Francis D Glamser & Donald A Cabana. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 1. Thousand Oaks, CA: Sage Reference, 2003.
Over the past 100 years, Americans’ common experience and social view of death have changed markedly. At the beginning of the 20th century, death was likely to occur at any age and was especially common among the very young. In 1900 in the United States, half of all deaths occurred among children under 15 years of age, and infant mortality rates were quite high by today’s standards. Because deaths were usually the result of infections, diseases, or accidents, they could occur to anyone at any time, and they could occur suddenly. People usually died in bed at home.
Not only has the timing of death changed, but so have its causes and locations. Increasingly, death is caused by chronic diseases such as heart disease and cancer, which are concentrated among the elderly. Therefore, death is now most likely to occur in a hospital or nursing home. It is estimated that 45-50% of deaths in the United States occur in hospitals, and another 35% in nursing homes (Marshall 1980; Foley et al. 1995). This means that only about 25% of deaths occur in private homes.
These demographic and medical changes have served to remove death as a visible, normal part of life. In an earlier day, by the time a person reached adulthood, he or she had witnessed a great deal of death. Cemeteries adjacent to the churches and wakes held in private homes reinforced the omnipresence and inevitability of death. Now cemeteries are easily avoided, and wakes occur in funeral parlors, away from the eyes of the community. All of these changes make it easy for most Americans to deny death until well into middle age. People who are likely to die are placed in hospitals or nursing homes, and so are removed from their communities and the daily lives of others.
A similar situation exists in regard to prison inmates in general and to death in prisons in particular. We send criminals off to corrections facilities, many of which are located in remote areas, and the public does not have to think about them. When they die, the public does not have to know about it. Dying in prison is not something the average citizen ever thinks about. Older inmates and those with long sentences, however, think about it a great deal. For long-term inmates who have lost contact with the outside world, dying in prison is the ultimate confirmation of a wasted life. The fear of dying in prison haunts many inmates who see themselves as unlikely to survive their sentences.
Hospitals, nursing homes, and prisons are all what sociologists refer to as total institutions, a concept developed by Erving Goffman (1961). In such settings, all aspects of daily living are supervised and controlled by staff members. What inmates eat, when and where they sleep, what they wear, and what they are permitted to do are all beyond their control. Living under such circumstances is unpleasant at best. Dying in a total institution has become a common experience in the United States.
Until very recently, the issue of prison death was not very visible. Most inmates served relatively short terms, and few grew old enough in prison to produce a large number of deaths. As we will discuss below, a larger, older, and sicker inmate population has changed things. The increased incidence of a number of infectious diseases, such as AIDS, hepatitis, and tuberculosis, means that death in prison is no longer limited to the elderly. For many reasons, some practical and some humanitarian, the subject of dying in prison is worthy of investigation.
Life inside a penitentiary is a microcosm of the world that lies beyond prison walls. The world “inside” would, at first blush, give casual observers little cause to notice any similarities between themselves and the more than 2 million men and women who inhabit the nation’s prisons and jails. A closer examination, however, reveals that prisoners
and nonprisoners have many more traits in common than most citizens would be comfortable acknowledging. Like anyone else, inmates harbor hopes and dreams, suffer disappointments and failure, and dare to plan for the future, all the while haunted by their past missteps. Like the individuals who make up the rest of society, they are husbands and wives, fathers and mothers, ordinary people who, for various reasons, have been segregated and isolated from the general population.
Prison society, despite its many similarities to the outside world, is nevertheless a world unto itself. The captives live in an environment punctuated by brutality and violence, in a landscape often harsh and unforgiving. It is a world in which fear, especially the fear of death, often reigns supreme. As in any other community, inside the prison gates death is the great equalizer, and death frequently assumes forms and shapes that serve as a stark reminder of man’s inhumanity to man and of human beings’ great vulnerability.
