As such, many incarcerated individuals live with a terminal or chronic condition for days, weeks, months or years prior to their death. The vast majority of deaths in prison are because of illness, such as heart disease or cancer among people aged 50 or older ( Carson and Cowhig, 2020). In 2016, over 4,000 people died while confined to a US federal or state prison. The growing number of incarcerated older adults in the USA means that more people live with serious illnesses and die behind bars. Studies suggest that completion of advance directives is highest among women, white people and college-educated people ( Rao et al., 2014), and low completion rates are partially driven by lack of awareness of their importance ( Yadav et al., 2017). Yet, a relatively low percentage of Americans (26–37%) have completed an advance directive. The Act requires these facilities to provide education to staff and patients about these documents ( Patient Self-Determination Act, 1990). For example, the Patient Self-Determination Act (PSDA) of 1990 requires all health-care entities receiving Medicare or Medicaid funding honor patients’ advance directive documents, including health care power of attorney and living wills. There have been significant efforts to increase the use of advance directives in the USA. Patients use a health care power of attorney to designate a person (or people) to make health-care decisions on their behalf if they are temporarily or permanently unable to communicate their wishes. Typically, an advance directive includes a health care power of attorney and a living will or statement about a person’s care preferences at the EOL. Advance directives are a component of advance care plans that allow people to communicate their wishes for care at the EOL with their loved ones and health-care team. Although appropriate for adults of any age, advance care planning is of particular relevance for older adults and those with terminal conditions approaching the EOL ( American Medical Association Code of Medical Ethics Opinion 5.1, 2021 American Geriatrics Society, 2017). This study describes and compares these EOL decision-making policies and provides suggestions to optimize care in this area.Īdvance care planning is the process that supports patients to understand and share their goals and preferences for future care. In this study, we analyze correctional policies that provide guidance, rules and/or restrictions on EOL decision-making for incarcerated people across US federal and state prison systems, including the process for documenting patients’ EOL wishes. Although supporting patients to make informed medical decisions is a core element of community standard care for people with serious, life-limiting illness, no studies to our knowledge have analyzed the US prison policies regarding patient autonomy and decision-making among incarcerated patients regarding decisions about medical care at the EOL. Medical decisions commonly made at the EOL (“end-of-life decision-making”) may include identifying a health care power of attorney and deciding in advance to accept or decline curative medical interventions or advanced life support (“do not resuscitate orders”). As a result, there is a growing need for specialized geriatric and of end-of-life (EOL) care in prisons, including clear delineation of the decisions people, who are incarcerated, can make when facing serious, life-limiting illness. Although prison deaths occur among people of all ages, older adults account for most deaths in prison because of their increased burden of chronic and/or serious life-limiting illnesses ( Carson and Cowhig, 2020). Older adults make up the fastest growing age demographic in prison populations, comprising 3% of the prison population in 1993 but 10% of the prison population in 2013 ( Carson and Sabol, 2016). The US prison population is aging rapidly, eclipsing the rate of increase of the population of non-incarcerated older Americans.
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