"You can't die here": an exploration of the barriers to dying-in-place for structurally vulnerable populations in an urban centre in British Columbia, Canada.

BACKGROUND: One measure of quality in palliative care involves ensuring people approaching the end of life are able to receive care, and ultimately die, in the places they choose. Canadian palliative care policy directives stem from this tenet of autonomy, acknowledging that most people prefer to die at home, where they feel safe and comfortable. Limited research, however, considers the lack of 'choice' people positioned as structurally vulnerable (e.g., experiencing extreme poverty, homelessness, substance-use/criminalization, etc.) have in regard to places of care and death, with the option of dying-in-place most often denied. METHODS: Drawing from ethnographic and participatory action research data collected during two studies that took place from 2014 to 2019 in an urban centre in British Columbia, Canada, this analysis explores barriers preventing people who experience social and structural inequity the option to die-in-place. Participants include: (1) people positioned as structurally vulnerable on a palliative trajectory; (2) their informal support persons/family caregivers (e.g., street family); (3) community service providers (e.g., housing workers, medical professionals); and (4) key informants (e.g., managers, medical directors, executive directors). Data includes observational fieldnotes, focus group and interviews transcripts. Interpretive thematic analytic techniques were employed. RESULTS: Participants on a palliative trajectory lacked access to stable, affordable, or permanent housing, yet expressed their desire to stay 'in-place' at the end of life. Analysis reveals three main barriers impeding their 'choice' to remain in-place at the end of life: (1) Misaligned perceptions of risk and safety; (2) Challenges managing pain in the context of substance use, stigma, and discrimination; and (3) Gaps between protocols, policies, and procedures for health teams. CONCLUSIONS: Findings demonstrate how the rhetoric of 'choice' in regard to preferred place of death is ethically problematic because experienced inequities are produced and constrained by socio-structural forces that reach beyond individuals' control. Ultimately, our findings contribute suggestions for policy, programs and practice to enhance inclusiveness in palliative care. Re-defining 'home' within palliative care, enhancing supports, education, and training for community care workers, integrating palliative approaches to care into the everyday work of non-health care providers, and acknowledging, valuing, and building upon existing relations of care can help to overcome existing barriers to delivering palliative care in various settings and increase the opportunity for all to spend their end of life in the places that they prefer.

From Cultural Safety to Anti-Racism: Reflections on Addressing Inequities in Palliative Care.

The purpose of palliative care is to ease the suffering of individuals with a serious and often life-limiting illness throughout the course of their disease by providing holistic care that considers the physical, spiritual, and psychosocial dimensions of health and well-being. Research shows that a palliative approach to care is cost-effective for the healthcare system and results in improved quality of life for patients and their loved ones. However, it is well-documented in the literature that structurally vulnerable populations have greater difficulty accessing equitable and culturally safe palliative care. Several domains are identified as contributing factors to the disparities seen in the literature, including systemic racism, cultural differences around death and suffering, and language barriers. Although Canada has had a national palliative care framework since 2018, ongoing issues of access and equity continue to disproportionately impact certain groups, including racially marginalized, immigrant, and low-income communities. In this commentary, successes and ongoing gaps in providing culturally safe and anti-racist palliative care are explored. In these proposed interventions, we advocate for a palliative approach to care that is grounded in equity, justice, and human rights.

Palliative Education and Care for the Homeless (PEACH): A Model of Outreach Palliative Care for Structurally Vulnerable Populations.

The Palliative Education and Care for the Homeless (PEACH) program comprises a community palliative care team serving some of the most complex clients in the healthcare system. Formal partnerships bring together physician, nursing, psychosocial and homecare, health and housing navigation supports. PEACH has served over 1,000 clients, leading field-defining research, medical education and public advocacy. The PEACH program demonstrates that innovation through deep interorganizational and intersectoral integration can drive value-based impact for the most complex clients, providing instructive lessons for public health system reform well beyond the margins faced by people who are unhoused. This paper describes how PEACH's unique model, critical community partnerships and research have been necessary for it to become a leader in community-based palliative care for structurally vulnerable people.

Exploring the Barriers and Facilitators Experienced by Palliative Health Care Providers Working with Patients Experiencing Homelessness during the COVID-19 Pandemic.