Prisons possess unique qualities that separate them from the outside. They have their own language, argot, and slang. There is a clear socioeconomic pecking order, with customs and mores peculiar to the prison environment. Prisons even have their own systems of justice: There is the official system, the myriad rules, regulations, policies, and procedures promulgated by prison officials to govern inmate behavior and guide prison operations, and then there is the inmate system, one that leaves little room for error and is devoid of compassion or forgiveness. The inmate justice system is based on the simplest of predicates: The strong prevail, dominating the weak, with the weak finding a subclass of the weakest inmates to dominate. It is a system that enforces rules and regulations in a variety of ways: through fear tactics, intimidation, strongarming, threats, assault, extortion, and death. Enforcement of the rules is violent, frequently fatal, and can strike without warning.
One additional characteristic that helps define the nature of the penitentiary is magnification. Virtually every facet of prison life is affected by magnification. The unrelenting stresses in prison, feeding off of paranoia, fear, and violence, create an environment in which everything becomes exaggerated. The most insignificant events quickly become larger than life. A simple headache becomes a migraine, a stomachache becomes a malignancy, an unpaid debt involving a soda pop or a package of crackers becomes a death sentence.
Death and dying in a prison setting take on the numerous shapes and forms found in any society, with one noteworthy exception: executions. Death by violence, suicide, terminal illness, aging, and disease are common in prisons, but prison officials are currently being forced to cope with significant changes in the mix of causes of prison deaths. The graying of the nation’s prison population will continue to have an impact on the role of death and dying inside the walls, but death by violence and suicide will always loom large.
Between 1988 and 1994, the number of prison deaths per year in the United States doubled, from 1,449 to 2,986, while the prison population increased by only 50%. Since 1994, the number of deaths annually has hovered around 3,000 (Camp and Camp 2000). Initially, this disproportionate increase can be explained by the rapid increase in deaths related to AIDS among inmates. More recently it reflects the culmination of the dramatic growth of the prison population in the United States over the past two decades and the higher proportion of long sentences. The net effect is that increasing numbers of inmates are growing old in prison, and more are dying. Although the proportion of prisoners who die in any one year is low (slightly more than 2 per 1,000), the prison system must respond to the absolute number of deaths.
The numbers and percentages of prisoners who are serving long sentences have been growing since the 1980s. The most dramatic growth has been in the absolute numbers of prisoners serving long sentences. Merianos et al. (1997) identify three long-term prisoner groups: natural lifers, life-sentenced prisoners, and those sentenced to 20 years or more. Although many prisoners assigned to the last two categories may not serve their entire terms, many of them will grow old in prison, and some of them will die there.
A look at the change in the numbers of prisoners serving long sentences between 1986 and 1995 makes it clear why the numbers of people dying in prison have remained high in spite of a great reduction in AIDS deaths. In 1986, approximately 85,000 prisoners were serving one of the three categories of long sentences noted above. They constituted 17% of the total prison population. By 1995, the number of long-term inmates had grown to more than 246,350, representing 25% of the total prison population (Merianos et al. 1997).
The aging of the prison population is partially the result of changes in sentencing policies throughout the United States. Increases in crime during the 1980s and early 1990s created a demand for longer sentences, truth in sentencing laws, and “three strikes” laws. Although most prisoners leave prison within a few years, the number of those who do not has been steadily increasing (Merianos et al. 1997).
Currently, more than 100,000 inmates age 50 or older are housed in state and federal prisons; of these, 35,000 are age 65 or older. Inmates age 50 or older now account for 8.6% of the prison population, up from 5.3% in 1991 (Camp and Camp 2000; Cohn 1999). Researchers have identified three categories of older prisoners: (a) inmates who are serving life sentences, who have grown old in prison; (b) inmates who have long histories of repeated incarcerations; and (c) inmates who have been convicted of criminal offenses late in life (see, e.g., Aday 1994). It is estimated that as many as 50% of older inmates are first- time offenders, most of whom were sent to prison at or above the age of 60. These older inmates have usually committed crimes against persons (Aday 1994).
