"We Take Care of Patients, but We Don't Advocate for Them": Advance Care Planning in Prison or Jail

Perceptions and experiences of clinicians and correctional officers facilitating palliative care for people in prison: A systematic review and meta-synthesis

BACKGROUND

As the number of people ageing in prison with complex healthcare needs continues to increase, so does the need for palliative care in the restrictive prison context. Palliative care for people in prison is facilitated by correctional officers, and prison- and hospital-based clinicians. A collective analysis of existing research to identify common experiences of these stakeholders globally has not been completed.

AIM

To explore the perceptions and experiences of correctional officers and prison- and hospital-based clinicians who facilitate palliative care for people in prison.

DESIGN

A systematic review and meta-synthesis.

DATA SOURCES

Keywords and subject headings related to palliative care and prisons were used to search seven databases with no time limitations. Peer-reviewed research in English, containing qualitative data from stakeholders facilitating palliative care for people in prison were included, and appraised using the CASP tool.

RESULTS

Two analytical themes emerged: (i) a prison lens on a palliative approach and (ii) coping complexities. Palliative care is 'translated' into the prison setting according to security and environmental constraints. Stakeholders experienced ethical, personal and professional difficulties, because prison-based palliative care did not align with community norms. Ambiguous policy and expectations regarding prioritising care needs and balancing custodial rules led to role stress.

CONCLUSIONS

Providing palliative care for people in prison is complex and impacts stakeholders and people in prison with palliative care needs. Supporting person-centred care through a multi-service approach, stakeholder education and standards will improve the quality and accessibility of care.

A Survey of State Correctional Health Care Providers on Advance Care Planning: Opportunity for Collaboration With Corrections

Prison populations are rapidly aging. Persons in prison age quicker and suffer more chronic illness and disability than their nonincarcerated peers, posing challenges to caring for prisoners who are chronically ill and dying. The goal of our study was to describe state prisons' practices and policies addressing persons in prison with advanced chronic and life limiting illness through a national web-based survey of state-level prison health care professionals. In particular, we focused on advanced care planning, use of health care directives, decision-making about goals of care, including life sustaining treatments, The response rate was 22% for a sample size 152 completed surveys. The average age of respondent was 52 years; majority were female and Caucasian, and had worked in corrections more than 8 years. Nearly half were registered nurses. Most reported their prison did not have a dedicated end-of-life care program and only 11% offered a peer-care program. However, two-thirds indicated their facility provided the opportunity to designate a health care agent with physicians most likely responsible for facilitating completion of a health care directive. It is evident the care of persons aging and dying in prison is complex and requires further investigation addressing staff and prison population education, ethics guidelines for care, compassionate release, and advance care planning. This study suggests that hospice and palliative care professionals could collaborate with corrections professionals and national organizations to provide innovative education and support to enhance the humane care of this vulnerable population.

Advance Care Planning: Perspectives of People Living in Prison

A person-centered approach to advance care planning is recognized as a fundamental need, yet its routine implementation remains a challenge across disparate settings, such as prisons. The purpose of this study was to gain the perspectives of people who are incarcerated about advance care planning. Four focus groups were conducted with people living in 1 men's and 1 women's state prison (n = 26). Handwritten field notes were taken, transcribed, deidentified, and verified before the completion of independent thematic analysis by 2 experienced qualitative researchers. Key themes regarding advance care planning were identified: components of advance care planning, initiation and continuation of advance care planning, barriers to implementing advance care planning, and facilitators to implementing advance care planning. Participants noted several key components related to the name, structure, and content of advance care planning programs. Insights about who should initiate the conversation, when to continue the conversation, and how to deliver education about advance care planning were obtained. Findings contribute to identifying best practices for infusing advance care planning into prisons. Best practices will inform the development of a toolkit of contextually relevant, person-centered approaches to advance care planning that are tailored to meet the unique needs of people who are incarcerated.

