Dying for a change: a systematic review of compassionate release policies

Abstract

Purpose –

The purpose of this study was to systematically review literature to investigate trends in compassionate release policies, facility implementation, barriers at both the incarcerated individual and institutional levels, as well as gaps in the literature. The absence of uniform and appropriate policies to address suitable interventions at the end-of-life has aggravated the challenges and issues facing health-care systems within a correctional facility. A response to address and alleviate these barriers is policies related to compassionate release, a complex route that grants eligible inmates the opportunity to die in their community. Despite the existence of compassionate release policies, only 4% of requests to the Federal Bureau of Prisons are granted, with evidence demonstrating similarly low rates among numerous state prison systems, signifying the underuse of these procedures as a vital approach to decarceration.

Design/methodology/approach –

A systematic review was completed using preferred reporting items for systematic reviews and meta-analyses guidelines. Centre for Agriculture and Biosciences International Abstracts, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Education Resources Information Center, Google Scholar, MEDLINE, PsycINFO, PubMed, Social Services Abstracts and Social Work Abstracts were searched from inception to March 2021. Inclusion criteria included: the compassionate release policy (or related policy) is implemented in the USA; reported qualitative and/or quantitative outcomes; and reported original data.

Findings –

Twenty studies formed the final data set. Data analysis revealed four main themes: language barriers, complexities of eligibility criteria, over-reliance on prognostication and social stigma. Barriers to inmates’ access to compassionate release policies include unclear or technical language used in policy documents. Eligibility criteria appear to vary across the country, including disease prognoses and the ability to predict terminal declines in health, creating confusion amongst inmates, lawyers and review boards. Stigmas surrounding the rights of incarcerated individuals frequently influence policymakers who experience pressure to maintain a punitive stance to appease constituents, thus discouraging policies and interventions that promote the release of incarcerated individuals.

Research limitations/implications –

Further research is vital to strengthen the understanding of compassionate release policies and related barriers associated with accessing various types of early parole. To promote social justice for this marginalized population, end-of-life interventions in corrections need to be consistently evaluated with outcomes that improve care for dying inmates.

Practical implications –

Within correctional facilities, correctional health-care workers should play an integral role in influencing prison and medical staff attitudes toward dying inmates by providing an understanding of how to effectively support this vulnerable population. Social workers should participate in research that focuses on effective guidelines for correctional facilities to provide compassionate end-of-life care for inmates.

Social implications –

Racial disparities in the US criminal justice system are prevalent and well documented, as individuals of color are arrested far out of proportion to their share of all individuals in the USA. This particular population is thus challenged with poor access to and quality of health care in corrections. Correctional health-care workers can play an integral role in influencing policymakers, as well as prison and medical staff attitudes toward dying inmates by providing an understanding of how to effectively support this vulnerable population.

Originality/value –

Currently, there are no published research articles that provide a systematic review of compassionate release policies in the USA.

Introduction

The unique needs of an aging prison population continue to demonstrate itself as an imperative and significant topic of conversation between health care professionals and correctional administrators (Rothman et al., 2017). The number of elderly incarcerated individuals in the USA continues to grow, calling for multiple policy changes from health care advocates and scholars, including increased training for correctional staff and the revision of compassionate release policies to increase their utilization among state and federal correctional systems (Wylie et al., 2018; Williams et al., 2012). Compassionate release policies provide the opportunity for incarcerated individuals to die in their community. Although nearly all states have some form of a compassionate release policy, they are remarkably underused. Barriers continue to exist that complicate the utilization of these policies, including prognosis requirements and applicants being required to have served a specified portion of their sentence (Dubler, 1998; Price, 2018).

The lack of knowledge regarding optimal end-of-life care for seriously ill, incarcerated patients has exacerbated the existing barriers already endured by aging incarcerated populations (Rothman et al., 2017). Though substantial research and resources have concentrated on dying with dignity for individuals who retain their civil liberties, these have been greatly limited for incarcerated populations. Correctional settings, in general, lack end-of-life care models and the justification for imprisonment often impedes the provision of quality health care for incarcerated individuals (Hoffman and Dickinson, 2011). As prisons exist as isolated systems, incorporating strict regulations and social functioning, it is necessary to customize end-of-life care needs to satisfy this specific environment (Handtke and Wangmo, 2014). Health and behavioral factors, in addition to low health literacy and living in an isolated environment with significantly diminished independence, has created a great challenges for the terminally ill accessing appropriate end-of-life care (Handtke and Wangmo, 2014).

