures) and excluded homeless persons on the basis of a range of conditions Inhibitors,research,lifescience,medical common among this population (e.g., mental illness and substance use). In particular, anti-drug policies were identified as a barrier to care and, where formal policies did not exist, participants reported that substance-using homeless persons were identified by intake personnel as disruptive and, on the basis of this, denied services. Participant accounts suggest that these operating policies Inhibitors,research,lifescience,medical were perceived as discriminatory

because they prevented a particular population (e.g., homeless persons) from accessing services, thus reinforcing inequities in access to the end-of-life care system. As two participants noted: “It’s driven by Inhibitors,research,lifescience,medical the fact that the health care system has failed that population…When they are trying to access care in the mainstream facility, they experience discrimination and disrespect and poor care. (Nurse Practitioner)” “For some people, it is addictions or mental illness that prevents them from getting the best care. It’s the attitude of their health care provider not being particularly welcoming or understanding of their situation…I think they’re certainly stereotyped in a negative way and I think that people Cell press are kind of inclined to say “Oh the homeless, that homeless guy” and it just conjures up a whole set of connotations about how we expect them to look, how we expect him to act and how we can treat them. (Physician)” Lack of continuity of care Participants expressed frustration with the lack of continuity of care for this population. They highlighted two particular challenges with implications for the end-of-life care system. First, participants noted that poor continuity of care (e.g. lack of follow-up, poor discharge planning, etc.) often precipitated the need for end-of-life care services among homeless persons with chronic diseases (e.g. HIV/AIDS).