203 - Decisional capacity and advance care planning in older people who are incarcerated

Abstract

AbstractThere is a growing number of older people incarcerated across the United States. With a population of greater than 300 million, the US has 5% of the world’s population, yet incarcerates 25% of the world’s prisoners. From 2000 to 2005, the percentage of prisoners in federal and state correctional institutions who were 55 and older increased by 33%. According to the American Civil Liberties Union older prison population has climbed 1300% since the 1980s, with 125,000 inmates aged 55 or older incarcerated.Correctional facilities are the largest mental health institutions with 1 out of 5 individuals with serious mental health or substance use disorders. These facilities lack the capacity to provide long-term care for those with severe physical or mental health disorders even in the most ideal circumstances.Individuals within the criminal justice system have a higher burden of chronic physical and health disorders and have a lower life expectancy.Health care decision making is one area where patients in custody have autonomy in discussing advance directives, substitute decision makers and medical decision making. However, prisoners are at risk of suboptimal care, unmet palliative and end of life care needs, and lacking or inappropriate surrogates. Without documentation of advance directives or surrogates there are bureaucratic, practical, and legal barriers particularly for those without family or friends. In addition, some individuals involved in the correctional system’s only surviving family members may also be their victims, thus have a conflict of interest.This presentation will explore capacity and substitute decision making for individuals involved in the criminal justice system who have severe mental and physical health disorders. A case description will be used to illustrate a decision-making tree for patients who are incarcerated. As the world population continues to age, the number of older people who are incarcerated and unable to make healthcare decisions will continue to increase. In this special population, correctional system clinicians and providers need to be familiar with strategies to address the need for advance care planning before older people lose decisional capacity.