LGBTQ+ Adults: Unique Opportunities and Inclusive Approaches to Care

LGBTQ+ Adults: Unique Opportunities and
Inclusive Approaches to Care

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Physicians
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Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
CME Provider Information

VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved by: Florida Board of Nursing/Florida Board
of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
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through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number:
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Home Administrators and Illinois Respiratory Care Practitioners.
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provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021–06/06/2024.
Social workers completing this course receive 1.0 continuing education credit(s). VITAS Healthcare Corporation of California,
310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number
10517, expiring 01/31/2023.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No
NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive
CE Credit in Illinois.
CE Provider Information

• To improve understanding of the unique healthcare needs
the LGBTQ+ community faces, with focus on older adults
• To provide equitable, respectful, affirming, and clinically
appropriate care to LGBTQ+ adults, regardless of their
sexual orientation, gender identity, and gender expression
• To prevent suffering and establish trust in clinicians
Goal

• Improve understanding of the LGBTQ+ population’s needs
• Improve knowledge, confidence, and comfort with
LGBTQ+ needs and terminology
• Understand the reasons behind healthcare challenges
faced by the LGBTQ+ population, including:
– Delays in diagnosis and treatment
– Barriers in advance care planning
– Inadequate bereavement support
Objectives

American Experience. Milestones in the American Gay Rights Movement. Available at:
https://www.pbs.org/wgbh/americanexperience/features/stonewall-milestones-american-gay-rights-movement/
• December 10, 1924
– The Society for Human Rights founded
in Chicago
• December 15, 1950
– Senate rules homosexuals a “security risk”
• April 1952
– American Psychiatric Association
lists homosexuality as a sociopathic
personality disorder
• December 15, 1973: Removed
from list of mental illnesses
• April 27, 1953
– Homosexuals banned from working
for the federal government
– Ban lifted in 1977; repealed in 1995;
explicitly repealed in 2017
LGBTQ+ History

• June 28, 1969
– The Stonewall Riots: The Stonewall Inn, New York City:
• “During the days of June 27-31, 1969, gay people ascended into the
streets and openly resisted the harassment and criminal exploitation
of their community…oppressions which they had long endured in
silence. Rich-poor-drag-butch…gays stood together and fought in
a mass act of resistance. Those days were the birth pangs of the
gay liberation movement.”
• June 28, 1970
– First gay pride marches in New York City (“Christopher Street
Liberation Day”), Los Angeles, San Francisco, and Chicago
LGBTQ+ History

• June 5, 1981
– First official reporting to the
Centers for Disease Control and
Prevention (CDC) of what would
be known as the AIDS epidemic
• October 11, 1987
– National March on Washington
• September 21, 1996
– Defense of Marriage Act
• October 28, 2009
– Matthew Shepard Act
passed by Congress
• June 26, 2015
– Federal legalization of
same-sex marriage
LGBTQ+ History

Curry, C. (2017). Global Citizen. 9 Battles The LGBTQ Community In The US Is Still Fighting. Available at: https://www.globalcitizen.org/fr/content/9-battles-the-lgbt-community-in-the-us-
is-still-fi/Human Rights Campaign. Fatal Violence Against the Transgender and Gender Non-Conforming Community in 2022. Available at https://www.hrc.org/resources/fatal-violence-
against-the-transgender-and-gender-non-conforming-community-in-2022
• Parenting
• Gay conversion therapy
• Employment discrimination
• Housing discrimination
• Bathrooms, schools, and other
public accommodations
• Unequal healthcare
• Criminal justice
• Acceptance
• Violence
The LGBTQ+ Fight Continues

A few years ago, Nancy Kelly had a disturbing experience
during an emergency visit to a small hospital outside Durham,
North Carolina, where the 67-year-old from Swanville spends
her winters.
She had severely sprained her ankle getting off the plane and
needed help. She had been married to Kate DeHaven since
2013, the year after Maine voters approved a referendum to
allow same-sex marriage.
But at the hospital, when she told the person doing the initial
intake that her emergency contact person was her wife, she told
Kelly not to disclose that information to others at the hospital.
“She said, ‘You don’t want to tell people that here,’ as if I’d get
inferior care because I was married to a woman,” Kelly said.
“This kind of thing makes you feel very insecure about how
much you can tell people. It also causes you to develop fear and
that is a loss of dignity. It can become a constant daily reminder
that you are not part of accepted society.”
While Kelly and DeHaven, who is 76, have
taken all legal steps available to them, they
still worry that when they leave Maine they
will be discriminated against because of
their sexual orientation

