What does a ‘good death’ look like when you don’t have a home?

Research reveals time and time again that being homeless is detrimental to your health.

It also dramatically shortens your life.

People who are homeless also have significantly greater rates of chronic disease, serious mental illness and substance abuse difficulties.

And, despite having complex health needs, they are less likely to access healthcare and much more likely to die at a younger age than the general population.

When we reflect on a good death, many of us may picture being at home in a warm bed surrounded by our family and friends, or perhaps we may choose to die in the supportive care of an acute hospital, hospice or nursing home.

But what does a good death look like when your home is in long-term homeless accommodation, unsuited to meet complex medical needs, or you are vulnerably housed – that is, living in substandard, insecure rental accommodation?

Research from the Health Research Board in 2024 reported that there were 121 deaths among people who were homeless in 2020, equivalent to 10 deaths per month. The median age of those who died was 41 (42 years for men and 36.5 years for women).

According to a 2021 report by P Dr Austin Ó Carroll, there are several complex reasons why homeless people have a much higher mortality rate than the general population. These include a high rate of substance misuse, accidental and violent deaths, and a high prevalence of mental illness and suicidality.

Ó Carroll’s report also highlights that “people experiencing homelessness generally come from areas of poverty which experience excess mortality and morbidity independently of homelessness”, and “there is a much higher prevalence of severe physical illness among the homeless population”.

While people experiencing homelessness die from many of the same physical conditions as the housed population, such as cancer, chronic obstructive pulmonary disease (COPD) and cardiovascular disease, the difference is that they die at a much younger age. More startling still is that young homeless people are dying from diseases that are wholly preventable and treatable.

Ciara Cotter is a clinical nurse manager with Dublin Simon Community’s primary care nursing team. Her role involves caring for clients who are dying. Coupled with co-ordinating care with the local hospice, GPs, acute hospitals and palliative care teams, she works to ensure that patients receive the care they need in safe accommodation.

Recalling a young woman patient who died at the age of just 41 from cervical cancer, Cotter says many people experiencing homelessness develop end-stage cancers at a young age because the transient nature of their lives means they are excluded from cancer screening programmes.

How do you receive a letter inviting you to take part in a screening programme if you don’t have an address?

“Often, our role with palliative care is to do with having clients with end-stage cancers ... often as a direct result of missed screening while they are younger, and they often present with end-stage cancers quite young,” she says.

Most of the patients who have been assessed as needing palliative care are in long-term homeless accommodation. Cotter says that since 2024, the Dublin Simon Community has cared for seven such patients. Of these, six were under 65.

[ Homeless numbers rise 9% in a year as latest figures show fresh increaseOpens in new window ]

Long-term homeless accommodation is home to people experiencing homelessness, and Cotter says most palliative care patients wish to remain in their accommodation for as long as possible.

“The main role of the nurse is really an advocacy role ... it’s referring clients to the specialists, identifying any deterioration and just making sure that their symptoms are managed and their care is provided where they want to be, and oftentimes that is where they call home.”

While the building may not be suitable for someone who is dying, Cotter and her team do all they can to ensure patients’ needs are met. This includes bringing in specialised medical beds and co-ordinating visits by nurses from the Irish Hospice Foundation (IHF).

The IHF’s forum on End of Life 2026 took place in September at Croke Park. It explored the theme Every Death Matters: Dying, Death and Bereavement in a Changing Ireland – Emerging Narratives, and focused on under-represented voices, including the experiences of migrants and people experiencing homelessness.

Unfortunately, long-term homeless accommodation is not set up to care for someone who is dying, and of the seven palliative care patients cared for since 2024, four died in a hospice and three in an acute hospital.

Cotter says the Simon Community has identified the lack of palliative care beds as a gap in homeless health services; the charity would like to have one at its Usher’s Island Health and Addiction Care facility in Dublin.

When a client dies, Dublin Simon provides a funeral in the Church of Our Lady of Lourdes on Seán McDermott Street in Dublin, attended by the charity’s staff, some of whom would have cared for the person for many years. If, as is often the case, there is no family present, staff will lead the eulogy and prayers, and the charity also funds the burial in Glasnevin Cemetery.

According to the IHF, while almost three-quarters of people want a good death at home, only one-quarter actually die at home. The charity advocates for a good death wherever the patient may be – at home, in a hospice, a nursing home, or an acute hospital.

When long-term homeless accommodation is your home and it is not set up to care for your needs, or if you are vulnerably housed – living in substandard, insecure rental accommodation – that choice of where you would like to die is taken away.

Dr Aoibheann Conneely is a consultant in palliative medicine at St James’s Hospital and Our Lady’s Hospice and Care Services Dublin. She has a special interest in inclusion health, an approach that aims to address the extreme health inequalities experienced by socially excluded people.

St James’s Hospital has pioneered inclusion health in Ireland thanks in no small part to the work of Dr Clíona Ní Cheallaigh, consultant in infectious diseases and general medicine and clinical lead of the Inclusion Health Service at the hospital.

As part of her job in palliative medicine, Conneely cares for patients with life-limiting conditions who are experiencing homelessness. She also liaises with colleagues in community palliative care or the hospice to ensure these patients receive the specialised care they need.

[ Palliative care: We do death well in Ireland, but what about the lead-up period?Opens in new window ]

“Each life is a person,” says Conneely. “No one life is more important than the next. No one death is more precious than the next; each one is precious, and no one should suffer. We have to be careful not to have a punitive approach within health and social care, and focus on the person, their story, the adversity they have lived through, have an awareness of the trauma they have lived through, and treat them with dignity and respect both in living and in dying.”

According to Conneely, a good death is one where the person is cared for, feels safe, and is surrounded by the people they wish to be with. “For some people this is at home; for others it may be in long-term accommodation as long as their care needs are met ... for some it may be hospital, for others hospice.

“I think what is hard for people is when that choice isn’t there, when they don’t have a choice to be at home because they don’t have one. Or when they don’t have a choice to be ... in their accommodation if, for various reasons, that is just not possible due to limitations on resources within that accommodation despite best efforts.”

Conneely recalls a patient she cared for a number of years ago while working as a junior doctor in another hospital.

Her patient was a man in his 60s who was living in long-term hostel accommodation. It was a wet hostel, where alcohol was allowed. He was admitted to hospital with a chest infection, and an X-ray revealed a mass on the lung. Lung cancer was one possible diagnosis, which would have required further appointments.

When he missed his follow-up appointment due to a fear of attending the hospital, the respiratory consultant visited him at his hostel to encourage him to return. With the support of the consultant, hostel and hospital staff, he agreed to return, and sadly he was diagnosed with lung cancer. As he became weaker, Conneely was asked to see him; she organised a brain scan, which revealed that the cancer had spread to his brain and he was not strong enough to withstand treatment.

The man was estranged from his daughter, but with his permission the hostel staff were able to contact her. He was transferred to the hospice for end-of-life care and was reunited with her.

“I was a young doctor at that time, but it showed me how staff across all services can be so compassionate and empathetic, trying to support that patient in their way, not being judgmental about the life he lived, not being judgmental about missed appointments, etc,” says Conneely.

Asked what one thing was needed to improve palliative care for the homeless in Ireland, Conneely says: “End homelessness. In an ideal world, people wouldn’t be dying in homelessness. I shouldn’t have a specialist interest in this area because it shouldn’t exist.”