"Just too busy living in the moment and surviving": barriers to accessing health care for structurally vulnerable populations at end-of-life.

BACKGROUND: Despite access to quality care at the end-of-life (EOL) being considered a human right, it is not equitable, with many facing significant barriers. Most research examines access to EOL care for homogenous 'normative' populations, and as a result, the experiences of those with differing social positioning remain unheard. For example, populations experiencing structural vulnerability, who are situated along the lower rungs of social hierarchies of power (e.g., poor, homeless) will have unique EOL care needs and face unique barriers when accessing care. However, little research examines these barriers for people experiencing life-limiting illnesses and structural vulnerabilities. The purpose of this study was to identify barriers to accessing care among structurally vulnerable people at EOL. METHODS: Ethnography informed by the critical theoretical perspectives of equity and social justice was employed. This research drew on 30 months of ethnographic data collection (i.e., observations, interviews) with structurally vulnerable people, their support persons, and service providers. Three hundred hours of observation were conducted in homes, shelters, transitional housing units, community-based service centres, on the street, and at health care appointments. The constant comparative method was used with data collection and analysis occurring concurrently. RESULTS: Five significant barriers to accessing care at EOL were identified, namely: (1) The survival imperative; (2) The normalization of dying; (3) The problem of identification; (4) Professional risk and safety management; and (5) The cracks of a 'silo-ed' care system. Together, findings unveil inequities in accessing care at EOL and emphasize how those who do not fit the 'normative' palliative-patient population type, for whom palliative care programs and policies are currently built, face significant access barriers. CONCLUSIONS: Findings contribute a nuanced understanding of the needs of and barriers experienced by those who are both structurally vulnerable and facing a life-limiting illness. Such insights make visible gaps in service provision and provide information for service providers, and policy decision-makers alike, on ways to enhance the equitable provision of EOL care for all populations.

Cellulosic ion-exchange membranes for hemodialysis.

The application of cellulosic ion-exchange membranes to hemodialysis was studied in vitro. The membranes were prepared by radiation-grafting methacrylic acid and vinylpyridine to films of DuPont cellophane PD-215 to produce cation-exchange and anion-exchange membranes, respectively. Solutions of urea, creatinine, glucose, and uric acid were studied for their interactions with and diffusion through the membranes. Ultrafiltration rates were also determined. Cuprophane and PD-215 cellophane were studied as controls. Dialysis plots for the membranes revealed a mechanism of "assisted transport." Initially, the solutes were removed from solution by a sorption/adsorption mechanism followed by a steady-state diffusion process. The calculated diffusivities for these later steady-state regions increased linearly with capacity for urea, creatinine, and uric acid, while for glucose the reverse was true. The combined processes involved provided considerably greater mass transport per unit thickness than either DuPont PD-215 cellophane or Cupropane.