• Gender Identity
– Our internal experience and
naming of our gender
– It can correspond to or
differ from the sex we were
assigned at birth
• Gender Expression
– The way we communicate our
gender to others through such
things as clothing, hairstyles, and
mannerisms
– It also includes how individuals,
communities, cultures, and society
perceive, interact with, and
try to shape our gender
Understanding Gender

• Sexual Orientation
– To whom a person is sexually attracted
– Some people are attracted to people
of a particular gender; others are
attracted to people of more than
one gender
• One should not assume that sexual
orientation and gender identity or
expression are static
Understanding Gender
Sex
Identity
Attraction
Expression

Farmer, D. et al. (2015). Hospice and Palliative Care for Older Lesbian, Gay, Bisexual and Transgender Adults: The Effect of History, Discrimination, Health Disparities and
Legal Issues on Addressing Service Needs. Palliative Medicine and Hospice Care - Open Journal, 1(2), 36–43. https://doi.org/10.17140/pmhcoj-1-107
• Approximately 3 million older adults
in the US identify as members of
the LGBTQ+ community
• 1.5 to 1.7 million Baby Boomers
–The first “out” generation
• One of the most understudied and
underserved groups in health
disparities research
– Most research centered around
HIV/AIDS and STDs
– History of perceived and endured
social stigma attached to being
a sexual minority
• Reluctance to self-identify as
LGBT –> absence of research
The LGBTQ+ Older Adult

Farmer, D. (et al.) (2015). Hospice and Palliative Care for Older Lesbian, Gay, Bisexual and Transgender Adults: The Effect of History, Discrimination, Health Disparities and
• Older LGBTQ+ adults:
– Grew up in a less tolerant era
– Commonly concealed sexual
identity/orientation
– Experienced invisibility
– Experienced denial of self
– Were compelled to conform
for sake of public acceptance
– Came of age before the
Stonewall Riots
– Face difficulty of reconciling
this new reality with years
of stigmatization and
self-imposed isolation

Farmer, D. et al. (2015). Hospice and Palliative Care for Older Lesbian, Gay, Bisexual and Transgender Adults: The Effect of History, Discrimination, Health Disparities and Legal Issues
on Addressing Service Needs. Palliative Medicine and Hospice Care - Open Journal, 1(2), 36–43. https://doi.org/10.17140/pmhcoj-1-107
• Older LGBTQ+ people are at
increased risk of being affected by:
– Interpersonal violence in
intimate relationships
– Violence perpetrated by other
LGBTQ+ people
– Hate crimes
– Vulnerability compounded
by stress from social status
as minority group
– Minority stress from the incongruity
between personal needs and
experiences and the structure and
morality of the dominant
society/culture
– Stress increased from
marginalization and lack of rights
– Increased stress —> physical and
mental health problems

Movement Advancement Project and Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (2010). Improving Lives of LGBTQ Adults.
Available at: https://www.lgbtmap.org/policy-and-issue-analysis/improving-the-lives-of-lgbt-older-adults
• 2x as likely to age as a single person
• 2x as likely to live alone
• 3-4x less likely to have children
to support them
• More likely to be
prematurely institutionalized
• 5x less likely to access aging services
• Due to a lifetime of social stigma and
prejudice, which leads to fear of
potentially unwelcoming or hostile
healthcare professionals
Compared to heterosexual counterparts, LGBTQ+ adults are:

• LGBTQ+ individuals dealing with
stigmatization and victimization
daily develop:
– Competence
– Resilience
– Strength
– Coping skills
• The coming-out process
– Personal growth and
self-awareness
– Increased coping ability
Social Support

• LGBTQ+ individuals often have smaller social support
systems due to lower likelihood of being partnered and
increased likelihood of living alone and childless
• Formalized, paid care less utilized
– More precarious economic situation,
fewer family support options
Social Support

• Use of “families of choice,” not biologic
– Particularly among older LGBTQ+ persons
• Challenges
– Caregiving friends lack legal power/authority
to make medical or end-of-life decisions
– Inability to perform sustained caregiving
tasks over a long period of time
Social Support

Dennis, J. (2014) 'We Made This Family': End-of-Life Care in the LGBT Community. HuffPost Healthy Living,
The Blog. Available at: https://www.huffpost.com/entry/death-and-dying_b_4508724
When Eleanor went into a nursing home to receive the
care she needed in her final days, she was open about
who she was as a lesbian.
“You still have time before you die to repent, change
your ways and be saved,” a Certified Nursing Assistant
(CNA) at the nursing home told her.
Aversion to Healthcare

