Now, three years later and after attending many more vigils, it’s not necessarily any easier for Steve when a hospice patient, with whom he usually has developed an intimate bond, dies, but he certainly has a much better understanding of death—and of his own humanity. "One of the biggest fears in prison is that you’ll die alone," he says. "When I walk into the room and his eyes light up, it’s really rewarding."

Steve was among the first group of 19 hospice volunteers at Oregon State Penitentiary, Salem, a maximum security facility that houses about 2,000 male inmates. The program, launched in April 1999 after 20 months of preparatory work, came about after health services manager William Cahal, CCHP, attended a session on hospice at an NCCHC conference.

Since OSP is one of the few state prisons with an infirmary, it receives many of the most desperately ill patients. "We were providing very good medical care for dying patients, but since we always tout ourselves as meeting community standards I felt we should look into this hospice philosophy," says Cahal, who was nurse manager at the time.

The much-acclaimed program won NCCHC’s 2001 Program of the Year Award in recognition of its "proactive role" in preparing individuals and the system to deal with dying inmates, and in helping those inmates to experience humane, comfortable and dignified deaths.

The team felt that none of those hospices exactly suited their needs, so they created a model that blends features from other programs with their own enhancements. Of primary importance: To create a model that could be adopted by other Oregon prisons, with a single governing body to oversee the entire program. To date, three facilities offer hospice care.

Another priority was to have inmates, rather than staffers or community members, serve as hospice caregivers, says nurse manager Ted Randall, RN, who’s OSP’s volunteer coordinator. He now manages 21 volunteers, most of whom have been involved from the start.

Volunteers must meet certain criteria to take part in the program. For example, inmates convicted of sex or drug crimes are disqualified, and any who end up in disciplinary segregation are dropped

A respected community hospice trainer conducted the initial education and still meets monthly with the volunteers for refreshers and to help keep them motivated. A weekly meeting with a nurse covers matters such as how to move patients or place pillows. A third type of meeting occurs at the chapel, where volunteers work through bereavement issues with the chaplain or a social services professional.

The interdisciplinary hospice team, which includes one volunteer representative, meets weekly to discuss patient treatment plans.

Another notable aspect of the program is that terminally ill inmates live in their cells as long as possible. "We start them on pain medication if they need it and assign a volunteer to visit them. When the disease progresses to the point where they can’t live there anymore, we bring them to the infirmary," says Cahal.

Those in the last stages of life may be moved to a room that affords more privacy. With murals on the walls and furnished with a couch and chair, a television, VCR and CD player (most of which were donated, Cahal points out), the setting is more comfortable for patients and visitors.

Visitation rules are quite relaxed for hospice patients, and may vary depending on what’s appropriate for any given patient. The volunteers may visit 24 hours, family members, including children, may visit daily, and even inmate "family" and friends can visit. In the last day or two of life, volunteers and family can remain at the bedside continually.

Patients also are granted special requests, such as favorite foods.

Universal Acceptance
Cahal says that while the hospice has been largely trouble-free, the planners did make one misstep: they failed to adequately consider the attitudes of the health care workers.

"We went to great lengths to educate the custody staff, but took it for granted that the health care staff would accept it," says Cahal. Some nurses felt their role in "health care" did not extend to the dying; others said the inmates didn’t deserve hospice. Deeper discussion of hospice philosophy and good experiences with the program have overcome those grumblings.

As important, the hospice has been embraced by those terminal patients who are ready to accept death, by their families, by the prison population at large (many of whom used to suspiciously view the infirmary as the "place of death") and by volunteers.

For Steve, who’s serving a life sentence but hopes for parole, the experience has been transformational: "It has touched parts of me that hadn’t been touched in many years. It raised questions about my values, and showed me that some things I thought were important really aren’t. Now I realize that family and friends and close relationships are what’s truly important."

— About the Author: Jaime Shimkus is NCCHC publications editor.