Correctional facilities encounter complex challenges with respect to the provision of humane health care, with barriers associated with end-of-life care delivery continuing to emerge for this aging population (Williams et al., 2015). A strategy that aims to address and alleviate such barriers, however, are policies related to compassionate release, which may include medical parole, medical release or geriatric parole, although these policies may differ in regard to requirements. For terminally ill applicants who have a viable release plan for housing and medical care, these policies comprises an imperative step toward reducing mass incarceration rates, promoting dignity at the end-of-life for incarcerated populations and advancing a public health approach for an aging and marginalized population. The existence of these barriers consequently motivates healthcare providers and human rights advocates to view this crisis as a human rights issue; one that impacts the rights and needs of an elderly and terminally ill population (Maschi et al., 2016).

Background

The complexities of care, paired with an overcrowding, aging population and a lack of resources, create vast challenges in providing end-of-life care within correctional settings (Turner et al., 2011). With more than two million prisoners in the USA alone, this incarcerated population is quickly shifting from younger to older adults (Institute for Crime and Justice Policy Research, 2016). Incarcerated individuals are also enduring longer prison sentences, therefore resulting in potentially lifelong internment (Maschi and Richter, 2017). The Bureau of Justice Statistics reports that between 2001 and 2013, nine out of ten of prisoner deaths were because of an illness-related cause. Incarcerated individuals are medically and socially vulnerable and thus develop chronic illness and disability approximately 10–15 years earlier than nonincarcerated individuals (Williams et al., 2015). The lack of uniform and appropriate policies to address suitable interventions at the end-of-life has merely exacerbated the challenges and issues facing health care systems within a correctional facility. Several challenges exist for implementing appropriate care for incarcertated populations, including social, economic and political influences, amongst the unique issues related to the social organization of correctional settings (Burles et al., 2015). Because of these alarming factors, there is a critical obligation to identify the needs and appropriate interventions for the dying to provide compassionate care at the end-of-life, including the opportunity to qualify for compassionate release (Depner et al., 2018; Handtke and Wangmo, 2014).

The involvement and advocacy of health care providers aiding the movement of compassionate care in correctional settings is instrumental in attempting to bring dignified deaths to incarcerated individuals; however, there continues to be a lack of correctional institutions with on-site hospice facilities, resulting in an increased need for incarcerated individuals to access community hospitals or hospices at the end of life (Klock and Liantonio, 2018). The path of using community services entails a great burden for patients, families and communities as they may incur costs related to security and transportation (Klock and Liantonio, 2018). Correctional facilities are enduring reduced economic resources, creating additional barriers for correctional staff to meet end-of-life care mandates (Stern et al., 2010). Moreover, increased correctional staff time and appropriate training for end-of-life care would also add to financial costs (Penrod et al., 2013). With limited resources and mounting demands, medical care professionals will continue to struggle to provide vital interventions at the end-of-life. According to a 2012 Human Rights Watch report, it is estimated that the incarceration and provision of health care for US prisoners over the age of 55 is an annual cost of $2.1bn for taxpayers and state and federal governments (Maschi et al., 2014). In response to these alarming costs, correctional administrative officials need to establish policies and strategies to address how the penal system deals with health care costs for incarcerated individuals (Burles et al., 2015). Rising medical care costs for older and terminally ill incarcerated populations have become an increasing financial concern to society, thus pressuring stakeholders to provide alternate methods of care, including compassionate release and geriatric parole (Berry, 2009).

Compassionate release programs, or some variation of these policies, exist in every US state to alleviate the financial and labor stress on correctional facilities; however, these policies are rarely used (Berryessa, 2020; Prost and Williams, 2020). In federal correctional settings, the applicant requests the Warden for compassionate release by providing an application and supporting documentation. Once the Warden receives the application, regulations require a prompt review and a decision is made at the local level. If denied, the applicant may contest the decision; however, this is a time-consuming procedure. If the applicant is approved, the application is referred to the Bureau’s Office of General Cousel for a final review and processing (Sample, 2019).

Despite these policies having the potential to promote decarceration, lessening the workload for correctional staff members, increasing safety and providing a dignified death for terminally ill incarcerated individuals, only 4% of applicants are being granted compassionate release on an annual basis (Berryessa, 2020). To address this underutilization, the US Department of Justice Office of the Inspector General (OIG) released a report in 2013 of their evaluation of the Federal Bureau of Prisons’ (BOP) utilization of compassionate release policies. The OIG reported that these policies was not reliably implemented nor was it managed appropriately as several guidelines were misinterpreted by various BOP officials (United States Department of Justice, 2013). In response to this evaluation, several policy requirements were revised by the BOP, resulting in the release of two additional federal incarcerated individuals (Office of the Inspector General, 2016). Consequently, the OIG made further recommendations to the BOP to address the expansion of inclusion criteria of eligible applicants for compassionate release including lowering the age requirement from 65 to 50 years of age and eradicating the requirement of serving a minimum of ten years on a prison sentence (Office of the Inspector General, 2016). As of September 2021, the BOP has not implemented the recommendations urged by the OIG.

