Administrators' Perspectives on Changing Practice in End-of-Life Care in a State Prison System

Each year correctional institutions across the United States house larger numbers of inmates, who are older and have more chronic and serious illnesses than prior years (Bureau of Justice Statistics, 2009). Longer prison sentences in a ‘get tough on crime’ environment are common across the United States, keeping offenders in prison into their later years of life (Abner, 2006). In 2009, approximately10% of all inmates were serving a life sentence (Moore, 2009). The number of sentences for life without parole issued in the United States increased by 600% from 1972–2009 (Nellis & King, 2009). Six states (i.e., Maine, Pennsylvania, Louisiana, Illinois, Iowa, and South Dakota) now have policies that interpret the sentence of life as excluding any option for early release or parole; or, as commonly stated, life is life (Mauer, King, & Young, 2004). While life sentences have increased dramatically, the number of death sentences issued from 1998–2007 decreased by 62% (Death Penalty Information Center, 2010); however, this decrease in sentencing is somewhat misleading. The death penalty was reinstated by the US Supreme Court in 1976 and executions resumed in 1977 (Snell, 2011). Following a peak in executions in 1998, there has been a downward trend in completed executions (from 99 executions in 1998 to 43 executions in 2011) (Criminal Justice Project, 2012). During that same period, the total number of inmates housed on death row decreased by only 7%: from 3492 in 1998 to 3199 in 2011. (Death Penalty Information Center, 2012a). Even among those whose death sentences are carried out, a death sentence equates with long-term incarceration. The average time between sentencing and execution has been on an upward trend for decades; in 2011, death row inmates spent 178 months (almost 15 years) aging in the highly restrictive setting of death row before execution (Death Penalty Information Center, 2012b). In 2005, a record 137 inmates on death row were 60 years or older, an increase by 351% since 1996. (Death Penalty Information Center, 2012c). Collectively, these trends have created a demographic shift in prison populations. Once incarcerated, a continually growing number of inmates can be expected to live out a large portion of their lives and eventually die in prison. The significance of this trend is amplified since inmates are thought to have physiologic ages 10-15 years older than their chronological ages (Mitka, 2004). Compounding the scope of concern, this demographic shift has occurred during a time of economic restraint. In sum, prison administrators are challenged to do more with less during a time when care demands posed by older, sicker inmates are escalating. In particular, the provision of humane end-of-life (EOL) care for aging inmates is a need that has reached a level of concern that is only expected to increase in the years to come (National Institute of Corrections, 2010). Prison administrators are obligated to lead the implementation of improved standards in prison health care to “ensure the most basic of human rights for prisoners, including access to care” (Stern, Greifinger, & Mellow, 2010, p. 2103). Prisons are hierarchical, bureaucratic organizations; staff members are accustomed to decision-making that requires approval through a chain of command. In sum, nurses and other health care providers who value EOL care and believe it should be implemented in their State Correctional Institution (SCI) need the support of administration to change protocol in one case or for all cases. In this organizational climate, implementation of new practices or a change in protocol without administrative approval places frontline staff at risk (e.g., reprimand or the potential for injury/harm). Compounding this dilemma, unsupportive attitudes held by security personnel, healthcare staff, other prison staff, and the public can influence the administrator’s prioritization of the need to address EOL care. A deeper understanding of the contextual backdrop of end-of-life care in a statewide prison system exposes challenges to changing practice in this area.