Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Increasing numbers of elderly persons and the growing frequency of long sentences will result in higher costs to house and treat older inmates. Carefully considered early release programs are recommended.

Prison medical staffs share many of the ethical concerns of their counterparts on the outside, but with a peculiar twist; other issues are unique to prisons. This review points to the need for an agreed-on code of ethics for the correctional medical profession.

An unworkable standard of eligibility coupled with a needlessly complex review process makes the New York Medical Parole Law ineffective. Recommended modifications offer possibility of substantial improvement.

This "complex environment" for mental health providers is briefly surveyed, and responses are suggested.

The impact of elderly inmates on correctional systems is discussed. An on-going hospice program in Texas and the Project for Older Prisoners (POPS) in Louisiana are seen as steps in the right direction.

This knowledgeable account of the program at the Federal Medical Center in Springfield, MO stresses the growth in human compassion among those involved as evidenced in close-ups of two inmate patients. Challenges are presented by prison environment, work with community hospice, and the recruitment and training of inmate volunteers.

Arguments involving the value of persons, social contract theory, definitions of justice, just recompense, and a utilitarian view of social benefits and burdens are seen to provide support for provision of end-of-life care to dying prisoners.

Hopeful signs of improvement are descried in both the UK and USA, and broad support is urged.

After a brief history of the development of hospice programs in U.S. prisons, present efforts are reviewed, as well as challenges and creative solutions. Issues of appropriate standards, program initiation, and adequate training are discussed.

The approach to end-of-life care in the Texas Department of Criminal Justice is briefly surveyed, and the components of a recently developed program are described in some detail.

This very negative estimate of the feasibility of adequate end-of-life care in prison settings is based on the current lack of appropriate standards for such care, which requires compassion and nurturing totally foreign to the prison culture. Since no notice is taken of current successful on-site programs, the solution invoked is compassionate release, which would require an overhaul of the political culture.

The inherent tensions perceived in attempts to realize compassionate end-of-life care in prisons urge the expansion and improvement of medical release policies.

Both outpatient and inpatient services are provided with help from a community hospice.

Data from a survey of state, federal, and Canadian systems, a literature search, and analysis of ongoing programs yield an array of issues and recommendations for the management of long-term and elderly inmates.

Arguments are presented against placement of offenders to work in hospice care and AIDS care programs. Such alternative sentencing short changes patients, whose needs are primary, and imposes new burdens on professional care providers. The article suggests that some judges place offenders in hospices to help out, with the intention only of furthering the helper's rehabilitation."

Growing numbers of these inmates are straining correctional budgets. The advantages of hospice approaches for cost control and humane care are detailed.

Practical medical issues affecting implementation of New York’s Medical Parole Law of 1992 are discussed by the then chief medical officer for New York State’s prisons.

Excerpts from a journal kept by an inmate volunteer in a California prison hospice program document his growth toward emotional involvement with others.

Personal appeals to shared emotion and experience can be effective in garnering support of staff and administration for compassionate end-of-life care in prisons.

The effectiveness of the intensive care unit could be markedly enhanced through incorporating the principles of end-of-life care. This candid account generates a knowledgeable plea for change.

The ambiguities of this term are demonstrated statistically and indicate the impossibility of meeting any of the usual criteria for definition. Uncertainty is the name of the game at this stage in life.

Against the background of two patient deaths in a psychiatric/forensic unit, the grieving processes of other patients observing them are carefully charted and analyzed. Security parameters and the acceptability of only some manifestations of grief were important variables.

Several case examples illustrate characteristics of inmate patients and the prison hospital setting. The subjects’ emotional interference with otherwise available coping mechanisms is discussed.

Staff and inmate perceptions of the need for end-of-life care brought about the development of this early program. This step-by-step account provides policy statements, guidelines, and recommendations for future programs.

