Balancing punishment and compassion for seriously ill prisoners

Health Care During Incarceration: A Policy Position Paper From the American College of Physicians

The American College of Physicians (ACP) has a long-standing commitment to improving the health of all Americans and opposes any form of discrimination in the delivery of health care services. ACP is committed to working toward fully understanding and supporting the unique needs of the incarcerated population and eliminating health disparities for these persons. In this position paper, ACP offers recommendations to policymakers and administrators to improve the health and well-being of persons incarcerated in adult correctional facilities.

A stepwise guide for healthcare professionals requesting compassionate release for patients who are incarcerated

PURPOSE

Compassionate release is a process that allows for the early release or parole of some incarcerated people of advanced age, with life-limiting illness, complex medical care needs or significant functional decline. Despite the expansion of State and Federal compassionate release programs, this mechanism for release remains underutilized. Health-care professionals are central to the process of recommending compassionate release, but few resources exist to support these efforts. The purpose of this paper is to provide a guide for health-care professionals requesting compassionate release for patients who are incarcerated.

DESIGN/METHODOLOGY/APPROACH

This study is stepwise guide for health-care professionals requesting compassionate release for patients who are incarcerated.

FINDINGS

This study describes the role of the health-care professional in requesting compassionate release and offers guidance to help them navigate the process of preparing a medical declaration or request for compassionate release.

ORIGINALITY/VALUE

No prior publications have created a step-wise guide of this nature to aid health-care professionals through the compassionate release process.

Death and Dying in Prison: An Integrative Review of the Literature

OBJECTIVE

The purpose of this integrative review was to synthesize and explore the qualitative research literature that describes the experience of being terminally ill while incarcerated, in order to inform future inquiry when it comes to the end-of-life (EOL) needs of incarcerated persons.

BACKGROUND

Mass incarceration has been a major issue in the United States, with rates sharply increasing since the 1970s. In the past two decades, the number of older incarcerated persons has grown by 500%, highlighting the importance of EOL care and decisions among this demographic.

METHODS

The search terms included prison OR incarceration AND "death and dying" OR "end of life." Primary research articles were considered in the search parameters. The Joanna Briggs Institute critical appraisal checklist for qualitative research was coupled with ConQual to score the quality of the selected qualitative studies.

RESULTS

Searches yielded 233 articles published after 2000. Following screening, 29 full-text articles were assessed for eligibility, and 7 qualitative studies met criteria and were included in the review. The ConQual scores of the synthesized findings were determined to be either "low" or "moderate."

DISCUSSION

Five main categories were observed across the themes elicited by the studies: EOL services in prison, social contact and human interactions, thoughts of death and fear of dying, wishes and decision-making, and guilt and coping. Many of these themes may be considered by correctional nurses who provide supportive "good death" care for incarcerated persons who are dying.

"No One Wants to Die Alone": Incarcerated Patients' Knowledge and Attitudes About Early Medical Release

CONTEXT

Deaths among incarcerated individuals have steadily increased in the U.S., exceeding 5000 in 2014. Nearly every state has a policy to allow patients with serious life-limiting illness to apply for release from prison or jail to die in the community ("early medical release"). Although studies show these policies are rarely used, patient-level barriers to their use are unknown.

OBJECTIVES

To assess incarcerated patients' knowledge of early medical release policies and to identify patient-level barriers to accessing these policies.

METHODS

A cross-sectional survey of 46 male patients in two state prisons and one large urban jail who had visited a primary care provider at least three times within three months was conducted.

RESULTS

Participants' average age was 64 years, and 89% had more than one chronic illness. Fewer than half (43%) demonstrated the knowledge needed to apply for early medical release and 22% demonstrated no relevant knowledge. Participants with sufficient knowledge were significantly more likely to endorse anxiety (35% vs. 0%, P = .003) and loneliness (65% vs. 30%, P = .017).

CONCLUSION

Many medically complex incarcerated patients in this study did not demonstrate sufficient knowledge to apply for early medical release suggesting that patient education may help expand access to these policies. Moreover, seriously ill patients with knowledge of early medical release may benefit from enhanced psychosocial support given their disproportionate burdens of anxiety and loneliness. Our findings highlight the pressing need for larger studies to assess whether improved patient education and support can expand access to early medical release.

