Standards of Medical Care in Prisons: Legal Basis and Unique Challenges

1. Chapter 9 Health Care

2. Objectives • Appreciate the legal basis for standards of medical care within prisons • Identify the similarities and differences between community and correctional medicine and be familiar with unique end of life issues present in correctional environments • Explain the process of intake screening and the importance and exceptions of confidentiality

3. The Right to Health Care • Estelle v. Gamble – “any attempt to withhold or delay medical care constitutes cruel and unusual punishment” • Standard of competence is deliberate indifference • Standards of care in the community and correctional environment change constantly

4. Initial Screening • Upon arrival: • Overall health status? • Communicable disease risk factors? • Obvious signs of mental illness? • Medications? • Physical examination for pre-existing conditions? • Alcohol/drug abuse? • Reasons to necessitate separate housing?

5. Initial Screening (cont.) • Mental status and cooperation may reflect stress, frustration, disappointment • May feel insecure and/or be concerned for his/her safety • Plans for follow-up care should be made if chronic conditions are present • Initial screening interview may set the stage for inmate’s cooperation with medical personnel

6. Clinics and Sick Call • Inmate should understand procedure for sick call • Some institutions have instituted nominal inmate co-pay to prevent abuse • Should have continuity and teamwork so that the same staff care for the same inmates • Some conditions can be improved through patient education films, question and answer sessions, and counseling

7. Confidentiality • Medical record should be treated with same confidentiality as in the community • Can disclose medical information in limited circumstances: • Provision of healthcare to individual • Health and safety of inmate • Health and safety of staff • Health and safety of those transporting inmate

8. Medical Emergencies • Heart disease, stroke, peripheral vascular emergencies are common • Main function of staff in emergencies is: • Rapidly respond to scene • Stabilize the patient • Transport inmate to appropriate facility • Staff should be trained in CPR, advanced cardiac life support, and advanced trauma life support

9. Medical Emergencies (cont.) • Transportation should be done on stretcher or backboard • Security should be a high priority to prevent escape • Incident report should be written as soon as possible, including times, medication, and procedures administered

10. Medication • Prescription medication is commonplace among inmates • Cost is a major expense for correctional facilities • Good recordkeeping is essential • Team approach with frequent monitoring is best for pain medication • Correctional personnel can be helpful with observation of inmate activities

11. Medication (cont.) • Alcohol and drug abuse are major issues prior to incarceration and may continue to be problems within the facility • Need a comprehensive treatment approach • Correctional staff can assist in preventing the manufacture of “homemade” alcohol inside institution • Random urine monitoring program can also help manage substance abuse within the institution

12. Infection Control • Confinement lends itself to the spread of infectious organisms • Prior needle use predisposes inmates to infectious diseases • Incidence of HIV in prison populations is high • All personnel should have access to disposable gloves and CPR masks

13. Infection Control (cont.) • Each institution should have a routine testing policy for TB, hepatitis B, hepatitis C, and HIV • Treatment of HIV is expensive, time consuming, and complex • Medical and correctional staff should have yearly TB tests and should consider HIV tests as well

14. Unique Medical Situation • Use of Force • May be necessary to subdue or restrain an inmate who is a danger or threat • Medical staff should be present if possible and perform careful examination afterward • Fights or Riots • Need to have a plan to deal with disturbances and practice plan at regular intervals • Prior use of radio frequencies and transportation of injured persons will be difficult under actual circumstances

15. Unique Medical Situations (cont.) • Hostage Situations • Medical staff should prepare for their role in emergency management, triage, and transport • Hunger Strikes • Inmate should be in locked cell with water turned off • Frequent exams, including drawing blood electrolytes • Add IV fluids if strike persists

16. Eldercare • Aging inmate population is taking a toll on correctional institutions • More offenders are aging and dying in penal institutions • Older inmates require more medical attention, need special diets, and eventually will need geriatric services

17. End-of-Life Considerations • In-custody deaths might be due to natural or unnatural causes • Death by unnatural causes should always require an autopsy • Site of death should be treated as a potential crime scene • Living wills should be properly drawn and notarized as part of the inmate’s record

