Medical decision making & incarcerated patients: What every healthcare worker needs to know
US healthcare workers must be prepared to care for incarcerated people.
Unfortunately, few of us are taught how to do this.
For 19 years, I have answered ethics questions, including re: patients in prison.
Here are 7 pieces of ethical advice to protect your patients:
Advice # 1: Incarcerated people get to make their own medical decisions.
We are used to adult patients making their own decisions.
Having an armed guard at the bedside confuses the usual bedside dynamic.
Focus on the patient's goals and values - they get to make their own healthcare decisions, just like non-incarcerated people.
"Our incarcerated patients have already received their sentences—their freedom has been taken away. Our job is to ensure that they are not also sentenced to substandard or unethical care when they are seriously ill or dying."
Advice #2: This includes Advance Care Planning
Fortunately, incarcerated people retain the right to make advanced care planning decisions.
This includes appointing a surrogate decision-maker (such as a family, friend, etc.)
They also can change their minds about healthcare decisions and who to be a surrogate, just like non-incarcerated people.
Advice #3: Incarcerated patients have a right to access medical care like everyone else.
Clinicians must share the risks, benefits, and alternatives to treatment decisions with the patient.
Don't limit options due to assumptions about the prison/jail environment.
Advice #4: Wardens/Prison medical staff should not make medical decisions for incarcerated people
Quick story:
An incarcerated patient in the ICU was too ill to make his own decisions.
A prison doc told me he would be the patient's decision-maker. 🤔
I told him this was highly unusual and that unless he could produce documentation that gave him this right, we would find a family member or friend to help make decisions.
He hemmed and hawed, but produced no evidence.
We found the man's sister instead.
Advice #5: Incarcerated people's surrogates deserve timely communication
Whenever possible, communicate directly with surrogates. Push back if prison staff attempt to be middlemen for complex health information.
Some states insist info be passed to family through prison channels. When faced with these limitations, I encourage hospital staff to focus on what needs to be done to protect the patient.
If prison requirements compromise timely care, I always recommend documenting who/what/why/how in the EMR and notifying Risk Management.
Sometimes, working with the prison can reduce/relieve these limits.
Advice #6: Attempt to get dying hospital patients who are incarcerated access to farewell visitors
Prisons may limit visitors to incarcerated patients.
Dying patients should have access to loved ones to say goodbye. Even if only by video or phone.
Incarcerated people and their families deserve humane treatment, especially at the end of life.
The First Step Act of 2018 grants federal prisoners a path to release when they have a terminal condition and are not expected to live long.
Advice #7: Use resources (ethics, legal, corrections experts) to advocate for the patient
If you're having trouble providing regular care, consider reaching out to resources:
Ethics Consult
Risk Management
Correction Expert
Advocacy group
TL;DR - ethical care for incarcerated people
#1: Make their own medical decisions
#2: Including Advance Care Planning
#3: Right to standard care
#4: Prison staff don't make medical decisions
#5: Communication with Surrogates
#6: Visitors for Dying
#7: Use resources to advocate
Want to know more?
For an in-depth explanation of these topics, please read "Providing Ethical and Humane Care to Hospitalized, Incarcerated Patients With COVID-19" by Drs. Leah Rorvig and Brie Williams.
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Dr. Burgart: Thank you for bringing attention to the critical issue of healthcare rights for those who are incarcerated—Americans who are still considered (and treated like) slaves under the exception clause of the 13th Amendment to the U.S. Constitution. One important point to highlight is that the reason so many incarcerated individuals end up in the ICU or ER is the complete absence of proper healthcare in American federal prisons. Outside of administering diabetes medication or similar routine pills, healthcare doesn’t exist, despite popular opinion. If you break a bone and have two months until release, you won’t receive treatment. If you tear your ACL, you will never be treated. Even getting something as simple as a brace is a major hassle. If you have a cavity, say goodbye to the tooth—it’s getting pulled. On can identify those who’ve spent the longest time behind bars simply by the gaps in their teeth.
The incarcerated have no way to voice this complete lack of basic medical rights while they’re in prison. Once released, they’re often focused on rebuilding their lives—advocating for prison healthcare reform becomes the last thing on their mind in the face of survival.
And I’m not even touching on the conditions of state or county prisons, which can be just as inhumane as those in Belarus.
It’s also important to challenge the perception that all those incarcerated are violent criminals. Many of them are, yes. But I know of doctors who chose to honor the Hippocratic Oath over federal law, administering non-FDA-approved drugs or using unapproved methods to save their patients’s lives. I’d take such a doctor any day over one who blindly follows the corporate line and disregards patient well-being. Who is truly more ethical?