Health Care Department Operations Manual

Chapter 4 – Special Circumstances

Article 1 – Health Care

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4.1.1 Hunger Strike and Food Refusal Event

Policy
- California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) staff shall promptly identify, assess, monitor, and treat patients participating in a hunger strike or refusing food. Clinical and custody staff shall collaborate in an attempt to promptly address the issue(s) and obtain a resolution that is satisfactory to the patient and the department.
Purpose
- To ensure that the patient is provided all necessary care and treatment while also working to promptly resolve the hunger strike or food refusal.
Responsibility
- The Chief Executive Officer (CEO), or designee, and Warden, are responsible for the implementation, monitoring, and evaluation of this policy.
Procedure
- Individual Hunger Strike or Food Refusal Event
  - Beginning on Day One
    - When a staff member becomes aware of a patient who has refused nine consecutive meals, the staff member shall immediately notify the respective Facility (or Unit) Sergeant or Lieutenant where the patient(s) is housed as soon as practical, prior to being relieved from duty. The respective Sergeant or Lieutenant shall then follow the custody process pursuant to the California Department of Corrections and Rehabilitation, Department Operations Manual (DOM), Chapter 5, Adult Custody and Security Operations, Article 10, Hunger Strike.
    - The Chief Medical Executive (CME) shall ensure that the patient’s primary care team is informed of the hunger strike or food refusal during the daily morning huddle.
      - The Primary Care Team shall ensure that information concerning the hunger strike or food refusal is being discussed during the daily huddles with the goal of rapidly resolving the matter until the patient has ended the hunger strike or food refusal event.
    - The CEO, or designee, shall inform the institution’s Regional Health Care Executive (RHCE) when one or more patients refuse nine or more consecutive state-issued meals.
    - Staff shall continue to offer the patient(s) the regular provision of state-issued meals at every regularly scheduled meal serving time, except as otherwise prescribed by a physician and ensure the patient(s) have access to water at all times.
      - In the event of a hunger strike, custody shall remove food items from the housing of those who are participating in a hunger strike pursuant to the DOM, Chapter 5, Adult Custody and Security Operations, Article 10, Hunger Strike. Should a patient refuse to have their food removed from their cell, they would not be considered a hunger strike participant.
    - Within 24 hours of the patient beginning the hunger strike or food refusal, licensed health care staff shall review the health record to determine if the patient is at a high-risk for complications of starvation or refeeding. Factors to consider include:
      - Prior hunger strikes or food refusal events within the past 12 months.
      - A body mass index (BMI) of less than 18.5.
      - Evidence of subcutaneous fat or muscle loss.
      - Abnormal levels of potassium, phosphorus, or magnesium prior to the hunger strike or food refusal.
      - Poorly controlled medical or mental health conditions.
    - The primary care provider (PCP) shall consider initiating a medical hold to ensure that the patient is not transferred without the knowledge and approval of the CME.
      - If at any time a transfer is clinically indicated, it shall be coordinated by the Health Care Placement Oversight Program and shall include communication between the sending and receiving institutions’ Warden, CEO, CME, Chief of Mental Health (CMH), and Chief Psychiatrist.
    - The Registered Nurse (RN) shall initiate a hunger strike or food refusal PowerPlan to ensure the following:
      - A PCP visit for initial assessment within seven days.
      - A routine Mental Health Evaluation or Developmental Disability evaluation.
      - An initial RN assessment followed by daily nursing rounds.
      - Daily hunger strike or food refusal nursing rounds shall be documented in the health record and include weight, vital signs, the patient’s appearance, mobility, and ability to attend to activities of daily living, whether or not the patient has eaten any food, whether the patient is drinking fluids, and any other relevant information obtained by assessing the patient.
  - Within 48 Hours of Initiation of Hunger Strike or Food Refusal
    - The CEO, or designee, shall meet with the patient(s) in an attempt to resolve the hunger strike or food refusal and continue with follow-up meetings as needed until the hunger strike or food refusal event is resolved.
    - During the meetings, every effort shall be made to promptly resolve the matter which led to the hunger strike or food refusal.
    - Information from these meetings shall be communicated to the CEO and Warden and discussed regularly.
  - Hunger Strike or Food Refusal Event in Patients in the Mental Health Services Delivery System or the Developmental Disability Program
    - Patients in the Mental Health Services Delivery System
      - Patients in the Mental Health Services Delivery System (MHSDS) participating in a hunger strike or food refusal shall have an initial evaluation within 72 hours to assess for symptoms of mental illness that may be impacting the patient’s decision to participate in a hunger strike or food refusal.
      - Patients in an inpatient setting who are refusing to eat shall have an initial evaluation by the treating mental health clinician as soon as possible and no later than the next business day.
      - During the initial evaluation, the mental health clinician shall determine whether the patient’s decision to decline food:
        
        Meets the definition of hunger strike participant or food refusal participant.
        