Background: Patients experiencing homelessness not only have higher rates of medical complexity, comorbidity, and mortality, but also face barriers to accessing palliative care services. In structurally vulnerable populations with palliative care needs, these barriers are compounded, creating significant challenges for both patients and providers that have important health equity implications. Objective: The aim is to explore the experiences of palliative care providers working with patients experiencing homelessness during the COVID-19 pandemic and understand the barriers they faced in providing care, as well as facilitators that aided in the success of their teams. Methods: Seven health care providers from two Canadian palliative outreach teams involved in delivering palliative care services to patients experiencing homelessness during the COVID-19 pandemic participated in audio-recorded and transcribed videoconferencing interviews. Analysis was completed using generic descriptive thematic analysis. Results: Five key themes were identified: (1) factors negatively impacting patient health, (2) use of technology, (3) care provider emotions, (4) care provider education and advocacy, and (5) outreach team factors. Conclusion: Identified barriers during the pandemic included worsening of existing patient vulnerabilities, as well as challenges incorporating technology into care. Providers faced increased emotional burden, with a rise in workload, stress, fear, and grief. However, several facilitators allowed teams to provide high-quality care to this vulnerable population, including team support, interprofessional collaboration, and advocacy and education initiatives. The outreach model also proved to be a highly flexible, resilient, and adaptable model for providing care during the COVID-19 pandemic.

Assessing the impact of a health navigator on improving access to care and addressing the social needs of palliative care patients experiencing homelessness: A service evaluation.

BACKGROUND: Health navigators are healthcare professionals who specialize in care coordination, case management, navigating transitions, and reducing barriers to care. There is limited literature on the impact of health navigators on community-based palliative care for people experiencing homelessness. AIM: We devised key performance indicators in nine categories with the aim to quantify the impact of a health navigator on the delivery of palliative care to patients experiencing homelessness. DESIGN: Data were collected prospectively for all patient encounters involving a health navigator from July 2020 to 2021 and reviewed to determine the distribution of the health navigator's role and the ways in which patient care was impacted. SETTING AND PARTICIPANTS: This study was conducted in Toronto, Ontario with the Palliative Education and Care for the Homeless (PEACH) Program. At any one time, the PEACH health navigator served a total of 50 patients. RESULTS: We identified five key areas of the health navigator role including (1) facilitating access (2) coordinating care (3) addressing social determinants of health (4) advocating for patients, and (5) counselling patients and loved ones. The health navigator role was split evenly between activities pertaining to palliative care for structurally vulnerable populations and community-based palliative care for the general population. To achieve high impact outcomes, a considerable investment of time and energy was required of the health navigator, speaking to the importance of adequate and sustainable funding. CONCLUSIONS: These findings underscore the potential for health navigators to add value to community-based palliative care teams, especially those caring for structurally vulnerable populations.

Palliative care for people who use drugs during communicable disease epidemics and pandemics: A scoping review on access, policies, and programs and guidelines.

BACKGROUND: People who use drugs with life-limiting illnesses experience substantial barriers to accessing palliative care. Demand for palliative care is expected to increase during communicable disease epidemics and pandemics. Understanding how epidemics and pandemics affect palliative care for people who use drugs is important from a service delivery perspective and for reducing population health inequities. AIM: To explore what is known about communicable disease epidemics and pandemics, palliative care, and people who use drugs. DESIGN: Scoping review. DATA SOURCES: We searched six bibliographic databases from inception to April 2021 as well as the grey literature. We included English and French records about palliative care access, programs, and policies and guidelines for people ⩾18 years old who use drugs during communicable disease epidemics and pandemics. RESULTS: Forty-four articles were included in our analysis. We identified limited knowledge about palliative care for people who use drugs during epidemics and pandemics other than HIV/AIDS. Through our thematic synthesis of the records, we generated the following themes: enablers and barriers to access, organizational barriers, structural inequity, access to opioids and other psychoactive substances, and stigma. CONCLUSIONS: Our findings underscore the need for further research about how best to provide palliative care for people who use drugs during epidemics and pandemics. We suggest four ways that health systems can be better prepared to help alleviate the structural barriers that limit access as well as support the provision of high-quality palliative care during future epidemics and pandemics.

Utilization of Point-of-Care Ultrasound in a Specialist Palliative Care Team Across Multiple Care Settings: A Retrospective Chart Review.