To attain a deeper understanding of current compassionate release policies available to elderly and terminally ill and suggestions for policy implications and future research, a systematic review of published research literature was performed with a focus on compassionate release policies and an in-depth analysis of qualitative and quantitative findings. There are no published systematic reviews of compassionate release policies available in current literature; however, Holland et al.’s (2020) content analysis of current compassionate release policies in the USA provides an in-depth exploration of eligibility criteria, application contents and processes, review and pre- and post-release phases. This review of literature provides insight into the critical steps necessary to increase access and approval to compassionate release policies. Thus, to improve accessible compassionate release policies, this study explores the underutilization of current compassionate release policies, with specific aims:

• Q1. what are the eligibility requirements for compassionate release?;

• Q2. how do these requirements impact accessibility for incarcerated applicants?; and

• Q3. what are the current revision recommendations for compassionate release policies?

Methods

The systematic review of literature adhered to the guidelines specified by Littell et al. (2008) and incorporated the application of the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines (Moher et al., 2009). These methodologies commonly appear in systematic literature reviews as they enable researchers to analyze the most significant evidence-based research available regarding health care policies and interventions.

Search strategy

The search of literature was completed using the following databases: Centre for Agriculture and Biosciences International Abstracts, CINAHL, Cochrane Library, Education Resources Information Center, Google Scholar, MEDLINE, PsycINFO, PubMed, Criminal Justice Abstracts and Social Work Abstracts. These databases were searched from inception to March 2021. Within each database, the following keywords were applied following the author’s consultation with two information specialists: compassionate release OR early release OR medical parole OR early parole OR medical furlough AND inmate*OR prison*. Articles were published in the English language and included both qualitative and quantitative designs.

Inclusion criteria

This literature review’s criteria for eligibility included:

1. the compassionate release policy (or related policies) is implemented in the USA;

2. reported qualitative and/or quantitative outcomes;

3. reported original data; and

4. the study was in the English language.

Search results

The initial database search produced a total of 335 articles (see Figure 1); after the removal of duplicates, 315 articles remained. The lead author reviewed the titles and abstracts, eliminating 253 that did not meet the inclusion criteria. A full article review of the remaining 62 titles resulted in the elimination of 47 articles that did not fulfill the inclusion criteria or were incomplete studies. The lead author exhaustively searched for incomplete studies from their original authors.

Figure 1.

PRISMA flow diagram of included studies

The lead author then abstracted and synthesized information from the remaining 20 articles, in accordance with Littell et al. and PRISMA guidelines. Studies were excluded because of language or origin country of the compassionate release policies. Studies that addressed other policies related to incarcerated populations were also excluded. This author rated the suitability of each study as great, moderate or poor, depending on the degree to which the study appropriately addressed the research questions (Jahan et al., 2016). Once this author was confident in the set of data, a full-text analysis of the articles (n = 20) was executed to assess the quality and bias of each article. From each original article examining compassionate release policies, the following five items of information was recorded:

1. first author;

2. journal;

3. year of publication;

4. study location (if provided); and

5. research design (see Table 1).

Table 1.

Basic information of included studies

First Author	Year	Journal	Location	Research Design
Aday	2006	Journal of Death & Dying	Missouri, USA	Qualitative
Berry	2009	Maryland Law Review	National	Qualitative
Berryessa	2020	American Journal of Bioethics	National	Qualitative
Boothby& Overduin	2007	Prison Journal	Midwest University, USA	Qualitative
Dubler	1998	Journal of Law, Medicine, & Ethics	31 US States	Qualitative
Holland	2020	Journal of Death & Dying	46 US States	Qualitative
Holland	2021	Mortality	50 US States	Quantitative
Mahon	1999	Journal of Law, Medicine, & Ethics	National	Qualitative
Martin	2019	Journal of Humanities and Social Science	31 US States	Quantitative
Maschi	2016	Journal of Human Rights & Social Work	47 US States	Qualitative
Mitchell	2017	AMA Journal of Ethics	National	Qualitative
Murphy	2012	Marquette Law Review	Wisconsin, USA	Qualitative
O’meara	2010	Federal Sentencing Reporter	Wisconsin, USA	Qualitative
Penrod	2013	Public Health Nursing	Unknown State	Qualitative
Price	2018	Families Against Mandatory Minimum	National	Qualitative
Prost	2020	American Journal of Public Health	National	Qualitative
Rothman	2017	Palliative Medicine	California, USA	Quantitative
Williams	2011	Journal of Internal Medicine	National	Qualitative
Williams	2012	American Journal of Public Health	National	Qualitative
Wylie	2018	Psychology, Public Policy, and Law	50 US States	Qualitative

