Cancer care behind bars: treating prisoners with cancer.
Approximately 9% of U.S. inmates face cancer while in prison (U.S. Department of Justice, 2006). As patients with cancer, they are not much different than nonprisoners. However, for the oncology nurses who care for them, this patient population has some interesting challenges. Imagine if every time you consulted with a patient, a uniformed security officer was present. Or, perhaps a patient's only interaction with others was during a brief clinic visit while the rest of the time was spent in solitary confinement. The psychosocial issues that patients with cancer experience are difficult enough, but prisoners' experiences are compounded by a number of other issues, not the least of which is having limited control over treatment and care decisions.
Despite the challenges, nurses working in the prison system still keep the human element of the cancer experience at top of mind.
"Prisoners have the same rights to health care and not to be judged," says ONS member Vienafe (Faye) Jornadal-Recinto, RN, MSN, AOCN[R], OCNS. "They have already been judged in court and sentenced. The nurse's role is to provide compassionate care." Jornadal-Recinto is the manager and clinical nurse specialist for the Hematology-Oncology Service at Nashville General Hospital at Meharry in Tennessee. The management company that oversees Tennessee correctional facilities contracts with the hospital to provide medical care for both county and state prisoners.
"This population is referred to as the forensic patients at our institution," Jornadal-Recinto says. Inpatients are treated in a 20-bed lockdown unit in the regular hospital, and forensic outpatient services are limited to one day a week.
ONS member Gail Kwarciany, RN, MSN, BC, OCN[R], AOCNS[R], is an oncology clinical nurse specialist at the University of Texas Medical Branch (UTMB) at Galveston. She works in a unique environment, the Texas Department of Criminal Justice Hospital, a maximum-security prison and hospital providing inpatient and outpatient care to most prisoners in the state of Texas. Kwarciany says that it is a general hospital with 172 inpatient beds, with oncology on a 36-bed medical-surgical unit. It is the only facility like it in the country.
"Care provided to the prisoners is the same as in the free world [non-prisoner patients]," Kwarciany says. "National Comprehensive Cancer Network treatment and ONS guidelines are followed, and we're honest about prognosis and the treatment plan.
Care at Jornadal-Recinto's institution is similar. "Each group receives the same patient education on their disease, treatment, and side effects, and it is reinforced at each visit."
Differences in Treatment
Although cancer treatments for prisoners and non-prisoners are similar, oncology nurses many notice several differences. "Education of the prisoner's family is not done, and the nurse's communication with them is limited," Jornadal-Recinto reports.
Family visitation is limited to the prison, and the chaplain is the point of contact for families in both the Tennessee and Texas systems. In Texas, Kwarciany says, nurses can contact chaplains on behalf of patients to speak with their families.
Communication is also an important part of the treatment plan. The prisoners return to their respective facilities, where care continues in the facility's infirmary, which is staffed with physicians, nurse practitioners, and nurses. Jornadal-Recinto says that she gives copies of the plan of care and physician orders to the officers who accompany the patients, and additional copies are faxed directly to the prison facility. The hospital's head of oncology also holds a monthly clinic at the jail.
Any home medications are provided by the infirmary. If a drug's cost is questioned, the prison physician speaks to the treating physician to see whether a less expensive drug can be used, similar to working with a free-world patient's insurance company.
Transportation expenses are also factored into the cost of treatment. "Texas is a large state, and if there are challenges with distance, the prisoner may get moved closer to Galveston. The infirmary in that prison is more aware of the needs of patients with cancer," Kwarciany says.
Symptom management is done in the local infirmary for prisoners in Tennessee and Texas. The doctor or nurse practitioner at each prison communicates with the hospital to determine the severity of the condition. Patients with fever and neutropenia are admitted to the hospital.
Delivering care requires working in collaboration with security. "We balance the medical care with security issues and keep the human component," Kwarciany reports.
Nothing can be left in the room that may be used as a weapon. Nurses never turn their backs on patients, and they do not share personal information, as they would with a free-world patient. "In Tennessee, the nurse enters the room with an officer. There is also a screening unit with a metal detector that screens everyone before and after they enter the unit," Jornadal-Recinto says.
Kwarciany adds, "The nurses do not have knowledge of why a person is in jail, although the guard's actions may give some inkling of who is minimal security and who is on administrative segregation [solitary confinement]."
Research and Hospice
Prisoners are considered a vulnerable population when it comes to research. States differ in their practice of allowing prisoners to participate in cancer treatment trials. Texas allows prisoners to enroll in trials after review by a designated state agency. Currently the Tennessee Department of Corrections does not allow prisoners to participate in cancer treatment trials.
The Texas Department of Criminal Justice has the Research, Evaluation and Development (RED) Group, which acts as the institutional review board for the prison system. Research protocols are approved by the RED group and the UTMB review board, which has a prison representative. Kwarciany has first-hand knowledge of the system: "I did my master's thesis on hope and symptom distress in the prison population. I found [symptom distress] similar to patients in the free world."
Hospice services are provided to the prisoners in Tennessee in a skilled facility at their prison home. In Texas, a prison in Dallas has a hospice unit. Kwarciany reports that the prisoners say they receive good care.
Neither institution offers formal support groups for prisoners; however, the inpatient unit in Texas has three beds per room, and Kwarciany has found that patients support each other and reinforce education. In Tennessee, Jornadal-Recinto says that an outreach nurse goes to the prison and talks with prisoners about cancer prevention and screening.
Prisoners with cancer are a special population. Oncology nurses treat this group as they do free-world patients, providing honest information about their disease, treatment plan, and prognosis. Some free-world challenges, such as cost of treatment and transportation, are similar in the prison population but are made more difficult by patients whose decisions are not their own.
U.S. Department of Justice. (2006). Medical problems of jail inmates [Bureau of Justice Statistics Special Report]. Retrieved from http://bjs.ojp.usdoj.gov/content/pub/pdf/mpji.pdf
Contributing Editor Susan Pillet, RN, CPNP, CPON[R], is an advanced practice nurse for the Cancer Institute of New Jersey in New Brunswick.
[By Susan Pillet, RN, CPNP, CPON[R], Contributing Editor]
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|Date:||Aug 1, 2010|
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