Background: Technological advancements have rapidly increased the use of point-of-care ultrasound (POCUS) across various medical disciplines, leading to real-time information for clinicians at the bed side. However, literature reveals scant evidence of POCUS use in palliative care. The objective of this study was to examine the use of POCUS in a specialist palliative care setting. Methods: A retrospective chart review was conducted from January 2018 to June 2019 in Brampton, Canada, to evaluate characteristics of patients for whom POCUS was utilized. Patients were identified through pre-existing logs and descriptive information was collected from electronic health records, including demographic information, life-limiting diagnosis, patient assessment location, diagnosis made with POCUS, and, if applicable, volume of fluid drained. Results: We identified 126 uses of POCUS in 89 unique patients. Sixty-two patients (69.7%) had a cancer diagnosis, with patients most commonly suffering from gastrointestinal, lung, and breast pathologies. Sixty-one POCUS cases (48.4%) were in the outpatient setting. Eighty-one POCUS cases (64.3%) revealed a diagnosis of ascites and 21 POCUS cases (16.7%) revealed a diagnosis of pleural effusion. Other diagnoses made with POCUS included bowel obstruction, pneumonia, and congestive heart failure. During the study period, 52 paracentesis and 7 thoracentesis procedures were performed using POCUS guidance. Conclusion: We identified multiple indications in our specialist palliative care setting where POCUS aided in diagnosis/management of patients in both inpatient and outpatient settings. Further studies can be conducted to identify the potential benefits in symptom burden, patient and caregiver satisfaction, and health care utilization in palliative care patients receiving POCUS.

COVID-19 vaccine coverage and factors associated with vaccine uptake among 23 247 adults with a recent history of homelessness in Ontario, Canada: a population-based cohort study.

BACKGROUND: People experiencing homelessness face a high risk of SARS-CoV-2 infection and transmission, as well as health complications and death due to COVID-19. Despite being prioritised for receiving the COVID-19 vaccine in many regions, little data are available on vaccine uptake in this vulnerable population. Using population-based health-care administrative data from Ontario, Canada-a region with a universal, publicly funded health system-we aimed to describe COVID-19 vaccine coverage (ie, the estimated percentage of people who have received a vaccine) and determinants of vaccine receipt among individuals with a recent history of homelessness. METHODS: We conducted a retrospective, population-based cohort study of adults (aged ≥18 years) with a recent experience of homelessness, inadequate housing, or shelter use as recorded in routinely collected health-care databases between June 14, 2020, and June 14, 2021 (a period within 6 months of Dec 14, 2020, when COVID-19 vaccine administration was initiated in Ontario). Participants were followed up from Dec 14, 2020, to Sept 30, 2021, for the receipt of one or two doses of a COVID-19 vaccine using the province's real-time centralised vaccine information system. We described COVID-19 vaccine coverage overall and within predefined subgroups. Using modified Poisson regression, we further identified sociodemographic factors, health-care usage, and clinical factors associated with receipt of at least one dose of a COVID-19 vaccine. FINDINGS: 23 247 individuals with a recent history of homelessness were included in this study. Participants were predominantly male (14 752 [63·5%] of 23 247); nearly half were younger than 40 years (11 521 [49·6%]) and lived in large metropolitan regions (12 123 [52·2%]); and the majority (18 226 [78·4%]) visited a general practitioner for an in-person consultation during the observation period. By Sept 30, 2021, 14 271 (61·4%; 95% CI 60·8-62·0) individuals with a recent history of homelessness had received at least one dose of a COVID-19 vaccine and 11 082 (47·7%; 47·0-48·3) had received two doses; in comparison, over the same period, 86·6% of adults in the total Ontario population had received a first dose and 81·6% had received a second dose. In multivariable analysis, factors positively associated with COVID-19 uptake were one or more outpatient visits to a general practitioner (adjusted risk ratio [aRR] 1·37 [95% CI 1·31-1·42]), older age (50-59 years vs 18-29 years: 1·18 [1·14-1·22], ≥60 years vs 18-29 years: 1·27 [1·22-1·31]), receipt of an influenza vaccine in either of the two previous influenza seasons (1·25 [1·23-1·28]), being identified as homeless via a visit to a community health centre versus exclusively a hospital-based encounter (1·13 [1·10-1·15]), receipt of one or more SARS-CoV-2 tests between March 1, 2020, and Sept 30, 2021 (1·23 [1·20-1·26]), and the presence of chronic health conditions (one condition: 1·05 [1·03-1·08]; two or more conditions: 1·11 [1·08-1·14]). By contrast, living in a smaller metropolitan region (aRR 0·92 [95% CI 0·90-0·94]) or rural location (0·93 [0·90-0·97]) versus large metropolitan regions were associated with lower uptake. INTERPRETATION: In Ontario, COVID-19 vaccine coverage among adults with a recent history of homelessness has lagged and, as of Sept 30, 2021, was 25 percentage points lower than that of the general adult population in Ontario for a first dose and 34 percentage points lower for a second dose. With high usage of outpatient health services among individuals with a recent history of homelessness, better utilisation of outpatient primary care structures might offer an opportunity to increase vaccine coverage in this population. Our findings underscore the importance of leveraging existing health and service organisations that are accessed and trusted by people who experience homelessness for targeted vaccine delivery. FUNDING: The Public Health Agency of Canada. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Drug Overdoses During the COVID-19 Pandemic Among Recently Homeless Individuals.