The measurement used in the study and challenges in accessing compassionate release policies are summarized in Table 2).

Table 2.

Barriers to compassionate release policies

First Author	Measurement	Barriers to compassionate release
Aday (2006)	Interviews	Eligibility criteria unclear Need for increased policy education Social stigma
Berry (2009)	Content analysis	Complex language Eligibility criteria unclear Public safety risks
Berryessa (2020)	Interviews	Complex language Eligibility criteria unclear Reliance on prognosis Social stigma
Boothby and Overduin (2007)	Questionnaire	Public apathy Social stigma
Dubler (1998)	Interviews	Eligibility criteria unclear Social stigma
Holland (2020)	Content analysis	Complex language Eligibility criteria unclear Reliance on diagnosis and prognosis Sentencing issues Social stigma
Holland (2021)	Content analysis	Care requirements Complex language Eligibility criteria unclear Reliance on diagnosis and prognosis Social stigma Sentencing issues
Mahon (1999)	Policy analysis	Need for increased policy education Restrictive eligibility criteria
Martin (2019)	Nonexperimental comparative analysis	Eligibility criteria unclear Social stigma
Maschi (2016)	Content analysis	Care requirements Complex language Eligibility criteria unclear Reliance on diagnosis and prognosis Sentencing issues Social stigma
Mitchell and Williams (2017)	Interviews	Complex language Eligibility criteria unclear Need for increased advocacy Reliance on diagnosis and prognosis Social stigma
Murphy (2012)	Policy analysis	Eligibility criteria unclear Lack of policy education Need for increased advocacy Reliance on diagnosis and prognosis
O’Meara (2010)	Policy analysis	Complex language Eligibility criteria unclear Need for increased advocacy Reliance on diagnosis and prognosis Sentencing issues Social stigma
Penrod et al. (2013)	Interviews	Eligibility criteria unclear Lack of education for correctional staff Need for increased advocacy Reliance on diagnosis and prognosis
Price (2018)	Policy analysis	Care requirements Complex language Eligibility criteria unclear Reliance on diagnosis & prognosis Sentencing issues Social stigma
Prost and Williams (2020)	Policy analysis	Complex language Eligibility criteria unclear Need for increased policy education Reliance on diagnosis and prognosis Sentencing issues Social stigma
Rothman (2017)	Bivariate analysis	Need for increased advocacy Need for increased end-of-life education Reliance on diagnosis and prognosis
Williams (2011)	Policy analysis	Complex language Eligibility criteria unclear Need for increased policy education Reliance on diagnosis and prognosis Sentencing issues Social stigma
Williams (2012)	Interviews	Complex language Eligibility criteria unclear Neglecting disabilities Need for increased policy education Reliance on assessments Reliance on diagnosis and prognosis Social stigma
Wylie (2018)	Content analysis	Care requirements Complex language Eligibility criteria unclear Reliance on diagnosis and prognosis Sentencing issues Social stigma

To assess the extent to which compassionate release laws are meeting the basic human rights of incarcerated individuals, the application of a human rights framework is necessary (Maschi et al., 2016). The human rights framework provides assessment guidelines to aid in the development and evaluation of existing public health and criminal justice policies, such as compassionate release (Maschi et al., 2016). This theory is situated on a foundation of values and principles related to the dignity and respect for all individuals, promoting a holistic relationship of all human rights in civil, political, economic, social and cultural domains (United Nations, 2012). Further principles include participation of key stakeholders, nondiscrimination, transparency and accountability, particularly from government officials (Maschi et al., 2016). These essential principles can guide policy and practice interventions to effectively meet the needs of aging and terminally ill incarcerated individuals (Maschi et al., 2016). Moreover, the human rights framework underscores the respect and dignity which should be allotted to all human beings; a crucial aspect in promoting compassionate treatment and early release of elderly and terminally ill incarcerated populations (Maschi et al., 2016). Presently, there are a lack of theoretical frameworks in studies related to compassionate release, indicating a major gap in the literature. Therefore, the human rights framework has the capacity to contribute to future research regarding compassionate release policies.