Clinical Ethics Consultation for Patients Impacted by Incarceration: A Single Center Retrospective Review

Health care professionals and patients impacted by incarceration face unique medical, legal, and ethical issues. The frequency and nature of ethics consultations for these patients are underexplored. This study aimed to characterize the primary ethical issue and contextual features of ethics consultations involving patients impacted by incarceration. We conducted a qualitative concept content analysis of ethics consultations involving patients impacted by incarceration and calculated descriptive statistics of demographics to compare these patients with the broader population of patients impacted by incarceration at a single institution from January 1, 2015, through June 30, 2022. We identified 37,184 patients impacted by incarceration (people currently or formerly incarcerated or whose surrogate decision-maker is incarcerated) at our institution. Most were White (70%) and non-Hispanic (88%); 51% were male, 49% female. Individuals impacted by incarceration comprised 3% (n = 38) of ethics consults. Most were White (58%), male (79%), and hospitalized (92%). The primary ethical issues were surrogate decision-making (34%) and fiduciary duties (beneficence/nonmaleficence/best interest; 16%). The primary contextual feature was intra-family communication challenges (37%). Incarceration status impacts access to decision-makers and the provision of medically necessary care. Ethics consultation for women and individuals in outpatient and emergency settings could be underutilized. More education about ethics consultation services and coordination with correctional officials is recommended.

End-of-Life Care Planning: Perspectives of Returning Citizens

Demographic shifts toward an older and sicker prison population present challenges for corrections leaders and incarcerated people. The priority of custody and control over care in prisons can deprive people of a modicum of autonomy even about expressing their end-of-life wishes. This study was undertaken to inform best practices and identify essential components of end-of-life care planning (EOLCP) for people who will likely die incarcerated. Individual interviews with formerly incarcerated people (n = 16) provided insights on EOLCP knowledge, perceptions, and future plans as each reflected on experiences while incarcerated. Zoom Video Communications were used for the interviews, and audio recordings were transcribed verbatim, verified, and deidentified prior to thematic analysis. Themes were defined and discussed until consensus was reached between the 2 researchers. End-of-life care planning themes included the following: understanding of and experience with advanced directives/care planning (AD/ACP), defining AD/ACP, timing of AD/ACP accessibility to health care resources, how to approach EOLCP in prison, advantages of EOLCP, and barriers to EOLCP. Formerly incarcerated peoples' knowledge, perceptions, and future plans revealed important considerations when developing a contextually relevant toolkit for EOLCP for people living in prison.

Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned

Background

The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice.

Methods

We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus.

Results

From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems.

Conclusion

The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.

Death in Prison: increasing transparency on next of kin notification and disposition of remains

BACKGROUND

Policies for next-of-kin (NOK) notification and disposition of remains surrounding death are unclear across the United States' (US) carceral systems. The goal of this study was to collect data on carceral system policies pertaining to NOK notification and disposition of remains for individuals who are incarcerated. We collected publicly available operational policies for the Federal Bureau of Prisons, Immigration and Customs Enforcement, 50 state prison systems, and the Washington D.C. jail for a total of 53 systems.

RESULTS

Approximately 70% of systems had available policies on NOK notification and disposition of remains. Few systems had information on time constraints for NOK notification, notifying parties or designated contacts person, and ultimate disposition of unclaimed remains. Several systems had no accessible policies.

CONCLUSIONS

Across the US, carceral systems vary in policies for notifying NOK after the death of an incarcerated individual and their processes for the disposition of remains. Carceral and health systems should work towards standardization of policies on communication and disposition of remains after death of an individual who is incarcerated to work towards equity.

Public Health and Prisons: Priorities in the Age of Mass Incarceration

Mass incarceration is a sociostructural driver of profound health inequalities in the United States. The political and economic forces underpinning mass incarceration are deeply rooted in centuries of the enslavement of people of African descent and the genocide and displacement of Indigenous people and is inextricably connected to labor exploitation, racial discrimination, the criminalization of immigration, and behavioral health problems such as mental illness and substance use disorders. This article focuses on major public health crises and advances in state and federal prisons and discusses a range of practical strategies for health scholars, practitioners, and activists to promote the health and dignity of incarcerated people. It begins by summarizing the historical and sociostructural factors that have led to mass incarceration in the United States. It then describes the ways in which prison conditions create or worsen chronic, communicable, and behavioral health conditions, while highlighting priority areas for public health research and intervention to improve the health of incarcerated people, including decarceral solutions that can profoundly minimize-and perhaps one day help abolish-the use of prisons.

End of Life: What Is the Anesthesiologist's Role?

