My first consult of the day is a 42-year-old man with end-stage metastatic cancer. Entering the room at the University of Maryland Medical Center, I see two police officers at his bedside. Sitting up in his bed, the patient, whom I’ll call Jimmy, looks much older than his age. He is emaciated with pale skin and short, thinning black hair with silver streaks. Jimmy is wearing a white, sleeveless undershirt, and a large, wooden cross hangs around his neck. He looks up with a smile.
Chained to his hospital bed, Jimmy tells me he was diagnosed with pancreatic cancer two years ago while in prison for a crime he committed as a teenager. Several regimens of chemotherapy have failed him, and now he is left in constant pain. His cancer is large, starting to press on other nearby organs and causes him severe back pain as it extends to the nerves surrounding the pancreas. In prison there is no effective pain management, he tells me. Ibuprofen is all he gets. He says sometimes when he is in pain, he closes his eyes and imagines a large window with a flower box like the one at his grandmother’s house, instead of the thick cement walls and metal bars of his cell.
Compassionate release of seriously ill prisoners became a matter of federal statute in 1984 and has currently been adopted by the majority of U.S. prison jurisdictions. Remembering this, and recognizing Jimmy’s advanced cancer and limited life expectancy, I inquire about whether he has sought a compassionate release. Jimmy moistens his lips and swallows hard. He says that his request is waiting to be approved by the parole commission. Tears pool in his eyes, and his face becomes red. He recalls when prison inmates heard he submitted paperwork, they told him he will get the “Back Door Parole,” meaning he will die in prison. Jimmy tells me the prison wardens are understanding but face their own problems serving aging populations that suffer from chronic diseases including cognitive, and functional decline. I discuss with Jimmy a plan for symptom management to ensure his comfort before he is discharged back to prison. He asks for a Bible.
Maryland taxpayers spend an estimated annual incarceration cost of approximately $37,200 per inmate, 19% higher than other states in the nation with $300 million each year is spent on incarcerating people from Baltimore City alone. With an incarceration rate three times that of the state and national average, Baltimore City is Maryland’s incarceration epicenter.
While all inmates have access to some care, it’s not always good. Maryland is subject to legal requirements about its medical care for inmates stemming from a settlement known as the Duvall case, where judges called the for-profit health care to inmates in Maryland “critically short of care providers.”
Judges have found “widespread and systematic failures” of prison health care in Arizona. Lawsuits have documented critical delays in managing emergencies like stroke and sepsis, and, in a case at Riker’s Island, death from untreated diabetes. Many inmates lose access to prescription medications or suffer injuries and chronic conditions that are overlooked and untreated.
I see Jimmy next in the emergency room a couple months after our initial encounter. He still does not get his release and has accumulated fluid in his belly that needs to be removed to alleviate his pain and shortness of breath.
Shortly after that visit, I learn Jimmy has died alone in his prison cell.
There is an urgent need to ensure access to quality palliative medicine, if not compassionate release, for incarcerated prisoners with advanced illness, a disproportionate percentage of whom are economically disadvantaged and from communities of color. Our system continues vacillating between compassion for alleviating human suffering and punishment.
Responding to the needs of dying prisoners will take a variety of approaches, none of which is easy. The California Medical Facility has successfully incorporated prisoner volunteers into a Peer Support program with training in the psychosocial and spiritual dimensions of end-of-life care. Recently, I reached out to several community based nonprofit hospice agencies and have found all to be receptive to extending services to prisoners.
Physicians have a moral obligation to speak up about the importance of compassion, dignity and safety for all especially our most marginalized, vulnerable populations. Indeed, promoting social justice in this manner allows us to care for the health and well-being of people we are privileged to serve.
Raya Elfadel Kheirbek firstname.lastname@example.org is a professor of medicine and chief of the Division of Gerontology, Geriatrics & Palliative Medicine at the University of Maryland School of Medicine.