Nikhil Sanyal explores how palliative care and the doctor-patient relationship are complicated when that patient is a prisoner
I recently looked after a man who was dying from metastatic lung cancer. This, in and of itself, is not a particularly remarkable statement given that I work as a palliative care doctor. However, this man was not like any of my other patients to date. He was a prisoner.
Prisoners, like all people, die. This is something we all know in an abstract way, but I think it’s easy to forget that prisons are full of people who get sick and need treatment.
When we hear of a particularly brutal crime, people will often express their anger or horror with the wish, “I hope they rot in jail.” Yet I wonder if people really give the death of a prisoner a second thought? Before I met and cared for this particular patient, I cannot say that I had. Consequently, it came as a shock the first time I cared for a man shackled to two large prison guards who remained present for all discussions—no matter how private or painful.
As doctors, we are steeped in the ethos that we must treat all patients with dignity and compassion. This principle applies to prisoners too, however, I think this can be easier said than done. This patient came from a prison that only deals with a certain category of crime and, as such, I likely unconsciously formed an opinion before I even met him. We all form judgments and being a doctor doesn’t make me immune to this. The real effort in caring for a prisoner came from overriding these judgments to show compassion.
Within palliative care, I think that there is an unspoken view that we should like all our patients. This is not realistic, although it would certainly make our role less complicated. True holistic palliative care involves attending to the physical, psychological, and spiritual needs of our patients and experiencing their death alongside them. This can often mean being present as patients voice their fears, unburden themselves of a lie, face the process of introspection that is commonplace when dying, or simply holding their hand. This is not easy to do when we may fundamentally disagree with or disapprove of the actions of the person we are caring for. The most skilled healthcare professionals can rise above this, but building that degree of skill takes time.
In this case, at times I found I had to stop and ask myself if I was providing the same level of care I would to another patient. Of course, I would never consciously have treated him differently, but at first I found reasons not to stay in his room too long, or to ask too many questions. When I realised I was doing this, I forced myself to stay longer in his room. When I found myself thinking about wrapping up the conversation, I asked just one more general open question.
As time went on, I think the patient opened up to me a little. He spoke of his dread of dying because he felt he was going to hell. If I had heard a non-prisoner patient say something like that, I would have immediately wanted to explore and assuage their fears. But with this patient I found that those reassurances would not come. Looking back, I find it uncomfortable to think that I may have left him to these fears.
I struggled between wanting to know more versus not, worried that any further knowledge might make my job more difficult. This struggle was made harder as our job as doctors relies heavily on asking (sometimes personal) questions, but I wanted to avoid accidentally leading this man to talk about events that had led him to prison. At a team level we knew only that his crimes were of a sexual nature, but on an individual level all it would have taken to find out more was to search the internet. I came close to doing this once but immediately felt ashamed and closed the window.
When healthcare staff are aware that a patient has committed specific crimes (or they know the nature of them), I think it is important to have open and free discussion about how caring for that patient is making them feel. Prison medicine focuses on the importance of risk assessments and balancing the provision of good clinical care with the protection of staff. While this is framed in terms of physically safeguarding staff, we should not forget the importance of making sure that staff are emotionally supported. Having team debriefs, where everyone can confront their feelings and reactions together, can help the team feel more comfortable around the patient and contribute to a safe, supportive working environment.
This case has made me think about what dying at Her Majesty’s pleasure is like and how palliative care is delivered differently to prisoners, partly out of the constraints of the system, but also due to our own prejudices and beliefs. With the prison population ageing and those detained more frequently living with comorbidities and complex illness, we need to think about how we will serve the needs of these patients while they serve their sentences. This may mean making progress with the prison palliative care movement, so that the deaths of prisoners whose preferred place of death is in custody are viewed as examples of good end of life care and not negative penal statistics.
One of the markers of a progressive society is how it protects and cares for everyone, including those who are in prison. This case showed me how important it is to remember that it is not my place to pass judgment on any patient, but to see the person in front of me who needs my care.
Nikhil Sanyal currently works as an ST3 in palliative medicine in the West Midlands.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.