The Hunger Games, Corrections Style Jeffrey E. Keller MD FACEP CCHP
Faculty Disclosure• “I do not have any relevant financial relationships with any commercial interests.”
Objectives• Describe the historical roots and modern definition of a “Hunger Strike.”• Identify reasons inmates may refuse to eat and the appropriate assessment, diagnosis and treatment for each.• Outline a step-by-step approach applicable to all types of fasting inmates that incorporates medical monitoring, housing, mental health and legal considerations.
“Hunger Strike”• The term “Hunger Strike” is often used inappropriately for any inmate who refuses to eat.
Bobby Sands• Member of the Irish Republican Army• Wanted to be considered a Prisoner of War rather than a common criminal• Announced fast on March 1, 1981• Died 66 days later• Generated international publicity for his cause
3 Criteria for a True Hunger Strike• The person intends to commit suicide• The suicide is done for a political or religious reason• A goal is to generate maximum publicity
Suicide by Starvation?• Buddhist monk setting himself on fire to protest totalitarian rule in Myanmar.• Al Qaida “suicide bombers”• Easier to push a button detonating a bomb than to not eat for 66 days.
Most Inmates Who are Fasting are not “Hunger Strikers.”• Religious fasts• Extreme dieting• Manipulative inmates who are secretly eating.• Tantrum throwers• Mentally ill inmates• Protesters (but not suicidal)• True Hunger striker.
The Approach to Each of These is Different• Housing. Special housing. Monitoring. Audience• Mental Health. Suicidal? Psychotic?• Medical monitoring? Weights, Vital signs, labs• Legal. Commitment? Involuntary feeding?
Step by Step Approach• Initial interview• Initial Physical Exam• Setting up a care plan• What about inmates who actually fast for a long time?
Initial interview--Questions• Are you expecting to die?• Are you protesting something?• Total fast or will you eat something?• How long will you fast?
Initial Interview--Education– You can fast for awhile– We cannot allow you to harm yourself– Court ordered feeding if necessary
Initial Interview Results• Suicide by starvation – True Hunger Strikers – Impulsive• Those who deny suicidal intent – Dieters – religious fasts• Psychotic and delusional
The Physical Exam• Weight• Fat reserves• Overall health• Labs?
Care plan--Housing• Suicide precautions• Who can Remain in the Dorms?• Separate from support group – Psychological support – Surreptitious feeding
Care Plan—Mental Health Evaluation• Suicidal• Psychotic• True Hunger Strikers• Protestors
Medical Monitoring• Repeat medical evaluations – Weights – Food logs – Vitals• Do not be an Enabler – “I don’t want a tray. I won’t eat it anyway.” – Don’t feed attention seeking more than necessary.
Care Plan--Legal• Psychotic inmates – Commitment• Hunger strikers – Timing is important – Aggressive interventions must be court ordered
Case 1—Extreme Dieter• Housing?• Medical monitoring?• Mental Health?• Legal?
Case 2—Religious Fast• Housing?• Medical monitoring?• Mental Health?• Legal?
Case 3--Protester• Housing?• Medical monitoring?• Mental Health?• Legal?
Case 4--Manipulator• Housing?• Medical monitoring?• Mental Health?• Legal?
Case 5--Psychotic• Housing?• Medical monitoring?• Mental Health?• Legal?
Case 6—True Hunger Strike• Housing?• Medical monitoring?• Mental Health?• Legal?