Anesthesiologists receive extensive training in the area of perioperative care and the specialized skills required to maintain life during surgery and complex procedures. Integrated into almost every facet of contemporary medicine, they interact with patients at multiple stages of their health care journeys. While traditionally thought of as the doctors best equipped to save lives, they may also be some of the best doctors to help navigate the chapters at the end of life. Successfully navigating end-of-life care, particularly in the COVID-19 era, is a complicated task. Competing ethical principles of autonomy and nonmaleficence may often be encountered as sophisticated medical technologies offer the promise of extending life longer than ever before seen. From encouraging patients to actively engage in advance care planning, normalizing the conversations around the end of life, employing our skills to relieve pain and suffering associated with dying, and using our empathy and communication skills to also care for the families of dying patients, there are many ways for the anesthesiologist to elevate the care provided at the end of life. The aim of this article is to review the existing literature on the role of the anesthesiologist in end-of-life care, as well as to encourage future development of our specialty in this area.

A systematic literature review exploring the psychosocial aspects of palliative care provision for incarcerated persons: a human rights perspective

PURPOSE

The purpose of this study is to explore the psychosocial aspects of palliative care provision for incarcerated persons drawing on a human rights perspective.

DESIGN/METHODOLOGY/APPROACH

Seven databases were searched to identify empirical studies published from 2010 to 2020. Articles included were qualitative, quantitative, mixed methods, written in English and with westernised health/prison settings, with a key focus on the psychosocial aspects of palliative care provision and human rights. The quality of the articles was appraised using the Mixed Methods Assessment Tool (2018).

FINDINGS

The results from 26 articles revealed multiple models of care, with the US prison hospice program depicted as optimal, because of the use of trained incarcerated caregivers, working as aides to the interprofessional team. The bereavement needs of caregivers were highlighted. The barriers to adequate psychosocial care were negative public discourse, prison processes and resources, provider attitudes and the incarcerated person's level of knowledge and trust. Identified facilitators were related to incarcerated persons' caregiving programs, a sense of purpose and visitation leniency. Human rights principles were identified in studies that featured compassionate release and advance care planning.

RESEARCH LIMITATIONS/IMPLICATIONS

There is inconsistency in the literature regarding what constitutes psychosocial care, which meant that the authors needed to draw on multiple literature sources to formulate a definition. Additionally, the review only included studies written in English, meaning some high-quality studies could have been missed. The articles that conducted interviews with incarcerated individuals were undertaken in male prisons only and not female prisons.

PRACTICAL IMPLICATIONS

Understanding the importance of psychosocial care for incarcerated persons with a life-limiting illness requires a shift in negative public discourse and the need for a stronger human rights focus. Some countries, such as the USA and UK, are achieving effective outcomes; however, countries such as Australia are yet to contribute to this knowledge base.

ORIGINALITY/VALUE

If palliative care is a human right, then its philosophy should be considered in its entirety, with the inclusion of psychosocial care.

Stakeholder-engaged research is necessary across the criminal-legal spectrum

People with lived experience of incarceration have higher rates of morbidity and mortality compared to people without history of incarceration. Research conducted unethically in prisons and jails led to increased scrutiny of research to ensure the needs of those studied are protected. One consequence of increased restrictions on research with criminal-legal involved populations is reluctance to engage in research evaluations of healthcare for people who are incarcerated and people who have lived experience of incarceration. Ethical research can be done in partnership with people with lived experience of incarceration and other key stakeholders and should be encouraged. In this article, we describe how stakeholder engagement can be accomplished in this setting, and further, how such engagement leads to impactful research that can be disseminated and implemented across disciplines and communities. The goal is to build trust across the spectrum of people who work, live in, or are impacted by the criminal-legal system, with the purpose of moving toward health equity.

Advance care planning at life milestones

Much progress has been made in advance care planning (ACP), especially related to end of life and palliative care. These advances have moved thinking about ACP from a checklist approach to an upstream recognition that ACP is an iterative process that should begin early in adulthood and be revisited with each milestone or life-changing event. It is recognized that there are many stages and milestones in adult life that contribute to changing loci of responsibility and life goals. These changes impact how individuals view their lives, the complexity of health care, and the myriad of health conditions they may encounter. ACP discussions should routinely be started and reexamined at the time of key life events like starting a career or a marriage and not delayed until hospitalization, the occurrence of a serious accident, or the development of a catastrophic illness.

