Hunger strike is a situation every correctional nurse will encounter at least once during their career. It is also one of the unique features of correctional nursing practice and not experienced by nurses in other specialties. Usually the first thoughts that come to mind when the subject of hunger strike comes up are the ethical conflicts; supporting an inmate during their hunger strike (an individual’s right to autonomy) and whether to intervene with life saving measures, such as force feeding (health care professional’s obligation to use their skills and knowledge to benefit the patient). These ethical issues were discussed in this month’s American Journal of Nursing with regard to the hunger strikers at Guantanamo Bay.
In my thirty years’ experience all but one inmate on hunger strike has resumed eating well before their condition became life threatening. It was skillful, concerned nursing care, especially patient advocacy, which eliminated the need to work through the ethical issues that take up so much of the discussion about hunger strikers in correctional settings. The focus of this blog is to describe the practical steps that nurses can take when an inmate informs staff that they are on a hunger strike. These include establishing the patient’s baseline health status, advising and educating the patient, and scheduling ongoing follow-up.
Notification: The highest level officials at a correctional facility will want to be notified when an inmate is on a prolonged fast or hunger strike. They often express concern about preventing the inmate from harms and want to avoid peer pressure or enlisting other inmates in joining the hunger strike. When a nurse is informed that an inmate is on a prolonged fast or hunger strike the first step is to make the proper notifications. These should be spelled out in facility specific policy and usually stipulate the dual responsibility of the facility health authority and chief medical officer to keep the facility command structure informed about the inmate’s health status, any change in condition, and involved in supporting the general plan of care. These leaders are also responsible for ensuring that mental health professionals are actively involved in evaluating and planning for the patient’s care.
Definition: All individuals periodically fast, so it is important to distinguish when fasting is considered a hunger strike or attempt at starvation. Sometimes the inmate will notify staff that they are not eating and the reason why; other times officers notice that an inmate is refusing foods (and maybe fluids as well) and take further steps to inquire about the inmate’s behavior. Correctional systems usually define a hunger striker as an inmate who goes without food and fluid for more than 24 hours or without food (but taking fluid) for more than two consecutive days.
Time is on our side: There is no need to rush into a confrontation with the hunger striker or struggle with the question of whether to force feed for some time. For healthy persons, serious risk does not arise until after 14 days of starvation, or until the patient has a Body Mass Index (BMI) of less than 18.5, or abnormal lab values (↓serum protein and albumin, ↓bicarbonate, abnormal kidney function or electrolytes). Persons with chronic medical or mental health conditions, who are pregnant, elderly or taking certain types of medication (e.g. insulin, diuretics, antacids) risk experiencing complications earlier. Nurses and custody staff should ensure that fluids are available at all times and food is offered according to the regular meal schedule. During this early period it is important for nurses to concentrate on building a therapeutic relationship with the patient; one that demonstrates respect, supports autonomy and self-determination, and preserves dignity.
Baseline Evaluation: When health services is notified or determines that an inmate is on a hunger strike the first step is to establish a baseline against which to monitor changes in the inmate’s health status. This evaluation should be conducted within the first 24 hours of notification if the inmate is at higher risk for complications. High risk includes patients who are elderly, pregnant, on a mental health caseload or have a medical condition that requires ongoing care. Inmates with these characteristics need to be followed and monitored on a more intense and frequent schedule. Inmates who are otherwise healthy still need to have a baseline health evaluation but it can take place anytime within 72 hours to 7 days after notification of hunger strike.
The baseline evaluation should include:
- Interview to determine what the inmate is refusing and the reason for refusal. Recommended questions to ask are:
- What was the last food you ate and when was it?
- Is this a total fast or are there certain foods you are willing to eat?
- How much fluid are you taking in?
- Are you refusing any prescribed medications or other treatments; if so why?
- Are you protesting something by not eating? If so what can you tell me about your protest?
- Are you expecting to die as a result of this fast?
- If not, how long do you intend to continue this fast?
This may not be a quick interview so plan to conduct it when you can give the patient your time and attention to the dialogue. The information that is obtained from this interview is important for the health care team to use in planning how to monitor and care for the patient over the course of the hunger strike. The nature of the encounter is the first step in establishing a relationship between the hunger striker and health care staff that is collaborative which will also be more critical over time.
2. Assessment of the patient’s physical and mental condition usually includes:
- Weight and height
- Vital signs
- Level of hydration
- Mental status evaluation
- Suicide risk assessment
- Any finding or condition that should be referred to a higher level of care.
3. Patient education about the adverse effects of dehydration, starvation and risk for complications. In particular patients should urged to drink fluids in order to maintain hydration, to take precautions against inadvertent injury because of weakness, dizziness, or confusion and when they are ready to resume eating to proceed cautiously. The nurse should also describe what the health care staff will do to monitor the patient while on hunger strike and attempt to solicit their agreement and cooperation. To supplement the information provided by the nurse during this initial encounter, the California Prison Health Care Service (CPHCS) has developed a one page fact sheet that can be given to inmates at the beginning of a hunger strike.
