Caring for Incarcerated Patients (Lozada, 9/15/2020)

I have deep gratitude for a powerful Grand Rounds this week by Dr. Christina Lozada, on Caring for Incarcerated Patients.

Dr. Lozada presented statistics on the state of mass incarceration in this country, reflected on her personal and professional experience of caring for incarcerated patients during her training, and encouraged us to do better in caring for incarcerated patients.

The US has the highest incarceration rate of any industrialized nation in the world.

• 4.4% of the world's population, 22% of the world's prisoners
• 2.3 million incarcerated people in the US, 4.5 million on parole, and 3 million ex-convicts
• ~870/100,000 US citizens 
• 57% in state prisons, 27% local jails/prison, 9% federal prisons

Who are our jail patients? 

Disproportionately young people of color, poor people, mentally ill people, poor people

• 34% non-Hispanic Black, 24% Hispanic
• Black and Hispanic men are incarcerated at 5.1 and 1.4 x rate of whites
• Mean age 32.1 (jail), 35.6 (prison)
• 10% are Veterans, 12-17% were homeless in the year prior to incarceration
• More than half have less than a high school diploma

Females are the fastest growing population in jails and prisons

• Compared to men, incarcerated women have higher rates of chronic disease, substance use disorder, and mental illness. 
• Elevated rates of depression, PTSD and antisocial personality disorder
• Most incarcerated women have experienced childhood physical and/or sexual abuse
• 6-10% incarcerated women are pregnant

Mental health issues are important

• 25% of all inmates have a mental health diagnosis (even higher for women 30-62%)
• 70-75% have taken a psychotropic medication
• Depression, PTSD and substance use disorder all very common. PTSD associated with higher rates of risky behavior including prostitution, IVDU, substance abuse

Dr. Lozada invoked The 8th Amendment of The Bill of Rights (1791) and Supreme Court Case Estelle vs. Gamble (1976) as the two main pillars of federal law that protect prisoners and should ensure them adequate access to high quality health care. She also called us to review our very own Hippocratic Oath.

The 8th Amendment guarantees freedom from cruel and unusual punishment. Estelle vs. Gamble ensures: access to care (including hospitals and specialists), ordered care (i.e. ordered by a physician), medical care without bias to the incarcerated status, proper medical records, confidentiality, autonomy (right to refuse care). 

While the law guarantees provision of care for prisoners, it frequently falls short of an acceptable standard of care. This is because standards are vague and/or undefined. There are differences in budgets and policies across federal, state and local jurisdictions.

Three important ethical issues to take into account in caring for incarcerated patients that may not be well-respected or well understood.

• Privacy: incarcerated patients have the same right to privacy as any other patients (including HIPAA protections, having officers in the room during interviews/examinations, etc)
• Autonomy: incarcerated patients have the right to make their own medical decisions and the right to refuse medial care as well
• Surrogate decision maker: incarcerated patients have the same right to designate a surrogate decision maker in case they are unable to make their own medical decisions (the warden is NOT the default surrogate)

Correctional Care Companies (private, for-profit corporations that are contracted to provide health care inside jails and prisons) have inverse incentives for care delivery

• These companies get paid per patient per day: while they provide direct medical care (e.g. urgent care, chronic disease management), any care that requires transfer to hospital or specialist care comes out their profits
• There have been hundreds of lawsuits against them, multi-million dollar settlements
• Investigative reporters have uncovered hundreds of preventable deaths: including ignoring visible and growing cancerous tumors, placental abruption and chorioamnionitis leading to fetal demise, untreated DKA, undiagnosed ruptured duodenal ulcers, and more.

What do we know about how shackles in the hospital impacts care?

• inability to break falls when ambulating
• difficulty positioning during seizure management
• reduced mobility increasing the risk of thrombosis
• impede physical exam maneuvers
• prevent development of physician-patient trust
• reinforce stigma and judgement of incarcerated patients

Of note, The British Medical Association advocates that patients should be examined and treated without restraints or prison officials unless there is a security or escape risk

Patients who are incarcerated often experience their hospitalization as a negative one. They feel judged and mistreated. They feel unlistened to and mistrusted. Medical providers often refer to them as "jail patients" and describe them as unreliable, social outcasts, deserving of their medical ailments. Many of us do not have formal training on caring for incarcerated patients nor are we aware of laws and policies in place to ensure they receive good medical care.

What can WE do as medical providers caring for incarcerated patients?

• Ask prison officers to remove shackles in order to fully assess patient
• Ask prison officers to remove themselves from the room or stand at the doorway for more privacy
• Use accurate and stigma-free language that prioritizes individuals over characteristics
• Avoid defining people by the crime for which that are accused or convicted
• Ask if the patient consents to discussing PHI in front of law enforcement officials or asking officers to move out of hearing range
• Try to make a patient that is incarcerated feel more comfortable disclosing potentially legally detrimental elements of the medical history
• Become familiar with hospital policies related to the care of incarcerated patients
• Incorporate education of these topics into credentialing or regular hospital-based education meetings
• Take a tour of nearby jail medical facilities and put together a list of resources and contacts
• Ensure careful discharge planning as times of transition

And finally, consider the following thoughts:

Resources:

• AMEND: UCSF center designed to improve health inside correctional care facilities https://amend.us/providing-acute-care-for-seriously-ill-incarcerated-patients-in-the-community/
• American College of Emergency Physicians: https://www.acep.org/administration/resources/recognizing-the-needs-of-incarcerated-patients-in-the-emergency-department/
• AAFP Davis DM, Bello JK, Rottnek F. Care of Incarcerated Patients. Am Fam Physician. 2018;98(10):577-583.
• https://www.prisonpolicy.org/