The National Gay and Lesbian Task Force. LGBT Older Adults in Long-Term Care Facilities Stories from the Field. Available at: http://www.lgbtagingcenter.org/resources/pdfs/NSCLC_LGBT_report.pdf
When asked whether LGBT older
adults could be open with facility
staff, only 22% of LGBT respondents
answered “yes.” A smaller share
of respondents, who did not identify
as LGBT older adults, responded
“yes,” as the table shows.
Of the 289 service providers who
answered the survey, 247 felt that
LGBT older adults were not safe
coming out or were not sure that
they should come out.
LGBTQ+ Older Adults and Long-term Care (LTC)
LGBT Older Adults Non-LGBT Older Adults
Number Percent Number Percent
No or not sure 218 78% 390 84%
Yes 60 22% 76 16%
All responses 278 100% 466 100%

Fear of Being Out and Vulnerable
A majority of respondents (578 of the 649 respondents or 89%) predicted that staff would discriminate against an LGBT
elder who was out of the closet. A majority also thought that other residents would discriminate (526 or 81%) and, more
specifically, that other residents would isolate an LGBT resident (500 or 77%). More than half also predicted that staff
would abuse or neglect the person (346 or 53%).
649
346
500
526
578
Total number of respondents
Abuse and/or neglect by staff
Isolation from other residents
Discrimination by residents
Discrimination by staff
Possible Issues Affecting LGBT Older Adults

Stein, G., et al. (2020). Experiences of lesbian, gay, bisexual, and transgender patients and families in hospice and palliative care: perspectives of the palliative care team. Journal of Palliative Medicine, 23(6), 817-824.
Fear of Being Out and Vulnerable
Long-term Care
Experiences Related to Resident’s Real or Perceived Sexual
Orientation and/or Gender Identity
Number of
Instance
Percent of All
Instances
Verbal or physical harassment from
other residents
200 23%
Refused admission or re-admission, attempted or abrupt discharge 169 20%
Verbal or physical harassment from staff 116 14%
Staff refused to accept medical power of attorney
from resident’s spouse or partner
97 11%
Restriction of visitors 93 11%
Staff refused to refer to transgender resident by preferred
name or pronoun
80 9%
Staff refused to provide basic services or care 51 6%
Staff denied medical treatment 47 6%
Total 853 100%
ICU or Emergency Department
Type of discrimination
not mutually exclusive
No. Percent
Treatment decisions
or minimized
163 15.0
Treated disrespectfully 156 14.3
Denied or having limited
access to patient in ICU
or ED
93 8.5
Denied private time
with patient
80 7.3
Visiting hours limited 54 5.0
Other 39 3.6
Treated abusively 12 1.1
Have not observed the
mentioned actions
621 57.0

Chidiac, C., et al. (2021). Development and evaluation of an LGBT+ education programme for palliative care interdisciplinary teams. Palliative Care and Social Practice, 15,
26323524211051388.
Caring for LGBTQ+ Adults
n %
145 100
Clinical Role
Chaplain 2 1.38
Complementary therapist 1 0.69
Counsellor 23 15.86
Doctor 10 6.90
Healthcare assistant 21 14.48
Nurse 57 39.31
Occupational therapist 4 2.76
Others 15 10.34
Physiotherapist 5 3.45
Psychologist 2 1.38
Social worker 5 3.48
Pre-session Post-session
n % n %
145 100.00 145 100.00
Knowledge of general LGBT+ issues and needs
Not knowledgeable 48 33.10 1 0.69
Somewhat knowledgeable 84 57.93 73 50.34
Knowledgeable 13 8.79 71 48.97
Knowledge of LGBT+ issues and needs in palliative and end-of-life care
Not knowledgeable 81 55.86 2 1.38
Somewhat knowledgeable 60 41.38 71 48.97
Knowledgeable 4 2.76 72 49.66
Confidence in providing palliative and end-of-life care for LGBT+ people
Not confident 48 33.1 5 3.45
Somewhat confident 62 42.8 56 38.62
Confident 35 24.1 84 57.93

