A Step By Step Approach to the Hunger Games

So the Detention Deputies call medical and say that there is a certain inmate who has not eaten anything for the last four days.  Not an unusual occurrence in my experience; in fact, we medical providers most often hear about Hunger Games participants in this way, sometimes several days into their fast.  At this point, we do not know if this is a real fast (maybe the inmate is gaming), a true suicide-by-starvation patient, some who is just dieting to lose weight, or a psychotic inmate.  Today I would like to go through a step-by-step approach to the Hunger Games participants.

Step 1:  The Initial Interview.

As I mentioned in my last post, the initial interview consists of the following basic questions:

  1. Are you expecting to die as a result of this fast (in other words, is this Suicide-by-Starvation)?
  2. Are you protesting something by not eating?  What is it?
  3. Is this a total fast or are there certain foods you are willing to eat?
  4. How long do you intend for this fast to last?

As a result of the interview, we can sort patients into four basic groups:

  1. Those who intend to commit Suicide-by-Starvation.  A surprising number of inmates hem and haw when asked this question.  I don’t allow this; I insist on a yes-or-no answer.  If the inmate answers “Yes,”  then I think they should be treated like any other suicidal inmate, including observation, suicide smock, etc.
  2. Those who deny a suicidal intention.  These include the extreme dieters who just want to lose weight, the “I’m pissed off” group and the tantrum throwers I discussed in my last post.  If the inmate denies suicidal intent, then I insist on a firm end date for their fast.  If the inmate gives me some length of time that I am not comfortable with (one answer I have heard more than once is “40 days and 40 nights”), I tell them that I cannot allow them to hurt themselves by fasting for so long.   We then may negotiate.  I do not like to agree to more than five days, but since I know that most young healthy inmates can fast for a surprisingly long time before they suffer significant harm, I sometimes have agreed to longer.  I also know that fasting even for five days is extremely hard, and few will make it that long.  I am willing to watch and wait, in most cases.
  3. Psychotic, delusional inmates.  This is the only group where a response is urgent.  Everyone else can wait a few days to see if they carry through with their resolve; few will.  Psychotic inmates are an exception.  We want to intervene with these patients right away.

Step 2:  The Physical Exam.

This, of course, is usually done at the same time as the initial interview, but it does not have to be.  The purpose of the physical exam is to determine the current physical health of the patient.  The initial physical examination may only consist the following:

  1. Weight.  This is the most important fast-tracking tool you have.  A patient who eats absolutely nothing will lose ½-1 pound a day.  A patient who is not losing that much weight is eating something—perhaps surreptitiously.  You may also catch the gamers who only claim to be fasting because they are not losing weight.  I’ve even seen inmates gain weight during a supposed fast!
  2. Initial BMI is important for fasting inmates.  I will be less concerned and more tolerant of a fast by a patient with a BMI of 32 (obese) that one with a BMI of 18 (already underweight).
  3. Vital signs and a general assessment of overall health.  I will not be as tolerant of a fast in an inmate who has concomitant medical problems.
  4. Labs may not be needed initially for a healthy appearing inmate.  We will get labs eventually if this inmate fasts long enough, but most do not make it that far.  On the other hand, initial labs to check nutritional status, kidney and liver function and electrolytes may well be needed in those inmates who are ill-appearing or underweight or who have abnormal vital signs.

Step 3:  Setting Up a Care Plan

I mentioned the four factors to be considered in a care plan for fasting inmates in my previous post; these are

  1. Housing.  Suicidal inmates should be housed as any other actively suicidal inmate.  This may even involve the wearing of a suicide smock.  Many of those who deny suicidal ideation may need to be housed separately, as well.  Inmates who are not eating for a cause want and need an audience.  The “Hunger Strike” is done to generate interest and support from others.  Removing such inmates from their housing dorm deprives them of an appreciative audience and also an audience that will egg them on.  Dorm friends may also be surreptitiously feeding the fasting inmate.  The only fasting inmates who I would allow to remain in the dorms are those who are fasting for religious reasons or to lose weight.  Such inmates must have a rigid end date.  If they go past that date, I may then re-assign their housing.
  2. Mental Health.  As mentioned, psychotic inmates need urgent psychiatric evaluation.  Suicidal inmates also should be quickly seen by mental health just like other acutely suicidal inmates.  Mental health evaluations are also a good idea for the “Hunger Strikers” for a cause.
  3. Medical monitoring.  Minimum medical monitoring of fasting inmates consists of weights, vital signs and an eyeball appraisal of strength and health.  Medical monitoring may only need to be done every 2-3 days for religious fasts but most others should be checked daily for as long as they are eating nothing.  This is especially important for inmates who succeed in fasting for an appreciable length of time.  Medical monitoring must also include ensuring that Hunger Games patients have access to water and food.  Some inmates will ask (or demand) that we not bring their food trays to them.  “I won’t eat it anyway.”  But it is important not to be “enablers” to fasting inmates.  I usually tell them that they don’t have to eat but their food tray will be placed in their cell for the duration of each meal service and then removed.  Fasting inmates must have constant availability of water or some other rehydrating fluids.  If they will drink something with calories and electrolytes in it, like Kool-aid or Gator-aid, all the better.  Sometimes, if I really want to tempt an inmate to end his fast, I will place a supply of commissary food, like candy bars and chips, in the patient’s cell.
  4. Legal.  Early legal intervention may be needed for psychotic inmates, who may need to be committed to a mental hospital or may simply need a medical override to allow staff to give them their medications against their will.  Most of the other types of fasting inmates do not need legal intervention unless they are one of the few who actually fast long enough to show demonstrable self harm, discussed below.  However, I tell every inmate during the initial interview that I cannot allow them to harm themselves.  If they fast long enough, I will seek a court order to feed them through a tube against their will.  Sometimes telling them this is enough to tip the balance for them to begin to eat.