Results

Twenty articles, published between 1999 and 2021, met the study’s eligibility criteria. Of these articles, 75% were published between 2010 and 2021, 85% of the studies used qualitative methodologies and the majority of studies were published in law review (40%) or helath care journals (45%). Data analysis of the twenty articles revealed four main themes which impact the feasibility of compassionate release:

1. complicated language;

2. complexities of eligibility criteria;

3. overreliance on prognostication; and

4. social stigma.

Complicated language

Underutilization was attributed to vague and inconsistent statutory language, causing challenges for both reviewing boards and applicants (Berry, 2009; Holland et al., 2020; Wylie et al., 2018). The majority of compassionate release policies require “extraordinary and compelling” circumstances to grant an applicant with early release; however, these circumstances are not explicit and vary depending on the state (Murphy, 2012). Incarcerated individuals especially have revealed a limited comprehension of medical terminology, in addition to the normal and abnormal biological processes related to aging (Holland et al., 2021; Mahon, 1999; Maschi, 2016). Moreover, incarcerated individuals expressed uncertainty regarding which questions to ask and felt there were time limits in regards to interactions with medical staff to acquire clarity regarding their eligibility for compassionate release (Mitchell and Williams, 2017).

Complexities of eligibility requirements

All current compassionate release policies implemented in the USA necessitate a diagnosis which exhibits a chronic, permanent, terminal or irreversible physical or mental illness, condition or disease (Holland et al., 2020; Wylie et al., 2018). It is imperative to note that a few US states, including Arkansas and Wisconsin, specified that a medical condition could not be the sole justification for granting compassionate release and thus a diagnosis must be in conjunction with an additional evidence of need (Holland et al., 2020). Only Arkansas’ policy noted the inclusion of developmental disability, heightening eligibility challenges in other states as high rates of developmental disabilities are believed to exist within incarcerated populations (Boothby and Overduin, 2007; Williams et al., 2012; Wylie et al., 2018)., thus placing incarcerated individuals at higher risk of abuse, neglect and premature death (Aday, 2006; Murphy, 2012; Rothman, 2017).

The age of the applicant was a consistent, critical element in approximately 20% of compassionate release policies (Holland et al., 2020; Prost and Williams, 2020; Williams et al., 2012; Wylie et al., 2018). Age requirements vary by state, with the minimum age to qualify for consideration ranging from 55 years old to 70 years old (Holland et al., 2020; Williams et al., 2012). This criterion raises concern because of the accelerated aging that incarcerated populations experience while imprisoned, whereby incarcerated individuals age more rapidly, both physically and psychosocially, compared to their nonincarcerated peers (Aday, 2006). Older incarcerated individulals are susceptible to medical vulnerability, because of a history of poverty, lack of access to health care or substance abuse (Williams et al., 2015). Moreover, the majority of US States require a combination of age contingencies in addition to sentencing requirements, with these policies demanding that applicants serve between five and ten years of their sentence, depending on their age (Wylie et al., 2018).

Financial requirements exist in 11 US states, with four states requiring written confirmation that an applicant’s care would be financed upon release (Holland et al., 2020). Alabama is the only state that requires an applicant to obtain medicaid or medicare upon release, whereas Tennessee law requires a family member to sign a waiver releasing the Department of Corrections from the financial responsibility of caring for an incarcerated individual (Holland et al., 2020). Understandably, critics of compassionate release policies stress that compassionate release may cause applicants to be released to inadequate familial support who do not possess the financial resources necessary to provide adequate care at the end-of-life (Wylie et al., 2018; Williams et al., 2012).

Reducing the minimum age or years served requirements (e.g. requiring completion of 75% of one’s sentence or ten years, whichever is shorter) has been argued by health care advocates to increase access to compassionate release (Prost and Williams, 2020; Williams et al., 2012; Wylie et al., 2018). By removing charge-related exclusions and initiating shorter, time-sensitive deadlines with mandated agency response to reduce delays are valuable, in addition to the availability of pro bono counsel when administrative outlets have been exhausted (Holland et al., 2020; Prost and Williams, 2020).