• LGBTQ+ community has faced
health disparities from economic
insecurities and marginalization
• Less likely to have employer-based
health insurance or be covered by
their partner’s health insurance
– Unmet health needs, earlier
onset of chronic conditions
• Lack of healthcare professional
knowledge about LGBTQ+ populations
• Avoidance of healthcare system
by LGBTQ+ people due to fears of
discrimination and poor treatment
• Physician and medical student
discomfort with caring for
LGBTQ+ patients
LGBTQ+ Healthcare Disparities

Krehely, J., (2009). How to Close the LGBT Health Disparities Gap. The Center for American Progress. Available at: https://www.americanprogress.org/article/how-to-close-the-lgbt-
health-disparities-gap/
Healthcare and Health Insurance
Access to health-care and health insurance
Health Disparity #1 Heterosexual adults are
more likely to have health insurance coverage.
% of adults with health insurance
Health Disparity #2 LGB adults are more
likely to delay or not seek medical care.
% of adults delaying or not seeking healthcare
Health Disparity #3 LGB adults are more likely
to delay or not get needed prescription medicine.
% of adults delaying or not getting prescriptions
Health Disparity #4 LGB adults are more likely
to receive healthcare services in emergency rooms.
% of youth receiving ER care
82%
77%
17%
29%
13%
22%
18%
24%
Heterosexual LGB Transgender
57%

• Stress of “living as an LGBTQ+ person
in a homophobic society”
• Leading marginalized lives
• Stress of hiding one’s sexual orientation
• Enduring verbal, emotional, or physical
abuse from family members and from
larger society, including healthcare
• Care delivered without touching the
patient or with excessive precautions
• Blame for health status
• Roughness and abuse

Movement Advancement Project and National Center for Transgender Equality (2018). Religious refusals in health care: a prescription for disaster.
Available at: https://www.lgbtmap.org/file/Healthcare-Religious-Exemptions.pdf
Discrimination and Barriers to Care
Refusing to provide needed treatment jeopardizes the health and wellbeing of millions of people
Refusing to care for women or LGBT people.
Providers can refuse to treat women if the
treatment, such as medically-necessary
hysterectomies, violates their religious beliefs.
In many states, providers can turn away
LGBT people if treatment violates their beliefs.
Mississippi allows providers to refuse any
kind of care to transgender people, whether
or not that medical care is transition-related
Refusing to care for sexual health, including
HIV treatment or testing. Providers can refuse
to test for or treat STIs or prescribe medications
like the HIV-prevention drug PrEP, if doing so
violates their religious beliefs about, for example,
unmarried or LGBT people’s sexual health
Refusing to care for children of LGBT
parents. In Michigan, a pediatrician was able
to legally turn away an infant for a newborn
checkup because the baby had two mothers.

• Disability
• Poor mental
health
• Smoking
• Excessive drinking
• HIV infection
• Suicide attempts
• Violence
• Homelessness
• Depression
• Generalized
anxiety disorder
• Panic attacks
• Social isolation
• Reduced access
to preventive
healthcare
LGBTQ+ Health
LGBTQ+ populations are at higher risk of:

• Better health outcomes associated with:
– Living with a partner
– Having higher income
– Less lifetime victimization
– Having good physical and
mental functioning
– Having higher self-esteem
– Being a parent
– Having a favorable attitude towards
one’s own sexuality
• Despite this, evidence shows that older
same-sex couples do not gain the same
health benefits to the extent that
heterosexual couples do
LGBTQ+ Health

Healthline. Depression in the Face of a Terminal Illness and Death. Available at https://www.healthline.com/health/depression/terminal-illness
• Depression
• Affects about 26% of adults
• Affects 77% of terminally ill
• Underdiagnosed in people with a terminal illness
• Increases as a disease advances and causes more
painful or uncomfortable symptoms. The more a person’s
body changes, the less control they feel over their lives.
Mental Health
– Disbelief
– Panic
– Anxiety
– Anger
– Bitterness
– Denial
– Vulnerability
– Sadness
– Frustration
– Loneliness

Fredriksen-Goldsen, K., (2011). The aging and health report: Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults
Seattle, WA: Institute for Multigenerational Health. Available at: https://lavenderseniors.org/wp-content/uploads/2016/05/Caring-Aging-with-Pride.pdf
• Coming out, internalized
homophobia, and stigmatization
lead to higher risk for depression,
suicide, risky behavior, and
substance use
• Loneliness and social isolation
were significant contributors
about 50%
Mental Health Issues
• Suicide risk higher
– 39% in The Aging Health Report
cohort contemplated suicide
• Highest in transgender older adults
at 71%
• Race/ethnicity differences
– Highest rates of depression, stress
in Hispanic and Native American
– Higher rates of neglect in
Hispanic and African Americans

