Equitable palliative care in prisons: integrating advanced care planning

We thank the authors for their robust and impactful study, and appreciate the opportunity to respond. ¹

The authors cite an existing definition of ‘critical illness’ requiring reversibility, distinguishing from illness-related deterioration at the end of life. While analytically useful, this distinction may be less clear in ageing prison populations — where frailty and advanced multimorbidity coexist with episodes of acute deterioration.

Notably, 16% of reported incidents resulted in avoidable hospital admissions. ¹ In community settings, advanced care planning (ACP) and early palliative involvement reduce admissions. ² More consistent integration of these approaches within custodial health care could support clearer treatment-escalation decisions and reduce unnecessary transfers.

Barriers to palliative care include limited hospice access (often superseded by security constraints) and logistical challenges with opioid prescribing. Short staffing, identified in 15% of incidents, further restrict timely symptom control and anticipatory prescribing, particularly out of hours. ACP documentation is often absent in prisoners approaching end of life, contributing to patient uncertainty and inappropriate escalation. ³

The authors rightly recommend strengthened emergency response and clearer access protocols. We suggest that routine ACP, including documented ceilings of care and anticipatory prescribing pathways, should also form part of efforts to deliver equitable prison health care — reducing avoidable admissions labelled as ‘critical illness’ and mitigating uncertainty for primary care teams.