Foreword for

A Handbook for End-of-Life Care in Correctional Facilities
Volunteers of America
Alexandria, Virginia, 2001

The publication of this Handbook for Improving End-of-Life Care in Corrections marks a period of remarkable achievement in efforts to establish prison hospice programs. Ironically, this progress comes at a time of unprecedented challenges confronting correctional systems and particularly correctional health care.  

Swelling prison populations and crowded conditions have stressed state and federal departments of correction. An aging inmate population and high rates of drug abuse and of hepatitis, HIV infection, cancer, heart and lung disease all contribute to straining correctional health care budgets to the breaking point, and sometimes beyond. 

Distrust and tension surrounding access and quality of health services are facts of prison life.  Prisoners, their families and inmate advocacy groups are accustomed to fighting for adequate medical care. Indeed, the history of correctional health care is marked by battles fought, and mostly won, in the courts.

Dying in prison is the thing inmates dread most. However, in the current environment, marked by political support for harsh sentences and hard time, compassionate release programs have all but disappeared. For more than 3,300 inmates a year, death occurs in confinement. These days cynicism among seriously ill inmates runs high. The prospect of medically excellent and compassionate B even loving B care for dying inmates seems implausible, at best. Yet, these are precisely the goals of prison hospice programs and in demonstration projects around the country, this is exactly what is occurring. How is this possible? 

Credit for this improbable progress belongs to a number of individuals, organizations and stakeholders. Courageous, but also cautious wardens and superintendents, and leaders within departments of corrections have allowed these experiments to proceed, without sacrificing the priorities of detention, safety and security. Inmate rights advocates have provided impetus in continuing to push for state-of-the-art treatment and compassionate care for dying prisoners. Leaders in the hospice movement have reached out to prisoners and clinicians working in correctional health settings to offer expertise and resources in adapting protocols to the prison environment. And the nurses and physicians who care for inmates have exhibited true professionalism in adapting their practice to incorporate these innovative programs. 

But the largest measure of credit for the emergence of prison hospices belongs to inmates themselves. While the existence of prison hospice programs seems improbable, the altruism and tireless efforts of the inmate volunteers, on whom these programs depend, is truly extraordinary. 

In visiting with prison hospice volunteers and correctional staff and observing this progress, I have often thought of William Golding=s novel, Lord of the Flies. It is a story about adolescents stranded on a remote island and stripped of the usual constraints of civilized life. Gradually, cooperation gives way to competition, conflict and, ultimately, chaos. Penitentiaries are, in a sense, islands, deliberately isolated within society. They are dangerous places in which isolation and anger abound and hostility finds fertile ground. Here choices between cooperation and conflict must be made daily.  

Yet in the phenomenon of prison hospices we see the opposite of the chaos of Golding’s island. Prison hospice volunteers daily make a self-less commitment to others, with no hint of material reward, and work together to create a civil community in their midst.  More than one correctional official has confided to me that the hospice program is having a transformative effect on their facility.  

The patience, compassion and countless hours of work of the hospice volunteers, are declarations of the inherent dignity and value of human life. Their commitment to the program and to one another is a statement of hope. It is not merely a wistful belief in a better future, but a vow to build one. What a testament to the human spirit!

Ira Byock, MD, is Director of Promoting Excellence in End-of-Life Care.
The GRACE Project of the Volunteers of America  is one of the demonstration projects of Promoting Excellence in End-of-Life Care. 

Foreward for: A Handbook for End-of-Life Care in Correctional Facilities Volunteers of America Alexandria, Virginia, 2001 Ira R. Byock, M.D.

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