Krehely, J., (2009). How to Close the LGBT Health Disparities Gap. The Center for American Progress.
Available at: https://www.americanprogress.org/article/how-to-close-the-lgbt-health-disparities-gap/
Mental Health Issues
likely to experience psychological distress
% of adults experiencing psychological distress in past year
likely to need medication for emotional
health issues.
% of adults needing medication for mental health
Health Disparity #13 Transgender adults are
much more likely to have suicide ideation.
% of adults reporting suicide ideation
Health Disparity #14 LGB youth are much more
likely to attempt suicide.
% of youth reporting suicide attempts
9%
20%
10%
22%
2%
5%
50%
10%
35%
Impact of societal biases on mental health and well-being

Fredriksen-Goldsen, K.,. (2011). The Aging and Health Report: Disparities and Resilience among Lesbian, Gay, Bisexual, and
Transgender Older Adults. Available at: https://www.lgbtagingcenter.org/resources/pdfs/LGBT%20Aging%20and%20Health%20Report_final.pdf
• The following populations have
higher rates of the listed conditions:
– LGBT African Americans –
obesity, HTN, HIV
– LGBT Hispanics – HIV,
asthma, DM, visual impairment
Ethnicity and Sexual Orientation
• Specific medical conditions:
– Lesbian – breast, ovarian, and
endometrial cancer
– Gay – HD, anal cancer, and NHL
– Transgender – DM, CV disease,
liver disease, and breast, ovarian,
prostate, cervical cancer

Krehely, J., (2009). How to Close the LGBT Health Disparities Gap. The Center for American Progress.
Available at: https://www.americanprogress.org/article/how-to-close-the-lgbt-health-disparities-gap/
Physical Health Issues
Impact of societal biases on physical health and well-being
Health Disparity #5 Heterosexual adults are more likely to
report having excellent or very good overall health.
% of adults experiencing excellent or very good health
Health Disparity #6 Lesbian and bisexual women are less
likely to receive mammograms.
% of women receiving a mammogram in past 2 years
Health Disparity #8 LGB youth are more likely to be threatened
or injured with a weapon in school.
% of youth threatened or injured with a weapon
Health Disparity #9 LGB youth are more likely to be in physical
fights that require medical treatment.
% of youth in a physical fight requiring medical treatment
83%
77%
62%
57%
5%
19%
4%
13%
67%
Health Disparity #7 LGB adults are more likely to have cancer.
% of adults ever diagnosed with cancer
6%
9%
Health Disparity #10 LGB youth are more likely to be overweight.
% of youth who are overweight
6%
12%

Lawton, A. (2019). Fast facts and concepts #275 end-of-life and advance care planning considerations for lesbian, gay, bisexual, and transgender patients.
Palliative Care Network of Wisconsin. Available at: https://www.mypcnow.org/wp-content/uploads/2019/03/FF-275-LGBT.-3rd-Ed.pdf
• Advance care planning
• Partner and family involvement
• Discussion of sexual orientation
LGBTQ+ and End-of-Life Care

Seelman, A. (2019). Motivations for advance care and end-of-life planning among lesbian, gay, and bisexual older adults. Qualitative Social Work, 18(6), 1002-1016.
• Sense of agency
• Learning from others
• Reducing conflict
Age Race
Relationship
Status
Degree of
being “out”
Advance
Directive?
65 White/Caucasian Partnered Everyone Yes
65 African American/Black Single
Most people in
social network
No
67 White/Caucasian Single Everyone No
70 White/Caucasian Partnered
Most people in
social network
Yes
72 African American/Black Partnered
Most people in
social network
Yes
74 White/Caucasian Single A few close friends/family No
74 White/Caucasian Partnered
Most people in
social network
Yes
75 African American/Black Partnered
A few close
friends/family
No
77 White/Caucasian Single
Most people in
social network
Yes
LGBTQ+ Advance Care Planning

Hughes, M., et al. (2015). Lesbian, gay, bisexual and transgender people's attitudes to end-of-life decision-making and advance care planning. Australasian Journal on Ageing, 34, 39-43.
Stein, G. et al. (2001). Attitudes on end-of-life care and advance care planning in the lesbian and gay community. Journal of Palliative Medicine, 4(2), 173-190.
Hughes et al. 2015
• 18% Healthcare proxy
• 12% Living will
Reasons cited for not completing
• Not necessary now
• Not aware of document
• Not aware how to complete it
LGBT Advance Care Planning
Stein et al. 2001
• 42% Healthcare proxy
• 38% Living will
– Much higher than general population
as sample connected to LGBTQ+
health and social services

