Surviving a Large Scale Organized Hunger Strike at your institution

1. Surviving a Large Scale Organized Hunger Strike at your institution California Correctional Health Care Services 2011

2. Authors Have No Conflict of Interest Disclosures Alan Frueh MD Bonnie Gieschen MD Linda Maclachlan Pharm.D Jane Robinson RN Rebecca Yager RD John Zweifler MD Douglas Peterson MD

3. Objectives • Distinguish between the handling of an individual hunger strike and a mass hunger strike. • Describe the pathophysiology, stages, and risks of starvation. • Stratify the risk of refeeding and prescribe an appropriate refeeding diet.

4. Outline • CCHCS Policy Highlights • How it usually works • Challenges of a Mass Hunger Strike • What we knew and expected-July 2011 • HS 1-July 1-July 21, 2011 • Lessons learned • Mass Hunger Strike Policy • HS 2 September 26-October 14, 2011 • Starvation and Refeeding Syndrome • Stages of Hunger and Starvation • Refeeding • Risk Stratification • Clinical Guidance

5. CCHCS Policy Highlights

6. CCHCS Medical Services Program P & P: Hunger Strike PolicyChapter 22 (2006)

7. CCHCS Medical Services Program P & P: Hunger Strike PolicyChapter 22 (2006) • Front loaded with work • Intense utilization of resources before most P/I experience adverse effects • Inefficient, but manageable for sporadic strikers who are more likely to: • Have mental health issues • Have individual goals or grievances • Respond to early and intense interventions by healthcare and custody.

8. Challenges of a Mass Hunger Strike

9. CCHCS Medical Services Program P & P: Hunger Strike PolicyChapter 22 (2006) Existing policy poorly adapted to a mass hunger strike which is likely to: • Have large numbers of participants • Be politically motivated • Less likely participant has mental health condition contributing to strike • Be organized/pre-planned (food storage) • Be pre-announced

10. What we knew and expectedJuly 2011 • Strike rumors circulated in June 2011 • CDCR Intelligence expected: • 1000+ strike participants at Pelican Bay State Prison • Unknown numbers at CSP Corcoran

11. Limitations with existing policy: • CCHCS medical leadership recognized the limitations of existing policy and the difficulties it created: • How todoRN face-face assessments within 2 days • How to do full RN daily assessments thereafter • How to determine which participants are high risk • How to have PCP evaluation within 72 hrs and order labs • How to have Mental Health see every participant • How to keep track of this many participants

12. Limitations with existing policy: • Initial plans • Follow policy whenever possible • Fallback to declaring Emergency and following Emergency Incident Command System if needed

13. HS 1: July 1-July 21, 2011 • First day 6553 participants • 16 sites • Maximum 9,079 participants • Challenge was much greater than anticipated

14. July 2011 Strike: Number of participants by Institution (Does not include Out of State)

15. Experience July 1-July 21, 2011 • Due to large numbers of refusals staff was generally able to follow policy in spite of the large number of strike participants • Of the 9079 participants only 143 were deemed Persistent Hunger Strikers defined as: • Actively striking > 2 weeks and • Had a beginning wt and > one wt recorded during strike • Only 8 participants had weight loss > 15 lbs

16. July Strike: Outcome Weight Loss • Note >7700 participants never had a weight done (refused) • Custody did not clear or restrict canteen during HS 1

17. July Strike: Outcome Admissions • 37 admissions out of 9079 participants • 1/3 of these appeared related to lack of intake • Most were “Persistent Hunger Strikers” • Except for one patient inmate at PBSP, there was no evidence of refeeding problems at 3 wks.

18. Lessons learned from HS 1 • Routine labs are not supported by available data: • Especially electrolytes in the first 3 wks • Glucose (mild hypoglycemia) can be done by FS • UA (does not change management) • Labs may remain normal until refeeding begins

19. Lessons learned from HS 1 • Existing Policy not appropriate for a mass event • Need a policy covering a large scale strike • Identify, evaluate and follow high risk participants (underlying illness, meds, underweight etc.) • Institution/provider high risk patient lists • Clinically Complex Registry. • UHR • Mental Health Tracking System for MH patients. • Clinical assessments safely delayed until participant has lost 5% body weight (except for high risk persons)

20. Lessons learned from HS 1 • Baseline/periodic weights useful if can be obtained: • Participants status –risk of adverse events • Predicting risk of refeeding (Daily weights are not necessary) • The large majority of participants refused weights AND evaluations. • Close clinical observation needed for the participants who refuse weight and exam

21. Lessons learned from HS 1 • Routine, early AD/POLST completion not useful • Time consuming • Many participants refused • Those who completed chose full resuscitation and Rx • Appropriate for participants who have lost significant weight and are at higher risk. • Participants need education on responsibility to notify staff of need for health care • Participants need education on risks of starvation and refeeding. • Patient education hand-outs • Documentation of informed consent/effective communication once weight loss documented.

24. Lessons learned from HS 1 • Institutions need to stock up on supplies and equipment : • Scales (mark them, digital if possible), BP cuffs • Oral and intravenous rehydration supplies • MVI, thiamine (oral and IV or IM) • Pre-printed documentation templates • .

