Name of Project: Guiding Responsive Action for Corrections at End-of-life (GRACE)
Institution: Volunteers of America, Alexandria, VA
PI: Margaret Ratcliff, MSW
Abstract (as described by Project staff)
The GRACE Project promotes the development of high quality end-of-life care in prisons so that prisons can achieve the same standard of care as outside hospice programs. Using a collaboration of organizations, including four prison demonstration sites, the project develops and disseminates “End-of-Life Care Standards for Correctional Settings;” develops and shares information and resources through a resource center and a United States/Canadian conference; and demonstrates specific program enhancements in four prisons.
Brief Synopsis of Program Characteristics, Successes and Challenges
In an environment where prisoners were not allowed near each other’s cell (much less to touch one another) and in a period of conservatism that is squeezing, not expanding, services to prisoners, the GRACE project has done a remarkable job of breaking barriers and implementing hospice programs within prison settings.
The project has completed a 16-month planning phase and the 1st year of a two-year demonstration phase.
During the planning phase, the project identified institutions with special end-of-life care programs and engaged individuals from those sites in a process of study. The project collected information about current end-of-life care in state and federal prisons and in jails, compared this information with current practices with community hospice and palliative care standards, and then developed recommended standards. Representatives from 15 particularly successful programs (both state and federal) were invited to a three-day intensive work session in April 1999. Out of this meeting came the beginning of the project’s handbook, and the project explored possible approaches for adapting the National Hospice Organization's standards to the requirements of corrections. Next, teams of GRACE Project participants were formed to study each of the demonstration sites during two-day visits.
The demonstration phase followed the planning phase. In March 2000 the demonstration project was launched at a three-day Collaborators' Meeting of site representatives, project staff, and consultants, at the Louisiana State Penitentiary at Angola. Site teams conferred together to design plans for implementing and assessing their selected enhancements. At present, the demonstration projects are underway at four sites. The following statistics from each of the centers are current as of April 2001:
| Coxsackie Regional Medical Unit Coxsackie, New York |
Average Daily Census: 9 Infirmary beds: 60 |
| McCain Correctional Hospital McCain, North Carolina |
Average: 2-6 patients Available Beds: 100 infirmary, 4 hospice beds |
| Oregon State Penitentiary Salem, Oregon |
Average: 2-6 patients in infirmary Available beds: 21 in infirmary, plus general population |
| The Federal Medical Center for Women-Carswell Fort Worth, Texas |
Average Daily Census: 1-5 Available Beds: 60-bed medical surgical |
The demonstration sites provide an interdisciplinary team approach with care plans that encourage patient involvement in planning. The usual service (where no hospice program exists) consists of medical care as needed with an extensive use of outside hospitals for critical care. The care received in the demonstration sites is more individualized and includes a greater focus on family (including inmate family) involvement and offers inmate volunteer support.
Each of the four demonstration sites identified education and training as one of their key enhancements for the GRACE Project. Constraints include lack of staff availability for training programs, lack of training funds, and staff turnover—through job changes as well as shift changes within the institutions.
In addition to studying effective program development and practices, the project has developed Standards of Practice for End-of-Life Care in Corrections to aid professionals in adapting the community hospice model to correctional facilities, an annotated bibliography, and End-of-Life Care in Corrections: A Handbook for Caregivers and Managers.
The project is extremely collaborative, working with such groups as the American Correctional Association, the National Hospice and Palliative Care Organization, the North American Association of Wardens and Superintendents, the American Correctional Health Services Association, the American Correctional Chaplains Association, the National Prison Hospice Association, the Center to Improve Care of the Dying (Rand Corporation), the Third Age Center (Fordham University), and the Open Society Institute's Project on Death in America and Center on Crime, Communities, and Culture. In addition, four demonstration sites representing a variety of security levels, sizes, locations, and on-site medical services.
Highlights of each site follow.
