Locked up doc
A new monthly blog about health in justice
Capital news
This week I had to break some extremely bad news to a prisoner. He'd come into jail expecting to do the few years sentence imposed on him by his judge. I guess he'd been thinking that he'd then be going right back to whatever he used to do, which of course may or may not have been such a great idea!
Then out of the blue I came along with most unwelcome news of a drastic new sentence - and a capital one at that. Long story short: he’s going to die, there’s nothing we can do to prevent or postpone it, and most likely it’ll happen before his current sentence ends.
The need to impart such distressing news behind bars is somewhat of a communication crisis. And all crises require careful handling. What’s to be done in this case?
Breaking it well
Like many other aspects of medicine, breaking bad news is both a skill and an art. It should be as much part of a doctor's skillset as examining patients, ordering investigations for them, and performing treatments on them. And yet, even though the principle of equivalence of care is well established for all UK prisoners receiving healthcare on the NHS, it's so easy for equivalent communication to go missing from the prison roll count…
Before
Some things are easy on the outside and just a little bit more challenging on the inside. Breaking bad news though is never easy - in or out of jail. As with all hard tasks though, practice makes as perfect as possible and preparation really does help:-
Will they need an interpreter and where on earth has the interpretation handset got to
A huge amount of UK prisoners don’t understand even simple health conversations delivered in English.
What time of day would be best for the consultation?
Imagine an officer bursting in, announcing that it's bang-up time just as you've said the fateful words!
Could a nurse be present who works on their wing on a regular basis?
Then they can touch base at the meds hatch now and again.
Where is that box of not-completely-horrible NHS tissues?
Paper hand towels are so very rough on crying eyes!
And will you need to pull strings to enable them to phone out to any loved ones later today?
Phone access arrangements vary from prison to prison.
During
Regardless of the location in which it's done, breaking bad news is something that gets easier with practice. However, there are some particular things to consider during such consultations that happen behind bars:-
What do they prefer to be called?
Many prisoners use another name rather than their given one. If Prisoner number A1111AB answers to 'Buster' not 'Robert' then that’s what you should call him.
Do they have a faith that might help them at a time like this?
Ask them! They might like the prison chaplain to drop in on them.
Do they read well enough to digest any written information you might be about to give them?
50% of UK prisoners are functionally illiterate.
Do they get on well with their cell mate and, if not, would it be possible to have them moved?
Sobbing into your pillow is tricky when your bunk mate is a hostile soul.
And are they at risk of doing themselves harm over the next few hours?
The ACCT process may need to be invoked.
After
And lastly, following things up:-
When are they going to be seen again? They’ll have a lot to process so book them in for another appointment soon. If that consultation won't be with you, ask yourself: 'If my name disappeared from the prison's medical rota tomorrow, would others reading my notes know exactly what had (and had not) been communicated to this patient?'
Prison bars seems to distort the simplest of Chinese whispers.
Which other information is missing?
Ask the healthcare administrators to get copies of all relevant clinical correspondence and investigation reports.
Is their name down on the complex case discussion list?
If your establishment doesn't have one of these, it's time to start one!
Should they be considered for compassionate release?
I've only once succeeded in getting a detained patient released on compassionate grounds, but it's always worth a try.
And what about palliative care?
Again, if there isn’t a life-limiting illness register, it's time to create one. And palliative care services are excellent at advising on symptom control, even if your patient is still having curative treatment and/or has a prognosis of more than a year.
Dr Incog Nito, our resident blogger, is a doctor working behind bars in the UK.
We also welcome non-cynical guest bloggers who are keen to give Dr Nito a short rest.