18. End-of-Life Considerations (cont.) • Hospice care exists in some facilities using trained inmates as volunteers • Multiple professional staff are often involved • Frank discussions should be held with families of the terminally ill, including arrangements for the body • Some facilities allow for compassionate release of those with terminal illness

19. Healthcare Professional as Correctional Officer • Communication among all professionals is essential to ensure a safe and effective workplace • Avoid tension among staff members by holding training sessions together • All health care staff should be familiar with the principles of security and custody

20. Conclusion • Changes in sentencing laws have resulted in an increase of prison populations • Need for well-trained health care professionals is great within the prison system • Access to health care within a correctional facility is a constitutional guarantee

21. Chapter 10 Mental Health

22. Objectives • Outline issues inherent in the provision of mental health care in the correctional setting • Determine if inmate participation in mental health care and treatment should be required • Explore the right to privacy with regard to mental health records

23. Introduction • Inattention to mental health needs of inmates can lead to management problems, negative publicity, and litigation • Deinstitutionalization of mental hospitals has greatly decreased numbers of mentally ill in institutions • However, those who do not properly manage their medication may commit crimes when their behavior deteriorates • Data suggests that there are more mentally ill people in prisons than in mental institutions

24. Guidelines and Standards • Incarcerated individuals have rights of access to and provision of health care • Crucial issue is to avoid deliberate indifference toward the mental health needs of the incarcerated population • Need adequate health facilities, a well-defined program structure, understandable written policy, and quality assurance program

25. Access to Care • Ruiz v. Estelle established 6 issues for minimally adequate standards: • System to insure mental health screening • Provision of treatment while inmates are in segregation or special housing • Training of mental health staff • Accurate and confidential medical record system • Suicide prevention program • Monitoring for appropriate use of psychotropic medication

26. Screening • Initial screening should be done on an individual basis by a provider trained in detecting mental disorders and interviewing techniques • Providers must persist in obtaining necessary information to adequately screen inmates • Goal of screening is to identify quickly emergency situations and inmates who might require more extensive interventions

27. Treatment and Followup Care • Variety of treatment settings: • Outpatient • Inpatient • Transitional/Intermediate • Some facilities use state mental health system • Goal of transitional care is usually to stabilize the inmate in a sheltered environment

28. Treatment and Followup Care (cont.) • Goal of treatment is eventual integration into the regular prison population and preparation for release • Discharge planning and followup care are crucial • Assessing dangerousness to self and others must be reviewed before discharge

29. Crisis Intervention • Short-term interventions to deal with acute mental distress • All staff should be familiar with suicide prevention • Suicide prevention program includes training on signs and symptoms of potentially suicidal inmates, availability of a safe environment for housing, constant observation

30. Issues Arising from Confinement • Stress of being incarcerated can add symptoms of mental illness that may not have existed at the initial screening • Stressors include: • Involvement in legal system • Separation from existing community support • Peer-generated problems • Loss of control and decision making • Ongoing assessment is crucial

31. Legal Requirements • Hospitalization is voluntary unless an inmate is a danger to himself or others • Civil commitment for inmates is the same as for nonprisoners • Inmate must give informed consent to any type of psychiatric treatment except emergency treatment or treatment allowed after involuntary commitment

32. Privacy • Same expectation of confidentiality as in a community health care setting • Information should only be shared on a need-to-know basis even among health care professionals • Internal policy should define members of the health care team • Inmates have the right to access their health record unless doing so would be detrimental

33. Dual Roles of Staff • Clinical staff may feel caught between their roles as caretakers and as correctional workers • Patients need to be advised that information cannot be kept confidential if it affects the security of the institution, potential harm to inmate or others, or concerns serious damage to property

34. Special Treatment Procedures • Use of seclusion or restraint requires close attention in correctional environment • Review system is needed to ensure that special procedures are only used as necessary and that inmate’s psychological needs are addressed • Must be assessed to ensure that circulation has not been compromised and that toileting, meals, and repositioning are accomplished as necessary