AIMS: To examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre-pandemic, peak, and re-opening periods of the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control. DESIGN: Population-based retrospective cohort study conducted between September 30, 2018 and September 26, 2020. SETTING: Ontario, Canada. PARTICIPANTS: A total of 38 617 IRHH, 15 022 369 housed individuals, and 186 858 low-income housed individuals matched on age, sex, rurality, and comorbidity burden. MEASUREMENTS: ED visits for drug overdoses of accidental and undetermined intent. FINDINGS: Average rates of ED visits for drug overdoses between January and September 2020 were higher among IRHH compared with housed individuals (rate ratio [RR], 148.0; 95% CI, 142.7-153.5) and matched housed individuals (RR, 22.3; 95% CI, 20.7-24.0). ED visits for drug overdoses decreased across all groups by ~20% during the peak period (March 17 to June 16, 2020) compared with corresponding weeks in 2019. During the re-opening period (June 17 to September 26, 2020), rates of ED visits for drug overdoses were significantly higher among IRHH (RR, 1.56; 95% CI, 1.44-1.69), matched housed individuals (RR, 1.25; 95% CI, 1.08-1.46), and housed individuals relative to equivalent weeks in 2019 (RR, 1.07; 95% CI, 1.02-1.11). The relative increase in drug overdose ED visits among IRHH was larger compared with both matched housed individuals (P = 0.01 for interaction between group and year) and housed individuals (P < 0.001) during this period. CONCLUSIONS: Recently homeless individuals in Ontario, Canada experienced disproportionate increases in ED visits for drug overdoses during the re-opening period of the COVID-19 pandemic compared with housed people.

Palliative care for people who use substances during communicable disease epidemics and pandemics: a scoping review protocol.

INTRODUCTION: Communicable disease epidemics and pandemics magnify the health inequities experienced by marginalised populations. People who use substances suffer from high rates of morbidity and mortality and should be a priority to receive palliative care, yet they encounter many barriers to palliative care access. Given the pre-existing inequities to palliative care access for people with life-limiting illnesses who use substances, it is important to understand the impact of communicable disease epidemics and pandemics such as COVID-19 on this population. METHODS AND ANALYSIS: We will conduct a scoping review and report according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews reporting guidelines. We conducted a comprehensive literature search in seven bibliographical databases from the inception of each database to August 2020. We also performed a grey literature search to identify the publications not indexed in the bibliographical databases. All the searches will be rerun in April 2021 to retrieve recently published information because the COVID-19 pandemic is ongoing at the time of this writing. We will extract the quantitative data using a standardised data extraction form and summarise it using descriptive statistics. Additionally, we will conduct thematic qualitative analyses and present our findings as narrative summaries. ETHICS AND DISSEMINATION: Ethics approval is not required for a scoping review. We will disseminate our findings to healthcare providers and policymakers through professional networks, digital communications through social media platforms, conference presentations and publication in a scientific journal.

Retrospective Study of a Toronto-Based Palliative Care Program for Individuals Experiencing Homelessness.

