Surviving a Large Scale Organized Hunger Strike at

your institution

California Correctional Health Care Services 2011

Authors Have No Conflict of Interest Disclosures

Alan Frueh MDBonnie Gieschen MD

Linda Maclachlan Pharm.DJane Robinson RN Rebecca Yager RD

John Zweifler MDDouglas Peterson MD

Distinguish between the handling of an individual hunger strike and a mass hunger strike.

Describe the pathophysiology, stages, and risks of starvation.

Stratify the risk of refeeding and prescribe an appropriate refeeding diet.

Objectives

CCHCS Policy Highlights ◦ How it usually works

Challenges of a Mass Hunger Strike◦ What we knew and expected-July 2011◦ HS 1-July 1-July 21, 2011◦ Lessons learned◦ Mass Hunger Strike Policy◦ HS 2 September 26-October 14, 2011

Starvation and Refeeding Syndrome◦ Stages of Hunger and Starvation◦ Refeeding

Risk Stratification Clinical Guidance

Outline

CCHCS Policy Highlights

CCHCS Medical Services Program P & P:

Hunger Strike Policy Chapter 22 (2006)

Front loaded with work◦ Intense utilization of resources before most P/I

experience adverse effects Inefficient, but manageable for sporadic strikers

who are more likely to: ◦ Have mental health issues ◦ Have individual goals or grievances◦ Respond to early and intense interventions by healthcare

and custody.

CCHCS Medical Services Program P & P: Hunger Strike Policy Chapter 22 (2006)

Challenges of a Mass Hunger Strike

Existing policy poorly adapted to a mass hunger strike which is likely to:

◦ Have large numbers of participants ◦ Be politically motivated

Less likely participant has mental health condition contributing to strike

◦ Be organized/pre-planned (food storage)◦ Be pre-announced

CCHCS Medical Services Program P & P: Hunger Strike Policy Chapter 22 (2006)

Strike rumors circulated in June 2011

CDCR Intelligence expected:◦ 1000+ strike participants at Pelican Bay State Prison ◦ Unknown numbers at CSP Corcoran

What we knew and expectedJuly 2011

CCHCS medical leadership recognized the limitations of existing policy and the difficulties it created:

◦ How to do RN face-face assessments within 2 days◦ How to do full RN daily assessments thereafter◦ How to determine which participants are high risk◦ How to have PCP evaluation within 72 hrs and order labs◦ How to have Mental Health see every participant◦ How to keep track of this many participants

Limitations with existing policy:

Initial plans ◦Follow policy whenever possible ◦Fallback to declaring Emergency and following

Emergency Incident Command System if needed

Limitations with existing policy:

HS 1: July 1-July 21, 2011

◦First day 6553 participants◦16 sites◦Maximum 9,079 participants◦Challenge was much greater than anticipated

July 2011 Strike: Number of participants by Institution

(Does not include Out of State)

Experience July 1-July 21, 2011

Due to large numbers of refusals staff was generally able to follow policy in spite of the large number of strike participants

Of the 9079 participants only 143 were deemed Persistent Hunger Strikers defined as:

Actively striking > 2 weeks and Had a beginning wt and > one wt recorded during

strike

Only 8 participants had weight loss > 15 lbs

July Strike: Outcome Weight Loss

Weight Lost 7/20/2011

> 20 lbs lost 4

19.9-15 lbs lost 4

14.9-10 lbs lost 29

9.9-0 lbs lost 101

> 0 lbs gained 6

Grand Total 143

Note >7700 participants never had a weight done (refused)

Custody did not clear or restrict canteen during HS 1

July Strike: Outcome Admissions

Primary Diagnosis

Muscle weakness (generalized) 3

Dehydration 2

Abdominal pain, unspecified site 2

Other disorder metabolism 1

Other disorder eating 1

37 admissions out of 9079 participants 1/3 of these appeared related to lack of intake

Most were “Persistent Hunger Strikers”

Except for one patient inmate at PBSP, there was no evidence of refeeding problems at 3 wks.

Routine labs are not supported by available data:◦ Especially electrolytes in the first 3 wks◦ Glucose (mild hypoglycemia) can be done by FS◦ UA (does not change management)◦ Labs may remain normal until refeeding begins

Lessons learned from HS 1

Existing Policy not appropriate for a mass event◦ Need a policy covering a large scale strike

Identify, evaluate and follow high risk participants (underlying illness, meds, underweight etc.)◦ Institution/provider high risk patient lists◦ Clinically Complex Registry.◦ UHR◦ Mental Health Tracking System for MH patients.

Clinical assessments safely delayed until participant has lost 5% body weight (except for high risk persons)

Lessons learned from HS 1

Baseline/periodic weights useful if can be obtained:◦ Participants status –risk of adverse events◦ Predicting risk of refeeding (Daily weights are not necessary)

The large majority of participants refused weights AND evaluations.