Overreliance on prognostication

The application and utilization of compassionate release policies are often contingent on having a limited prognosis, established by a physician (Prost and Williams, 2020; Holland et al., 2020; Wylie et al., 2018; Williams et al., 2012). Currently, prognosis requirements are embedded within 22 states for compassionate release eligibility, with Florida and Hawaii necessitating that death be imminent (Holland et al., 2020; O’Meara, 2010). Prognostication, however, is a multi-faceted and complicated process for trained professionals, as it is common that physicians overestimate prognosis or even hesitate to provide a prognosis (Prost and Williams, 2020). The reliability of prognostication has been doubted across diverse disciplines, thus questioning the accuracy of estimated, death timelines. (Holland et al., 2020; Wylie et al., 2018; Williams et al., 2012). Moreover, clinicians are overwhelmed with the fear of litigation because of the legal consequences of releasing an incarcerated individual who survives beyond their expected timeframe, thus prohibiting conversations about the terminally ill and their potential for compassionate release (Prost and Williams, 2020; Wylie et al., 2018). Additionally, the lack of knowledge regarding severe and terminal illness among parole board members imposes a barrier for approval if they do not possess sufficient medical knowledge to comprehend the trajectory of a severe illness (Prost and Williams, 2020; Wylie et al., 2018; Williams et al., 2012). As a result, health care and prisoner advocates have encouraged for revisions to existing compassionate release policies to include “life-limiting illnesses” or “debilitating” conditions to substitute the overreliance on prognosis, thus assisting health care professionals comfort level in supporting dying patients in their applications for compassionate release (Holland et al., 2020; Prost and Williams, 2020; Williams et al., 2012; Wylie et al., 2018).

Social stigma and public apathy

In addition to saving taxpayers money, the provision of and access to humane health care remains as a prevalent motivator for using compassionate release policies. In the context of COVID-19, employing compassionate release policies was an ethically-justified response to provide incarcerated individuals with appropriate measures to safeguard their health, especially for older individuals and those with immune-compromised health conditions (Berryessa, 2020). The release of vulnerable incarcerated individuals has lacked compassion, as the historical pattern of denying early release continues during this pandemic (Berryessa, 2020; Holland et al., 2021). In many states, the applicant must have a housing or discharge plan; however, many older patients who have been incarcerated for decades have limited to no familial support to care for them at the end-of-life (Williams et al., 2012). Additionally, long-term care facilities are either unable or unwilling to provide housing for incarcerated individuals (Halsted, 2017). Although applications for compassionate release were granted during the initial onset of the pandemic, currently, they are scarce and relatively few incarcerated individuals have been released on compassionate grounds (Berryessa, 2020). This hesitancy to grant early release during COVID-19 will result in the death of several ill and elderly applicants, as they endure the prolonged process of awaiting approval, thus denying this vulnerable population access to their basic, human rights. Governors and lawmakers have cited concerns regarding the release of dying individuals convicted of violent crimes, their potential for dangerous recidivism and the safety of community members (Berryessa, 2020; Holland et al., 2021). Understandably, the security and well-being of individuals in the community are justifiable concerns related to early release. Public safety and victims’ rights should be of utmost consideration; however, it is imperative to note that older age at release is a contributing factor associated with lower recidivism, therefore mitigating the potential public safety risks of compassionate release (Berryessa, 2020; Mitchell and Williams, 2017). Moreover, policymakers, often consisting of correctional facility administrators and/or members of the Department of Corrections in varying states, experience pressure to maintain a punitive stance to appease constituents, thus discouraging policies and interventions that promote the release of incarcerated individuals (Price, 2018). With the safety of incarcerated individuals and correctional staff of paramount concern, security therefore permeates decision-making in regard to end-of-life care (Penrod et al., 2013). Consequently, the number of prisoners who will die in prison will continue to increase, creating a significant need for correctional end-of-life care provision, including accessibility to compassionate release policies (Mitchell and Williams, 2017; Penrod et al., 2013). With a higher cost for care attached to aging incarcerated individuals, because of mobility challenges and an overall decline in health, public policy approaches to compassionate release have become more visible, demonstrating stakeholders’ and policymakers’ motivation to release eligible applicants with the opportunity to die in their community (O’Meara, 2010; Martin, 2019).

Discussion

The prospect of dying a dignified death remains a dimming hope for many incarcerated individuals. Prevelant barriers in accessing compassionate release policies currently exist, including the unclear or technical language used in policy documents. Vague and complex terminology inhibits eligible applicants’ understanding of their eligibility and may deter incarcerated individuals from pursuing compassionate release in warranted situations. Eligibility criteria of compassionate release policies appear to vary across the country, including disease prognoses and the ability to predict terminal declines in health, creates confusion amongst applicants, lawyers and review boards. Stigmas surrounding the rights of incarcerated individuals frequently influence policymakers who experience pressure to maintain a punitive stance to appease constituents, thus discouraging policies and interventions that promote the release of incarcerated individuals.

