Exploring the factors that prevent or facilitate palliative care at 'home' for adults experiencing structural vulnerability: a scoping review.

BACKGROUND

While most people express a preference to be cared for and die at home, not all people have access to a safe or stable home. Government policies often position home death as a proxy measure of quality end-of-life care, yet structurally vulnerable populations, including those who are precariously housed, homeless, or living in supportive or transitional housing, are frequently excluded from this possibility. This scoping review aims to summarize the current literature on the factors that facilitate or prevent palliative care at ‘home’ for structurally vulnerable adults.

METHODS

We conducted a scoping review following Joanna Briggs Institute’s (JBI) methodology, searching eight academic databases and relevant grey literature sources. Studies were eligible for inclusion if they were published in English, and addressed three core eligibility criteria: housing status, health status, and high-income country context. Data were extracted and analyzed using narrative synthesis and thematic analysis.

RESULTS

A total of 33 studies were included. Five overarching themes influenced the ability to remain at home at end-of-life: systemic complexity, financial resources, value systems, social supports, and education and training. The review highlights how systemic barriers, including restrictive housing and healthcare policies, fragmented care structures, and stigmatization, limit opportunities for home-based care. Notably, narrow definitions of home and dominant cultural values about appropriate places to die further constrained access to palliative care in non-traditional settings. At the same time, flexible, community-based models and strong relational supports were identified as facilitators of dying in place.

CONCLUSION

This review underscores that people experiencing structural vulnerability are too often denied the choice of where they die. Addressing inequities in end-of-life care requires policy reforms that support flexible service models and recognize diverse forms of home, including shelters, transitional housing, and supportive housing, as legitimate places of care and dying. Findings provide an evidence base to inform equity-oriented policies aimed at expanding end-of-life options for structurally vulnerable populations. REGISTRATION: A protocol for this review was registered in the Open Science Framework registries: https://doi.org/10.17605/OSF.IO/X8TJ7 .