The challenge of caring for incarcerated patients

A recent survey found gaps in clinicians' understanding about care under incarceration.

When a patient is brought from a jail for hospital care, there's a lot hospitalists and nurses need to know, from how to handle decision making to whether shackles are required.

“Doctors and nurses want to do the right thing. They want to provide the same care to incarcerated patients as we do all our patients, but we need guidance and clarity on how to do so,” said Lawrence A. Haber, MD, an associate clinical professor of medicine at the University of California, San Francisco (UCSF), and a hospitalist at San Francisco General Hospital and Trauma Center.

To assess clinicians' knowledge, attitudes, and practices regarding incarcerated patients, he and colleagues surveyed 26 attendings, 26 residents, and 24 registered nurses at a 284-bed safety-net hospital that serves as the primary referral hospital for its county's jail system. Survey participants were asked knowledge questions focused on documented legal rights and hospital policies, with a single open-ended question assessing their perceptions regarding differences in care.

The results showed gaps in understanding around the topics of legal surrogate decision makers, in-hospital shackling rights, and mandatory bedside presence of custody officers, according to results published online in January by the Journal of General Internal Medicine. As one physician said, “I am unsure of the policies regarding incarcerated patients and never received training in this during residency or from my employer.”

The clinicians reported that they generally feel safe when caring for incarcerated inpatients and interacting with officers. However, some physicians reported safety issues and difficulties in the patient-doctor relationship. One physician reported being physically assaulted by a patient in custody who was shackled to the bed. Another wrote, “I try my best to provide the same care to incarcerated patients...but the reality is the doctor-patient relationship is severely affected by their captivity. There is no true autonomy, which should be the foundation of the relationship.”

The vast majority of clinicians said they believe that incarcerated patients should receive the full range of hospital care, including transplants. However, some clinicians reported that incarcerated hospitalized patients received fewer medical interventions (39% of physicians and 5% of nurses) and fewer nonmedical interventions (80% of physicians and 25% of nurses).

Dr. Haber and lead author Katherine C. Brooks, MD, an assistant clinical professor of medicine at UCSF and a hospitalist at San Francisco General Hospital and Trauma Center, recently spoke with ACP Hospitalist about their findings.

Q: What led you to study this issue?

Dr Haber
Dr. Haber

A: Dr. Haber: My own discomfort and uncertainty around managing hospitalized patients who arrive in custody from the community or from our local jail. As someone interested in health equity, there were things about caring for incarcerated patients that started to bother me. Seeing your patient shackled to a bed, having privileged conversations with a patient while a third party watches over the interaction, not being able to fully disclose discharge plans or communicate with a patient's family—these things felt distinctly at odds with our usual practices or what we try to model for trainees.

Q: Can you describe your most interesting results? Did they surprise you?

Dr Brooks
Dr. Brooks

A: Dr. Brooks: There seemed to be a disconnect between providers' opinions and practices. Most providers felt strongly that incarcerated individuals should receive the full range of medical care and expressed that they should be treated the same as nonincarcerated patients. At the same time, we were surprised by how few providers are asking correctional officers to step out of the room or remove shackles for a history or exam. Many providers feel unsure if they are even allowed to advocate for their patients' privacy or request removal of shackles.

Q: What could be done to improve or better standardize hospital care for incarcerated individuals?

A: Dr. Haber: I think as a first step, clarifying for clinicians the rights of incarcerated patients and current institutional policy and then developing best practices around four major clinical areas: shackling, patient privacy, surrogacy, and discharge counseling. When we understand that there are differences in care that are forced by the intersection between health care and the criminal justice system, then we can work towards mitigating the negative health consequences of incarceration. For example, I don't think it's enough to just say, “We treat everyone the same here” and then keep a patient in shackles while we examine them. That's not the same care we usually deliver.

Q: Do you have any advice for hospitalists who care for incarcerated patients?

A: Dr. Brooks: When in doubt, remember that incarcerated patients are entitled to the same standard of medical care and have the same decision-making rights related to their medical care as nonincarcerated patients. If a custody officer or other health care provider tells you something that feels like it goes against these basic principles, it's worth looking into it further and advocating for your patient to supervising custody officers, hospital administrators, legal advisors, or the referring health care provider at the correctional institution.

Q: What are the key takeaways of this study for clinicians?

A: Dr. Haber: If you care for patients who are incarcerated and are confused about best practices, you are not alone. The first step in moving towards equitable and excellent acute care for this population is acknowledging the confusion and disparate practices. The second step is asking what we can do to change practices and policy to improve acute care for these patients. Finding local rules and policy can be challenging, but good starting points include asking your risk management department, hospital security group, or the health care provider at the referring correctional facility. If it turns out specific hospital policy doesn't exist, that's a good time to start making one!