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

The information provided below is an overview of the concerns and concepts integral to establishing an inmate volunteer group whose main objective is to facilitate an improvement of end-of-life care within the correctional setting. The outline provided is designed to stimulate thought processes aimed at problem solving and to examine examples of ways to accomplish your goal.

1. Examples

• assistance with activities of daily living (bathing, meals, dressing etc.);
• pastoral assistance;
• letter writing, reading to the patient;
• housekeeping assistance, companionship;
• assistance with aspects other than direct care such as program support which may include providing artwork, clerical duties, peer education etc.;
• vigil assistance.

1. Sources for guidance when making your decision:

• state and federal laws;
• institutional rules;
• departmental guidelines;
• American Correctional Association;
• National Commission on Correctional Health Care.

1. The type of institution you are working in will guide you somewhat. Such as, minimum, medium or maximum security; average length of stay of inmates.
2. When you invest in the training of these inmates, it is helpful to try to establish a number of participants who will most likely be remaining within the institution and with the program for some time. You can do this by establishing length of time remaining on the sentence as a condition of participation.
3. Your first consideration for choosing volunteers is always security of the institution. Part of that is safety of your visitors. Keep in mind that your institution’s hospice policy will most likely incorporate the inmate’s family into the unit of care. How much interaction your volunteers will have with the family (including women and children) is a point which can guide you in establishing your criteria.
4. A good place to start is to begin looking at the criteria you use for the following roles if they apply within your institution:
• orderlies (persons who do general housekeeping duties);
• pastoral care assistance (inmate pastors or inmates given special privileges to visit and pray with other inmates);
• trustees (inmates who have earned special privileges through good behavior and are classified differently within the institution);
• inmates who are given jobs with some degree of responsibility and accountability.
5. When establishing a criteria, try to be as open-minded as is safely possible. If you deny participation based on a selection process which is too restrictive, you risk eliminating an excessive percentage of your population. For example, if you eliminate all inmates who have been convicted of drug charges, or all inmates who have been convicted of a violent crime, you eliminate a large percentage of the population who will then never be able to participate. People grow and change, and often can function very well in the volunteer role in the restricted environment of the prison. Examples of more reasonable criteria include: May participate if conviction of drug related charges is more than five years old, or may participate if conviction of violent crime is more than five years old and no report of violent behavior has been recorded. A tool to guide you is the inmate’s disciplinary record. His mental health record should also be considered. Any inmate with a recent or past record of recurrent depression should be screened very carefully. Working with dying persons is not for everyone and may facilitate feelings of depression in those persons who have been identified as at risk for suicidal behaviors.

   Another important point to consider is whether the inmate's behavior in the past can reasonably be considered to be rehabilitated or not—for example, someone who is a convicted pedophile or someone who has been diagnosed as a sociopathic personality. There will be persons who should be eliminated from participation to ensure security and safety of all concerned.

1. If the volunteers' role will include assistance with activities of daily living, a nurse or nursing assistant may be the most appropriate person. The inmates will require guidance from someone knowledgeable about physical needs and changes.
2. A social worker, pastor, or someone who can assist the volunteers with the inevitable feelings of loss and grief may be your best choice.
3. Security should be included from the beginning. Choose a person who works well with security and can mediate problems effectively. Some institutions may be able to have joint supervision of the volunteers, such as a team of two persons: one from security and one from either the medical, pastoral or social services department.
4. The person who supervises the volunteers must be given an opportunity to participate in the selection process and in the writing of volunteer policy.

