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?

True Hunger Strike—Week 2

• Housing?

• Medical monitoring?

• Mental Health?

• Legal?

True Hunger Strike—Week 4

• Housing?

• Medical monitoring?

• Mental Health?

• Legal?

True Hunger StrikeInvoluntary Feeding

• WHO

• Guatanamo experience

• How it is done

Summary

• “Hunger Strike” = “Suicide by Starvation”

• Hunger Games Response

– Housing

– Medical monitoring

– Mental Health

– Legal

Questions? Comments?