Close clinical observation needed for the participants who refuse weight and exam

Lessons learned from HS 1

Routine, early AD/POLST completion not useful◦ Time consuming◦ Many participants refused◦ Those who completed chose full resuscitation and Rx◦ Appropriate for participants who have lost significant weight and

are at higher risk.

Participants need education on responsibility to notify staff of need for health care

Participants need education on risks of starvation and refeeding.◦ Patient education hand-outs◦ Documentation of informed consent/effective communication

once weight loss documented.

Lessons learned from HS 1

Institutions need to stock up on supplies and equipment :◦ Scales (mark them, digital if possible), BP cuffs◦ Oral and intravenous rehydration supplies◦ MVI, thiamine (oral and IV or IM)

Pre-printed documentation templates

.

Lessons learned from HS 1

Literature based clinical guidance useful for staff◦ Role of vitamins/mineral supplements ◦ Assessment of risk/management of refeeding

Share with ED doc’s if participant transferred out

Communication and tracking issues:◦ Daily manual tracking + large # of participants = errors◦ Participants start and stop eating

Recognize data limitations due to refusals and initial collection and recording errors do not allow firm conclusions

Lessons learned from HS 1

Mass Organized Hunger Strike Policy

Custody had different approach:

Treated HS 2 as a “disturbance”

Separated HS leaders from rest of population

Removed food and canteen items from identified participants’ cells◦ Disallowed canteen privileges (except for hygiene items)

for participants

Coordinated tracking with medical via SharePoint site.

HS 2: Sept. 26-Oct. 17, 2011

High numbers but:◦ Resources focused more appropriately◦ Improved organization and communication◦ Less staff and leadership stress and fatigue

HS 2: Experience with new policy

HS 2: Experience with new policy

Weight loss: HS 1 vs HS 2

HS 2: Experience with new policy

0-9.9 lbs 10-14.9 lbs 15-19.9 lbs > 20 lbs

HS 1 10 29 4 4

HS 2 417 90 40 18

Larger numbers of weights recorded probably due to:◦ Greater number of inmates consenting to being weighed◦ Improved tracking on the SharePoint

Increased weight loss could be due to:◦ More weights taken◦ Participants did not have access to stored food this time

No deaths or serious morbidity occurred

HS 2: Experience with new policy

Continue to improve shared tracking

Removal/restriction of canteen helpful◦ Dis-incentive to participants◦ More certain of actual intake, clinically more predicable

Mass HS Policy needs improvement◦ How best to monitor large #’s of participants

Time vs Weight vs Both? Regular direct observation of refusers?◦ How best to manage starvation- when start vitamins?◦ How best to address refeeding

Determine risk and control initial intake

Institution and HQ meeting to revise… stay tuned…

Lessons learned-HS 2

Starvation and Refeeding Syndrome

Effects of Malnutrition

Stages of Hunger Strike

1-3 days

Use up glycogen

8-14 days

Risk of refeeding syndrome begins Day 10

4-7 days

Muscle protein metabolized to glucose

Depletion of K+ Phos, Mg++

Stages of Hunger Strike

15-18 d•ataxia•difficulty standing•bradycardia•orthostasis•“mental sluggishness”•sensation of cold•weakness

> 42 daysLoss of > 30% body wt life-threatening

• increased confusion• trouble concentrating• somnolent state• incoherent• arrhythmias

35-42 d“oculo-motor “

•nystagmus•diplopia•trouble swallowing•extreme vertigo•vomiting•converging strabismus

Initiate applicable CCHCS Hunger Strike PolicyBaseline weight (same scale/digital if possible)Identify high risk participantsRefer as appropriate to Mental HealthReview medication lists

◦ Stop nonessential mediations◦ Stop antacids (interfere with phosphate absorption)◦ Stop diuretics if possible

Offer educational informationDocument refusals

Clinical Interventions- Early

Clinical InterventionsOffer patients:

◦ Thiamine 100 mg po daily◦ B complex 1 po daily◦ Multi-vitamin (e.g. Tab-a-vite) one po daily

Encourage 1.5L or more /day fluid intake◦ Watch more closely if refusing fluids◦ If clinically significant dehydration offer:◦ Oral rehydration Pedialyte- (IV only if refuses)

Symptomatic hypoglycemia treat as clinically indicated:◦ Food, LNS, Glucose gel, D50 IV

Fall precautions Before voluntary refeeding assess risk

Definition: Wide spectrum of biochemical abnormalities

and clinical consequences Hypophosphatemia is the adopted surrogate

marker but not pathognomonic.   

Refeeding Syndrome

Refeeding Syndrome Physiology

40

How to recognize and respond to refeeding syndrome: Yantis, Mary Ann; Velander, Robyn Nursing2011 Critical Care. 4(3):14-20, May 2009.

