Commissioner's Directive

INTRODUCTION

Purpose of the Guidelines

1. To assess and manage the health of inmates who choose to engage in a hunger strike.

Definition of Hunger Strike

2. At the Correctional Service of Canada (CSC), an inmate is on a hunger strike when both of the following are present:
   1. the inmate declares himself/herself as being on a hunger strike;
   2. the inmate refuses all solid food and all fluids except water for a period of at least seven days.

Note: Fasting for religious or spiritual purposes should NOT be construed as a hunger strike.

AUTHORITIES

3. Corrections and Conditional Release Act (CCRA), section 89

Provincial/territorial mental health legislation and regulations;

Provincial/territorial standards of practice for health professionals

SPECIFIC RESPONSIBILITIES

All Staff

4. Working in collaboration, staff must try to resolve the issue(s) identified by the inmate as the reason(s) for declaring a hunger strike.
5. During a hunger strike, all requirements for consent apply per CD 803 - Consent to Health Service Assessment, Treatment and Release of Information.
6. As per section 89 of the CCRA: “The Service shall not direct the force-feeding, by any method, of an inmate who had the capacity to understand the consequences of fasting at the time the inmate made the decision to fast.”
7. As prolonged engagement in a hunger strike may cause serious personal injury/harm and/or death, Do Not Resuscitate Orders and directions regarding care within Advance Directives do not apply. For any inmate who loses capacity to make a conscious choice, or becomes unconscious, CSC staff will intervene to preserve life.

Inmate Declaration of a Hunger Strike (Days 0-6)

Nurse

8. Upon learning of a potential or actual hunger strike, immediately verify the status of the declared hunger strike by asking the inmate if and for how long he/she has gone without solid food and fluids (determine if he/she is drinking water).
9. Review the inmate's Health Care record.
   1. Determine the potential health risks of fasting for the inmate.
   2. Determine if there are any known medical conditions that would warrant intervention before seven days.
10. Counsel the inmate to ensure he/she is making an informed decision.
    1. Ask the inmate his/her reasons for declaring a hunger strike.
    2. For inmates on methadone or suboxone, see section on hunger strikes in Specific Guidelines for the Treatment of Opiate Dependence (Methadone/Suboxone®) for information on counselling regarding involuntary tapers.
    3. Advise the inmate of the potential negative health consequences of fasting so that he/she can make an informed decision about continuing.
11. With the inmate's consent, conduct an initial physical and mental health assessment.
    1. Review all medications and consult with the Institutional Physician to determine any required changes in dosage, or methods of distribution and/or administration.
    2. For inmates on methadone or suboxone, see section on hunger strikes in Specific Guidelines for the Treatment of Opiate Dependence (Methadone/Suboxone®) for guidelines on involuntary tapers.
    3. Include vital signs, urine screen for ketones, weight and signs of dehydration in the initial health assessment.
12. Assess the ability of the inmate to understand the consequences of the decision to fast.
13. Refer to mental health professionals as necessary.
14. Inform the Correctional Manager of the declaration of a hunger strike.
15. Inform the Chief, Health Services, of the declaration of a hunger strike when the Chief next reports to work.

Correctional Manager

16. The Correctional Manager will direct correctional staff to monitor and record the following in the unit log book:
    1. whether the inmate is accepting/preparing food;
    2. whether food is missing from the meal tray and/or the inmate is eating;
    3. whether the inmate is attending the dining area; and
    4. whether the inmate is ordering food items from the canteen or has other food items in his/her cell.
17. The Correctional Manager will direct the correctional staff to submit a summary of the information entered into the log book on an observation report before the end of their shift.

HungerStrike (Day 7 and Ongoing)

Nurse

18. Conduct a daily assessment of the inmate's physical and mental health.
    1. Include vital signs, urine screen for ketones, weight and signs of dehydration.
    2. Assess the status of any known medical condition that may be affected by a hunger strike (e.g., diabetes).
    3. If the inmate refuses to consent to these assessments, observe the inmate's condition daily to monitor for signs of weakness, lethargy, altered mental state, pallor, tremor, dehydration, etc.
    4. Assess the ability of the inmate to understand the consequences of the decision to fast and refer to mental health professionals as necessary.
19. As required, counsel the inmate to ensure he/she is making an informed decision and to help him/her decide to end the hunger strike.
20. List the inmate for an assessment by the Institutional Physician on or about day 7 after declaration of the hunger strike (sooner if warranted), to determine what additional medical observations, assessments and interventions are required.

21. Keep the Physician and Chief, Health Services, apprised of the inmate's status. List the inmate for ongoing appointments with the Physician as required.

Correctional Manager

22. The Correctional Manager's responsibilities are the same as those for days 0-6.

Institutional Physician

23. As required, assess the inmate and advise regarding changes in care.
24. Consult with mental health professionals as necessary regarding the need for counselling and assessment of mental status.
25. As required, counsel the inmate to ensure he/she is making an informed decision and to help him/her decide to end the hunger strike.

Chief, Health Services

26. Ensure timely assessments by the Nurse and Physician of inmates who declare or are on a hunger strike, as outlined in previous sections.
27. For inmates on methadone, ensure the Physician refers to section on hunger strikes in Specific Guidelines for the Treatment of Opiate Dependence (Methadone/ Suboxone®) for guidelines on counselling and dosage adjustments.
28. Inform the Parole Officer once the inmate has declared a hunger strike and when the inmate has reached day 7 after the declaration of the hunger strike.
29. Ensure the Institutional Head, the Regional Director, Health Services, and others with a need to know are kept informed of the inmate's health status.

REPORTING

Chief, Health Services

30. Report to the Manager, Clinical Services, when an inmate has declared a hunger strike and again when an inmate has reached day 7 after the declaration of the hunger strike.
31. After day 7, provide daily updates of the inmate's health status or change in hunger strike status.

Manager, Clinical Services

32. Once the inmate has reached day 7 after the declaration of a hunger strike, report weekly to the Regional Director, ealth Services. Report more frequently if the inmate’s health condition warrants.

Institutional Head

33. Within 48 hours of an inmate declaring a hunger strike, report the incident as per Annex C of CD 568-1 - Recording and Reporting of Security Incidents.

ENQUIRIES

34. Strategic Policy Division
    National Headquarters
    Email: Gen-NHQPolicy-Politi@csc-scc.gc.ca
    
    Assistant Commissioner,
    Health Services

Original signed by:
Leslie MacLean

ANNEX A
CROSS-REFERENCES AND DEFINITION

CROSS-REFERENCES

CD 568-1 - Recording and Reporting of Security Incidents, Annex C

CD 800 - Health Services

CD 803 - Consent to Health Service Assessment, Treatment and Release of Information

Specific Guidelines for the Treatment of Opiate Dependence (Methadone/Suboxone®)

DEFINITION

Force feeding: the practice of feeding a person without his/her consent. This would include use of mechanical means such as feeding tubes and/or intravenous.