Prison

Prison

Tuesday 23 September 2014

The ‘Do Not Resuscitate’ Movement in Prisons

I decided to write this post following recent media coverage of two deaths of prisoners in UK prisons during the past week. Both were natural deaths, in the sense that the cause of death in both cases was a long-standing serious illness, but the detail that caught my eye was that the two cons concerned had both signed ‘Do Not Resuscitate’ (DNR) instructions – one had even had it tattooed on his body.

Pity about the spelling
These two stories interest me because I myself signed just such an order – often referred to in medical circles as a “No Code” – while I was in prison. It is a legal form that (in theory, at least) is supposed go on a patient’s (or prisoner’s) file to prevent the administering of cardiopulmonary resuscitation (CPR) – including chest compressions or the ‘kiss of life’ or advanced cardiac life support (ACLS) if that person’s heart stops or they have ceased breathing. In essence, a DNR means that if you stop breathing, you don’t want to be brought back. You want to stay ‘brown bread’ (dead).

You might be surprised just how common this sentiment is in prisons, even among those cons who aren’t feeling suicidal. I know a fair number of lifers, or inmates serving Indeterminate Sentences for Public Protection (IPPs), as well as elderly prisoners, who have signed up for DNR in order to make their wishes clear. 

As I’ve written in the blog previously, I’m not the suicidal type myself, but I have seen some real horror stories inside prison when it comes to healthcare – or the lack of it – in the nick. After one terminally-ill prisoner who really wanted to die was repeatedly resuscitated by wing screws (who no doubt meant well), I decided that in the unlikely event that my slightly high blood-pressure did stop my ticker beating, I most certainly didn’t want to suffer the same fate.

IRC Morton Hall
My reasoning was as follows: if I was so unwell that I experienced sudden cardiac death while in prison, there would almost certainly be an extended delay in any type of help arriving. If you doubt this, just look at the media coverage of the recent death in detention of Rubel Ahmed, a 26-year old immigration detainee at Morton Hall Immigration Detention Centre in Lincolnshire. 

Although the alleged circumstances of Mr Ahmed’s death are being disputed by the Home Office – which has informed his family that he committed suicide – other detainees have spoken of him suffering from chest pains the evening before his death and claim that he desperately tried to attract staff attention to get help by banging on the locked door of his room, but was ignored until it was too late to save his life. Let’s hope that the truth behind this tragic incident will eventually come to light during the investigation and inquest. 

However, this sort of incident is one of the main reasons that I – and other prisoners – signed up for DNR. Perhaps the one thing worse than being dead is surviving in some horrendous persistent vegetative state on life support owing to irreversible brain damage because of long delays before CPR is attempted. Being in prison was bad enough, but that would be far more of a trauma for my family, so I spoke to the duty nurse in Healthcare and asked if I could sign up.

Typical DNR form
The reaction was somewhat unexpected. I was immediately quizzed as to whether I felt suicidal? No, I explained, but I do have a history in my family of sudden cardiac death, as well as higher blood pressure than normal for a man of my age. The nurse reacted with about as much hostility as if I’d put in a request for a length of rope or some cyanide with which to top myself!

Next, she made an urgent appointment for me to see the duty doctor. This was actually the first time I’d seen one in the slammer. He was extremely pleasant and we had a very relaxed chat about my concerns. 

Although he did express the view that CPR in such cases can have a positive outcome, he also agreed that extended delays in the administration, such as can occur in prison setting, might not be a great clinical decision in some cases. Having satisfied himself that I wasn’t about to use the TV coaxial cable to string myself up anytime soon, he agreed to put the required note on my medical file and to ensure that both wing staff and the healthcare team were aware of my wishes. He did, however, book me in for a routine electrocardiogram (ECG), just to check my heart. And he tested my blood pressure, which wasn’t too bad.

Getting the message over
Of course, in reality I also accepted that even having signed up for DNR, there was no means of guaranteeing that the night screws – who often find that they have to deal with this type of emergency – would even be aware of the notes on my prison file. When the alarm is sounded at 3 am, checking the computer doesn’t come very high on the list of priorities.