4. Disposition or initial plan of care. The nurse will schedule the primary care provider (PCP) to review the patient’s chart or see the patient based upon clinical findings. High risk patients need to be seen promptly or at least have their chart reviewed, including the nurse’s findings from the baseline evaluation. Patients who are not high risk should been seen or at least the chart reviewed within 48 hours but not longer than 72 hours after notification. The nurse also refers or schedules the patient to be seen by behavioral or mental health staff. The urgency of the referral is based upon the patient’s condition. Emergent or immediate referrals would include patients who are suicidal or psychotic. Urgent referrals would be anyone already on a mental health caseload. These appointments should take place within the next 72 hours. Routine referrals should be evaluated by mental health before the end of the first week.
5. Documentation of the baseline evaluation in the patient’s health record. This should always include a narrative progress note of the date and time health services was informed, most recent fluids and nourishment taken, and who was notified. Documentation also includes the findings of the interview and assessment, what was covered in patient education and their understanding, as well as the disposition. The note should list the specifics of all subsequent appointments that were scheduled. A flow sheet may be initiated for serial recording of health status (weight, vital signs, mental status, suicide assessment, hydration etc.).
Ongoing Monitoring: Once the baseline evaluation is completed nurses continue to monitor the inmate’s condition. On a daily basis the nurse checks to make sure that food and fluids have been available, monitors the patient for changes in mental status, collects information about fluid and food intake, solicits the patient’s description of bothersome signs and symptoms, provides advice to increase comfort and maintain hydration. It is also important that the nurse checks to make sure that provider appointments or referrals are taking place as scheduled, to review and act upon provider recommendations and orders.
Periodically, usually three times a week, the nurse collects supplemental information to include weight, mental status, hydration level, medication and treatment compliance. The provider may also have written orders for routine laboratory testing or labs when vital signs are abnormal. The nurse will schedule provider appointments based upon the results of monitoring or at least once a week. Each of these encounters as well as nursing actions should be documented at least in the progress notes. Use of a flow sheet to monitor changes in signs and symptoms can supplement but should not replace the narrative in the progress note.
Many facilities have adopted the use of a multidisciplinary treatment team to manage the ongoing monitoring and care of inmates while on hunger strike. Participants include medical, nursing, mental health and custody staff. It is helpful to also include the chaplain, food service personnel and anyone else who has a positive relationship with the inmate. These teams meet weekly or more often as necessary to share information, develop or revise the treatment plan and to coordinate interventions. Components of the plan should address housing, mental health needs, medical monitoring, legal advice and preparations for court intervention if necessary. Much of the discussion in developing and revising the plan of care will concern resolving the reason for not eating as well as management of medical and mental health status. Nurses should be prepared to think of this as a negotiation that preserves the patient’s health while finding a solution to the inmate’s issue that is realistic and acceptable while incarcerated.
Nurses maintain daily contact with an inmate on a hunger strike and each of these encounters is an opportunity to strengthen the nurse-patient relationship. It is important to maintain open and non-judgmental communication with the patient. Demonstrating respect for the inmate’s autonomy by providing choices and emphasizing the control they have without fasting will help dissipate the need to continue the strike. Findings ways to preserve the patient’s dignity may also help facilitate the patient’s decision to resume taking food.
Refeeding syndrome is a complication sometimes experienced by patients when they start to take nutrition again and the body doesn’t adjust to changes in glucose metabolism and electrolyte balances. Risk for refeeding syndrome increases the longer a patient has fasted, how much weight they have lost (BMI) and the presence of underlying medical or mental health conditions. Nurses monitor patients at risk of refeeding syndrome on a daily basis which may include vital signs, intake and output, collecting lab specimens, EKG monitoring, observation for fluid overload, provision of electrolyte or vitamin/mineral supplements. Even inmates at low risk still benefit from the advice start by eating and drinking small amounts and to increase portions very slowly over several days to a week.
Additional resources for nursing care of patients while on hunger strike include:
- Oregon Department of Corrections Policy and Procedure P-G-05.1 Management of Inmate Hunger Strikes available at http://www.oregon.gov/doc/OPS/HESVC/docs/policies_procedures/Section_G/PG05.1%20Management%20of%20Inmate%20Hunger%20Strikes%202012.pdf
- Federal Bureau of Prisions, Clinical Practice Guidelines, Medical Management of Malnutrition (September 2014) avaialable at: http://www.bop.gov/resources/pdfs/malnutrition.pdf
- Jail Medicine by Jeffrey Keller. A Step by Step Approach to the Hunger Games (May 29, 2012) available at http://www.jailmedicine.com/a-step-by-step-approach-to-the-hunger-games/
- Caple, C. Schub, T. Refeeding syndrome: caring for the patient with or at risk for. Nursing Practice & Skill, Cinahl Information Systems, Glendale CA (April 18, 2014).
What practical advice would you give nurses about the care of inmates while on hunger strike or prolonged fasting? Add to the advice given here by responding in the comments section of this post.
For more on this subject Lorry Schoenly discusses the ethics involved in the care of patients in the correctional setting, including hunger strike in Chapter 2 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.
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