Most first-time offenders, of course, are young; in 1999, the average age of initial incarceration was 31.8. However,
the average age of first-time offenders has increased almost 2 years since 1991 (Camp and Camp 2000). As crime rates have increased over the past two decades and the U.S. population has aged, numbers of arrests of older people for serious offenses have increased greatly. Because judges now often have less latitude in sentencing than they had in the past, more of these older offenders go to prison, and some will die there.
Because of lifestyle and socioeconomic factors, older inmates tend to be in poorer health than their counterparts on the outside, and they develop health problems much earlier. Inmates often come from the poorest segments of society, and they exhibit a high incidence of such health problems as hepatitis, tuberculosis, diabetes, hypertension, cancer, emphysema, asthma, arthritis, stroke, and, in recent years, acquired immune deficiency syndrome (AIDS). They are also more likely to have been exposed to alcohol abuse, heroin use, amphetamine use, and tobacco than persons on the outside (Marquart et al. 1997).
Given these kinds of health problems, which have their roots largely in lifestyle and environmental factors associated with poverty, a prisoner with a chronological age of 50 may exhibit the health problems of a much older person on the outside (Cohn 1999). Thus the mortality associated with an aging prison population begins to become evident in a relatively brief period of time.
The inmate who has grown old while serving time may be housed with the prison’s general population or, increasingly, in a unit specifically designed for geriatric and/or disabled inmates. Such an inmate may die unexpectedly in the unit or in the acute care facility following complications of chronic illness. If the inmate unexpectedly expires in the housing unit, the unit officers begin CPR while summoning security and alerting the acute care facility. Sudden death is handled the same as other deaths. Health care personnel continue resuscitation efforts even as the inmate is removed by ambulance to the prison hospital. If the inmate expires, the prison’s security department and administration are notified, and then the usual procedures for contacting the inmate’s family are initiated.
An inmate who dies of terminal illness while in custody may have lingered for months. In these circumstances, prison officials must deal with the same issues that would be relevant for a terminally ill patient in the free world. Decisions and final instructions must be communicated by the inmate and/or his family concerning resuscitation and life-support measures. Very often, the inmate has either outlived all of his family members or has not had contact with them for many years. Like many geriatric inmates, those who are terminally ill often have no home but the penitentiary. In essence, the prison staff has become their family. The absence of family or friends at the bedside of a dying inmate is a stark reminder of the custodial surroundings. The second author of this chapter (a former state penitentiary warden) recalls visiting with one older inmate who was dying of cancer and had but a few days to live. He recalls how profoundly saddened he was because he had known the inmate for more than 20 years. It was like losing a family member. Tearfully, the inmate laughed and said what a shame it was that a man lying on his deathbed had to call his warden the only family he had.
Because many inmates who are terminally ill have lost contact with family members, other inmates and prison staff must fulfill that role. This means that there are no family members to claim the body or make final arrangements. At the Louisiana State Penitentiary in Angola, when an inmate must be buried on the prison grounds because no one claims his body, the inmates build the casket as well as plan and conduct the funeral service, which can be very moving. When such services are held, inmates are permitted to attend, and some funerals are very well attended by both inmates and staff.
The data displayed in Table 1 show the growing importance of natural deaths in prisons over time as the prison population ages. As the table shows, the total numbers of deaths annually are roughly comparable over the period in question; that is, the absolute numbers of deaths overall are fairly stable. The table also shows that the proportion of deaths attributable to natural causes has been rising as the proportion attributable to AIDS has been falling. This shift is almost one for one in terms of both percentages and absolute numbers. Although the total number of inmate deaths per year was fairly stable between 1994 and 1999, these annual figures are more than double the number in 1988, when 1,449 prisoners died. The sharp rise in the numbers of inmate deaths between 1988 and 1994 was caused by the increasing incidence of AIDS among prisoners, especially in large states (e.g., New York, Florida, California, and Texas). The continuation of this higher level of mortality may be attributed to the growing population of older inmates, as indicated by the increased numbers of deaths from natural causes.