Step 4:  What about the inmates who actually fast for a long time?

The “tipping point” when correctional staff must become more aggressive in their efforts to end the fast comes when the inmate has fasted long enough to cause some demonstrable, objective self -harm.  This may be that the inmate has become officially “underweight” by BMI criteria (<18.5 defines underweight; <17 defines severely underweight).  Abnormal lab values that help define this are low serum protein and albumin (signs of malnourishment), abnormal kidney function, low bicarbonate level (indicating metabolic acidosis), or abnormal electrolytes.

When one of these objective criteria has been reached, legal intervention to allow for forced feeding via NG tube should be considered.  Fortunately, I have never yet reached this point with any of my inmates.  If one of you has experience with this, I would like to hear about it!

11 thoughts on “A Step By Step Approach to the Hunger Games

  1. Troy Baker

    As usual, great article… So I have an unrelated question. Summer is almost here, and our work crews are already starting to have run-ins with bees. Do you have any advice on bee sting protocols that you can share?

    1. Jeffrey Keller Post author

      I don’t have a bee sting protocol! When I worked in the ER, I saw tons of bee stings. My response to most of these was: “You’re OK! Here’s my bill.” There are a couple of tricks to bee stings, such as using a credit card to dislodge an embedded stinger and knowing that local swelling at a bee sting site is not an allergic reaction but caused by the venom the bee injects. If someone is truly allergic to bees, they need to have their Epi-pen at their side. That is off the top of my head. I’ll add bee stings to the list of stuff to write about! If I run across a good reference, I will send it to you, Troy!

  2. Kim Getsinger

    I have witnessed several fasting patients in the past. They usually fall into the category of protesting. If they appear serious enough about it I will attempt to convince them that eventually at some point they will lose the legal if not the physical ability to refuse and we can consider “implied consent” as reason to start a nutrition program.
    We had one inmate who not only refused to eat, but he also refused to wear jail clothing. He was made to wear a sheet (Toga) when going to court, but otherwise he was nude while in his cell. Although he started out with an abundant supply of adipose tissue he eventually became within a reasonable BMI. His fasting started out as a serious protest but he quickly modified it to be “nothing solid”, which meant he would drink juices, milk and punch but not solid food. His vital signs stayed in a normal range and his weight loss was gradual. Eventually he modified his diet even further to include everything but fish which only limited his diet one day out of two weeks. He was also found to be buying candy from the commissary on occasion.
    I have only seen a couple of inmates that were seriously trying to harm themselves by refusing food. By far most fasts have been in protest category and diets are short lived. I am aware that when someone is not able to verbally consent to a procedure for reasons of physical or mental limitations “implied consent” is then justified and the patient is treated with what would be in the patient’s best interest, and the implication is that the patient would agree if he/she were alert and oriented. What is unclear to me is at what point do you consider a conscious patient to be unaware of or unconcerned with the dangers of fasting?
    Can the doctor use this criteria of implied consent or must a court order be sought?

    1. Jeffrey Keller Post author

      Implied consent is only applicable if the patient is unconscious or similarly unable to respond. Otherwise, you must have a court order to initiate feeding, IVs, or other invasive procedures against a patient’s will. Anyway, that is how I understand it!

  3. andrew jonathan dorfman, md

    i am about to begin as a physician in maximum security prison — i am new to correctional medicine, and boarded in FM.

    does anyone have any experience in guiding patients to return to eating after prolonged self-starvation/fasting, on the order of 40 or more days? is there any known literature of this type to review?

    i appreciate this site, the comments and suggestions, and have it flagged as a resource.

    thanks much, ajd

    1. Jeffrey Keller MD Post author

      Hi Andrew! Your best bet might be to attend the Society of Correctional Physicians meeting in Nashville on October 27th. They are going to specifically discuss Hunger Strikes there and you can talk to a number of physicians who have extensive experience with the problem of re-feeding after prolonged fasting. If you go, I will see you there!

  4. Tim M.

    for help with the refeeding process, try consulting your facility’s dietitian — that what we’re here for! however, i’ve run into problems with this population, mainly that the assessments that are indicated to monitor the patient during the refeeding period are not agreed/consented to by the patient (lab draws, weight check, vitals, etc). in this case, i usually just strictly limit what foods they are allowed to eat, making sure to promote V-8 for electrolytes and hydration.

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  7. Karen

    I’m late to the JailMedicine.com party and wish I would have found this A LONG TIME AGO, like 4 years ago, when I started working at our state’s only maximum security penitentiary as an APRN.
    When it comes to hunger strikes, we have had a few go the distance and since we don’t force feed, we have a written policy for IV fluids, based on judgment of provider/exam, labs, urine. One very sneaky inmate who always seemed to gain weight-even when in our direct observation cells-confided that he would drink, drink, drink, when allowed to shower every other day!

    1. Jeffrey Keller MD Post author

      Good case, Karen! I also have had hunger strike inmates who gained weight while on “hunger strike” due to all of the food they were eating surreptitiously.


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