Correctional officers become end of life caretakers: Winnebago County Jail partners with local hospice to provide care to terminally ill inmate.

Kathy Baxter, RN, director of patient services for Hospice Care of America--a hospice agency founded in Rockford, Ill., in 2004-was a bit surprised to receive a call in February 2008 from Capt. Timothy Owens of the Winnebago County Jail in Rockford. Owens called to learn about the availability of hospice services for an inmate who had been diagnosed with advanced esophageal cancer and was beginning to experience rapid physical decline. Baxter assured Owens that hospice provides services for anyone with a life-limiting illness, wherever they may live.

Thus began a complex and very rewarding partnership between a health care agency and a detention facility, a first-time experience for both that culminated in a peaceful death with comfort and dignity. This partnership raises a number of issues faced by detention and correctional facilities with aging populations. How can one inmate be given preferential treatment, logistically and psychosocially, over others? How can maintaining the security of many be balanced with meeting the physical, emotional and spiritual needs of one who is dying?

Championing the cause to incorporate comprehensive medical care into the secure environment of the Jail system was nurse practitioner Sandra Nienaber, CNP. Undaunted by comments from some detention staff like, "There she goes, breaking all the rules, and nobody is stopping her," and "You're just spoiling him," Nienaber embraced the judicial philosophy of avoiding "deliberate indifference" and went out of her way to provide the little things that made a difference in the inmate's comfort and quality of life. In addition to administering and monitoring his medications under the direction of the jail medical director Dr. Eric Henley, she also managed to bring the inmate, who was housed in the medical unit, popsicles in flavors that did not make him nauseated, as well as watermelon, peaches and special sandwiches. However, even Nienaber admitted it was a challenging situation. "After I gave [him] a pillow, I had four or five other inmates wanting pillows. But we have to set boundaries, and sometimes we have to say 'no,'" Nienaber said, explaining that the inmate's medical needs determined that he received these additional privileges. "Most of the inmates were accepting of that. I believe many of the inmates, if they had pillows, would have given them up for him," she said.

"How do you treat someone who has broken the law? You do the right thing for the right reason. You suspend judgment," Nienaber said. Security staff and inmates eventually followed her lead and joined the hospice team in supporting the inmate's needs. When hospice home health aide Valerie Murphy, CNA, who was responsible for providing personal care for the inmate, needed extra time bathing him in the shower, the correctional officer who monitored her biweekly visits adjusted the shower stall so the hot water would stay on for as long as necessary. Security provided a lockdown of the other inmates during those times of personal care, and when Murphy was not there, the inmate's cellmate helped him clean up.

As part of the hospice team's security clearance, each member of the team--the nurse, hospice aide, social worker and chaplain--underwent a thorough background check. This level of clearance is the equivalent of what is needed for volunteers serving at the jail. The hospice team also went through a comprehensive orientation introducing them to the jail environment, outlining the security restrictions and explaining how any potential safety concerns would be handled. Conversely, hospice worked with the administrative and medical staff of the jail to develop and implement a plan of care that would provide symptom management and emotional/spiritual support for the inmate, as well as prepare for the increased medical care needs anticipated during the final stage of the inmate's disease progression and death.

"Certainly, our population is aging just like the rest of the community," Winnebago County Jail Superintendent Andrea Tack said. "We are starting to see that our senior inmate population is growing, and this is something we are going to have to face in the future. First of all, we are a correctional facility. Safety and security are number one, and sometimes it gets difficult to find balance. But I think it's important to be willing to at least try and recognize the needs."

Tack admitted, "I don't know that we ever could have done anything like this in the old jail." The new jail, which opened in June 2007, is complete with medical units for men and women, along with medical examination/treatment rooms and a medical records room. This new facility also has vastly improved supervision over the old linear-style jail where the officers had to open multiple doors to gain access to the inmates. In the new jail, an officer is assigned to each unit and has direct supervision. Owens explained that the difference in the new design is that it is like being in the inmates' living room instead of just being in their apartment building.