As we have noted, the increase in prison deaths between 1988 and 1994 is related to the large increase in the numbers of inmates dying from AIDS-related causes. The late 1980s witnessed an epidemic of illicit drug use among the urban poor in the United States at the same time the human immunodeficiency virus (HIV) was spreading within the general population. Among needle-sharing drug users the virus spread easily, and many of the victims found their way into the prison system. At one point, 18% of men coming into New York State correctional facilities tested HIV-positive. As of 1999, it was estimated that 3% of all inmates in the United States were infected with HIV (Greifinger 1999).
AIDS-related deaths in U.S. prisons reached a peak of 1,010 in 1995. By 1999, the number had fallen to 242. This decrease can be attributed to the availability of better and more effective treatments for HIV/AIDS, in spite of the fact that inmate populations have continued to grow, as have the numbers of HIV-positive prisoners, although somewhat more slowly. The current HIV infection rate is 3.4% among female inmates in state prisons; among male inmates, the rate is 2.1% (Kohn, Hasty, and Henderson 2001). The rate of HIV infection among prisoners is approximately 20 times that found in the general population (Marquart et al. 1997).
Suicide poses a constant threat in the prison setting, especially in the late fall and early winter months, which include the holiday season. Inmate suicides can be profoundly disturbing for several reasons. First, of course, they are extremely unpleasant. Inmates frequently hang themselves with shoestrings (a slow, agonizing death by strangulation), slash their wrists, arms, or throats, or even run themselves headfirst into concrete walls.
In such situations, when an inmate is found without any visible signs of life, the officers must immediately notify both prison health care and security officials. If the inmate has obviously been dead for more than 5 minutes, resuscitation efforts are not initiated. The area is sealed off to maintain the integrity of evidence, and the coroner is summoned to initiate an investigation and to determine officially whether the death is a result of suicide or foul play. The inmate’s body is not disturbed until the coroner and prison investigators have thoroughly examined the body and the scene.
Occasionally, however, even the most stringent rules of evidence and procedure are not followed. A young inmate in a southern prison known to the second author was serving a life sentence for murdering his wife’s lover. The young man had been on antidepressants and was on suicide watch continuously. Despite the prison’s best efforts, the inmate committed suicide early one morning by hanging himself with a shoelace and slashing his wrists and arms. In his shirt pocket was found a copy of divorce papers that he had received the day before. Also in his pocket was a picture of himself with his wife and 3-year-old daughter. On the back of the photograph he had penned the words “so much pain.” The prison officers, who had worked with the young man and liked him, were so upset by his death that, with the warden’s permission, they cut him down before the coroner arrived. In their view, leaving him to hang there was unnecessarily degrading.
In most cases, however, the scene is secured and evidence is collected, including photographs. The position of the body and any objects around the body that could have resulted in death (e.g., pills, rope, sheets, razor blades, shoestrings) are examined as part of the effort to determine the cause of death. If the coroner finds the death to be a suicide, the body is shipped to the state medical examiner for an autopsy, as required by law. The prison investigators then continue to collect evidence and interview other inmates and staff. A key aim of the investigation is to determine whether or not staff interventions could have prevented the death.
Any inmate who expresses or is reported to have expressed suicide ideation is placed on suicide watch. The ramifications of such a move can be profound for the inmate, who may be moved to a bare cell in an electronically monitored psychiatric unit where professional health care staff can observe him or her. Living this way indefinitely can become debilitating for the inmate, but the primary purpose of suicide watch is to prevent the inmate’s death.
Suicide is the third leading individual cause of inmate deaths in state and federal correctional facilities, accounting for about 6% of all deaths (Camp and Camp 2000). However, suicide remains the leading cause of death in jails among inmates who are facing the initial stages of incarceration and who are often under the influence of drugs or alcohol (Hayes 1995). It is interesting to note that in Australia, suicide is the leading cause of death among prison inmates, at 47% (Dalton 1999). The reasons for the high proportion of deaths attributable to suicide in that country’s prisons are unknown, but it may be a function of Australia’s relatively young inmate population and the very low incidence of AIDS among prisoners. It may also reflect a relatively good state of health among persons who enter the prison system.