Glucose takes K+, P, Mg++ into the cells

Increased demand for thiamine (cofactor cellular enzymatic reactions)

Insulin follows

When a malnourished person begins to eat:

Glucose enters blood

Clinical Manifestations: Symptoms:

◦Unpredictable◦Deterioration can be rapid◦May occur late. ◦Variable

Mild derangements may have no symptoms. Spectrum: N/V, lethargyrespiratory insufficiency,

cardiac failure, hypotension, arrhythmias, delirium, coma death.

Refeeding Syndrome

Clinical Evaluation: Screening exam, review medications

Risk assessment based on:◦ BMI, wt loss , length of fasting◦ What if no baseline weight?

ECG (if irregular pulse, abnormal HR, ↓ K+ or Phos)◦ If cardiac abnormalities-monitoring recommended

 

Evaluation and Management

Clinical Evaluation: (cont) Labs:

◦ Baseline Phos +, Mg + +, Ca + +, K +, Na +, urea, Cr before refeeding

◦ During refeeding monitor electrolytes daily (as indicated based upon refeeding risk assessment)

◦ Life-threatening changes usually seen in the first 3 days

  Watch fluid intake/output and weight

◦ If gain > ½ lb per day or 3.3 lbs/wk likely fluid retention

Evaluation and Management

Risk Stratification: adapted from

Negligible risk: Fasting < 7-9 days, with BMI>18.5 kg/m2

Modest risk: Any one  of the following criteria: a BMI > 16 but <18.5 kg/m2 or loss of >10% body weight (but < 15%)

High risk: (either) Major risk factors (any one of the following) a BMI <16 kg/m2 weight loss >15% Low K+, Mg++,PhosLesser risk factors: (two or more of the following) a BMI <18.5 kg/m2 weight loss >10% H/O ETOH, co-morbid/meds

Extreme risk: More than one of the following: BMI <16 kg/m2 weight loss >15% Low K+, Mg++, Phos No food > 21 days H/O ETOH, co-morbid/meds ChemoRx, other significant comorbidity

Risk Stratification

Refeeding Guidance adapted…

Level of Risk Management of Patient

Negligible risk: Fasting < 7-9 days, with BMI>18.5 kg/m2

Eat and drink freely and no monitoring is necessary.Watch hydration if have not been taking fluids

Modest risk:

BMI > 16 but <18.5 kg/m2 orloss of >10% body weight (but < 15%)

Strongly consider giving thiamine 100 mg prior to refeeding

Add to D5NS or given IM.

<20 kcals/kg/day  for the first 2 days CDCR Heart Healthy Diet tray (Provides 2750 kcal)

½ of each meal tray the first 2 days

• Fluid limited to around 30ml/kg/day(Example 170 lb man= 2310 ml/day)

Blood tests  above before refeeding starts Repeated at approximately 24 and 48 hours of

refeeding

Daily multi-vitamin and trace element supplement.

Refeeding Risk- Modest

Refeeding with “Food”

Level of Risk Management of PatientHigh risk:

Major risk factors :(any one of the following) a BMI <16 kg/m2 weight loss >15% Low K+, Mg++,PhosLesser risk factors: (two or more of the following) a BMI <18.5 kg/m2 weight loss >10% H/O ETOH, co-morbid/meds

Refeeding in clinical setting with careful observation  ( In most cases community hospital) Monitor closely-transfer to higher level of care if:

K+ <3.0 mmol/l Mg++ <0.5 mmol/l Phos <0.5 mmol/l

Strongly consider Phos, K+, Mg++ even if baseline ok

Strongly consider thiamine 100 mg prior to refeeding.

Intake 10 kcal/kg/day for the first 24 hours, taking either: CDCR Heart Healthy or Carnation Instant Breakfast Lactose Free Increase by 5-10 kcal/kg/day.

Fluid < 30ml/kg/day. (zero” fluid balance x 1 wk) Blood test daily x 1 week (LFT’s 2x/wk) Daily multi-vitamin and trace element supplement.

Refeeding Risk- High

Level of Risk Management of Patient Extreme risk:

More than one of the following: BMI <16 kg/m2 weight loss >15% Low K+, Mg++, Phos No food > 21 days H/O ETOH, co-morbid/meds ChemoRx, other significant

comorbidity

Admit to hospital Restore volume, fluid balance and electrolytes.

IV Thiamine Supplementation of K+, Phos, Mg++

5 kcal/kg/day for Day 1  NG continuous or intermittent LNS if can’t eat Carnation Instant Breakfast Lactose or If pt can eat CDCR Heart Healthy diet

Monitoring of the ECG for at least the first 48 hours

Blood test daily x 1 week (LFT’s 2x/wk) Normal labs- can have TOTAL body depletion low Even if high or renal failure may need supplements If low need to give supplements WITH low levels of

feeding

Once po well established begin daily MVI & trace element

Refeeding Risk- Extreme

Refeeding with LNS

Questions?Terra.Rasmussen@cdcr.ca.gov

For copies of Policy, Clinical Guidance and Decision Support