The Winnebago County Jail has long been a pioneer, willing to adapt to a changing population with the increased aging of its inmates. These changes have addressed increased medical needs alongside diverse and sometimes opposing public sentiments concerning jail conditions and cost of housing inmates. In addition to taking care of the day-to-day priorities of housing the jail's population and equipping the staff, Owens is ever conscious of his responsibilities to the taxpayers of Winnebago County.

Owens' 21 years of experience have shown him that one of the most cost-effective ways to provide the greatest level of safety and security is to emphasize rehabilitation while inmates are incarcerated. He has learned that rewarding good and positive behavior decreases the need for additional security staff. And with this recent situation, he discovered that partnering with hospice to share the burden of medical care for inmates at the end of their life also saves local taxpayer dollars. Although the jail's intent was not to seek public approval, the response from the community has been very positive.

Prior to electing hospice care, the Winnebago inmate had become increasingly uncomfortable due to the spread of his cancer. The jail's medical staff worked closely with the custodial staff under the direction of Owens to arrange for the inmate's care and treatment. The hospice staff also worked with the court to modify his diet, schedule appointments and transport him to the oncologist. Henley, the jail medical director, recognized the level of care this inmate would require at the end of his life and recommended the logical next step, which was to look to the private sector for hospice services. The sheriff agreed that the same standard of care should be provided within the correctional facility, if possible. Another reason for contacting hospice, according to Nienaber, was to establish a link with the community for the inmate's ongoing medical care if the court decided to release him from custody.

Hospice team members visited the jail and explained their services to the inmate, including the hospice philosophy of promoting comfort, dignity and autonomy while not unnaturally prolonging or hastening the dying process. Although this inmate had no reimbursement source, such as Medicare, Medicaid or private insurance, to pay for his hospice services, he learned that in accordance with the mission of Hospice Care of America, his care would be provided "with integrity and respect ... without regard for race, creed or ability to pay."

Lorna Sullivan, RN, hospice nurse, along with hospice medical directors Dr. Joseph Eckburg and Dr. John Roska, was able to assist the medical staff at the jail with pain and nonpain symptom management. Hospice also provided the new medications the inmate needed, along with a low-air-loss mattress for his hospital bed in the medical unit and a wheelchair. Hospice social worker Julie Sanderson, LCSW, assisted in developing a contingency plan for when the inmate could no longer perform self-care. This plan included petitioning the court for a standing furlough that would allow him to go to the hospital, if necessary, and a release from custody that would permit him to be transferred to a nursing home if and when needed. Explaining how grateful the jail was, Owens said, "They made it a lot easier for us. They helped us whenever we did a court appearance. They were there. They had knowledge in the case. I just wish we had other experiences that were as comfortable as this one."

Precrisis planning, such as the necessary security clearance that allowed the team unlimited access to the inmate and a standing furlough granted by the judge, came in handy when, in the middle of the night, the inmate collapsed from internal bleeding as a result of his cancer. Hospice was called. Sullivan, the nurse who was on call, responded immediately. The inmate was hospitalized at Swedish American Hospital in accordance with the contingency plan that was in effect. There, all of his acute medical needs were met.

Although his case was never resolved, after leaving the hospital, the inmate was released from the custody of the Sheriff's Department into the care of Alden Park Strathmoor nursing facility. The inmate passed away peacefully and comfortably on April 18. All interests of the individual and the community had been served. Safety and security of the inmates and the public were never compromised, and the inmate received excellent medical care at the end of his life.

"We worked together to provide a solution in an environment that is not conductive to exceptions. It was truly one of those amazing accomplishments in that we were able to give him a good death. That was always our focus, " Nienaber said. The partnership formed between the Winnebago County Jail and Hospice Care of America continues to provide the availability of additional care and support for incarcerated individuals who face critical health care needs at the end of life.

Marty Johnson-Swagerty, RN, is founder and executive director of Hospice Care of America.