Exploring strategies and approaches to improve end-of-life care services for people experiencing homelessness: a systematic review and meta-synthesis of qualitative studies

As a socially disadvantaged group, people experiencing homelessness face numerous difficulties and challenges in accessing end-of-life (EOL) care. Existing strategies often fail to meet their needs, with evident deficiencies in workforce allocation, financial support, and service coverage, as well as a lack of consideration for their unique circumstances. This study synthesizes published qualitative research to explore the expectations and needs of people experiencing homelessness in EOL care, as well as the perspectives of service providers. Its aim is to identify effective strategies and approaches to improve EOL care services for this population, ultimately promoting more targeted and higher-quality care. We systematically searched PubMed, Web of Science, CINAHL, Embase, Cochrane Library, and CNKI from inception to November 2024 for primary qualitative studies addressing the EOL needs and service challenges of homeless populations. Using inductive thematic analysis in conjunction with Bronfenbrenner’s ecological systems theory, we examined systemic barriers and potential solutions across the microsystem, mesosystem, exosystem, macrosystem, and chronosystems, providing a critical framework for building an inclusive EOL care ecosystem for people experiencing homelessness. A total of 20 publications representing 16 independent studies were included. The synthesis yielded four major findings: People experiencing homelessness’ EOL Dilemmas and Attitudes, EOL care from the perspective of service providers, Challenges and Barriers to EOL Care, Strategies and Recommendations for Improving EOL Care Furthermore, by applying Bronfenbrenner’s ecological systems theory, these findings were integrated into a cross-system, multi-level analytical framework. This study systematically synthesized qualitative evidence on EOL care for people experiencing homelessness, revealing the multifaceted challenges and profound structural barriers they face at the EOL. Our synthesis indicates that the lack of trust and the need for dignity permeate all systemic levels, from the micro to the macro, in EOL care for this population. Reliance on traditional biomedical models alone may not fully address their complex needs. Future efforts should be further advanced through cultural sensitivity, cross-sectoral collaboration, and service evaluation, in order to build an inclusive, respectful, and diverse EOL care system that ensures equitable and dignified care for people experiencing homelessness.