Tony is a 48-year-old man who has spent most of the last 19 years in prison. A lifelong smoker, he recently started coughing up blood, and subsequent investigations revealed a large tumour in his lung, as well as bone metastases in his spine and femur. He has been estranged from his two sons for many years; his wife, however, has stayed in touch and visits regularly.
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1. What physical symptoms might you expect Tony to develop as a result of his cancer?
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The most likely symptoms are breathlessness, cough and pain. However, numerous other symptoms are possible including fatigue, weight loss and chest infections.
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2.What other problems might Tony develop?
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A wide range of psychological and emotional problems are possible as a consequence of both his diagnosis/prognosis and his imprisonment. These might include remorse and guilt about his crime and his estrangement from his sons, hopelessness at being unable to make amends with his family, fear of dying, anxiety about his future and that of his wife, depression and grief, anger and disappointment at not being able to leave the prison. He may also feel socially isolated, although given the length of time he has been in prison, it is likely that he has social networks within the prison and relies on fellow prisoners and staff for emotional support. However, he may have to be separated from his friends within the prison if he is moved to a different wing or transferred to a different prison or to an outside hospital.
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3. Tony has developed a persistent cough, is very breathless on exertion and has pain in his back. How would you manage these symptoms in the prison setting?
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Most prisons do not have inpatient facilities, so it is likely that Tony would be nursed on the wing (i.e. in a cell). Medication would only be administered at set times and, depending on the prison, there may or may not be access to controlled drugs at night. In a typical cell, he would be sleeping on a standard prison bed or bunk, which is narrower than a normal single bed, and might not have a headboard; therefore, nursing him in an upright position would be difficult. Although it might be possible to administer intermittent oxygen, this could not be left in the cell because of security and safety restrictions. Physiotherapy might be helpful; however, this might be limited or non-existent inside the prison, and it might not be possible to send Tony out to a local service because of staffing limitations (any prisoner needing to leave the prison for medical appointments needs to undergo risk assessment and may require escorting by two prison officers).
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4. What options would you explore for where Tony could be cared for at the end of his life?
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The options for place of care at the end of life are limited and will depend on a number of factors, including the type and seriousness of the crime committed and the work done by the prisoner to address offending behaviour. A growing number of prisoners are serving sentences for sex offences, and they pose particular challenges in relation to place of care at the end of life. Often, their victims were family members; therefore, contact with family may be completely lost. For Tony, possible options for place of care might include hospice, hospital, care home, staying in prison or compassionate release.
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5. The patient’s condition deteriorates and it becomes apparent that death is imminent. He has expressed a wish to see his wife and say goodbye. How likely is it that this could be arranged?
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Correct answer:
Prisons have fixed visiting times, and visits outside of these times are very unusual. However, some prisons are now trying to be more flexible in order to address the needs of dying prisoners and their family members. Whilst there are obvious complexities in trying to arrange for Tony’s wife to be present at the very end of his life, it is likely that the prison would do everything possible to facilitate this. Some prisons have now created palliative care suites with family rooms and facilities for family members to stay outside of the usual prison visiting times.
