BOP Program Statement 6031.06 § 37

ORDERS

The Bureau remains committed to the principle of preserving and extending life. A seriously ill

or dying inmate will be provided with care consistent with this goal. Emergency resuscitative

measures must always be performed on an inmate who suffers cardiopulmonary arrest inside a

general population institution (Care Level 1, 2, 3 institutions). However, when an inmate is at a

community hospital/nursing center/skilled nursing facility, pre-existing advance directives, living

wills, and/or DNR orders will be honored.

Inmates and health care providers are increasingly confronted with difficult and sensitive

decisions regarding health care, including the decision to have extraordinary means of care and

life support withheld and care re-directed to comfort in terminal or irreversible illness. Inmates

may direct, in advance, to withhold or withdraw certain medical treatments when recovery or

cure is not medically possible. The Bureau’s withholding or withdrawal of resuscitative or life-support services pursuant to an advance directive or DNR order is consistent with judicious

medical practice and is not equivalent to assistive suicide, voluntary euthanasia, or expediting of

the inmate’s death.

The inmate’s right to refuse medical treatment is not absolute and, in all cases, will be weighed

against legitimate government interests, including the security and orderly operation of

correctional institutions.

Inmates may appoint, in advance, proxy decision makers who will make critical health care

decisions for them should they become incapacitated and unable to make such decisions for

themselves; however, this proxy decision maker will not be another inmate or Bureau staff

member.

End-of-life care authorized by the CD, or RMD or Medical Director in their absence, will

continue regardless of care setting (e.g., MRC, community-based facility, etc.) as long as the

treatment does not exceed the scope of medical services the Bureau provides and the inmate,

inmate’s family, or proxy decision maker does not request discontinuation of ongoing treatment.

If authorized to discontinue treatment, the inmate will be provided with comfort/palliative care.

a. Implementation. To facilitate the creation and implementation of an advance directive, each

institution will develop an Institution Supplement describing local implementation procedures.

Each Institution Supplement addressing an advance directive must:

 Provide information that complies with the law of the state where the institution is

located. A copy of the relevant state’s statutes should be attached to the Institution

Supplement if available. This includes state laws addressing the non-liability of health

care practitioners who implement an advance directive in good faith.

 Include a sample standard form for inmate use, if available, from the relevant state

statutes on advance directives.

 Include instructions for inmates wishing to execute an advance directive before or after

the onset of a seriously debilitating or terminal illness, including the option to retain

private legal counsel for assistance at the inmate’s expense.

 Require filing an inmate’s executed advance directive in the inmate’s EHR via the

Document Manager function, with the original retained per state law. A notice that an

advance directive is on file is entered into the Alerts section of the EHR.

When the seriously ill or dying inmate receives care in a community hospital or medical center,

and the organization has policy and procedures regarding the involvement of next of kin, the

Bureau will adhere to the following:

 The hospital will follow its established bylaws concerning seriously ill or dying inmates

(e.g., implement advance directive/living will/initiating DNR orders, discontinuing

mechanical life support, etc.), according to the wishes of the inmate or next of kin.

 The Bureau will be kept informed of the treatment the inmate is receiving, but the

hospital’s medical personnel will retain authority for decisions concerning treatment.

b. Implementation at MRC’s and Care Level 3 facilities with specific 24-hour care medical

units (e.g., SSU). Each Institution Supplement addressing DNR orders must:

 Provide information that complies with the law of the state where the institution is

located. A copy of the relevant state’s statutes should be attached to the Institution

Supplement if available. This includes state laws addressing the non-liability of health

care practitioners who implement an advance directive in good faith.

 Instruct that in all cases, decisions expressed by a competent inmate supersede any

previously executed advance directive to the contrary.

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 Include that DNR orders will only be invoked and honored when an inmate is housed at a

Care Level 4 facility (i.e., MRCs) or Care Level 3 facilities having a long-term care or

inpatient mission approved by the Medical Director. Emergency resuscitative measures

must always be performed on an inmate who suffers cardiopulmonary arrest at a general

population institution. The CD may consult with the RMD regarding terminally ill

inmates housed at facilities not providing inpatient care.

 Include that a validly executed advance directive will only be invoked and honored while

the inmate is under a physician’s direct care at a community health care facility, Care

Level 4 facility (i.e., MRCs), or Care Level 3 facility having an approved long-term care

or inpatient mission.

Community health care facilities will implement the advance directive in accordance with their

medical bylaws and relevant state and local laws.

The Institution Supplement will also include the following procedures for implementing DNR

orders:

 A valid DNR order must be documented in the EHR and include:

 Standard terminology (i.e., “Do Not Resuscitate”)

 Signature by the ordering physician and a signed paper copy retained if required by

state law

 Inmate’s diagnosis

 Inmate’s prognosis

 Inmate’s written advance directive or other authorized expression of health care

decisions, as well as available documentation of the inmate’s informed consent

 Documentation regarding the inmate’s competence when the decision to enter a DNR

is based on their expressed request

 Wishes of immediate family member(s) if available

 Decisions and recommendations of other medical staff or consultants, including

documentation of identifying information (name, credential, etc.)

 DNR orders are subject to annual review by the ordering physician.

 Inmates with DNRs in their EHR remain entitled to maximal therapeutic efforts short of

resuscitation.

 Bureau physicians at facilities authorized to implement DNRs may not be compelled to

sign a DNR when the inmate’s expressed decisions conflict with their clinical judgment

or ethical or religious convictions.

To protect the interests of both the inmate and the government, the government may, in some

cases, seek judicial or administrative review of the declaration in an advance directive.

When the inmate is unconscious or otherwise unable or incompetent to participate in the

decision, every reasonable effort will be made to obtain written concurrence of one or several

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immediate family members. The attending physician must document these efforts in the health

record.

A DNR order may be the result of two attending physicians’ decision that the inmate is in

terminal illness status and further medical treatment is futile. When a DNR order conflict exists

between the primary care physicians and the inmate or the inmate’s proxy decision maker, a

referral to the MRC/Care Level 3 ethics committee will be made.

Should the committee be unable to resolve the conflict, the issue will be referred to the Bureau’s

Medical Director for final determination.