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

Abstract

Background: Despite rapidly aging populations in prisons and jails, evidence suggests that advance care planning (ACP), an essential component of geriatric care, is not widely conducted in correctional healthcare settings. Objectives: Investigate correctional health care providers’ ACP knowledge and experience, their perspectives on barriers to ACP in correctional settings and how to overcome those barriers. Design: Qualitative Study Setting: Four prisons across two states and one large city jail in a third state. Participants: 24 correctional healthcare providers (e.g. physicians, nurses, social workers) participated in individual semi-structured phone interviews about ACP in correctional settings. Results: Participants demonstrated low baseline ACP knowledge; 85% reported familiarity with ACP, but only 42% provided accurate definitions of ACP. Fundamental misconceptions included the belief that ACP was done by providers without soliciting patient input. Multiple ACP barriers were identified, many of which are unique to prison and jail facilities, including provider uncertainty about the legal validity of ACP documents in prison/jail, patient mistrust of the correctional healthcare system, patients’ isolation from family/friends, and institutional policies that restrict use of ACP. Clinicians’ suggestions for overcoming those barriers included ACP training for clinicians, creating psychosocial support opportunities for patients, revising policies that limit ACP, and systematically integrating ACP into healthcare practice. Conclusion: Despite an increasing number of older and seriously ill patients in prisons and jails, many correctional healthcare providers lack knowledge about ACP. In addition to ACP barriers found in the community, unique barriers to ACP exist in prisons/jails. Future research and policy innovation are needed to develop clinical training programs and identify ACP implementation strategies for use in correctional settings.

Who Should Make Decisions for Unrepresented Patients Who Are Incarcerated?

“…16 Similarly, not all correctional settings allow individuals to complete advance directives, 14 and there is evidence that correctional clinicians have limited knowledge of the role of advance care planning. 17…”

“…Current research on surrogate selection for people experiencing incarceration is sparse. 17,30,31 Without more robust input from key stakeholders, especially those who are incarcerated, health care professionals' ability to take good care of unrepresented patients who are incarcerated will be limited. Although the prospect of engaging an individual's prison family is promising, views of people actually experiencing incarceration should be gathered first.…”

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

“…All six studies used qualitative methods to explore ACP in correctional settings. Five studies were conducted in the United States (Ekaireb, Ahalt, Sudore, Metzger, & Williams, 2018 ; Sanders et al, 2014 ; Sanders & Stensland, 2018 ; Sanders, Stensland, & Juraco, 2018 ; Stensland & Sanders, 2016 ), and one was conducted in Switzerland (Handtke & Wangmo, 2014 ). The correctional facilities sampled in the US included four state prisons (Ekaireb et al, 2018 ; Sanders & Stensland, 2018 ), one jail (Ekaireb et al, 2018 ) and one state medical classification centre (Sanders et al, 2014 ; Sanders et al, 2018 ).…”

“…Four papers included participants who were prisoners (Handtke & Wangmo, 2014 ; Sanders et al, 2014 ; Sanders et al, 2018 ; Sanders & Stensland, 2018 ), and one paper included composite characters that had been developed through semi-structured interviews with prisoners (Stensland & Sanders, 2016 ). Three papers included participants who were healthcare professionals, including nurses (Ekaireb et al, 2018 ; Sanders et al, 2014 ; Sanders et al, 2018 ), social workers (Ekaireb et al, 2018 ; Sanders et al, 2014 ; Sanders et al, 2018 ), and physicians (Ekaireb et al, 2018 ). No papers included participants who were non-healthcare correctional staff.…”

“…Five of the six included studies described ways the corrections system can impact the process of ACP and the ability for healthcare staff to enact the preferences of prisoners (Ekaireb et al, 2018 ; Handtke & Wangmo, 2014 ; Sanders et al, 2014 ; Sanders et al, 2018 ; Stensland & Sanders, 2016 ). Barriers related primarily to how restrictive prison policies impacted ACP processes (Ekaireb et al, 2018 ; Handtke & Wangmo, 2014 ; Sanders et al, 2014 ; Sanders et al, 2018 ; Stensland & Sanders, 2016 ) and issues related to inadequate access to prisoner health information in medical records (Ekaireb et al, 2018 ; Sanders et al, 2014 ; Sanders et al, 2018 ; Stensland & Sanders, 2016 ). Facilitators included access to medical facilities that allow prisoner ACDs to be executed (Sanders et al, 2018 ) and the presence of well-developed ACP policies and procedures (Sanders et al, 2014 ).…”