1. Decide how many volunteers you need. Select and train more volunteers than you need. They will not all work out. Some institutions will be able to hire hospice professionals to train their volunteers, some will need the pro bono assistance of the outside hospice community. Either way, it is cost and time effective to train a larger group rather than a smaller group even if you keep some inmates in reserve. The basic philosophy of hospice will not change and will not have to be taught but once. Ongoing education is another matter.
2. A way to decide how many volunteers you need is to establish how many volunteers will be assigned to each patient. Will volunteers be assigned to help all of the patients on the unit? Assigning them individually may be more effective if you can do this, because it allows for personal preferences, personality, racial, ethnic, religious and cultural differences. Consider that your patient will form emotional bonds with those inmates who care for him, particularly if companionship is part of the care. Assigning only one or two volunteers who are permitted to interact with the patient can be devastating to the patient if his volunteer is removed based on disciplinary action, illness, or discharge or transfer from the institution. This is not a time to subject the patient to additional losses. For this reason, the patient should have a number of volunteers assigned to him to provide a wide base of support.
3. Consider your state's policy and record on compassionate releases. Are your dying inmates going home or are they dying in your facility? How many deaths have you had in the past three years? What do your projected numbers look like relative to AIDS, Hepatitis B and C? What is the average age of your inmate population? Do you have a high percentage of lifers?
4. Enlist the help of your "inmate leaders." Call a meeting and give them basic information on hospice and the institution’s plan to improve end-of-life care. Provide them with information on what the volunteer role will be. Each institution has such leaders whether they are officially recognized or not. "Buy in" on the part of the inmate population is important. Sources of leaders may include:
• leaders of religious organizations such as inmate pastors of formal churches;
• presidents of inmate clubs such as Angola's Lifer's Association or "Vets Incarcerated" (these should not be confused with gang affiliations but are much like free world organizations such as Rotary clubs);
• leaders of self-help groups such as AA and NA;
• "old timers" who have emerged as inmates whom the younger inmates listen to, and who interact well with staff.
5. Choose your first group very carefully. If in doubt, don’t include a particular inmate. You won’t get a second chance to make a first impression with your volunteers. Many people, custody and non-custody staff alike will be watching and waiting for your plan to fail. Inmates within your population will be suspicious of the institution’s motives. If your attempt to establish a quality inmate volunteer group fails, you are not likely to be allowed to try this again any time soon.
6. Compile a list of candidates for participation either by peer-referral from you inmate leaders, through referral by staff, or written requests from inmates who wish to participate. Establish a group of persons who will review records to eliminate persons who are unsuitable based on your criteria. Record checks should include:
• incarceration charge and initial housing date;
• in-house disciplinary records (has he been written up on rule infractions?);
• mental health history and current status;
• living area (does the applicant live in a dormitory or is he in administrative lock down);
• sentence and length remaining on sentence;
• current work assignment if any.
7. The more names you start with, the larger your pool will be to choose from. Use your criteria and your staff’s knowledge of the inmates to eliminate those who are undesirable.
8. Design an interview tool. What questions can be asked to tell you something about the inmates who are volunteering to participate?
9. Have the inmates fill out an application.
10. Review the application and choose candidates to interview. Approach this task as if you were hiring staff and wanted the best person for the job.
11. The interview board should include:
• The security officer who has twenty-four-hour accountability for the unit where care will be provided as he will be the security officer most involved with the process;
• The person chosen as volunteer coordinator. Other people can be added to the board, but the decision to accept an inmate volunteer applicant should not be based on only one person’s evaluation of records and interview.
12. After records have been reviewed and interviews have been held, the number of inmates who are appropriate and desirable will have narrowed considerably. Have the members of your board confer privately to choose applicants.
13. When making your final selections, consider the following points:
• Is there varied religious, racial, and cultural representation within your selected group?
• Does someone in the interview group have a specific skill that would be helpful to a patient or to the program? (Such as, interpreter for the deaf, literacy tutor, or inmate pastor, etc.)
• Does the inmate present well in the interview? Is he interested in making someone else comfortable and improving end-of-life care, or does he seem more focused on his own needs and impressing you with his accomplishments?
• Is the inmate overly concerned with what he or she will get out of participating?

