Caring for Custodial Patients
Alice Kennedy
Reece Frechette
Admitting
- Custodial patients retain full autonomy over medical decisions and are held to the same standards for capacity and informed consent as all patients.
- This applies to consent for treatments, surgeries, transplantation, psychiatric care, end-oflife care, and code status changes.
- Patients should have an assigned surrogate decision-maker if they become incapacitated.
- Request advanced directives from the correctional agency, as most facilities complete these during intake.
- If unavailable, ask correctional officers or the VUMC case manager to contact the custodial supervisor, or reach out to VUPD for assistance.
- Consult Ethics or Legal services as needed.
Throughout Admission
- The custodial agency maintains responsibility for patient safety.
- Correctional officers manage restraints (handcuffs/shackles).
- Address restraint concerns directly with officers; escalate to VUPD if unresolved.
- Custodial patients are not allowed visitation per VUMC policy and you may not inform surrogates of location.
- Specific requests may be approved by VUPD and the custodial agency, typically only for end-of-life situations.
Privacy and Documentation
- A flag in Epic identifies patients under custody.
- Document only information pertaining to clinical care.
- HIPAA protects incarcerated patients' health information with specific exceptions: disclosure is permitted when necessary for healthcare provision, patient or facility safety, or security maintenance.
- The minimum necessary standard and SAMHSA regulations requiring patient consent for substance use disorder treatment disclosures continue to apply.
- Medical status should not be discussed with corrections officers except when necessary for care coordination.
- When uncertain about documentation in complex situations, consult Legal Services.
Discharging
- Confirm the receiving facility can safely manage ongoing medical needs before discharge —do not assume jails have adequate staffing or resources.
- Coordinate with the receiving facility's physician or administrator in advance to identify formulary restrictions, on-site capabilities (laboratory testing, hemodialysis, medical housing, nursing monitoring), and follow-up needs both at the facility and for potential release.
- Provide sufficient medication supply with clear verbal instructions, as patients in custody typically cannot access written discharge plans.
- Discharge planning is a constitutional right for incarcerated individuals with serious medical needs.
- Specific dates, times, and locations of follow-up appointments should not be shared with patients due to security concerns, but inform patients about results and care plans using clear verbal instructions.