Advance care planning ahead of life-altering clinical deterioration in secure settings: Do not wait until a crisis

All professionals involved in someone's care should be equipped to support individuals, and the people close to them, to understand how their health is likely to change, consider the burdens and likely outcomes of treatment options and make realistic, informed recommendations to guide future care. This can be particularly challenging in forensic mental health, when it covers cardiopulmonary resuscitation alongside recommendations about acute hospital admission and medical escalation within and outside of hospital settings. Some clinicians question whether or not the harms of raising the spectre of invasive ventilation and potential mortality risks unnecessary anxiety and psychological harm amongst detained patients. Instead, we argue that timely advance care and treatment escalation planning with each patient, informed by psychiatric clinicians, is long overdue.

Care for Incarcerated Patients Hospitalized with COVID-19

The COVID-19 pandemic has reshaped health care delivery for all patients but has distinctly affected the most marginalized people in society. Incarcerated patients are both more likely to be infected and more likely to die from COVID-19. There is a paucity of guidance for the care of incarcerated patients hospitalized with COVID-19. This article will discuss how patient privacy, adequate communication, and advance care planning are rights that incarcerated patients may not experience during this pandemic. We highlight the role of compassionate release and note how COVID-19 may affect this prospect. A number of pragmatic recommendations are made to attenuate the discrepancy in hospital care experienced by those admitted from prisons and jails. Physicians must be familiar with the relevant hospital policies, be prepared to adapt their practices in order to overcome barriers to care, such as continuous shackling, and advocate to change these policies when they conflict with patient care. Stigma, isolation, and concerns over staff safety are shared experiences for COVID-19 and incarcerated patients, but incarcerated patients have been experiencing this treatment long before the current pandemic. It is crucial that the internist demand the equitable care that we seek for all our patients.

Providing Ethical and Humane Care to Hospitalized, Incarcerated Patients With COVID-19

The COVID-19 pandemic is devastating the health of hundreds of thousands of people who live and work in U.S. jails and prisons. Due to dozens of large outbreaks in correctional facilities, tens of thousands of seriously ill incarcerated people are receiving medical care in the community hospital setting. Yet community clinicians often have little knowledge of the basic rights and ethical principles governing care of seriously ill incarcerated patients. Such patients are legally entitled to make their own medical decisions just like non-incarcerated patients, and retain rights to appoint surrogate decision makers and make advance care plans. Wardens, correctional officers, and prison health care professionals should not make medical decisions for incarcerated patients and should not be asked to do so. Dying incarcerated patients should be offered goodbye visits with their loved ones, and patients from federal prisons are legally entitled to them. Community health care professionals may need to advocate for this medically vulnerable hospitalized patient population to receive ethically appropriate, humane care when under their care in community hospitals. If ethical care is being obstructed, community health care professionals should contact the prison’s warden and medical director to explain their concerns and ask questions. If necessary, community clinicians should involve a hospital’s ethics committee, leadership, and legal counsel. Correctional medicine experts and legal advocates for incarcerated people can also help community clinicians safeguard the rights of incarcerated patients.

Prisons and COVID-19: A Desperate Call for Gerontological Expertise in Correctional Health Care

The large and continued growth of the older adult population within U.S. prisons affects not only criminal justice policy and correctional health practice, but also gerontology. Amidst the unfolding COVID-19 crisis, associated knowledge and skills surrounding older adulthood will be critical to assuring the needs of older adults incarcerated in prisons are met during their detention, while undergoing off-site intervention in community settings, and when preparing for release. We outline several key areas for which gerontologists and associated practitioners are especially well suited in the effort to curtail morbidity and mortality driven by the disease caused by the novel coronavirus. Critical gerontological knowledge and skills needed in prison health care include awareness regarding the unusual clinical presentations of COVID-19 among older adults, deconditioning among older adults due to immobility, challenges in prognostication, and advance care planning with older adults. Specific, targeted opportunities for gerontologists are identified to reduce growing risks for older adults incarcerated in prisons.