35. Medications • Medication prescription is a high risk area in correctional environment • Should be kept to a minimum • Sleep medication should be limited to acute situations • Medication compliance should be followed closely • Guard against polypharmacy • Close attention to side effects

36. Mental Illness • Antisocial personality disorder is diagnosed based on historical information • Criteria include pattern of disregard for others, criminal behavior, lying, impulsive, irresponsible, and aggressive behavior • Malingering is a behavior that involves an individual falsely claiming and consciously faking symptoms of an illness

37. Integration of Mental Health and Medical Care • Success for care delivery of mental health is related to adequacy of general medical services available in a prison • Significant number of psychiatric patients have concurrent mental illnesses

38. Conclusion • Few clinicians and other providers are trained during their professional education to work in correctional environments • Provision of adequate care constantly competes with maintaining adequate security • Correctional environment may be one of the last public strongholds for adequate care of seriously mentally ill

39. Chapter 11 Religious Programming

40. Objectives • Explore the role of prison chaplains and understand the challenges of providing religious programs in the correctional environment • Explain the major programs coordinated by prison chaplains and the available resources for religious programming • Describe the general legal framework within which prison religious programs operate

41. Historical Background • Religion has played a role in American corrections since the inception of penitentiaries • Earliest prison facilities were influenced by the Quaker belief that time away from society would change the hearts of offenders • Forced solitude caused emotional distress and mental illness for many early prisoners

42. Religious Accommodation and Freedom Legislation • First Amendment of Constitution – freedom of religion • Prison administrators can regulate religious practices in order to protect the security of the institution • Religious Freedom Restoration Act of 1993 – governments were prevented from interfering with individuals’ religious observances unless the interference was the least restrictive means of furthering a compelling government interest

43. Religious Accommodation and Freedom Legislation (cont.) • Religious Land Use and Institutionalized Persons Act of 2000 – prohibited the government from restricting prisoners’ religious worship opportunities unless the government can demonstrate that the restriction furthers a compelling government interest • Many corrections officials oppose these legislative initiatives for fear of lawsuits requesting religious accommodations

44. Religious Accommodation and Freedom Legislation (cont.) • In some states, inmate grievances have increased • All who work in a correctional environment should understand the impact of these laws • Cutter v. Wilkinson – inmates of small and unfamiliar religious groups won their appeal for the opportunity to meet for religious worship

45. Professional Standards • Professional standards require a balance between provision of religious programs and restriction of religious practices • Staff accommodate religious practices as long as the accommodation will not interfere with safety, security, and orderly operation of the institution • All religious programs must be voluntary

46. Professional Standards (cont.) • Religion should not be used as a tool for manipulation, nor should inmates be rewarded for participation • Chaplains are responsible for working with inmates of all faith groups • Rely on expertise of community religious leaders to complement the care and services they can provide

47. Role of Chaplains • Chaplain may serve as spiritual guide, preacher, teacher, dietitian, counselor, and advocate • Religious impact in institution depends on the unique pastoral manner in which the chaplain helps inmates • Gravest problem among religious service providers is that they lose sight of their role as correctional workers

48. Role of Chaplains (cont.) • Complexity of the multi-faith correctional environment requires a high level of professionalism to ensure that inmates of all faiths have the opportunity to benefit from religious programs • Integration of ministry and management is essential because of added dimension and challenges of ministry with an incarcerated congregation

49. Religious Pluralism • Chaplaincy corps should reflect accurately the beliefs of the inmate population • Religious issues outside of the chaplain’s expertise should be referred to qualified leaders in the community • Contract chaplains can be used as spiritual leaders for inmates whose beliefs differ from those of the full-time chaplain

50. Congregate Services • Meeting of several people to worship, study, or pray should be provided unless specific security or safety issues are presented • Inmates who become involved in religious programs often have improved attitudes and can draw upon a support group when they leave prison • Congregate services should be led by a person with proper credentials and should broadly appeal to all within a particular religion