End of Life Care in Frailty: Prisons

The numbers of older people in prison are rising rapidly. Prisoners aged 50 and over make up 16% of the total prisoner population in England and Wales and currently number 13,620; of these, 3,311 are in their 60s, and a further 1,747 are aged 70 or over.¹ These numbers are projected to continue to rise sharply over the coming years - the Ministry of Justice predicts that by 2022 the number of over-70s will increase by 19%.² It is widely recognised that long-term imprisonment accelerates ageing by about 10 years, so a prisoner aged 50 will have an equivalent health status to someone aged 60 in the general population.

Frailty in the prison environment

Most prisons were designed for young, fit men, so older frail prisoners are often housed in environments that are not suitable to meet changing needs. They may have to walk long distances or up steps to the healthcare unit, chapel or dining area. A study of 127 prisoners aged 55 and over in one UK prison³ revealed high levels of frailty; 26% could walk no further than 100m, 18.9% could not manage stairs unaided, and 30.7% had sustained a fall within the past two years. Most cell doors are not wide enough for wheelchair access, and cells are too small to accommodate the equipment required to meet activities of daily living.

End of life care

As a consequence of increasing ageing and frailty in the prison population, the number of deaths in custody from natural causes is also rising steadily, and the need for end of life care in prison is increasing. One key issue is that a high proportion of older prisoners are convicted sex offenders; currently around 45% of the over-50s and 87% of the over-80s. Because of the nature of their offences and often a lack of social support outside prison, early release on compassionate grounds is usually not an option for this group, so end of life care may have to be delivered in the prison setting. Alternatively, prisoners might be transferred to a local hospital, hospice or to another prison with in-patient facilities, taking them away from their existing support networks in prison.

Current advice and guidance

In order to improve end of life care for prisoners, the Macmillan Community of Practice has produced a Dying Well in Custody Charter,⁴ which is endorsed by the Ambitions for Palliative & End of Life Care Partnership and supported by Her Majesty’s Prisons and Probation Service and the Prisons and Probation Ombudsman. The Charter is a national framework for local action and self-assessment tool, and it outlines six ambitions, each of which provides details on standards and suggests what evidence is required to demonstrate that the standards have been met. These ambitions are:

1. Each person is seen as an individual
2. Each person gets fair access to care
3. Maximising comfort and wellbeing
4. Care is co-ordinated
5. All staff are prepared to care
6. Each community is prepared to help

There is a need to develop greater awareness about the frailty and vulnerability of older prisoners. Timely identification of frailty is crucial is supporting older prisoners to age well; validated frailty screening tools, frailty registers and regular multidisciplinary team meetings should be used in all prisons with an older population.

Both operational and healthcare staff in prisons need appropriate training and support to enable them to care appropriately for those with frailty needs and those approaching the end of life.

References

1. Prison Reform Trust. Prison: The Facts. Bromley Briefings Summer 2019. Available at: http://www.prisonreformtrust.org.uk/Portals/0/Documents/Bromley%20Briefings/Prison%20the%20facts%20Summer%202019.pdf .
2. Ministry of Justice. Prison Population Projections 2018-2023, England and Wales. 2019. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/735428/prison-population-projections-2018-2023.PDF 
3. Turner M, Peacock M, Payne S, Fletcher A, Froggatt K. Ageing and dying in the contemporary neoliberal prison system: Exploring the ‘double burden’ for older prisoners. Social Science & Medicine 2018;212:161-167.
4. Ambitions for Palliative & End of Life Care Partnership. Dying Well in Custody Charter Self-Assessment Tool: A National Framework for Local Action. 2018. Available at: http://endoflifecareambitions.org.uk/wp-content/uploads/2018/06/Dying-Well-in-Custody-Self-Assessment-Tool-June-2018.pdf.