The numbers of older people in prison and people approaching the end of life and deaths from so-called natural causes are on the rise in some parts of the world (see Deaths in prison). This means that prisons are increasingly faced with the challenges associated with older persons, including needs for palliative and end-of-life care.
Specialised end of life care is not common, although some recent initiatives point to a trend at least in high-income countries to develop such services.
It is not known how many countries have developed palliative care programmes or specialist facilities such as hospices in prisons in the past decade, as only a handful of studies have been undertaken on the topic – all in high-income countries such as the UK, Switzerland, France, and the US. One such initiative by the European Association for Palliative Care was a mapping of palliative care provision in prisons in eight European countries and Australia in 2021. It found that, despite increasing numbers of older people in prison, relatively few prisons provide inpatient facilities, requiring transfers to another prison or a hospital in the community. Of the nine countries, only England has any prisons that provide dedicated palliative care services in some selected prisons.
Similarly, specialised end of life care is not common, although some recent initiatives point to a trend at least in high-income countries to develop such services. In several French prisons ‘life support workers’ assist detained persons that are old, frail, or approaching the end of their life with daily tasks and needs. In Scotland, the charity Macmillan Cancer Support has developed a guide and other resources for people in prison at the end of life, and funds a national programme to support the implementation of 28 standards for palliative and end-of-life care in prisons, developed with prison healthcare and security staff. In an ongoing prison hospice project in the US, Humane, partnered with the California Department of Corrections and Rehabilitation to train people in prison to provide emotional support and practical care for their aging and dying peers, who upon graduation will be known as palliative care workers/volunteers. After piloting in the only prison hospice in California, there are plans to expand to at least two other prisons in the state by the end of 2023.
Mechanisms for early release from prison on compassionate grounds exist in some countries, but the number of people released for end-of-life care in practice is low.
Common barriers to using such mechanisms include restrictive eligibility criteria based on age or ‘closeness to death’; the exclusion of certain offences or sentences being served; complex and lengthy application processes that may not be completed before the person dies; and bureaucratic procedures that involve many different authorities or require coordination and agreement between clinicians and security staff in the prison on the person’s health status, security risk and access to suitable care in the community. In some cases, due to the length of their sentences and/ or the nature of the crime for which they were sentenced, some people may not have family connections and support available in the community and may, in fact, have more friends and support in the prison.
Challenges can be seen in Mexico, for example, where a presidential decree aimed at releasing older and terminally ill people, among others, has been criticised for failing to provide the necessary budget, personnel or guidance for the designated committee to identify and process eligible cases, which are also limited to the federal system. In the US, provisions implemented four years ago to help release people from federal prisons who are terminally ill or aging have had little effect: 80% of compassionate release requests filed between October 2019 and September 2022 were rejected, largely because political processes delayed the provision of guidance to judges for over three years.
Suspended sentences are another option, used in places like Czechia and France, to allow people to leave prison near the end of life but, in contrast to full release, this can require the person to return to prison to serve the remainder of their sentence if they recover from their illness.
Some prison systems with chronic overcrowding use measures like amnesties or executive clemency (exceptionally or regularly) to grant early release as a means of easing congestion in prisons with priority often, although not always, given to those with terminal or life-threatening illnesses or a serious disability. In Thailand, for example, where pardons are viewed as a regular part of the criminal justice process, one of eight initiatives undertaken in 2021 targeted people with serious illness or disability or those aged 70 years or older, resulting in the release of 84 people. Similar initiatives have also been seen recently in the Philippines.