Increase research interest and awareness

Limited research pertaining to the processes associated with compassionate release policies, including specific eligibility requirements, plagues the public’s ability to obtain a better understanding of the barriers related to compassionate release. Longitudinal studies are additionally necessary for compassionate release studies to appropriately demonstrate the potential positive and negative outcomes of early release. As the majority of studies available entailed qualitative research methodologies, there is a substantial amount of quantitative data missing from current compassionate release literature. The lack of descriptive statistics on compassionate release policies disrupts an understanding of the demographics of incarcerated applicants, to address potential socioecomonic and racial disparities, as well as the fiscal costs related to early release. Current literature also neglects to provide critical information on the processes compassionate release entails, such as the critical advocates used to assist in completing the application and typical timelines of review boards. The utilization of prognosis assessments is also vague; the lack of knowledge is especially critical given the substantial reliance placed on prognosis to be granted early release.

Health care professional’s advocacy for policy revisions

In an attempt to address the overwhelming incarcerated populations that exists in both state and federal correctional facilities in the USA, the majority of states have implemented compassionate release policies (Holland et al., 2020). This literature review revealed that despite the emergence of compassionate release policies within the USA, prison health researchers and advocates encourage imperative revisions to current mandates (Holland et al., 2020; Mitchell and Williams, 2017; Wylie et al., 2018). The majority of studies reported recommendations to lower the age of eligibility to 45 and 50 years of age because of the accelerated aging amongst incarcerated individuals (Holland et al., 2020). Health care administrators working within correctional settings must consider accelerated aging to determine eligibility criteria regarding age-related screening tools and medical care protocols (Williams et al., 2014). Moreover, it is the duty of state and federal prison administrators to amend policies to include specific mention of an applicant’s safety and well-being related to social and financial supports (Holland et al., 2020). Additional policy revisions must concentrate on reducing the timeline of the application process, as many eligible applicants die before a decision is established (FAMM, 2022). In regard to challenges related to discharge or housing plans post-release, an increase in policy driven incentives for community organizations to provide housing to the formerly incarcerated, particularly at the end-of-life, is crucial (Halsted, 2017). The inclusion of developmental disabilities and broader diagnostic categories, such as traumatic brain injuries and dementia, must also be considered when implementing compassionate release policies (Holland et al., 2020; Williams et al., 2015; Wylie et al., 2018). Increased monitoring of these policies is also essential to evaluate the impact of prognostication on applicants who would otherwise qualify for compassionate release (Wylie et al., 2018). Subsequently, advocates believe that prognoses should serve a lesser role in the criteria for compassionate release because of the known limits of mortality estimation (Holland et al., 2020; Mitchell and Williams, 2017; Wylie et al., 2018).

Current literature demonstrates that a greater empathy is necessary from the public to policymakers to attain a deeper understanding of the barriers to using compassionate release policies (Holland et al., 2020; Mitchell and Williams, 2017; Wylie et al., 2018). Regardless of the restrictions attached to compassionate release, whether related to age, diagnosis and/or sentence, states are still restricting incarcerated individuals to die within the confines of a correctional facility. Prison health advocates must encourage policymakers to retreat from the harsh practice of depriving incarcerated populations the free will to dictate where they can die and instead conduct relevant health assessments that do not artificially inflate risk and reporting results (Holland et al., 2020; Wylie et al., 2018).

Improved education for incarcerated individuals and correctional staff

Eligible applicants, correctional staff and medical professionals would benefit from increased education regarding the process to access compassionate release policies. The enhanced knowledge of compassionate release policies would aid correctional health care staff in supporting applications, leading to decarceration (Martin, 2019). In addition to decarceration, correctional staff members will also be allotted the prospect of providing safety and security to a smaller ratio of offenders. This heightened level of safety affords correctional officers, incarcerated populations and the communities in which they live with substantial benefits related to their overall well-being (Martin, 2019; Williams et al., 2017). As elderly offenders, especially those with health and mobility concerns, create a strain on labor resources within a correctional institution, the utilization of compassionate release policies can decrease this strain within the confines of an already high-stress environment, thus leading to positive effects related to job satisfaction and overall individual safety (Holland et al., 2020; Martin, 2019).

