Prison hospices are thriving due to greater acceptance, older population

First U.S. prison hospice founded in 1987

It's been 20 years since Springfield, MO, Medical Centers Hospice Program became the first U.S. prison hospice program, and now there are more than 70 hospice programs within state and federal prisons.

Proponents for prison hospice programs say there is no downside. The programs are budget neutral at worst, and some claim they actually result in less violence among the general inmate population. These qualities, and the highly publicized success of the hospice program at the Louisiana State Penitentiary in Angola, LA, and in other correctional facilities across the country, have made prison wardens increasingly open to starting hospice programs.

But arguably one of the biggest reasons for the jump in prison hospice programs from about 25 at the turn of the century to more than 70 this year is due to demographics: American prisons have a rapidly aging population.

"In 2002, there were 121,000 prisoners 50 years and older, which is almost triple the number of older prisoners in 1992," says Carol McAdoo, coordinating consultant for end-of-life care in corrections for the National Hospice & Palliative Care Organization (NHPCO) in Overland Park, KS.

"In 2005, there were over 167,000 inmates over age 50 in state and federal prisons, which is 11.1 percent of all inmates," McAdoo says.

In 1992, the number of inmates age 50 or older was 41,586, she adds.

The aging population is due to several factors, including increasing numbers of middle-aged people being convicted, three-strikes-you're-out laws, and prison sentences that have long mandatory terms, she says.

"Lifers and long-term inmates, those who have 20-plus year sentences, make up 23 percent of the total state and federal prison population," McAdoo says. "Of all inmates sentenced between 1995 and 2003, 24.5 percent were between 40 and 54 years old, and that has accounted for 46 percent growth in the prison population in that time period."

Also, inmates tend to age more quickly than the general population, McAdoo notes.

"Because of the lifestyle of people who are often incarcerated, the pre-prison lifestyle, they are approximately 10 to 12 years older physically than someone of their own chronological age in the free world," McAdoo says.

There are half a million people arrested each year who are age 50 years or more, McAdoo says. Of these older people, 17 to 24 percent are arrested for serious felonies, she adds.

"There's a tremendous increase in the number of elderly males who are incarcerated for sexual offenses, and there is some question regarding the root of that — whether they just now are discovered, or rather the cause is dementia," McAdoo says.

Also, there are increasing numbers of women who receive life sentences and long sentences for their crimes, McAdoo says.

There are approximately 3,300 inmates who die from natural causes in prison each year, and the number of deaths is increasing at nearly 4 percent per year, McAdoo says.

"The trend has been such that there's a large increase in the number of aging people in prison, and prisons are trying desperately to get ready for it, but they're not funded adequately," McAdoo says. "There are many prisons that receive multiple new inmates each year, but they receive no increase in the number of dollars that are contributed to the prison to run the health care system."

Given these trends, hospice is a good fit for correctional facilities, says Jamey Boudreaux, MSW, MDiv, an executive director of the Louisiana Mississippi Hospice & Palliative Care Organization (LMHPCO) in New Orleans, LA.

"We want to spread the word that there are good things going on in prisons," Boudreaux says. "I've been holding monthly [hospice] meetings at Angola since 1999."

LMHPCO has accepted the Angola hospice as a member of the hospice organization, and the prison hospice receives the same assistance and technical support of other hospice programs, he says.

"My job is to make sure they realize they are part of a much larger, global care picture," Boudreaux says. "They're pioneers, and it's affecting corrections across the country."

Correctional systems typically include a hospice budget within the health care program.

Some of the correctional systems use inmates as volunteers, and others rely on the regular medical staff. The more successful programs provide training, and this might come from area hospices, as was the case at the Angola prison.

"What they're doing at Angola with inmate volunteers is part of a volunteer core of 380,000 hospice volunteers across the country," Boudreaux says.

"Hospice nursing is not the same as regular nursing, so we had training for nurses, doctors, and security officers so they would understand what we were doing," says Carol Evans, LCSW, a consultant to the Louisiana State Penitentiary Hospice Program. Evans spent about a year training inmates and staff at the Angola prison. Previously she had worked for a hospice in New Orleans, LA.

"We had a meeting of inmate leaders and gave them an opportunity to ask questions," Evans recalls. "Then we went to the radio station run by inmates, and the inmate leaders identified who they thought would be best as part of the first volunteer group."

A Louisiana public hospital system funded Evans and other hospice training at Angola, but a lot of the work also was done on a volunteer basis, Evans notes.