Substance use and other mental health disorders among older prisoners

The goal of this study is to explore the status quo of mental health and substance use problems among older prisoners. Our review presents the prevalence as well as co-occurrence of substance use and other mental health disorders in older prisoners. We conducted a systematic review of literature following the PRISMA statement. The search was carried out in four databases and supplemented with manual screenings of bibliographies from all retrieved articles. Publications were included if they met specific inclusion criteria. A total of 17 articles were included and in half of them, older offenders were the main study population. Older inmates have higher prevalence of mental health disorders than younger prisoners and are more likely to use alcohol. Several studies mentioned an association between substance use and other mental health disorders. Access to treatment was a concern with several studies providing recommendations to improve this. Most studies were done on older male prisoners, confirming that older female prisoners constitute a subgroup of a subgroup which is even more vulnerable and under-researched. It is important to carry out more research on both older male and female prisoners to ensure optimal delivery of appropriate mental health care for older prisoners and to prepare for a currently younger population that will age with different and distinct mental health problems and substance use patterns.

U.S. Department of Corrections Compassionate Release Policies: A Content Analysis and Call to Action

Large and increasing numbers of inmates with chronic and terminal illnesses are serving time, and dying, in U.S. prisons. The restriction of men and women to die in prisons has many ethical and fiscal concerns, as it deprives incarcerated persons of their autonomy and requires comprehensive and costly health-care services. To ameliorate these concerns, compassionate release policies, which allow inmates the ability to die in their own communities, have been adopted in federal and state prison systems. However, little is known about the content of compassionate release policies within U.S. states' department of corrections, despite recent calls to release incarcerated persons who meet eligibility criteria into the community. The current study provides an overview of compassionate release policies in the United States, which vary widely across the compassionate release process. Specific policy recommendations are made to assure the timely access and utilization of compassionate release among eligible incarcerated individuals.

Encountering offenders in community palliative care settings: challenges for care provision

BACKGROUND

There is very little research into the way that offender management strategies impinge on the practices and decision-making of palliative care personnel in community settings.

AIMS

To improve understanding of the challenges that community palliative care service providers encounter when caring for people who have been sentenced to custody and are under the supervision of the prison or probation services.

METHODS

This paper discusses one part of a larger multidisciplinary study on bereavement, loss and grief in the criminal justice system. It reports the findings from a focus group with 10 health professionals working within specialist community palliative care services. Thematic analysis was undertaken to identify and explicate the most significant themes arising from the transcript data.

RESULTS

There were situations where the participants were able to identify that patients were under the jurisdiction of the criminal justice system or had relatives in custody. Three themes emerged that highlighted distinctive aspects of providing care to this patient group. These themes were: patients under prison, probation or police supervision altered the dynamics of care provision; prisoners were restricted from supporting or contacting their dying relatives in the community; and participants (professionals) were obstructed from supporting patients at home because of criminal or antisocial behaviour by relatives of the dying.

CONCLUSIONS

Health professionals face multiple challenges that curtail them from fully realising the aims of palliative care for patients and relatives under criminal justice supervision, in ways that merit further consideration and research.

Differences between incarcerated and non-incarcerated patients who die in community hospitals highlight the need for palliative care services for seriously ill prisoners in correctional facilities and in community hospitals: A cross-sectional study

BACKGROUND

Incarcerated populations worldwide are aging dramatically; in the United States, prisoner mortality rates have reached an all-time high. Little is known about the incarcerated patients who die in community hospitals.

AIM

Compare incarcerated and non-incarcerated hospital decedents in California.

DESIGN

Cross-sectional study.

SETTING/PARTICIPANTS

All state hospital decedents ( N = 370,831) from 2009 to 2013, decedent age over time examined with additional data (2001-2013).

RESULTS

Overall, 745 incarcerated and 370,086 non-incarcerated individuals died in California hospitals. Incarcerated decedents were more often male (93% vs 51%), Black (19% vs 8%) Latino (27% vs 19%), younger (55 vs 73 years), had shorter hospitalizations (13 vs 16 days), and fewer had an advance care plan (23% vs 36%, p < 0.05). Incarcerated decedents had higher rates of cancer, liver disease, HIV/AIDs, and mental health disorders. Cause of death was disproportionately missing for incarcerated decedents. The average age of incarcerated decedents rose between 2001 and 2013, while it remained stable for others.

CONCLUSION

Palliative care services in correctional facilities should accommodate the needs of relatively young patients and those with mental illness. Given the simultaneous growth in the older prisoner population with the rising age of incarcerated hospital decedents, community hospital clinicians should be prepared to care for seriously ill, incarcerated patients. Significant epidemiologic differences between incarcerated and non-incarcerated decedents in this study suggest the importance of examining the differential palliative care needs of incarcerated patients in all communities.