Hughes, M., et al. (2015). Lesbian, gay, bisexual and transgender people's attitudes to end-of-life decision-making and advance care planning. Australasian Journal on Ageing, 34, 39-43.
Stein, G. et al. (2001). Attitudes on end-of-life care and advance care planning in the lesbian and gay community. Journal of Palliative Medicine, 4(2), 173-190.
LGBT Power of Attorney Designations
45%
partner
Hughes et al. 2015
25%
biologic
relatives
17%
friends
7%
general
practitioners
6%
other
Stein et al. 2001
43%
partners
31%
relatives
19%
friends

Singer, P., et al. (1999). Quality end-of-life care: patients' perspectives. JAMA, 281(2), 163-168.
• Pain and symptom control
• Avoid inappropriate prolongation
of the dying process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships
with loved ones
What Do Patients With Serious Illnesses Want?

• Consider hospice if a patient meets 2 or more:
– Dependent in 2-3 of 6 ADLs
– SOB or fatigue at rest/minimal exertion
– Multiple ED visits or hospitalizations
– 10% weight loss in 6 months
– Recurrent falls with injury
– Decreased tolerance in physical activity
General Hospice Eligibility Guidelines

*Per Medicare guidelines, these 2 levels of care are provided on a temporary basis until the symptom(s) is optimally managed.
**Usually not offered more than monthly
Four Levels of Care
Hospice Support
Intensive Comfort Care®
(ICC)*
• Higher level of care
• Acute symptom management
• Patient’s bedside/preferred care setting
• VITAS RN/LPN/LVN/aide
• Temporary shifts of 8-24 hours until
symptoms stabilize
• Prevents ED visits/hospital readmissions
General Inpatient (GIP) Care*
• Higher level of care (GIP/VITAS IPU)
• Acute symptoms can no longer be managed
in patient’s preferred setting
• VITAS RN/MD/psychosocial team
• Temporary until symptoms stabilize
• Prevents ED visits/hospital readmissions
Routine Care
• Most common level of hospice care
• More robust and comprehensive compared
to home health care services
• Patient’s preferred setting
• Proactive clinical approach helps to
prevent ED visits/hospital readmissions
Respite Care**
• Provides temporary break (caregiver
burnout, travel, work, etc.)
• Up to 5 days of 24-hour patient care
• Medicare-certified hospital, hospice
facility, or long-term care facility

Hospice aide Based on individualized
plan of care; bathing, dressing, feeding,
in-home support to ensure a safe
environment, dignity, etc.
Registered nurse (RN)
Proactive symptom management,
wound care, medication reconciliation,
disease-specific education (i.e.,
disease process, aspiration precautions,
feeding techniques, wound prevention)
Hospice Support
Physician Collaborative support
with PCP and/or specialist, GOC
conversations with caregiver relating
to disease process and progression
Therapy services Physical therapy,
occupational therapy, speech therapy
for comfort, safety and dietary
modifications, education. Nutritional
counseling for education regarding
diet modification, aspiration
precautions, feeding techniques

*Not available with all hospice providers
Hospice Support
Respiratory therapist Education
on equipment use, such as O2 and
pulmonary hygiene
Volunteers To relieve caregiver for
a few hours wherever patient calls
home; emotional support, short-term
companionship
Chaplain Nondenominational support,
including spiritual and bereavement
support for family, death attendance*
Social worker Advance care planning
(ACP), grief support, family meeting,
support, community resources,
placement, funeral planning, emotional
need assessment, counseling,
death attendance*
Integrative services Massage, music,
pet visits*
Hospice trainings Patient/family/caregiver
educational resources on ACP, medication
administration, psychosocial needs,
disease progression by body system, and
the dying process to ensure they remain
knowledgeable/remain in preferred
care setting

– Provision of LGBTQ+ friendly forms
• Acknowledgement of multiple
family types and relationships
• Provision of appropriate questions
about sexual orientation and
gender identity
– Development and display of
non-discriminatory policies
– Use of inclusive brochures and artwork
– Having diverse staff including
designated LGBT liaison
– Providing staff training on
sensitivity to LGBT cultures,
issues, and concerns
– Availability of educational materials
on pertinent topics
Meeting the Needs
• A welcoming, inclusive, culturally sensitive environment is essential

