The Federal Medical Center at Fort Worth, Texas, built in 1956, is one of six federally run prison medical centers. Correctional medical centers like FMC-Fort Worth remain invisible spots on an American landscape in which the realities of prison life are largely obscured from the public‰s view.

NPHA Executive Director, Elizabeth Craig, visited FMC - Fort Worth in March, 1996 to observe and gather information about the unique prison hospice program. The prison is not a forbidding place from the outside; its complex of buildings sits on a grassy rise not far from the city. Except for the coils of razor wire that top its high fences and armed vehicles at its perimeter, FMC-Fort Worth is hardly distinguishable as a prison. But inside its walls nearly 1400 male inmates are incarcerated, approximately 580 of whom have been transferred from other prison facilities not designed to care for them. These inmates have a spectrum of illnesses ranging from chronic asthma to full-blown AIDS, making ambulatory to long-term care a necessity.

The 800 or so healthy inmates at Fort Worth are incarcerated there for the services they can provide at the Medical Center. One capacity in which the healthy population supports the hospitalized inmates is through their participation in a special program at Fort Worth, the Inmate Hospice Program. This program was introduced in 1994, and has since become a model for hospice in the corrections environment.

Hospice is a movement in health care which addresses the special needs of the terminally ill. An increasingly prominent feature in American community health care in the last ten years, hospice is now being considered by state and federal prison administrations. While attitudes toward death and dying are changing in our communities, at the same time the number of inmates dying in prisons is rising. This fact has been attributed to the increasing number of AIDS cases in the prison population, and a trend of tougher sentencing laws that began with the Sentencing Reform Act of 1987, and which has resulted in a burgeoning number of older inmates serving longer sentences. (According to a study by the Edna McConnell Clark Foundation, aging inmates are presently one of the fastest growing population groups in American prisons.)

Do the same innovations and standards currently being integrated into care strategies for the terminally ill on the outside apply to those serving prison time? If so, what are the benefits and costs to the corrections system and taxpayers? The example of the Inmate Hospice Program at FMC-Fort Worth provides some of the answers to these important questions.

In 1994, officials from the Administration at Fort Worth approached Joelle Koncelik, a prison social worker, and prison chaplain Ricardo Alcoser with a proposal to develop the program and learn about hospice care.

In order to integrate the new program successfully into the existingprison structure, an Advisory Committee was formed to draw on the expertise of key personnel at Fort Worth such as the Director of Nursing, a Lieutenant and a Captain from the Security Division, and a Health Services administrator. The early goal of Fort Worth's Hospice Program was to formulate an effective and comprehensive prison hospice that would meet the mandates of hospice care as established by organizations like the NHO and the World Health Organization, and which would also fit easily into the corrections and medical systems already in place at FMC-Fort Worth.

The Program

Koncelik, Alcoser and Corrections officials at the Federal Medical Center refer to three fundamental principles as forming the basis of the program: Cost, Care and Corrections. The philosophy is that if all three of these areas are addressed comprehensively, then all three will be improved, bringing benefit to both the patients and the overall corrections environment.

Care
"Palliative Care" is the foundation of Fort Worth's hospice approach to caring for its patients. The World Health Organization defines palliative care as the "active total care of patients whose disease is not responsive to curative treatment. The goal of palliative care is to achieve the best quality of life for terminally ill patients." This philosophical and practical approach is one that affirms life while communicating that death and dying are an integral and normal process to it.

The staff doctors, nurses, social workers and volunteers in the Long Term Care Unit are being trained on an ongoing basis regarding the protocols and procedures of comprehensive hospice care. Koncelik and Alcoser have brought in a wide spectrum of hospice care professionals who have shared their expertise and experience with the Fort Worth medical staff and inmate volunteers.

According to the hospice model, the medical needs of Fort Worth's hospice patients are only one facet in a holistic approach to care that also stresses the importance of the patient's psychological, social and spiritual needs. As the patients have abandoned aggressive curative measures, the main job of the medical staff centers on pain management and generally keeping the patient comfortable.

Inmate volunteers read aloud to the patients, write letters for them, or just sit with them quietly. As the prison is required to offer the inmates access to religious representatives of many different faiths, these individuals also become an invaluable part of the Care Team. The regular prison chaplain meets with the patients a few times a week, and a social worker meets with them daily.

One of the main objectives of the hospice program is to keep the patient actively involved in decision-making regarding his care, even though a cure may no longer be a realistic possibility. Joelle Koncelik says the hospice program encourages the patients to "focus on what they can still accomplish in the time left rather than commiserate over what won't get done because of time lost. The Care Team works together to foster a sense of independence in the patient, and helps him maintain as high a quality of day-to-day living as possible.