Older and incarcerated: policy implications of aging prison populations

Purpose The purpose of this paper is to explore the policy Implications of aging prison populations. Design/methodology/approach An examination of the worldwide aging trend in prison and its implications for correctional policy, including an examination of population aging in California prisons as a case example of needed reform. Findings Prison populations worldwide are aging at an unprecedented rate, and age-related medical costs have had serious consequences for jurisdictions struggling to respond to the changes. These trends are accompanied by a growing body of evidence that old age is strongly correlated with desistance from criminal behavior, suggesting an opportunity to at least partially address the challenges of an aging prison population through early release from prison for appropriate persons. Originality/value Some policies do exist that aim to reduce the number of older, chronically ill or disabled and dying people in prison, but they have not achieved that goal on a sufficient scale. An examination of the situation in California shows that recognizing how the healthcare needs of incarcerated people change as they age - and how aging and aging-related health changes often decrease an older person's likelihood of repeat offense - is critical to achieving effective and efficient policies and practices aimed at adequately caring for this population and reducing their numbers in prisons when appropriate.

Psychiatry and the dying prisoner

Due to the growing number of ageing prisoners in the American correctional system, penal institutions are increasingly caring for patients with chronic and potentially terminal medical conditions. To address this problem states have attempted sentencing reform initiatives and adopted compassionate release programmes; however, these efforts have failed to significantly reduce the number of elderly or seriously ill inmates. Correctional mental health services are now called upon to aid in the care of prisoners at the end of life. This article presents the common elements of prison hospice programmes and the role psychiatry plays in this multidisciplinary effort. The right-to-die movement holds future implications for correctional mental health professionals. The historical and legal background of this international movement is presented with particular attention given to landmark cases and statutes protecting institutionalized patients.

Detained and Dying: Ethical Issues Surrounding End-of-Life Care in Prison

Prisons are increasingly being called upon to provide end-of-life (EOL) care within the restrictive correctional environment. Several relatively recent phenomena have brought medical ethics to the forefront of prison EOL care-including aging behind bars, a paradigm shift in prison culture, the increasing rate of in-prison deaths, and the corresponding prison hospice movement. This article examines prominent ethical issues that emerge for prison personnel who are tasked with providing care to terminally ill offenders by presenting three offender composite characters that exemplify dying offenders and emergent ethical issues surrounding their care. Identification and critical analysis of these ethical issues demonstrate the need for strong commitment to ethical practice and highlights specific issues for prisons to examine in their own EOL care practice.

The Rikers Island Hot Spotters: Defining the Needs of the Most Frequently Incarcerated

OBJECTIVES

We used "hot spotting" to characterize the persons most frequently admitted to the New York City jail system in 2013.

METHODS

We used our Correctional Health Services electronic health record to identify 800 patients admitted in 2013 who returned most since November 2008. We compared them to a randomly selected control group of 800 others admitted in 2013, by using descriptive statistics and cross-tabulations, including data through December 2014.

RESULTS

The frequently incarcerated individuals had a median of 21 incarcerations (median duration 11 days), representing 18 713 admissions and $129 million in custody and health costs versus $38 million for the controls. The frequently incarcerated were significantly older (42 vs 35 years), and more likely to have serious mental illness (19% vs 8.5%) and homelessness (51.5% vs 14.7%) in their record. Significant substance use was highly prevalent (96.9% vs 55.6%). Most top criminal charges (88.7%) for the frequently incarcerated were misdemeanors; assault charges were less common (2.8% vs 10.4%).

CONCLUSIONS

Frequently incarcerated persons have chronic mental health and substance use problems, their charges are generally minor, and incarceration is costly. Tailored supportive housing is likely to be less costly and improve outcomes.

Will I stay or can I go? Assisted suicide in prison

Assisted suicide (AS) is a controversial practice with which physicians and nurses are confronted more and more often. In Switzerland, it is available for Swiss residents and in certain cases for foreigners. Prisoners meet the same prerequisites for AS as the general population and should therefore be eligible for it. Ethical issues, such as informed choice and the autonomy of prisoners, and organizational questions need to be addressed. They must not lead to a denial of this practice. Even though prisons constitute a special area of work for medical staff, it is important to address the possibility of AS in prison openly. This can raise awareness of the difficulties health-care professionals face working in closed institutions.

Palliative and end-of-life care in prisons: a content analysis of the literature

Purpose

– The growing numbers of terminally ill and dying in prison has high economic and moral costs as global correctional systems and the society at large. However, to date little is known about the extent to which palliative and end-of-life care is infused within global prison health care systems. The purpose of this paper is to fill a gap in the literature by reviewing and critically appraising the methods and major findings of the international peer-reviewed literature on palliative and end-of-life care in prison, identify the common elements of promising palliative and end-of-life services in prison, and what factors facilitate or create barrier to implementation.