Coxsackie Regional Medical Unit, New York State Department of Corrections, Coxsackie, NY
This project has made considerable progress in implementing an extensive training and continuing education plan, including a staff orientation containing information on the hospice program and curriculum development for CNAs. The site also conducts annual mandatory training including information on end-of-life. The state commissioner of correctional health services has approved the project’s inmate volunteer program. Changes to policies, such as forbidding inmates to touch one another, have been drafted and are under revision. Difficulties included negotiating training for inmate volunteers, nursing shortages and unexpected changes in Department of Corrections administration.
McCain Correctional Hospital, McCain, North Carolina
This project is providing training and continuing education, a comprehensive plan of care and an inmate volunteer program. In training and education, the project has secured teleconference equipment and has trained staff in its use. Working with NHPCO, the project has developed a relationship with Area Health Education Center that will develop future training programs to respond to the facility’s needs. McCain’s volunteer program has received approval to use inmate volunteers and a policy is being developed. The chaplain has identified 30 potential volunteers.
Oregon State Penitentiary, Salem, OR
This project is also focusing on training and continuing education and has established quarterly in-services with a community hospice representative. Staff and management have attended relevant conferences and the project has implemented protocols for end-of-life care. This site is also expanding access to end-of-life care services and has succeeded in providing services to the general prison population. This project uses volunteers who meet and help patients. Eligibility requirements were increased from six months to one year. A community hospice provider provides pain control consultation. The project has produced end-of-life pamphlets in English and Spanish, and a process was developed for natural families to be involved in end-of-life decisions when permitted by patients. Bereavement is an issue for “prison families,” and this project has written bereavement policies and a policy to identify and document bereavement needs of prison family. Bereavement services for staff are provided as needed.
Federal Medical Center for Women – Carswell, Fort Worth, Texas
This project is focusing on training and continuing education, outcome measures and bereavement. The project has developed a lesson plan for all first-time wardens, presented hospice information during a tele-health conference with general population staffs, trained 20 volunteers, provided a 30-minute hospice orientation to all executive staff and developed an orientation program for staff who are new to hospice. This facility also measures the outcomes of their efforts by using a questionnaire to diagnose the lack of understanding regarding advance directives. The survey was sent to all staff that come into contact with hospice patients. The hospice coordinator is writing a clinical guideline regarding hospice care, and also helped rewrite the supplement on advance directives. This facility has also implemented a significant bereavement program including bereavement services.
Exportable Products/Tools
Policy Issues
There are myriad policy issues surrounding the issue of providing care to prisoners, most of them having to do with the level of services that should be provided to prisoners versus the level of services provided to those on the “outside.”
Communications
The project has a web site at http://www.graceprojects.org/, where one can find information about the project, resources and information, featured programs, getting started, conferences and news, more about volunteers of America, partners and related links, frequently asked questions and contact information.
The project has conducted three national conferences regarding prison end-of-life care.
Considerable external communication has occurred in this project including an editorial for Innovations and the Journal of Palliative Medicine, and two additional articles were published in the Correctional Health report and the Journal of the American Jail Association. The project has also presented at professional conferences including AAHPM, an Albert Schweitzer Institute in Budapest, NCCHC and the American Correctional Association. It was also featured in a New York Times article.
The project has requested and received a communications grant to produce an orientation video on end-of-life care for correctional staff.
Of particular interest is the project’s resource center. It maintains communication among the demonstration sites and with other prison hospice programs throughout the country. It provides access to a network of information and referrals. Educational materials are gathered, such as policies, procedures, training curricula, sample forms and bibliography. Other materials are developed as need and opportunities arise. Available are the Standards, as well as the Handbook, which presents a list of challenges for palliative care programs in the prison environment, an overview of current palliative care practices in prisons, and concrete suggestions for addressing practical issues involved in improving end-of-life care in prisons. The Resource Center also provides information about upcoming events (conferences, training sessions) and updates on the progress of prison hospice programs around the country.
Words of Wisdom from the Project
Critical to the project’s success has been the enthusiastic cooperation of the partnering organizations--especially the wardens, chaplains and correctional health care professionals—as well as the media and other funding agencies.