The hospice coordinators are in regular contact with family members, who are given increased access to the hospice patients through visits or telephone calls. Designated members of the Care Team also help the family in the bereavement process when the patient dies. There is also bereavement counseling and debriefing for the Inmate Hospice Volunteers who often become close with the hospice patients they are assigned to.

Cost
Since its inception in 1994 the Hospice Program has proven to consistently reduce the costs of caring for its terminally ill inmates. A number of features of the hospice program contribute to its cost benefits. The central contributing factor is the self-containment of the program within the prison's Medical Center. As nearly all the medical and support needs of the hospice patients are met in the Long Term Care Unit, the number of outside trips to hospitals has decreased dramatically, saving the considerable expense involved. The patient benefits as well: rather than being shackled to a bed in a strange hospital, he stays in familiar surroundings with his Care Teams providing the support and care he is accustomed to.

Another cost-saving effect of the Hospice Program at Fort Worth is a marked reduction in what Koncelik calls the "heroic measures" that are often taken as the patient's vital functions weaken. After being better prepared psychologically and spiritually for death through the hospice approach, inmates more often request to sign "Do Not Resuscitate" orders, asking not to be put on ventilators or other means of life support towards the end. This saves the prison a huge amount of money that would otherwise be spent on procedures that have been increasingly viewed as undesirable from the standpoints of both patients and care-givers.

A vital component of the Hospice Program at FMC-Fort Worth is the Inmate Hospice Volunteer Program, made up of approximately fifty volunteers from the healthy prison population who perform a spectrum of functions as part of the Care Teams. Many of the services they perform, from range of motion exercises to psychological support as "buddies" of the sick inmates, would otherwise be done by either an expanded nursing staff or outside groups. Again, the Hospice Program's utilization of existing prison resources has proven to streamline the costs of caring for its most critically ill inmates while providing these inmates with a consistent and reliable support network.

Corrections
The full range of corrections issues effected by the introduction of a hospice to the prison environment were not able to be assessed until after the program was fully operating. Certain security issues were relatively easy to anticipate, particularly regarding the decrease in the movement of sick inmates in and out of the prison, which cut down on logistical concerns for the Security Division. Security officials did have to implement procedures for increased family visitations, but these were easily integrated into the existing security system in the Long Term Care Unit. The hospice program accommodates more frequent family visits because, unlike visits to inmates in outside hospitals where security measures have to be provided, at FMC-Fort Worth security is already in place.

The Inmate Volunteer Program posed another challenge. Central to daily life in every prison are "institutional counts," security procedures during which all the inmates are systematically counted. In the initial stages, procedures had to be set up between the Hospice Coordinators and Security, which would allow Inmate Hospice Volunteers to be counted out of their unit in the Long Term Care Unit if it was established that they needed to be with their assigned hospice patient. So far this system has run smoothly. In addition, the presence of Inmate Volunteers has actually strengthened security within the Long Term Care Unit. It has been proven that the volunteers routinely help deflect the number of disruptive incidents that can sometimes occur as hospice patients change in their ability to function physically and mentally in their environment.

The Hospice Program has had a positive impact on Fort Worth's healthy inmate population. The program sends out the message that prison officials and its Health Care staff are attending to the needs of even the sickest inmates. Much of this message is disseminated through the inmate volunteers. After an intensive three-week training program educating them about a wide range of health care and hospice issues, the volunteers are then prepared to work closely with the medical staff, and see first-hand that adequate care is being given to each patient. The positive picture that they bring back out to the general prison population cuts down on the customary resentment and distrust felt when an inmate dies. The personal benefits to the volunteers have also been keenly felt. One inmate volunteer recently observed that the Hospice Program at Fort Worth ‹is the only place here where we can show love.

In spite of all its successes so far, Fort Worth's Hospice Program has not been completely problem-free. Joelle Koncelik identifies the most challenging problem as the quarterly change in staffing in the unit. As a result, she has had to maintain an almost ongoing training program for new staff.

The Impact of Fort Worth

The logic of developing a hospice program for the Federal Medical Center at Fort Worth was threefold: the program would enhance the quality of care it could offer its sickest inmates, would assist in correctional issues and at the same time would decrease medical costs for the Bureau of Prisons. Reports from all sides have shown that the program has succeeded in accomplishing these goals. But the Inmate Hospice Program potentially has a positive impact beyond the perimeters of the Federal Medical Center at Fort Worth. In developing and implementing the extensive series of guidelines which define the Inmate Hospice Program, Fort Worth has done some of the important groundwork for what is becoming a new and necessary trend in prison health care: prison hospice. As Joelle Koncelik has said, "As corrections professionals, we are becoming expert in such trends as youthful offenders, more violent crimes and longer, non-parole sentences. Death in prison is another thing we will have to become expert in.