There is another irony about my own decision to sign up for DNR. In my first nick I trained as a gym orderly. When I was sent down I was actually in pretty good shape and used to visit the gym four times a week after work, as well as run regularly, so I was quite keen to stay fit and keep my weight down. Working in the gym was an attractive option.

A qualification many cons gain
Part of the gym orderlies’ course was called Heartstart, sponsored by the British Heart Foundation, and I am trained in Emergency Life Support (ELS) skills, including CPR. Quite a few cons take these courses, so there are probably more qualified first-aiders on prison landings than there are outside in the community. 

On occasion, cons who have given up the will to live, will attempt suicide and I’ve known individuals personally who have written ‘DNR’ on their chests, carved it into their flesh with razor blades or even tattooed it prominently on their bodies (a breach of the prison rules on tattoos, by the way). In these cases, there’s also no guarantee that anyone will take any notice of their wishes, but I suppose it is a pretty forceful statement of intent. For a person who doesn’t have anything much to live for, death – in either its natural or premature forms – can seem to offer a way out and, sadly, for some prisoners it can seem to be the best chance they have for release.

15 comments:

  1. If u have a prison job can u still do a course n not lose your job. Vas

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    1. Thanks for your comment, Vas. Sure. I did quite a few different courses, including the gym orderlies' course and various certificates, as well as doing my job.

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  2. My family has a history of high cholesterol, which has led to a couple of heart attacks. I have low blood pressure and no sense of fear, which probably explains why I drive too fast and crash my car

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    1. Thanks for your comment. From what I gather, low blood pressure can also be a problem for some people, although the real health risk is from high blood pressure. That's the first time I've heard that low blood pressure can impact on driving style!

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  3. Thank you, you've raised some really important issues. Whilst not a DNR issue I needed a tooth extracting during my time inside. After many months I was offered an appointment but declined it as I feared the rather randomly decent/appalling healthcare would leave me with more problems and pain without relief than I had without intervention (painkillers are very hard to get hold of on prison wings).

    I've only once witnessed a horrendous attempt to save an inmates life by staff. He'd hanged himself in his cell overnight, the OSG found him in the early morning and screamed loudly. A couple of radio calls later, real screws arrived - protocol to open the door - along with the nurses on duty that night. What amazed me was that a nurse was shouting for her 'other bag' to be brought to her. A few minutes could have saved a life. I sadly know now (after reading the Coroners report) that in this particular case nothing would have helped but the staff just didn't have the right equipment with them. Tragically the you young man succeeded in his suicide attempt and a young family was destroyed.

    I didn't serve a long sentence but know many who were. I can fully understand why a DNR request would be made. It's an absolutely miserable existence, especially on a life or IPP term. If I was on such a sentence I'd be looking for the fastest medical way out. Thankfully IPPs are no more but folk are still serving them.

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    1. Thanks for your comments and for sharing your own experiences. I think you've raised a very important point. Quite a few prisoners will refuse to use prison healthcare facilities because of their perception that the standard of care is so poor or even that the way in which some healthcare staff treat them is so rude and disrespectful that they would rather suffer in silence, in some cases with terminal outcomes.

      We all know that men in general can be notoriously neglectful of their own health and reluctant to seek medical advice at the best of times. My view experience is that this is even worse in a prison environment.

      Another key issue is the reluctance of healthcare staff to prescribe powerful pain-relief to cons. The default setting appears to be paracetamol or ibruprofen, whereas in the outside world much stronger medication would be prescribed. Obviously, there are concerns over trafficking or resale of opiate-based pain killers, but all too often, I think that prisoners can suffer unnecessarily.

      I've written on this blog before about prisoners returning to the nick from hospital after having serious surgery and having their prescribed medication confiscated by security. On occasion, I honestly believe that this is done deliberately to make cons suffer in agony, rather than because of genuine security concerns.

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    2. Doctors and their assistants sign the Hippocratic Oath so they are obliged to treat everyone the same way.

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    3. Thanks for your comment. Unfortunately, prison security staff don't sign the Oath and they can be a law unto themselves when it comes to confiscating medication issued by hospitals. I've also experienced the withholding of prescription glasses from the partially-sighted and witnessed removal of walking aids and other equipment even when authorised by healthcare.