25. Lessons learned from HS 1 • Literature based clinical guidance useful for staff • Role of vitamins/mineral supplements • Assessment of risk/management of refeeding • Share with ED doc’s if participant transferred out • Communication and tracking issues: • Daily manual tracking + large # of participants = errors • Participants start and stop eating • Recognize data limitations due to refusals and initial collection and recording errors do not allow firm conclusions

26. Mass Organized Hunger Strike Policy

27. HS 2: Sept. 26-Oct. 17, 2011 Custody had different approach: • Treated HS 2 as a “disturbance” • Separated HS leaders from rest of population • Removed food and canteen items from identified participants’ cells • Disallowed canteen privileges (except for hygiene items) for participants • Coordinated tracking with medical via SharePoint site.

28. HS 2: Experience with new policy • High numbers but: • Resources focused more appropriately • Improved organization and communication • Less staff and leadership stress and fatigue

29. HS 2: Experience with new policy

30. HS 2: Experience with new policy • Weight loss: HS 1 vs HS 2

31. HS 2: Experience with new policy • Larger numbers of weights recorded probably due to: • Greater number of inmates consenting to being weighed • Improved tracking on the SharePoint • Increased weight loss could be due to: • More weights taken • Participants did not have access to stored food this time • No deaths or serious morbidity occurred

32. Lessons learned-HS 2 • Continue to improve shared tracking • Removal/restriction of canteen helpful • Dis-incentive to participants • More certain of actual intake, clinically more predicable • Mass HS Policy needs improvement • How best to monitor large #’s of participants • Time vs Weight vs Both? Regular direct observation of refusers? • How best to manage starvation- when start vitamins? • How best to address refeeding • Determine risk and control initial intake Institution and HQ meeting to revise… stay tuned…

33. Starvation and Refeeding Syndrome

34. Effects of Malnutrition

35. Stages of Hunger Strike • 4-7 days • Muscle protein  metabolized to glucose • Depletion of K+ Phos, Mg++ • 8-14 days • Risk of refeeding syndrome begins Day 10 • 1-3 days • Use up glycogen

36. Stages of Hunger Strike • 35-42 d • “oculo-motor “ • nystagmus • diplopia • trouble swallowing • extreme vertigo • vomiting • converging strabismus • > 42 days • Loss of > 30% body wt life-threatening • increased confusion • trouble concentrating • somnolent state • incoherent • arrhythmias • 15-18 d • ataxia • difficulty standing • bradycardia • orthostasis • “mental sluggishness” • sensation of cold • weakness

37. Clinical Interventions- Early Initiate applicable CCHCS Hunger Strike Policy • Baseline weight (same scale/digital if possible) • Identify high risk participants • Refer as appropriate to Mental Health • Review medication lists • Stop nonessential mediations • Stop antacids (interfere with phosphate absorption) • Stop diuretics if possible • Offer educational information • Document refusals

38. Clinical Interventions • Offer patients: • Thiamine 100 mg po daily • B complex 1 po daily • Multi-vitamin (e.g. Tab-a-vite) one po daily • Encourage 1.5L or more /day fluid intake • Watch more closely if refusing fluids • If clinically significant dehydration offer: • Oral rehydration Pedialyte- (IV only if refuses) • Symptomatic hypoglycemia treat as clinically indicated: • Food, LNS, Glucose gel, D50 IV • Fall precautions • Before voluntary refeeding assess risk

39. Refeeding Syndrome Definition: • Wide spectrum of biochemical abnormalities and clinical consequences • Hypophosphatemia is the adopted surrogate marker but not pathognomonic.

40. Refeeding Syndrome Physiology • When a malnourished person begins to eat: • Glucose enters blood How to recognize and respond to refeeding syndrome: Yantis, Mary Ann; Velander, Robyn Nursing2011 Critical Care. 4(3):14-20, May 2009. • Insulin follows • Glucose takes K+, P, Mg++ into the cells • Increased demand for thiamine (cofactor cellular enzymatic reactions)

41. Refeeding Syndrome Clinical Manifestations: • Symptoms: • Unpredictable • Deterioration can be rapid • May occur late. • Variable • Mild derangements may have no symptoms. • Spectrum: N/V, lethargyrespiratory insufficiency, cardiac failure, hypotension, arrhythmias, delirium, coma death.

42. Evaluation and Management Clinical Evaluation: • Screening exam, review medications • Risk assessment based on: • BMI, wt loss , length of fasting • What if no baseline weight? • ECG (if irregular pulse, abnormal HR, ↓ K+or Phos) • If cardiac abnormalities-monitoring recommended

43. Evaluation and Management Clinical Evaluation: (cont) • Labs: • Baseline Phos +, Mg + +, Ca + +, K +, Na +, urea, Cr before refeeding • During refeeding monitor electrolytes daily (as indicated based upon refeeding risk assessment) • Life-threatening changes usually seen in the first 3 days • Watch fluid intake/output and weight • If gain > ½ lb per day or 3.3 lbs/wk likely fluid retention

44. Risk Stratification: adapted from

45. Risk Stratification

46. Refeeding Guidance adapted…

47. Refeeding Risk- Modest

48. Refeeding with “Food”

49. Refeeding Risk- High

50. Refeeding Risk- Extreme