• A lack of knowledge among healthcare
professionals creates access barriers
• An affirming or welcoming environment
for the LGBTQ+ patient and family
is key
• Acknowledgement and acceptance
help meet patient and family needs
Meeting the Needs

• Healthcare professionals and staff must:
– Understand the cultural context
of patients’ lives
– Take detailed, non-judgmental
patient histories
– Be self-reflective about their
own attitudes
– Avoid heterosexist/homophobic elements
– Allow for self-disclosure
– Accept gender assignments preferred
by transgendered persons
Meeting the Needs

• Staff should be:
– Sensitive to stigmatization and its history
– Knowledgeable about barriers to care that persist
– Ready and willing to rectify lack of knowledge
of LGBTQ+ populations
• The role and importance of self-defined family,
legal issues, advance directives, employee
benefits, and long-term care concerns
Meeting the Needs

To be fully seen by somebody, then, and
be loved anyhow – this is a human offering
that can border on miraculous.
– Elizabeth Gilbert, Author

American Experience. Milestones in the American Gay Rights Movement. Available at: https://www.pbs.org/wgbh/americanexperience/
features/stonewall-milestones-american-gay-rights-movement/
Chidiac, C., et al. (2021). Development and evaluation of an LGBT+ education programme for palliative care interdisciplinary teams.
Palliative Care and Social Practice, 15, 26323524211051388.
Curry, C. (2017). Global Citizen. 9 Battles The LGBTQ Community In The US Is Still Fighting. Available at: https://www.globalcitizen.org/fr/
content/9-battles-the-lgbt-community-in-the-us-is-still-fi/
Dennis, J. (2014) 'We Made This Family': End-of-Life Care in the LGBT Community. HuffPost Healthy Living, The Blog. Available at:
https://www.huffpost.com/entry/death-and-dying_b_4508724
Farmer, D. et al. (2015). Hospice and Palliative Care for Older Lesbian, Gay, Bisexual and Transgender Adults: The Effect of History,
Discrimination, Health Disparities and Legal Issues on Addressing Service Needs. Palliative Medicine and Hospice Care –
Open Journal, 1(2), 36–43.
Fredriksen-Goldsen, K., (2011). The aging and health report: Disparities and Resilience among Lesbian, Gay, Bisexual, and
Transgender Older Adults. Seattle, WA: Institute for Multigenerational Health. Available at: https://lavenderseniors.org/
wp-content/uploads/2016/05/Caring-Aging-with-Pride.pdf
References

Harding, R., et al. (2012). Needs, experiences, and preferences of sexual minorities for end-of-life care and palliative care:
a systematic review. Journal of Palliative Medicine, 15(5), 602-611.
Healthline. Depression in the Face of a Terminal Illness and Death. Available at: https://www.healthline.com/health/
depression/terminal-illness
Hughes, M., et al. (2015). Lesbian, gay, bisexual and transgender people's attitudes to end-of-life decision-making and
advance care planning. Australasian Journal on Ageing, 34, 39-43.
Human Rights Campaign. Fatal Violence Against the Transgender and Gender Non-Conforming Community in 2022.
Available at https://www.hrc.org/resources/fatal-violence-against-the-transgender-and-gender-non-conforming-community-
in-2022
Krehely, J., (2009). How to Close the LGBT Health Disparities Gap. The Center for American Progress. Available
at://www.americanprogress.org/article/how-to-close-the-lgbt-health-disparities-gap
Lawton, A. (2019). Fast facts and concepts #275 end-of-life and advance care planning considerations for lesbian, gay,
bisexual, and transgender patients. Palliative Care Network of Wisconsin. Available at: https://www.mypcnow.org/wp
content/uploads/2019/03/FF-275-LGBT.-3rd-Ed.pdf
Movement Advancement Project and National Center for Transgender Equality (2018). Religious refusals in health care:
a prescription for disaster. Available at: https://www.lgbtmap.org/file/Healthcare-Religious-Exemptions.pdf
References