To assist in eradicating this existing stigma, for both correctional workers and the public, prisoner health care advocates have urged for system-wide education and training to increase the utilization of compassionate release policies (Prost andand Williams, 2020; Williams et al., 2012; Wylie et al., 2018). Correctional staff involved in the provision of end-of-life care should be persuaded to share their experiences with policymakers and the public to emphasize incarcerated individuals’ needs and establish themselves as champions for human dignity (Mitchell and Williams, 2017). Nonetheless, if the standard of care available in-prison remains suboptimal to a basic standard of community care, it the essential role of health care professionals to advocate for prison release policies that result in improved quality of care (Mitchell and Williams, 2017; Holland et al., 2020).

Interventions should target elderly or terminally ill patients, correctional health care professionals, parole board members and other key correctional decision-makers.

While federal institutions are required to communicate the availability of compassionate release and provide application assistance to incarcerated applicants, similar efforts must be made at the state level. Moreover, education, such as handbooks stipulating eligibility and application information should be readily available in correctional settings and libraries. Additionally, correctional health care professionals should be well-informed regarding their jurisdiction’s compassionate release policies and procedures. Advocates express hope that an increased understanding of compassionate release policies will result in greater acceptance for these policies, thus providing an avenue for older incarcerated individuals or those at the end-of-life to die within their community. Further, efforts to increase public awareness of compassionate release policies can be critical as constituents can influence vital decision-making through advocacy (Williams et al., 2012; Wylie et al., 2018; Prost and Williams, 2020).

Ethical considerations

The ethical value of human dignity should serve as a central benefit to compassionate release policies. The maintenance of human dignity is a fundamental and ethical principle of end-of-life care (Mitchell and Williams, 2017). In regards to terminally ill incarcerated patients who have a constitutional right to appropriate care, the conservation of dignity during their illness is not only an ethical imperative for clinicians, yet a constitutionally protected right as well (Mitchell and Williams, 2017; Wylie et al., 2018). Permitting terminally ill or elderly applicants to die with a lack of social support and access to quality end-of-life care as a part of their punishment is grossly severe and a violation of the Eighth Amendment, which prohibits the use of cruel and unusual punishment within the criminal justice system (Human Rights Watch, 2012; Maschi et al., 2016). In adopting a human rights perspective, individuals who are incarcerated should receive adequate physical and psychological care in the prison system, with access to supports post-release (Maschi et al., 2016). Thus, compassionate release policies should afford incarcerated populations a degree of control and autonomy at the end-of-life, alongside the opportunity to die with dignity with the support of their loved ones. Health care advocates for incarcerated individuals thus encourage prison medical staff to increase communication and build rapport with patients to allow a greater level of trust amongst incarcerated individuals, as they argue that end-of-life is challenging enough without the added complexities of seeking compassionate release (Mitchell and Williams, 2017; Murphy, 2012; O’Meara, 2010; Penrod et al., 2013).

Implications for correctional health care advocates

Health disparities in the USA’ criminal justice system are prevalent and well-documented, as incarcerated individuals struggle with a lack of autonomy and significant power imbalances in correctional facilities. This particular population is thus challenged with poor access to and quality of health care in corrections. To promote social justice for this marginalized population, end-of-life interventions in corrections need to be consistently evaluated with outcomes that improve care for dying patients. Within correctional facilities, health care advocates should play an integral role in influencing prison and medical staff attitudes toward the dying by providing an understanding of how to effectively support this vulnerable population; to treat terminally ill incarcerated individuals as patients approaching the end-of-life not as individuals for whom suffering and dying are yet another appropriate phase of punishment. Moreover, correctional health care professionals should exercise their advocacy skills in supporting dying patients with their application for compassionate release and participate in research which focuses on effective guidelines for correctional facilities to provide compassionate end-of-life care for incarcerated populations.

Conclusion

By adopting a human rights perspective for incarcerated individuals, those facing lifelong internment would be the recipients of suitable physical, emotional and spiritual care, particularly at the end-of-life. An arduous process remains, however, for dying incarcerated individuals to request approval for compassionate release, thus intensifying the responsibility of correctional health care professionals to advocate for the terminally ill and to allow these dying individuals to live in an environment that prioritizes patient-centered care. Barriers to compassionate release policies, including vague language and unreasonable requirements for approval, continue to torment older and terminally ill incarcerated individuals who choose to pursue an avenue that promotes dignity at the end-of-life. Health care professionals, legislators and advocates must promote future research to explore these existing barriers, in addition to championing for vital amendments to current compassionate release policies, as opposed to the punitive forms of punishment which pervasive social stigmas generate and propagandize.