Background: Individuals experiencing homelessness face increased morbidity and mortality. The Canadian Toronto-based Palliative Education and Care for the Homeless (PEACH) program was launched to better support those experiencing homelessness with life-limiting illness. Objective: To describe the population served by PEACH. Methods: A chart review of deceased clients from 2014 to 2017 was conducted. Results: Sixty-three individuals were included in the analysis. 85.7% were male and the median age was 60 years. 35.4% resided in shelters, 26.2% in supportive/transitional housing; only 3.2% were sleeping on the streets. Cancer was the most common diagnosis (61.9%). 58.7% of clients had mental health diagnoses and 61.9% endorsed substance use. Locations of death included palliative care unit and hospice (44.4%), hospital (23.8%), supportive housing (12.6%), and shelter (7.9%). Discussion: PEACH serves diverse clientele with unique care needs. This study will inform further palliative care research and interventions for those experiencing homelessness.

The effect of a Housing First intervention on primary care retention among homeless individuals with mental illness.

BACKGROUND: Primary care retention, defined as ongoing periodic contact with a consistent primary care provider, is beneficial for people with serious chronic illnesses. This study examined the effect of a Housing First intervention on primary care retention among homeless individuals with mental illness. METHODS: Two hundred individuals enrolled in the Toronto site of the At Home Project and randomized to Housing First or Treatment As Usual were studied. Medical records were reviewed to determine if participants were retained in primary care, defined as having at least one visit with the same primary care provider in each of two consecutive six-month periods during the 12 month period preceding and following randomization. RESULTS: Medical records were obtained for 47 individuals randomized to Housing First and 40 individuals randomized to Treatment As Usual. During the one year period following randomization, the proportion of Housing First and Treatment As Usual participants retained in primary care was not significantly different (38.3% vs. 47.5%, p = 0.39). The change in primary care retention rates from the year preceding randomization to the year following randomization was +10.6% in the Housing First group and -5.0% in the Treatment As Usual group. CONCLUSION: Among homeless individuals with mental illness, Housing First did not significantly affect primary care retention over the follow-up period. These findings suggest Housing First interventions may need to place greater emphasis on connecting clients with primary care providers.

Perceptions of palliative care in a South Asian community: findings from an observational study.

BACKGROUND: Patients often view "palliative care" (PC) as an approach that is synonymous with end-of-life and death, leading to shock and fear. Differing cultural and social norms and religious affiliations greatly determine perception of PC among diverse populations. METHODS: This prospective observational study aimed to explore perceptions of PC among South Asian community members at one Canadian site. Patients who identified themselves as being of South Asian origin were consented and enrolled at a PC Clinic at a community hospital in Brampton, Ontario serving a large South Asian population. Participants filled out an 18-question survey created for the study and responded to a semi-structured interview consisting of 8 questions that further probed their perceptions of PC. Survey responses and semi-structured interviews content were analyzed by four authors who reached consensus on key exploratory findings. RESULTS: Thirty-four participants of South Asian origin were recruited (61.8% males), and they were distributed by their age group as follows: [(30-49) - 18%; (50-64) - 21%; (65-79) - 41%; (≥ 80) - 21%]. Five main exploratory findings emerged: (i) differing attitudes towards talking about death; (ii) the key role of family in providing care; (iii) a significant lack of prior knowledge of PC; (iv) a common emphasis on the importance of alleviating suffering and pain to maintain comfort; and (v) that cultural values, faith, or spiritual belief do not pose a necessary challenge to acceptance of PC services. CONCLUSIONS: Observations from this study provide a source of reference to understand the key findings and variability in perceptions of palliative care in South Asian communities. Culturally competent interventions based on trends observed in this study could assist Palliative Physicians in delivering personalized care to South Asian populations.

Caregiving at the margins: An ethnographic exploration of family caregivers experiences providing care for structurally vulnerable populations at the end-of-life.

BACKGROUND: People experiencing structural vulnerability (e.g. homelessness, poverty, racism, criminalization of illicit drug use and mental health stigma) face significant barriers to accessing care at the end-of-life. 'Family' caregivers have the potential to play critical roles in providing care to these populations, yet little is known regarding 'who' caregivers are in this context and what their experiences may be. AIM: To describe family caregiving in the context of structural vulnerability, to understand who these caregivers are, and the unique challenges, burdens and barriers they face. DESIGN: Critical ethnography. SETTING/PARTICIPANTS: Twenty-five family caregivers participated. Observational fieldnotes and semi-structured interviews were conducted in home, shelter, transitional housing, clinic, hospital, palliative care unit, community-based service centre and outdoor settings. RESULTS: Family caregivers were found to be living within the constraints of structural vulnerability themselves, with almost half being street family or friends. The type of care provided varied greatly and included tasks associated with meeting the needs of basic survival (e.g. finding food and shelter). Thematic analysis revealed three core themes regarding experiences: Caregiving in the context of (1) poverty and substance use; (2) housing instability and (3) challenging relationships. CONCLUSION: Findings offer novel insight into the experiences of family caregiving in the context of structural vulnerability. Engaging with family caregivers emerged as a missing and necessary palliative care practice, confirming the need to re-evaluate palliative care models and acknowledge issues of trust to create culturally relevant approaches for successful interventions. More research examining how 'family' is defined in this context is needed.