Advance care planning in Asian culture

Ageing has been recognized as one of the most critically important health-care issues worldwide. It is relevant to Asia, where the increasing number of older populations has drawn attention to the paramount need for health-care investment, particularly in end-of-life care. The advocacy of advance care planning is a mean to honor patient autonomy. Since most East Asian countries are influenced by Confucianism and the concept of 'filial piety,' patient autonomy is consequently subordinate to family values and physician authority. The dominance from family members and physicians during a patient's end-of-life decision-making is recognized as a cultural feature in Asia. Physicians often disclose the patient's poor prognosis and corresponding treatment options to the male, family member rather to the patient him/herself. In order to address this ethical and practical dilemma, the concept of 'relational autonomy' and the collectivism paradigm might be ideally used to assist Asian people, especially older adults, to share their preferences on future care and decision-making on certain clinical situations with their families and important others. In this review article, we invited experts in end-of-life care from Hong Kong, Indonesia, Japan, South Korea, Singapore and Taiwan to briefly report the current status of advance care planning in each country from policy, legal and clinical perspectives. According to the Asian experiences, we have seen different models of advance care planning implementation. The Asian Delphi Taskforce for advance care planning is currently undertaken by six Asian countries and a more detailed, culturally sensitive whitepaper will be published in the near future.

Identifying barriers and facilitators to implementing advance care planning in prisons: a rapid literature review

BACKGROUND

Limited information is available describing advance care planning (ACP) within correctional facilities, despite its increasing relevance due to the ageing population in prisons and the high rates of complex medical comorbidities. In Western countries, self-determination with respect to making future medical decisions is a human right that prisoners do not lose when they are remanded into custody. ACP enables individuals to plan for their health and personal care so their values, beliefs and preferences are made known to inform future decision-making, for a time when they can no longer communicate their decisions. This paper examines the limited academic literature relating to ACP within prisons to identify barriers and facilitators that influence the uptake of ACP and advance care directive (ACD) documentation. Common themes related to ACP in a correctional setting were extracted and synthesised to produce a high-level analysis of barriers and facilitators influencing ACP uptake for prisoners within a correctional setting.

RESULTS

Six articles met the selection criteria and reported on the experience of ACP and ACDs in prisons; five from the United States of America and one from Switzerland. Three dominant themes were identified, with related subthemes: system-level factors, attitudes and perceptions, and ACP knowledge and comprehension. Barriers to ACP and ACD implementation were more prominent in articles than facilitators.

CONCLUSIONS

Limited academic literature regarding the implementation and experience of ACP in prisons is available. The dominance of barriers identified in studies highlights key challenges for improving ACP uptake in correctional settings. Further research is required to understand the barriers, enablers, and attitudes to ACP in prisons.

Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review

BACKGROUND/OBJECTIVES

Advance care planning (ACP) has shown benefit in some, but not all, studies. It is important to understand the utility of ACP. We conducted a scoping review to identify promising interventions and outcomes.

DESIGN

Scoping review.

MEASUREMENTS

We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for ACP randomized controlled trials from January 1, 2010, to March 3, 2020. We used standardized Preferred Reporting Items for Systematic Review and Meta-Analyses methods to chart study characteristics, including a standardized ACP Outcome Framework: Process (e.g., readiness), Action (e.g., communication), Quality of Care (e.g., satisfaction), Health Status (e.g., anxiety), and Healthcare Utilization. Differences between arms of P < .05 were deemed positive.

RESULTS

Of 1,464 articles, 69 met eligibility; 94% were rated high quality. There were variable definitions, age criteria (≥18 to ≥80 years), diseases (e.g., dementia and cancer), and settings (e.g., outpatient and inpatient). Interventions included facilitated discussions (42%), video only (20%), interactive, multimedia (17%), written only (12%), and clinician training (9%). For written only, 75% of primary outcomes were positive, as were 69% for multimedia programs; 67% for facilitated discussions, 59% for video only, and 57% for clinician training. Overall, 72% of Process and 86% of Action outcomes were positive. For Quality of Care, 88% of outcomes were positive for patient-surrogate/clinician congruence, 100% for patients/surrogate/clinician satisfaction with communication, and 75% for surrogate satisfaction with patients' care, but not for goal concordance. For Health Status outcomes, 100% were positive for reducing surrogate/clinician distress, but not for patient quality of life. Healthcare Utilization data were mixed.

CONCLUSION

ACP is complex, and trial characteristics were heterogeneous. Outcomes for all ACP interventions were predominantly positive, as were Process and Action outcomes. Although some Quality of Care and Health Status outcomes were mixed, increased patient/surrogate satisfaction with communication and care and decreased surrogate/clinician distress were positive. Further research is needed to appropriately tailor interventions and outcomes for local contexts, set appropriate expectations of ACP outcomes, and standardize across studies.