Meeting end-of-life care needs for patients in custody

To the Editor: The medicolegal complexities of withholding and withdrawing medical treatment in end-of-life (EOL) settings have been discussed in the Journal by White and colleagues.1 EOL care is becoming increasingly important in the incarcerated population, posing unique challenges for health services.

Although health teams are accustomed to discussing EOL issues and instituting advance care directives (ACDs) within the general community, knowledge of the legal implications of implementing ACDs in the prison setting is lacking.

We see that it is becoming more important to have reference frameworks when exploring the EOL wishes of inmates. An ageing prisoner population, increasing incarceration times, underuse of preventive and screening schemes before incarceration, mental illness, illicit drug use, and high rates of tobacco smoking and alcohol misuse are some of the identified behaviours limiting life expectancy in this group.2

To ascertain current Australian practices, we emailed the prison health authorities of other jurisdictions. A number of jurisdictions are beginning to engage patients in custody regarding their EOL care wishes, and are trialling the implementation of ACDs. However, to our knowledge, no jurisdiction has established EOL care policies for prisoners with life-limiting diagnoses.

Within the Australian Capital Territory, we have access to palliative care expertise both from our public hospital (the Canberra Hospital) and local hospice. To date, only one prisoner has been transferred to the hospice for EOL care. In the United States, hospice care is available in a specially allocated area of a prison hospital.3 Identified factors influencing the EOL wishes of prisoners include sentence length, ethnic minority status, and the patient's trust of the custodial system. Although access to hospice care has been incorporated into some US prisons, there are no published Australian or international studies on management of withholding and withdrawing treatment in this setting.

The distinct demographics of the prison population in Australia mean that more work is required to inform justice health systems on how to effectively implement ACDs, EOL care requirements and subsequent decisions about life-sustaining medical treatment.