The Good Wishes Project: An End-of-Life Intervention for Individuals Experiencing Homelessness.

Background: Individuals experiencing homelessness face marginalization, dehumanization, and barriers to accessing quality palliative care. Inspired by the 3 Wishes Project, the Good Wishes Project (GWP) facilitates granting wishes to individuals experiencing homelessness and receiving palliative care with a goal of enhancing comfort and personalizing the end-of-life experience. Objective: The main objective of this study was to elicit provider perspectives on the utility of the GWP in the delivery of end-of-life care to a population of homeless and vulnerably housed individuals. Design: For this qualitative study, GWP client information and wish data were collected anonymously and analyzed quantitatively and descriptively. Semistructured interviews were conducted with health and social service professionals who cared for GWP clients. Interviews were recorded, transcribed, and analyzed through qualitative content analysis. Results: At the time of evaluation, there were a total of 27 clients in the GWP. At 14 months after the project's launch, 40 wishes had been made, 24 of which had been granted. Wishes were classified into five categories: basic necessities, end-of-life preparations, personal connections, paying-it-forward, and leisure. From the provider perspective (n = 7), the project was found to have utility in three main domains: establishing and enhancing connection, satisfying basic needs, and promoting person-centered care. Conclusions: The GWP is a promising psychosocial intervention in providing quality palliative care to individuals experiencing homelessness, whose lives have largely been burdened with hardship and marginalization.

Providing Data-Driven Equitable Palliative and End-of-Life Care for Structurally Vulnerable Populations: A Pilot Survey of Information Management Strategies.

BACKGROUND: Considerable gains are being made in data-driven efforts to advance quality improvement in health care. However, organizations providing hospice-oriented palliative care for structurally vulnerable persons with terminal illnesses may not have the enabling data infrastructure or framework to derive such benefits. METHODS: We conducted a pilot cross-sectional qualitative study involving a convenience sample of hospice organizations across North America providing palliative care services for structurally vulnerable patients. Through semistructured interviews, we surveyed organizations on the types of data collected, the information systems used, and the challenges they faced. RESULTS: We contacted 13 organizations across North America and interviewed 9. All organizations served structurally vulnerable populations, including the homeless and vulnerably housed, socially isolated, and HIV-positive patients. Common examples of collected data included the number of referrals, the number of admissions, length of stay, and diagnosis. More than half of the organizations (n = 5) used an electronic medical record, although none of the record systems were specifically designed for palliative care. All (n = 9) the organizations used the built-in reporting capacity of their information management systems and more than half (n = 6) augmented this capacity with chart reviews. DISCUSSION: A number of themes emerged from our discussions. Present data collection is heterogeneous, and storage of these data is highly fragmented within and across organizations. Funding appeared to be a key enabler of more robust data collection and use. Future work should address these gaps and examine opportunities for innovative ways of analysis and reporting to improve care for structurally vulnerable populations.

Hospitals, clinics, and palliative care units: Place-based experiences of formal healthcare settings by people experiencing structural vulnerability at the end-of-life.

The process of dying pronounces inequities, particularly for structurally vulnerable populations. Extending recent health geography research, we critically explore how the 'places' of formal healthcare settings shape experiences of, and access to, palliative care for the structurally vulnerable (e.g., homeless, substance users). Drawing on 30 months of ethnographic data, thematic findings reveal how symbolic, aesthetic, and physical elements of formal healthcare 'places' intersect with social relations of power to produce, reinforce, and amplify structural vulnerability and thus, inequities in access to care. Such knowledge may inform decision-makers on ways to enhance equitable access to palliative care for some of societies' most vulnerable population groups.