Movement Advancement Project and Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders.
(2010) Improving Lives of LGBTQ Adults. Available at: https://www.lgbtmap.org/policy-and-issue-analysis/improving-
the-lives-of-lgbt-older-adults
The National Gay and Lesbian Task Force. LGBT Older Adults in Long-Term Care Facilities Stories from the Field.
Available at: http://www.lgbtagingcenter.org/resources/pdfs/NSCLC_LGBT_report.pdf
Seelman, A. et al. (2019). Motivations for advance care and end-of-life planning among lesbian, gay, and bisexual
older adults. Qualitative Social Work, 18(6), 1002-1016.
Singer, P., et al. (1999). Quality end-of-life care: patients' perspectives. JAMA, 281(2), 163-168
Stein, G., et al. (2020). Experiences of lesbian, gay, bisexual, and transgender patients and families in hospice and
palliative care: perspectives of the palliative care team. Journal of Palliative Medicine, 23(6), 817-824.
Stein, G., et al. (2001). Attitudes on end-of-life care and advance care planning in the lesbian and gay community.
Journal of Palliative Medicine, 4(2), 173-190.
References

• RS
– 59 y/o male with stage 4 pancreatic
cancer and increasing pain
– Living at home with partner of over
20 years who is POA
• Husband persistently questioned
about marital status by clinicians,
creating undue burden
– No children, no family involvement
– Oncology recommended; hospice
but no referral generated
– Patient contacted local LGBTQ+ resource
center who referred patient to LGBTQ+
friendly private duty who then advised
patient to contact VITAS
– Patient received hospice services for
37 days, including 4 days of continuous
care during final stages
Case Study

• CG
– Chapter member of nationwide LGBTQ+
senior advocacy group, aware of VITAS
LGBTQ+ advocacy/support
– Patient living alone at home; however,
moved to ALF due to limited ability
to provide self-care
– 70 y/o male with colon cancer currently
on chemo, history CHF, CAD, and prior
MI presents to ER for chest pain, CT
reveals liver metastases
– Patient A&O x3, signed own consents and
enrolled with VITAS upon discharge to ALF
• No spouse/partner, no children. Sister
who lives out of the area
is POA
– Patient received hospice services for
47 days, including 4 days of continuous
care during final stages
Case Study

• Pathologized, “sociopathic personality disturbance”
• Marginalized, ostracized, sinful, and immoral, “Won’t
marry a gay person;” “Can’t adopt”
• Heterocentrism homophobic environment
• Legally sanctioned discrimination
Why? Health Disparities
• Healthcare professional refusal care for LGBTQ+ patients
• State laws allowing discrimination - Mississippi
• Deliver healthcare consistent with religious and
moral beliefs
• Loneliness, depression, and suicide
• Shrinking social networks and housing discrimination
Stigma Discrimination
Treatment Refusal
Health Disparities

• LGBTQ+ persons are part of every community
• Many live in poverty and had little to no health
insurance prior to the Affordable Care Act of 2010
• More likely to experience economic insecurity
Background

• Increased likelihood of financial and health
problems in later life
– Lifetime of discrimination
– Less likelihood of having employer-sponsored
pensions and health insurance
– No coverage under a partner’s health plan
– Having to pay more for healthcare even
with insurance
– Denial of most survivor and death benefits
Background

• Older LGBTQ+ persons:
– Are 2x as likely as heterosexuals
to live alone
– Are 4x more likely to be childless
– Face institutionalized discrimination
via unequal access to benefits and
services, e.g., from agencies
servicing the elderly
Background

• Minority stress
– Negative mental and physical
health outcomes associated
with living within the societal
prejudice of a heterosexist society
• Invisibility of sexual orientation
– Lack of sensitivity and
inadvertent insensitivity
in addition to overt discrimination
– Internalized prejudice,
internal struggle
Background

• Natural Love of the same sex
• LTC Needs
• Advanced care planning/
advanced directives
• Psychosocial needs
• Socioeconomic needs
• Universal fear of hospice
• Aversion to healthcare
• Family unit
• Cultural inclusion
• Culture of understanding (empathy)
Topics

• Transgender
• The LGBTQ+ Veteran
• The LGBTQ+ Caregiver
• Exclusion
Topics

Harding, R., et al. (2012). Needs, experiences, and preferences of sexual minorities for end-of-life care and
palliative care: a systematic review. Journal of Palliative Medicine, 15(5), 602-611.
• Partner as part of decision-
making and treatment
planning process
• Mistrust erodes the patient-
physician relationship
– Heterosexism bias leads
to feelings of lack of support
• Less likely to share
emotions and fears
– Receive emotional support
outside healthcare team
Goals-of-Care Discussions

• Advance care planning (ACP)
• Isolation
• Emotional support
• Reconciliation with loved ones
• Mitigate family dynamic
• Caregiver burnout
• Grief
• Bereavement
• Closure
Hospice Support

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