ABCD Exchange : April 1999 : Upfront - Angola Prison Hospice

President's Letter - When the Care System Fails
QuickScan - News in Brief
Lunch Bunch - New Models of Grief
In the States - Sanctions for Undertreating Pain

Behind Bars: Angola Prison Hospice Offers Care to Dying Inmates
by Joseph Cerquone

Angola, Louisianaís infamous maximum security prison, is among the unlikeliest places for an end-of-life success story to emerge. With a storied reputation for violence, the institution is "home" for over 5,000 inmates, most of whom are expected to grow old and die behind bars. Yet, for the past year, a hospice program has been underway that has made better dying possible for those in its care, while having a positive effect on the general prison population.

"This program has caught inmatesí attention like none other," said Assistant Warden Dwayne McFatter, a thirty-year-staff veteran. "The biggest fears an inmate has are dying in prison and dying alone. Hospice canít do anything about the dying in prison part. But it can ensure that an inmate will not die alone unless thatís what he chooses."

Meantime, hospice chaplain Father Joel LaBauve said the program filters a positive message about the value of life throughout Angola. "If we encourage that, it means society is better off in the long run," LaBauve said.

In 1998, its first year of operation, the Angola hospice program cared for 17 patients. Staff adhere to generally accepted pain control standards, with some adjustments for the prison environment. For example, oral time-release morphine is administered, though morphine patches are not. In part, clinicians must be wary because the program operates within a general treatment area where non-hospice patients also receive care. Although the latter group have been known to "cheek" medications to sell them later, the Angola hospice program has not experienced such violations.

Those who organized the hospice decided to use only inmate volunteers, believing that this approach stood the best chance of winning over the general prison population, which can be distrustful of Angolaís medical care. The interdisciplinary team is formed along the traditional hospice model, though unlike ordinary teams, it has representatives from classification (to check into patient and inmate backgrounds) and security (to enforce prison security procedures and policies).

Unlike Medicare-certified hospice programs, the Angola hospice does not strictly adhere to the six-month terminal disease prognosis. In some cases, patients receive aggressive treatment.

"Thereís nothing magical about the six-month time frame," nurse Tanya Tillman said. "Outside, thatís a requirement which stems from making hospice Medicare reimbursable. We try to err on the side of the patient—what his needs are in terms of palliative care. Disease prognosis is hard in any medical facility, especially with end-stage cirrhosis. Some patients contract hepatitis, but never show symptoms. Others die quickly."

As for aggressive treatment, Tillman said that chemotherapy and radiation can provide "emotional" as well as physical palliation. "Inmates donít have a lot of control in prison," she explained. Pursuing aggressive treatment allows them "to exercise some control."

Does an "enforcement mentality" ever stand in the way of the care? Occasionally disagreements arise in team meetings, according to LaBauve. He credited strong support from the wardenís office, plus the exemplary record set by inmate volunteers, with reducing barriers. "The backing from the wardenís office is huge," Rev. LaBauve said. "Without it, things would not have gone as smoothly."

The program has about 35 inmate volunteers, all of whom went through a rigorous screening and training program. Applicants must apply in writing; must have had no drug violations in the previous two years; and must undergo investigations into their behavior, including drug screening and classification and security checks. Pedophiles are disqualified from applying. Hospice staff interview all candidates. A three-member panel rules on applications, with one negative vote enough to reject an applicant. Of 80 recent applicants, 20 were accepted.

"Iíve had inmates tell me they want to volunteer because they think it would look good on their record," Tillman said. "I automatically reject them. Most commonly, however, they say they want to volunteer because they believe that, if they volunteer now for someone, someone will do the same later on for them."

Volunteers often provide direct patient care, such as feeding, shaving or bathing patients, reading to them, and providing companionship. Volunteer duties come in addition to inmatesí regular duties; they receive no special breaks or privileges for their service.

"The stereotype of people in prison is that they donít care about anyone," Assistant Warden McFatter noted. "Hospice is breaking that stereotype."

According to Rev. LaBauve, the volunteer work has had a positive effect on volunteers and the general prison population. "It has a way of putting them in touch with matters of life and death that they have never touched before," he said. "They come to relate at a deeper level."

McFatter added that the hospice program has helped boost inmatesí estimation of the general medical care at Angola. "The volunteers stay in our treatment area for hours," he explained. "They see not only the care the hospice patients get, but also what average inmate receives."

Two distinct sets of mourners may receive bereavement care: the patientís biological family, plus his "prison family," inmates with whom he has shared years, sometimes decades. An inmateís immediate family may stay around the clock with a patient who is near death. Staff make phone calls to family members to keep them informed about the patientís status. The hospice program sends sympathy cards and refers family to community resources for support and counseling.

The hospice program also works with the "family" inside the prison. "Weíre oriented in both directions," Rev. LaBauve said, noting that factors such as alienation, geographic distance, and economic circumstances sometimes prevent meaningful contact between patients and biological family members—a loss that can be eased by an inmateís relationships with other prisoners. In LaBauveís words, "when a patient has spent twenty-twenty five years behind bars, part of his real family is the men he has spent all that time with."

LaBauve believes it is appropriate to mourn those who have committed serious crimes. "What can one say except that their crimes were horrible," LaBauve said. "Iím not saying you [accept the] negative aspects of a crime. But anything that is done to dehumanize someone—be it an innocent person or a criminal—is a bad thing. The more we can appreciate a personís humanity, the better off weíll be."

In keeping with the goal of involving inmates, prisoners make caskets. Graveside funeral services are open to anyone who wants to attend.

"Our largest funeral was back in August when 37 biological family members and 50 inmates attended," Tillman said. "Those are significant numbers. It wasnít uncommon before for no one to show up."

Last winter, staff planned to apply for state licensure for the program, in part to help it survive any changes that might come from a change in administrations at Angola. Although there are no indications anyone wants the hospice to cease operation, "having a licensed program would make it tougher to dismantle," Tillman said.

Meantime, program staff are willing to share what theyíve learned over the past year with interested parties, but they are hesitant to offer up the Angola Prison Hospice as a model.

"Every program has to conform to its own state and institution," Tillman notes. "Our program happens to be what works for us. But weíre open to sharing any part of it that another institution might be able to use."

Joseph Cerquone is director of communications for the Alliance for Aging Research in Washington, D.C.

For more information, contact the Angola Prison Hospice Program, Louisiana State Penitentiary, Angola, LA 70712. Also, a twenty-three minute video, Angola Prison Hospice Opening the Door, is available from the Open Society Institute, New York, New York (212) 548-0600

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This content is provided by Americans for Better Care of the Dying. For more information, visit www.abcd-caring.org.