Although in the United States suicide is much less common in prisons than in jails, it remains a relatively constant cause of death in U.S. prisons. In general, prisoners who commit suicide do so in the early years of their confinement. They are usually housed alone at the time of their suicide, and they often have histories of prior attempts and/or mental illness. Precipitating events may include new legal problems, marital or relationship difficulties, and conflicts with other inmates (Hayes 1995).
The numbers of suicides in most state correctional systems are relatively low compared with deaths due to
health-related causes. In 1999, 39 states reported 5 or fewer suicides in state prisons, and only 5 states reported 10 or more suicides (Camp and Camp 2000). These low numbers may be attributed to increasing awareness of suicide prevention in the corrections field (Hayes 1995). Lindsay Hayes provides an excellent overview of a prison suicide prevention program in a 1995 article on suicide in adult correctional facilities. He reviews and explains the importance of inmate assessment, communication among staff members and inmates, housing decisions, inmate supervision, prompt intervention, reporting, and follow-up.
Nothing is more surreal in the penitentiary than a death by execution. It is a time of stress and tension for inmates and staff alike. The violent murders that take place in prisons are shocking, the deaths of terminally ill and geriatric inmates are sad conclusions to largely failed lives, and inmate suicides are testimony to the fragile nature of our existence. All of these kinds of deaths, in their own way, have profound effects on prison staff who have come to know the victims over the course of their years in prison. However, executions are different from any other kind of death. It is interesting, but perhaps not surprising, that most wardens who are called on to carry out executions are ambivalent, at best, about the death penalty.
Condemned prisoners may spend a decade or longer awaiting their fate. In theory, prison staff are not supposed to get close to inmates. In practice, it is all but unavoidable. For this reason alone, most wardens do not permit death row officers to be part of the execution team.
Over the years, prison officials have developed procedures for carrying out executions; in any given prison, these procedures are referred to collectively as the execution protocol. The protocol consists of every eventuality that must be covered for an execution to be carried out properly. The amount of planning required is enormous. The warden must designate staff volunteers for various duties on the execution team. This task alone is both timeconsuming and stressful, as the warden attempts to strike a delicate balance in selecting staff who are volunteers, but not eager volunteers.
The inmate must be asked to decide on a menu for a last meal and on funeral arrangements following the execution. If the inmate has no family or anyone else to claim the body, the prison must arrange for burial in a prison cemetery. The warden must also determine if the inmate wishes to be sedated just prior to the execution. Such topics are not the stuff of normal conversation.
Arrangements must be made for the inmate’s family, if any, to have a final visit. The second author, a former warden, recalls a mother’s tearful good-bye with a son who was scheduled for execution in a few days. As she turned to leave, she looked at the warden and pleaded with him not to kill her child. He has described that moment as the single most difficult of his long career in corrections.
If prison officials are not already deeply stressed by the plethora of details they must attend to in preparing for an execution, they are likely to become so when they conduct the execution rehearsals. The various U.S. states employ five different methods of execution: electrocution, hanging, firing squad, gas chamber, and lethal injection. Each method has its own idiosyncratic nuances that prison officials must contend with, and each gives officials cause for concern, because nothing, absolutely nothing, causes more stress than the possibility of a botched execution. Endless questions and scrutiny from the media, the knowledge that the inmate died a needlessly agonizing death, criticisms from capital punishment opponents and self-serving politicians—all these add up to a warden’s worst nightmare. So regardless of the method employed, rehearsals are a grotesque necessity.
Hanging a condemned inmate correctly is practically a science. The knot must be placed in exactly the right location under the jaw, the weights must be precise, the trapdoor must operate efficiently. The electric chair, under the best of circumstances, is ripe for human and/or mechanical errors. If the wiring is not done correctly, the chair will either not work at all or, worse yet, severely burn and otherwise injure the condemned prisoner without causing unconsciousness. The gas chamber is the most dangerous and complex of the five methods. Most prisons that use gas chambers for executions include in their execution protocols checklists of some 40 procedures that must be done correctly and in a particular order. One mixup, one batch of chemicals in the wrong proportions, and the prison officials’ worst fears will come true. Lethal injection and the firing squad pose fewer risks for error than do other methods, but neither is completely foolproof.