Based on anecdotal accounts of successful programs, the author’s own experience, and the skimpy literature, this broad survey of prison hospice issues discusses criteria for admission and for DNR orders, pain medication protocols, family visitation, inmate volunteers, approaches to housing, and compassionate release. Topics for research and tentative guidelines for prison hospice care indicate how much the former is needed to improve the latter.

Components and operation of the hospice unit at the California Medical Facility-Vacaville are briefly noted.

This brief survey of the medical needs of these inmates was an early call for attention to the problem, urging the gathering of solid data and the development of standards of care.

Hospice care in an inpatient psychiatric/forensic unit (minimum security) encourages psychological growth for all involved. Caring for the psychosocial needs of inmates and medical staff is emphasized.

The problems posed by older inmates are briefly surveyed, together with a report of research, and a summary of issues for policy and program development. Little attention to medical care is given in this dated discussion.

The survey reported here indicates that "elderly inmates pose a minimal threat to society, they require special medical attention and care, and as a group they consume a disproportionate amount of correctional funds." A "structured supervised release" policy is urged.

The efforts of Departments of Corrections to improve efficiency and reduce costs in care of the elderly, the terminally ill, and the chronically ill are informally surveyed.

This follow-up on the 1997 NIC Information Center report Prison Medical Care: Special Needs Population and Cost Control attempts to sharpen its approach with some definitions. Self-reported data from 53 correctional jurisdictions give some general ideas about numbers, availability, programs (and non-programs), licensure, policies, operational issues, advantages, difficulties, and future prospects.

This examination of case law and of the peculiarities of the physician-patient relationship in prisons calls for increased scrutiny of the circumstances surrounding an inmate patient’s refusal of medical treatment. A more cautious approach is required than in the free world.

The move towards managed care promises to benefit corrections in light of recommended strategies: discharge planning, entitlement security, outreach, and case management. The dangers inherent in capitated payment are noted.

The broad Eighth-Amendment provisions for adequate standards of correctional health care are shown to be supported by case law. In particular, financial considerations are disallowed in determining appropriate levels of care.

The coordinator of an Illinois program discusses aspects of hospice care that tend to challenge prison administrations, and offers some savvy personal observations.

This National Public Radio interview with Fleet Maull presents a close-up view of the prison hospice movement at or very close to its inception.

This brief summary of the GRACE (Guiding Responsive Action for Corrections at End of Life) Project lists present partner organizations, summarizes the need for prison hospice and earlier responses to it, details project procedures, and looks toward future developments.

Results of a survey of current compassionate release statutes, procedures, and programs indicate serious inefficiency in applying these goals; some jurisdictions even lack such mechanisms. The need is emphasized and a model statute is presented.

This groundbreaking account of end-of-life care at Louisiana’s peculiar institution samples politics, procedures, and people.

The coordinator of a new hospice program in a federal prison presents personal experiences, especially regarding the "institutional support network."

National Prison Hospice Association director surveys goals, development, and operation of this Federal Medical Center program and sees the beginnings of a "necessary trend in prison health care."

The author tells how she found new meaning for her life while helping dying inmates through their final hours.

These challenges inherent in the care and supervision of elderly inmates are based on a survey of state prisons in the southern USA. While these prisoners are expected to have special health problems, the prospect of death and dying is not mentioned.

Nationwide efforts are sampled: hospice in a Florida women’s prison and a Texas men’s facility, volunteer training in Michigan, and staff training in Philadelphia.

Legal and ethical issues relating to provision of costly medical interventions for prisoners are analyzed.

Hospice professionals describe the development of a program at a nearby maximum security prison for women.

This presumably official 20-page document gathers brief policy statements regarding all phases of the program issued over the past ten years.

Ambiguities of the deliberate indifference standard open prison personnel to liability in dispensing medicines when custodial staff make medical decisions and when medical staff prescribe ineffective medications for punitive non-medical reasons. Various remedies answering to legal requirements are discussed.

In an interview at Louisiana State Penitentiary-—Angola, inmate volunteers provide a moving account of prisoners helping their friends through the dying process.