****If you have inmates currently working on your medical units in any capacity who wish to participate and meet your criteria, they should be given priority when choosing your volunteers because they already know the routine on the units. These inmates have established a work ethic on the medical units. Free people will be more accepting of their participation because these inmates already work on the units and have been minimally exposed to issues concerning patient care.

1. This area will be guided by the duties the inmates are allowed to perform.
2. Screening for TB should be ensured. (Even if you do this as normal procedure; verify the documentation.)
3. Some programs require a VDRL screening (a test for sexually transmitted disease). Others require screening for a patient’s ability to lift weight safely.
4. Consider early on, what your program’s position will be concerning allowing a person with known HIV or AIDS to participate as a volunteer. The question will come up and it’s best to address it early. Personally, it’s been my experience that volunteers who can easily identify with another person’s illness are sometimes the most effective volunteers. As long as the volunteer is healthy enough to safely participate, I would encourage institutions not to restrict those persons who are HIV positive or who have full-blown AIDS from participating.

1. Interactions with the patient and the staff will lead the volunteer to be privy to information concerning the patient’s medical diagnosis and condition. For this reason, staff needs to solicit the patient’s written permission to share this information with the volunteer at the outset.
2. The volunteer should be required to sign a confidentiality statement and be subject to dismissal as a volunteer if confidentiality is not maintained.

1. Establish, with the assistance of your education providers, what the curriculum will be and how long it should take.

(The LSP program involves forty hours of training. We complete it in one week—Monday-Friday, 8:00 a.m. until 4:30 p.m.)

2. Duties assigned will also guide your training. For example, if your volunteers are allowed to assist with activities of daily living, then they need information and instruction on how to feed a patient, how to transfer a patient safely from bed to chair, etc.
3. Basic training information should include: the philosophy of hospice, patient rights and responsibilities, volunteer responsibilities, information on patient confidentiality, stages of grief, basic communication, what physical and emotional changes to expect from a patient at the end of life, near death experiences, how to sit with a patient and be nonjudgmental particularly where religion is concerned.
4. State and national hospice and palliative care associations are excellent resources to consult when choosing the basic training guidelines for your volunteers.

Should your volunteers be paid or unpaid? There are successful models that: 1) do not pay volunteers and expect them to participate in addition to their assigned jobs; 2) assign volunteers on regular work assignment rosters and pay them as they would for any other service provided; 3) maintain a larger group who are not paid but a select few who have to earn the paid spots.

Consider what your institutional rules say about paid assistance, and also consider your institutional goal concerning how many inmates the institution expects to be working at any given time. Some institutional rules may prohibit having an inmate provide a service he is not paid for, while others, such as Angola, limit the participation that can be provided by paid workers. Also, some institutions have difficulty finding jobs for their inmates while others have more jobs available than they have inmates to fill them.

A point to remember is that if there is no obvious secondary gain (like money) for assisting with the program, you may find that the volunteers participate for the right reasons. But again, there are very successful models that make strong arguments for tangibly rewarding their volunteers.

• your volunteers will meet for discussion and to receive instructions (we meet monthly);
• ongoing education will be provided (a good time to do this is at volunteer meetings);
• you will review each volunteer’s continued participation(yearly is sufficient).

I encourage staff at other prisons to network with other institutions throughout the country. There are many different models to emulate. Finding an existing model that will exactly meet the needs of your institution will not be possible. Careful consideration and trial-and-error will establish a volunteer program which meets the unique needs of your institution and the inmates you care for. The National Prison Hospice Association and Volunteers of America can help you contact other institutions for a more comprehensive look at end-of-life care in prisons. [See Resources and Tools page for links to these organizations’ websites.]

Featured Innovator, Tanya Tillman, RN, hospice case manager and inmate volunteer coordinator at the Louisiana State Penitentiary Hospice Program in Angola, Louisiana developed these guidelines. Feel free to contact her for further information by posting a comment to the online discussion, or after June 1, 2000, by calling her directly at 225-655-2266 or (2262).

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