Following an execution, the coroner is required to establish the cause of death. Once the inmate has been pronounced dead, the body is stripped, bathed, and dressed in clean prison clothing. If the gas chamber is the instrument of death, officials are required to wait from 10 to 15 minutes after the inmate expires before the chamber can be unsealed. At that time, officers dressed in protective rubber gear and wearing gas masks to prevent contact with the cyanide poisoning unceremoniously wash the body down with a garden hose. The body is then dressed and turned over immediately to a private funeral home.
In terms of total numbers, execution ranks between suicide and homicide as a cause of death in U.S. prisons. In 1999, the 95 executions carried out accounted for 3% of all deaths in prisons. More than half of all executions that year occurred in two states: Texas (35) and Virginia (14). The most common number of executions in a state for 1999 was zero, as was the case in 33 states. Only 5 states reported more than 4 executions that year. As a cause of death in prison in any given state, execution is uncommon (Camp and Camp 2000).
As in any other community, in prisons violent death occurs in many different ways; in prisons, however, such deaths often include a degree of brutality and callousness seldom found in the outside world. The perpetrators of violent deaths in prisons frequently intend to degrade and disrespect their victims. Although inmates and staff frequently claim to be immune to the effects of violence, some violent deaths in prisons can shake even the most hardened officers and inmates. In one incident that took place in a midwestern maximum-security prison, a long-simmering dispute between two inmates spilled over at the breakfast table one morning. Seated at one end of the dining hall, the two men began to quarrel. Challenges and threats were issued, and without warning each one pulled out a shank, a homemade knife. Almost before officers had time to react, other inmates sitting nearby began to scatter, some shouting encouragement to the two combatants, others excitedly calling the officers to intervene. As quickly as it started, the dispute ended with one of the men being decapitated. When all the other prisoners had put as much distance as possible between themselves and the assailant, there remained one man sitting at the table where the murdered, headless inmate was slumped forward into his tray of food. The man was an older prisoner, his craggy features and prison-made tattoos betraying the ravages of his long sentence. Unaffected by the commotion around him, he continued to eat his breakfast. Suddenly, to the horror of staff and inmates alike, he grabbed the decapitated head by the hair and disgustedly tossed it over his shoulder, cursing it for getting blood on his food. The most chilling aspect of violent death in prison is the unwritten maxim of the inmate code: Don’t interfere.
Most states have very stringent laws concerning the investigation of violent death in prison. Wherever the death occurs, whether in a cell or out on the prison yard, the area must be handled as any other crime scene would. Physical evidence must be gathered and preserved, a chain of evidence maintained, witnesses (both inmate and staff) interviewed, and proper authorities notified. Although prison internal affairs investigators may conduct the preliminary investigation, once it becomes clear that a crime has been committed, an independent law enforcement agency (usually the state police) is called in. Violent death scenes present a dilemma for prison officials. On the one hand, officials are required to make sure such scenes are handled as any murder scene would be; on the other hand, they want to return a sense of normalcy to prison operations as quickly as possible. Neither inmates nor staff want to have to see the body of a murdered inmate lying around for several hours, but very often that is exactly what happens. The body cannot be moved until the coroner arrives and officially pronounces the inmate dead. Following removal of the body from the crime scene, it is transported to the prison hospital, where it is bathed, given a change of clothing, fingerprinted, photographed, and tagged. The body is then transported to a state medical examiner for an autopsy. Only after an autopsy is completed is the body released to a funeral home of the inmate’s family’s choice for burial. If no one claims the body, prison officials must provide a funeral service and burial in the prison cemetery.
For prison officials, perhaps the most difficult part of a violent death in prison is the responsibility of contacting the deceased inmate’s family. Frequently this task is left to a prison chaplain, but not when the murder victim is a prison employee, an eventuality that all wardens dread.