For instance, when Evans felt overwhelmed by the task, which included a 2.5-hour drive to Angola, she enlisted help from a friend, who would fly down at her own expense for a year to help with the training.

"Community hospice programs are generally very helpful to prisons in providing training to their inmates," McAdoo says. "There are multiple kinds of arrangements between hospice programs and prisons, but one of the major goals of NHPCO is to foster partnerships between community and state programs and state and federal correctional facilities."

This will increase dramatically the quality of end-of-life care, ease the mind of caregivers, and increase the level of training available for those who care for people who are dying, McAdoo adds.

"One of the multiple values of providing hospice care is the opportunity for the dying inmate to bring his or her life to closure to make amends, say 'I'm sorry,' reconnect with family members, and get ready for the end of his/her time," she says.

McAdoo and other prison hospice advocates say it's cheaper to let the inmates stay in the prison and receive hospice care, if that's what they choose.

"From a philosophical perspective, it might be interesting to people to know that it really doesn't cost any more to have a hospice program," McAdoo says. "The state is mandated to take care of their inmates and provide medical care to them, so to send them to a hospital and have them placed in the intensive care unit results in an ambulance trip, round-the-clock guards at the bed, and giving the inmate expensive treatment he or she might not want."

Convincing correctional officials of the cost-effectiveness of prison hospice programs is one obstacle. Another obstacle is the prison warden's attitude toward the idea.

"One of the things that is complex is that programs open and close and are not constant," McAdoo says. "They are very dependent on the will of the warden."

This issue could be resolved if hospice care was mandated by the Department of Corrections, which would mean states would find a way to accommodate the end-of-life needs of inmates, McAdoo says.

So far, this hasn't happened. The result is that programs thrive where there's a commitment at the top.

For example, Burl Cain, warden of the Louisiana State Penitentiary came up with the idea of starting a hospice at Angola in the mid-1990's after reading a Sunday newspaper article about hospice care.

"The article made me think about Angola and how we have people who are there for the rest of their lives," Cain says. "So hospice fits."

"I didn't have any money to start a hospice program, so we restructured how we do medical care," Cain says. "I challenged the medical staff that we have to do this and in two years we want the best hospice program in the country, and we did it."

Violent acts of inmates on inmates decreased dramatically since the mid-1990s, and Cain gives the hospice program at least some of the credit for this.

The Angola prison and its hospice are somewhat unique. It won a Circle of Life Award by the National Hospital System in 2000 and 2001, and there has even been a video produced about the program, Boudreaux says.

However, there are a variety of models for hospices in prison, and these vary greatly, McAdoo says.

Here are a few examples of how they work:

  • Topeka, KS: A women's facility in Topeka doesn't have many deaths, so a full-time hospice would be not be feasible, but it does have a set of policies and a plan of action that go into effect when an inmate is dying, McAdoo says.

"They have a death about once every three years," she explains. "So what they do is when a woman is identified as needing palliative care, or if she's diagnosed with a terminal illness, they put their program in place."

  • Vacaville, CA: A men's facility in Vacaville has a 16- or 17-bed unit dedicated to hospice care.
  • Oakdale, IA: The Iowa Medical and Classification Facility in Oakdale has two hospice and palliative care rooms that are in a special unit. Inmate volunteers live on that unit and are there around the clock to provide care for dying inmates, McAdoo says.

Inmates come to the Oakdale facility at the beginning of their incarceration, and this is where they are classified as to which prison they'll be sent, she says.

The facility doesn't have an infirmary, but when inmates have medical problems, they're sent to the University of Iowa Medical Center for treatment, McAdoo says.

"The approach they use for end-of-life care is to have a large cadre of volunteers and a nursing staff around the clock, but it's just like living in a home," McAdoo adds.

Need More Information?

  • Jamey Boudreaux, MSW, MDiv, Executive Director, Louisiana Mississippi Hospice & Palliative Care Organization, 717 Kerlerec St., New Orleans, LA 70116. Phone: (504) 945-2414. Toll-free: (888) 546-1500. Email: Web site:
  • Burl Cain, Warden, Louisiana State Penitentiary, Angola LSP, Angola, LA 70712. Telephone: (225) 655-2786.
  • Carol McAdoo, Coordinating Consultant for End-of-Life Care in Corrections, National Hospice and Palliative Care Organization, 8017 W. 113th Terrace, Overland Park, KS 66210. Telephone: (913) 522-4405. Email: