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

• As a terminally ill patient begins to be able to do less for himself, fear for his personal safety becomes an issue. He requires assistance with activities of daily living and protection from violence and manipulation by other inmates.

• It is often a time for reuniting families at a time when the incarcerated patient feels he has even less to offer estranged loved ones.
• The loss of family ties may become the patient's greatest regret and an important focus of the team's intervention.
• Members of the "altered community" of the prison environment become the dying patient's "family" even in the presence of traditional family.
• The patient may more readily accept assistance from another inmate than he will from staff.

• Even simple, platonic gestures are often discouraged in a prison environment.
• Simple human contact such as touching a patient's hand or shoulder during an assessment is often frowned upon but is a necessary point of advocacy for your patient.
• Frequently our mutual fears of being misunderstood prohibits touch in the prison environment.

• Our roles as "captors" and "captives" dehumanize a person and may convey the misconception that the patient does not require the same explanation you would expect to give a "free world" patient. When you convey this by not sharing information, you belittle the patient and promote distrust.
• As in any setting, compliance with treatment for maximum patient outcome (whether it be curative or palliative) depends upon the patient's clear understanding of his illness, what is required, and the reasons for the interventions outlining his best interests.
• The inmate patients' status as wards of the state predetermines a greater responsibility for the caregiver.

• By accepting the person as a human being, you need not accept his crime.
• All persons deserve quality care irrespective of their crimes.

• A time of self-review; this may be the first time the patient is willing to accept responsibility for his actions, including his crime. He may identify this as an issue he needs to address.
• How a person dies and the subject of advance care planning are monumental decisions, especially to a person who is told when to eat, sleep and work on a daily basis. He may find the prospect of making these decisions overwhelming.
• The patient's status as a ward of the state does not interfere with the patient's right to make medical decisions.
• To survive in the prison culture, a man must have a measure of self-sufficiency to be considered "a man" by his peers. When simple tasks such as eating and bathing are no longer possible without assistance, feelings of anger, fear and depression are amplified.

• Staff members are traditionally viewed as untrustworthy by inmates.
• Inmate patients are initially viewed as untrustworthy by staff. "Us against them" orientation of the prison environment makes honest, effective relationships more difficult to maintain.
• The inmate population may generally believe that the medical care its members receive is substandard.
• Inmate volunteers can be effective mediators for improved communication.

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