      In terms of the way some - not all - healthcare staff treat prisoners, I can only say that if I'd been on the receiving end of such rudeness and negligence (prescriptions lost, files mislaid, test results missing, medication not ordered etc) at my local doctor's surgery, I'd have put in a fair few formal complaints! Many other cons have had similar or worse experiences.

      Of course, I don't under-estimate just how challenging the prison environment can be, and some cons can also be very rude and abusive, particularly if they don't get what they feel they should. On the other hand, I pride myself on my politeness and had never been rude or shown anger or resentment to prison medical staff, yet at two prisons I've received some really appalling and humiliating treatment that was far from being what I'd expect or tolerate from NHS professionals outside prison.

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    4. All NHS professionals are registered with regulatory bodies that set out rules and codes of practice (eg NMC, the Nursing and Midwifery Council). If you make a complaint about a nurse, the NMC will investigate, and humiliating or maltreating a prisoner could well lead to their being struck off the register. It's worth considering even now; those individuals are probably still doing the same things to other prisoners. Despicable. Prison healthcare staff are supposed to provide an oasis of respectful, kind and competent care, where their patients can feel safe and valued. Anything less is unacceptable.

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    5. Thank you for your comments. The problem that prisoners often have with healthcare staff is that they rarely know their names and the personnel seem to change so frequently. I'm not sure whether this is because they are agency staff employed by NHS trusts. Without knowing names of the individual staff, it's very difficult to make complaints.

      I've been in two prisons where there have been serious professional mistakes made by healthcare staff (usually involving handing out the wrong medication to prisoners in error), yet even when written complaints have been made, there has been a complete cover-up. I was in the education department one day when a prisoner arrived late for class because he had been at a healthcare appointment. He suddenly collapsed on the floor and stopped breathing.

      A Code Blue was called and the alarm sounded. We commenced CPR because it took healthcare about 15 minutes to arrive and the lad had turned blue. Had we - the cons - not been Heartstart trained, I reckon the lad would have died. He had been given the wrong medication by healthcare for a serious medical condition and the negative reaction caused him to stop breathing. Later, after he'd recovered, he made a formal complaint, but healthcare completely denied that any mistake had ever taken place. That, I'm afraid, is the reality of prison healthcare and I could give another dozen examples from my own experience.

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  4. Working in the medical field I can tell you most medical staff have DNR'S on their files and most oncologists would refuse chemo for cancer, as we know the quality of life issues that occur if survival actually happens.

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    1. Thank you for your contribution. That is very interesting to know, particularly from a medical professional.

      I also think that sometimes there can be a confusion among non-medics between a DNR order and 'give no medical care'. As you'll be aware DNR applies to very specific medical circumstances, rather than euthanasia by the backdoor!

      I'm also interested by your comment on chemo. I have a close family member (now in his early 40s) who has twice had extensive treatment for non-Hodgkin's lymphoma over the past decade and is currently in remission. Obviously he enjoys a good quality of life (two kids and a professional job), so the outcome - thus far - has been positive. However, at my age, I'm not sure what I'd do if I was in the same position. Very interesting debate. Thanks for raising it.

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  5. Hmmm this reminds me of the Liverpool Care Pathway (LCP)

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    1. Thanks for your comment. As I understand it, the main problems with the Liverpool Care Pathway were lack of informed consent and, even more damaging, a link between NHS trusts and financial incentives for hitting targets when using the LCP. Following negative media coverage, I gather that the Department of Health ordered it to be phased out.

      One of my own concerns over DNR in a prison setting is the extent to which the factor of imprisonment may influence an individual signing up for a DNR order, particularly if they are serving life or a very long sentence. I accept that there is a quality of life issue here, but given the high numbers of cons who live with depression and other mental health conditions, it seems to me that such decisions can be heavily influenced by situational concerns (ie would the person make the same decision to sign up for DNR if they were living at home with their family?).

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  6. From a viewpoint of a student who has been researching this issue for a few months, the general consensus is that DNR orders are to be always respected. However there have been those instances where mix-ups have occurred and also good intentions were not understood well from bystanders. This is one of the reasons why these issues must constantly be revised, in order to prevent any more of these mistakes from happening again.

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