Design/methodology/approach

– A content analysis was conducted of the existing peer-reviewed literature on palliative and end-of-life care in prison. English-language articles were located through a comprehensive search of peer-reviewed journals, such as Academic Search Premier Literature databases using differing combinations of key word search terms, “prison,” “palliative care,” and “end-of-life care.” A total of 49 studies published between 1991 and 2013 met criteria for sample inclusion. Deductive and inductive analysis techniques were used to generate frequency counts and common themes related to the methods and major findings.

Findings

– The majority (n=39) of studies were published between 2001-2013 in the USA (n=40) and the UK (n=7). Most were about US prison hospice programs (n=16) or barriers to providing palliative and end of life care in prisons (n=10). The results of the inductive analysis identified common elements of promising practices, which included the use of peer volunteers, multi-disciplinary teams, staff training, and partnerships with community hospices. Obstacles identified for infusing palliative and end-of-life care in prison included ethical dilemmas based on custody vs care, mistrust between staff and prisoners, safety concerns, concern over prisoners’ potential misuse of pain medication, and institutional, staff, and public apathy toward terminally ill prisoners and their human rights to health in the form of compassionate and palliative care, including the use of compassionate release laws.

Research limitations/implications

– Implications for future research that foster human rights and public awareness of the economic and moral costs of housing the sick and dying in prisons. More research is needed to document human rights violations as well as best practices and evidence-based practices in palliative and end-of-life care in prisons. Future studies should incorporate data from the terminally ill in prison, peer supports, and family members. Future studies also should employ more rigorous research designs to evaluate human rights violations, staff and public attitudes, laws and policies, and best practices. Quantitative studies that use experimental designs, longitudinal data, and multiple informants are needed. Qualitative data would allow for thick descriptions of key stakeholders experiences, especially of the facilitators and barriers for implementing policy reform efforts and palliative care in prisons.

Practical implications

– This review provides a foundation on which to build on about what is known thus far about the human right to health, especially parole policy reform and infusing palliative and end-of-life care for the terminally ill and dying in prisons. This information can be used to develop or improve a new generation research, practice, policy, and advocacy efforts for that target terminally ill and dying in prison and their families and communities.

Social implications

– There are significant social implications to this review. From a human rights perspective, the right to freedom from torture and cruel and unusual punishment is a fundamental human right along with prisoners’ rights for an appropriate level of health care. These rights should be guaranteed regardless of the nature of their crime or whether they are in a prison placement. The information provided in this review can be used to educate and possible transform individual's and society's views toward the terminally ill and dying who are involved in the criminal justice system.

Originality/value

– This paper extends the extant literature by using both quantitative and qualitative analysis methods to organize, summarize, and critically analyze the international literature on palliative care and end of life care in prison. This review is designed to increase awareness among the international community of the pain and suffering of the terminally ill in prison and the facilitators and barriers to providing them compassionate care while in custody.

Consideration of forgiveness to enhance the health status of older male prisoners confronting spiritual, social, or emotional vulnerability

Participants in this study included 261 men, aged 45 and older, residing within state-managed correctional facilities in Oklahoma. Path analysis was used to examine an integrated mediation model. Spiritual ambivalence, loneliness, and depressive affect had direct negative associations with forgiveness, controlling for age, race, education, and type of crime. Forgiveness also maintained a direct positive association with perceived health status, whereas depressive affect maintained a direct negative association with perceived health status. In addition, a significant indirect effect of depressive affect on perceived health through forgiveness emerged. Overall, the model explained 38% of the variance in forgiveness and 23% in perceived health. Greater spiritual ambivalence, loneliness, and depressive affect diminish forgiveness among older male prisoners, yet higher levels of forgiveness, are associated with greater perceived health.

Aging in correctional custody: setting a policy agenda for older prisoner health care

An exponential rise in the number of older prisoners is creating new and costly challenges for the criminal justice system, state economies, and communities to which older former prisoners return. We convened a meeting of 29 national experts in correctional health care, academic medicine, nursing, and civil rights to identify knowledge gaps and to propose a policy agenda to improve the care of older prisoners. The group identified 9 priority areas to be addressed: definition of the older prisoner, correctional staff training, definition of functional impairment in prison, recognition and assessment of dementia, recognition of the special needs of older women prisoners, geriatric housing units, issues for older adults upon release, medical early release, and prison-based palliative medicine programs.

The hospitalized prisoner with a life-threatening illness: criminal first and patient second?

It is generally accepted that the Patient's Bill of Rights applies to all patients including prisoners. Yet, a prisoners' incarcerated status generally prohibits inmates from making any decision that may shorten his/her life, and as such, the de facto medical decision maker becomes the medical director of the state correctional facility. This case study highlights the challenges that arise when the ethically appropriate response to a hospitalized prisoner's terminal medical condition warrants decisions that are in conflict with that advocated by the correctional facility.