CorrectCare

Doc, I Gotta Have That Pillow!
When Requests for ‘Comfort’ and Care Collide

By Michael Puerini, MD, CCHP, and Steven Shelton, MD, CCHP-A

Many correctional health care providers come from a private practice environment in which we would do anything possible to improve the comfort of our patients.

We are all, first of all, caregivers, and good ones. While this caring is positive and important, in corrections not everything that is possible is practical.

This subject came up yet again at a meeting of health services managers for the Oregon Department of Corrections. Discussing the many requests we receive for items and accommodations that clearly are not related to medical necessity, we realized that there is wide variability in practice regarding “comfort” orders.

Since this subject resurfaces so often, we have written this article to shed light on the issues and describe what we are doing about it.

Job #1: Health Care
A 1976 Supreme Court case—Estelle v. Gamble—established the constitutional right of inmates to health care for their “serious medical needs.” This is the legal basis for health services in corrections.

With the positive evolution of health services in correctional settings, our time is consumed with delivering quality services to sick patients. And as inmate populations grow older, we increasingly are called upon to deal with very serious medical conditions.

In the mental health arena, we have become the caregivers of some of the most disturbed patients in our society. (For a vivid illustration, see the PBS Frontline program “The New Asylums,” which received the 2005 Anno Award of Excellence in Communication.)

Given the demands to deliver more and more “real” care, health staff time is an important resource that we must ration carefully, in much the same way that we ration our financial resources. We can no longer afford the luxury of spending a lot of time discussing nonmedical issues with patients.

Nevertheless, our staff has long come under pressure—from inmates and often from security staff—to intervene in areas of inmate comfort and prison operation.

Physicians, nurses and mental health staff are called upon to make bunk assignments, define inmate work (by restricting people from jobs they don’t like) and prescribe such elective items as mattresses, pillows and shoes. We are asked to make medical orders in the chart about how an inmate is shackled and even about what procedure to order when an inmate is searched.

Dealing with these requests can be touchy. After all, health care staff do have the power to bend the rules for our patients. Unlike just about everyone else, we can issue orders that result in a given inmate being treated differently from the others. We must wield this power carefully, always evaluating the medical evidence that supports such orders.

Sometimes there are objective reasons to bend the rules. Frequently, however, there is no clear, evidence-based indication for a medical order (“I am allergic to pork and can’t work in the kitchen”). Often it is outside our area of expertise or responsibility (“I need wide shoes.” “I need a soft pillow.”) Sometimes it simply seems more expedient to do as we are asked (“This patient needs a medical order for somebody to push his wheelchair”).

Consistent, Evidence-Based Care
There are many reasons for us to work toward a more objective, evidence-based approach to our work in correctional health care.

First, finding objective evidence of bona fide serious medical problems helps us to practice effective health care. For example, if a patient says he has severe nasal allergies but has no mucosal congestion or redness of the eyes, there is no objective evidence of serious illness. If the patient says he has diabetes, we check a hemoglobin A1C to confirm his claim.

At the Oregon DOC, we also work within the concept of levels of therapeutic care. We avoid prescribing elective and unnecessary items, even if there is no or minimal treatment cost involved.

Frequently, there is no objective, evidence-based intervention, in which case we should perhaps decline to discuss the issue. For example, no medical study supports the use of one kind of mattress over another. When we discuss such unproven remedies, we are taking this time from more important medical issues that need our attention.

Sometimes it seems easier to “give in,” but in the long term we will spend more time and energy if we do so. For example, patients sometimes argue for comfort items in a manipulative way, and by giving in to the request, we are encouraging manipulation. The Oregon Accountability Model says that our primary goal is to “hold inmates accountable,” even while delivering care.

Also, by practicing and prescribing in a consistent, objective, evidence-based way, we educate our patients about reasonable expectations in the health care arena. Such education is essential for our patients, many of whom will parole in the near future.

We also do ourselves a favor. Many correctional health professionals are frustrated with continual demands for nonmedical intervention. This simply is not what we have studied and trained for. By freeing ourselves up to practice our profession, we will increase our job satisfaction and effectiveness.

Finally, we minimize liability risk when we apply policies consistently between and within our institutions. We all know how inmates respond when they perceive that “the other guy got extra socks from health services” and they didn’t.

Remedying the Problem
Since 1994, the Oregon DOC has followed level-of-care policies and procedures that address these issues. (See ODOC Policy P-A-02.1.)

Since caregivers may become worn down from nonmedical requests from time to time, we suggest the following measures to reduce inappropriate requests and to help health staff handle those that do arise.

1. Provide regular, consistent education to patients about the proper role of health services in their lives, with emphasis on their expectations about necessary medical care, comfort items and levels of care (see “Notice” above). Subsequent messages could be worded more simply.

2. Be consistent with medical, nursing, dental and mental health orders. Generally, we should default to declining to provide comfort items or nonmedical orders unless there is a clear-cut medical reason with a solid foundation in evidence-based practice.

3. Consider developing a “formulary” for nonmedical interventions. What form this will take is open to an ongoing dialogue.

4. Develop a review process for nonmedical interventions at every institution and apply it consistently.

5. For all medical interventions in this area, there should be accountability for who made the order and why. Develop policy that ensures that health staff are held accountable and that provides for time-limited, written medical orders.

— About the authors:  Michael Puerini, MD, CCHP, is chief medical officer at OSCI, Salem, OR, and Steven Shelton, MD, CCHP-A, is medical director at ODOC. This article was written with assistance from Bridgett Whalen, RN, health services manager at TRCI, Umatilla; Garth Gulick, MD, staff physician at SRCI, Ontario; and Daryl Ruthven, MD, ODOC chief psychiatrist.

[This article first appeared in the Winter 2006 issue of CorrectCare.]