Évolution et surveillance des patients grévistes de la faim : expérience d’une unité hospitalière sécurisée interrégionale

[Interregional secure hospital units in the somatic care system for prisoners]

The mission of the inter-regional secure hospital units is to care for incarcerated prisoners. There are eight of them in metropolitan France, one in each prison region. They are jointly managed by the health establishments for care and by the prison administration for security. Each prisoner receives care equivalent to that provided to the rest of the population.

Between Sympathy, Fascination, and Powerlessness. The Experiences of Health Professionals During the Medical Monitoring of a Hunger Strike Among Undocumented Migrants

In 2014, a group of undocumented migrants started a hunger strike in Brussels. The medical monitoring was mainly done by young, committed health professionals with no prior experience of medical monitoring of people on hunger strike. Following the hunger strike, two focus groups were organized to assess the experiences of the health professionals during the medical monitoring of the hunger strike. Their main motivation for assisting was wanting to help the people on hunger strike but they were also curious about the living conditions among undocumented migrants and the reasons behind starting the strike. They were puzzled by the paradox of hunger strikers putting their life at risk in order to get a better life and obtain a residence permit. They felt conflicted about their own role as a caregiver: they did not know how to deal with patients who did not comply with medical advice, they struggled to build a relationship of mutual trust and feared that they would end up being instrumentalized by the hunger strikers or their environment. Afterwards, some of the health professionals were deeply touched by the experience and there were reports of symptoms of secondary traumatic stress such as re-experiencing and avoidance. During the focus group's discussions, the respondents made suggestions on how to improve the medical monitoring in the event of any future hunger strikes.

Hunger strike in prison: medical, ethical and legal aspects

BACKGROUND

A hunger strike is a common form of protest in prison and is a potential cause of many types of problems, both for facility administrators and health care staff. Issues of conflict of rights and obligations involved, and how to treat people who are subject, have created major controversies.

OBJECTIVES

To identify and review published studies that discuss the medical, ethical and legal considerations of managing a hunger strike in a prison setting from a physician's perspective.

METHODS

A database search using "Medline" "Ovid" and "Science Direct was conducted to identify relevant publications. We included case series, guidelines and, review articles.

RESULTS

The physician must clearly inform the striker of the risks and provide clinical assessment and regular monitoring of the concerned. The role of the psychiatrist is to detect an initial mental pathology underlying or secondary to fasting and assess the capacity of the striker's judgment. Thus, the clinician is faced with two paradoxical obligations: to assist and respect the striker's will. In addition, medical intervention is possible if the prognosis is life-threatening even without the patient's consent.

CONCLUSION

The current practice of non-consensual attitude among hunger-striking seeking in detention needs a closer inquiry. Medical practitioners should be aware of their ethical and legal responsibilities, and that they should act independently of government or institutional interests.

Security Hunger-Strike Prisoners in the Emergency Department: Physiological and Laboratory Findings

BACKGROUND

Medical treatment of hunger-strike patients, especially those in incarceration facilities, may pose clinical and treatment challenges for the treating physicians.

OBJECTIVE

The aim of our study is to describe the epidemiology and clinical and laboratory characteristics of hunger-strike prisoners presenting to the emergency department (ED) and to describe etiologies of hospitalization and complications among this group.

METHOD

We retrospectively examined clinical and laboratory manifestations of 50 hunger-strike prisoners who were referred for evaluation to the ED after a longstanding fast.

RESULTS

After a mean of 38 (28-44) days of a hunger strike, the most common complaints were chest pain and abdominal pain (14/60 [23.3%], 13/60 [21.6%], respectively). Mean weight loss percentage was 18.5%, and most patients were bradycardic (25/40 [62.5%]), and some hypothermic (16/50, [32%]). We describe several laboratory disturbances observed in these patients; leukopenia was the most common hematologic manifestation (31/50 [62%]), and a prolonged international normalized ratio was observed in 12/29 (41.3%) patients. We hospitalized 12% of the patients; the most common hospitalization cause was bradycardia (3/6 [50%]).

CONCLUSIONS

Our study found that the most common clinical symptom was chest pain, which has not been previously reported among hunger strikers. We observed a substantial number of laboratory disturbances due to muscle wasting and protein loss and due to presumed vitamin and micronutrient deficiencies. We suggest monitoring electrocardiograms for heart rate, blood count, chemistry, coagulation tests, and vitamin levels.

Serum Albumin and Prealbumin in Calorically Restricted, Nondiseased Individuals: A Systematic Review

PURPOSE

Undernutrition is often suspected in patients when serum albumin or prealbumin levels are low. We asked whether these measures are indeed low in undernourished people if no inflammatory illness is present.

METHODS

We did a systematic review to identify otherwise healthy subjects who were severely nutrient-deprived due to poor access to food or unwillingness to eat. We excluded children and pregnant women. We tabulated available measures of nutrient intake, anthropometry, serum albumin and prealbumin, and, when available, changes in these measures during nutritional intervention.

RESULTS

In otherwise healthy subjects, serum albumin and prealbumin levels remained normal despite marked nutrient deprivation until the extremes of starvation, that is, body mass index <12 or more than 6 weeks of starvation.

CONCLUSIONS

In these otherwise healthy subjects, serum albumin and prealbumin levels are not "markers of nutritional status." The "markers" failed to identify subjects with severe protein-calorie malnutrition until extreme starvation. That is, they failed to identify healthy individuals who would benefit from nutrition support, becoming abnormal only when starvation was already obvious. In contrast, serum albumin and prealbumin levels are known to fall promptly with injury or illness regardless of nutrient intake. They are negative acute-phase reactants. When these measures are low in sick patients, this cannot be assumed to reflect nutritional deprivation. Decisions about nutrition support should be based on evidence of meaningful benefit from this treatment rather than on assessment of "nutritional markers."

Episodes of voluntary total fasting (hunger strike) in Spanish prisons: A descriptive analysis

OBJECTIVE

To provide a description of the frequency and main features of the episodes of voluntary total fasting (VTF) taking place in Spanish prisons.

MATERIAL AND METHODS

Information on the episodes of VTF reported between 04/01/2013 and 03/31/2014 was gathered. Once the appropriate informed consent was given, other data on social, demographic, penitentiary and clinical aspects were collected. A descriptive study of such variables together with a bivariate analysis was then carried out by means of standard statistical techniques and binary logistic regression models. IBM SPSS Statistics v.20 software was used for this purpose. This study was approved by an accredited Clinical Research Ethics Committee.

RESULTS

354 episodes of VTF took place among an average population of 29,762 prisoners. Therefore, the incidence rate was 11.9 VTF episodes per ‰ inmates-year. Informed consent (IC) was given in 180 cases (50.8%). 114 were of Spanish nationality and the average age was 38.7 years old (95% CI 37.2-40.1). The median duration of the episodes was 3 days (IQR 1-10), ranged between 1 and 71 days. The main reason was a disagreement on the decisions of treatment groups (57 cases, 31.7%). The average weight loss was 1.3 kg (70.8 vs. 69.5; p < 0.0001) and 0.7 of the BMI (24.5 vs. 23.8; p < 0.0001). 60 prisoners (33.3%) lost no weight at all and only 8 (4.4%) lost over 12% of the basal weight (8.5 kg). Ketone smell was identified in 61 cases (33.9%) and ketonuria in 63 (35%).

CONCLUSIONS

Only one third of those who go on hunger strike in prison actually fast. Revindicative episodes of voluntary total fasting are somewhat common in Spanish prisons, but rarely are they carried out rigorously and entail a risk for those who fast.