The general public tends to overestimate the frequency of homicide as a cause of death in prisons. Since 1994, homicides have accounted for less than 3% of all prison deaths in the United States, and in 1999 only 21 states recorded 1 or more homicides in correctional facilities. Of the 3,213 inmate deaths in 1999, only 65 were homicides (Camp and Camp 2000). That said, some states and some specific facilities have much higher than average prison homicide rates. The states in which this was true in 1999 include California, Colorado, Maryland, Mississippi, Oklahoma, Oregon, South Carolina, and Tennessee. Because the absolute numbers of prison homicides tend to be very low (only 5 states had 4 or more in 1999), small variations from one year to the next can have large, perhaps misleading, effects on percentages. On the other hand, some facilities do have reputations for being particularly dangerous.
The importance of prison management and leadership in controlling inmate violence may be seen in the case of the Louisiana State Penitentiary at Angola, which used to be one of the most dangerous corrections facilities in the United States. Angola houses more than 5,000 long-term inmates, of whom 85% are unlikely to leave alive. One career guard told the first author that he could remember the bad old days, when killings occurred almost once a month. Now, a year can pass without a homicide, as was the case in 1999.
The dramatic increase in prison deaths that began in the late 1980s, primarily as a result of the AIDS epidemic, generated a great deal of interest in end-of-life care for prisoners. Continued high levels of mortality brought about by longer sentences and an aging prison population mean that prisons must have procedures in place to deal with the needs of dying prisoners. One response to those needs is hospice care.
The aim of hospice care is to assist dying persons to die with dignity and with a minimum of pain. Hospice programs provide emotional support for terminally ill patients and their family members in the final months of life. Such programs are now available in most communities, but their introduction into prisons is relatively recent. As of 2001, 19 states had at least one hospice program in a correctional setting, and 14 additional states had programs under development (“Growing Movement” 2002).
Offering hospice care in a prison involves dealing with many problems not encountered in home hospice care. Issues of security, drug use, inmate autonomy, visitation, and volunteer selection can all present challenges in a prison setting. Getting inmates to enroll in a hospice program can also be problematic. Admitting that one’s condition is terminal means accepting dying in prison—something most inmates fear. For younger prisoners who assume or hope they will be released someday, the fear of death is the fear of a sudden and violent death that will deny them a chance at freedom. Older inmates see dying in prison as the final degradation and the ultimate confirmation of a failed life. They will die in isolation, with no chance for redemption or reconciliation. Furthermore, accepting help amounts to an admission of vulnerability, which is difficult for inmates who have learned the importance of appearing tough (Price 1999). The National Prison Hospice Association addresses the special problems associated with hospice programs in correctional settings.
In an earlier day, when prison deaths were not as common and the numbers of sick and aged prisoners were not as high as they have been in recent years, parole boards might have released older dying prisoners to spend their final days outside the prison walls. Today, because of increases in the numbers of prisoners sentenced to life without the possibility of parole, and particularly because of growing public sentiment against parole, such compassionate releases have become far less common.
Faced with the highest prison HIV infection rate in the country, the New York State Legislature passed the Medical Parole Law in 1992. This law was designed to allow dying prisoners who are no threat to the community to be released early. For an inmate to qualify for possible release, the law requires that a physician certify that the inmate is so debilitated as to be beyond self-care and is unlikely to recover. The physician must also certify that the inmate is incapacitated to the point of being incapable of presenting a threat to society. The state parole board then reviews the case. Only about 20% of all requests for release made under this law are granted (Beck 1999).
Death maintains a constant presence in prison, whether through violence, aging, disease, or the purposeful, methodical means ordered by the courts. Executions may make the news briefly, but most of the dying that occurs in prisons is hidden from view. It is experienced by people who, by and large, have already been removed from the outside community and from public consciousness. However, it is not removed from the staff or inmates of our prisons. For these people it is real, and it affects them deeply.