        Requires an Interdisciplinary Treatment Team to modify the patient’s treatment plan or discuss the need for a higher level of care (HLOC).
        
        Is due to mental illness and if so shall:
        
        Determine the risks and benefits of removing food from housing.
        
        In the case of food refusal due to mental illness, a clinical decision shall be made as to the risks of removing food from the cell. Some paranoid patients may consume packaged foods from the canteen, so risks and benefits of eliminating food from the cell should be taken into account with consultation with mental health.
        
        Refer the patient to psychiatry for evaluation and further management of mental health symptoms.
        
        Upon referral, psychiatry shall evaluate the patient to determine whether the patient requires a medication adjustment, involuntary medications ordered under Penal Code (PC) Section 2602 or needs to be considered for a HLOC.
        
        Orders for admission to an inpatient program shall be placed as clinically appropriate.
        
        May be secondary to a developmental disability or cognitive or adaptive function deficits, and if so, shall order a routine Developmental Disability Program (DDP) Evaluation.
        
        Is possibly being coerced and if so, shall inform the Health Care Access Captain and the Associate Warden (AW) of Health Care.
      - Following the initial evaluation, patients shall be assessed by a mental health clinician every 14 calendar days or more frequently, as clinically indicated, to monitor any decompensation or need for a HLOC.
      - For patients not in the MHSDS, a routine Mental Health Evaluation shall be ordered if mental health symptoms are exhibited or suspected.
    - Patients in the Developmental Disability Program
      - Participants in the DDP, not included in the MHSDS, shall have an evaluation within 72 hours by the institutional DDP psychologist, or designee, to assess for developmental disability or cognitive or adaptive functioning deficits that may be impacting the participant’s decision to participate in a hunger strike or food refusal.
      - DDP participants in an inpatient setting who are refusing to eat shall have an initial evaluation by the DDP psychologist as soon as possible and no later than the next business day.
      - During the initial evaluation, the DDP psychologist shall determine whether the participant’s decision to decline food:
        
        Meets the definition of a hunger strike or is refusing food due to developmental disability or cognitive or adaptive functioning deficits.
        
        Requires adaptive support modification or if additional adaptive supports are needed.
        
        May be secondary to mental illness and if so, shall order a routine mental health referral.
        
        Is possibly being coerced or peers are asserting undue influence, and if so, shall inform the Health Care Access Captain and the AW of Health Care.
      - Following the initial evaluation, patients shall have a follow-up evaluation by the DDP psychologist every 14 calendar days or more frequently, as clinically indicated.
      - The PCP and DDP psychologist shall collaborate on the care of the participant.
        
        The DDP psychologist shall refer to the PCP for review and determination of medical decision-making capacity, as needed.
      - For patients not in the DDP, a routine MH DDP Evaluation shall be ordered, if cognitive or functional deficits are suspected.
  - Five Business Days After Initiation of Hunger Strike or Food Refusal
    - Five business days after the patient has been identified as a hunger strike or food refusal participant, and every five business days thereafter, the Facility (or Unit) Captain and Supervising Registered Nurse II shall interview the patient in an attempt to resolve the hunger strike or food refusal and document on a CDC 128-B, General Chono. A copy of the CDC 128-B shall be sent to the patient’s Facility/Yard/Unit clinic RN or health care staff designee. A copy of the CDC 128-B shall be filed in the health record if it is a hunger strike or food refusal. If it is a hunger strike, a copy shall also be filed in CDCR’s repository.
  - Within Seven Calendar Days of Initiation of Hunger Strike or Food Refusal Consultation
    - Within seven calendar days of initiation of hunger strike or food refusal, the patient shall be seen:
      - By a PCP for a clinical evaluation. The PCP shall see the patient no less often than weekly until the patient has resumed eating. The PCP shall refer to the CCHCS Hunger Strike, Fasting, and Refeeding Care Guide in managing the patient. The care guide is not a substitute for a health care professional’s clinical judgment.
        
        During the evaluation, the PCP shall provide education on the adverse effects and risks of fasting and the refeeding syndrome. The PCP shall explore the patient’s reason for the hunger strike or food refusal and identify any related medical care issues and attempt a resolution.
      - For a face-to-face triage assessment by an RN who shall provide education on the adverse effects and risks of fasting and the refeeding syndrome.
    - Licensed health care staff shall grant patients with medical decision-making capacity autonomy in health care decisions. For patients who either have psychiatric or medical factors that are influencing their decision not to eat, a court order for involuntary treatment shall be sought when clinically warranted and allowed by law. This may include psychiatric medications, appointment of a surrogate decision-maker, or involuntary feeding to avoid permanent harm or death.
  - Day 10 of Hunger Strike or Food Refusal or Clinical Deterioration of the Patient
    - The CEO, or designee, shall inform the institution’s RHCE when the hunger strike or food refusal results in:
      - Hospitalization;
      - A 10 percent weight loss;
      - A BMI of less than 18; or
      - Continuance beyond 10 calendar days.
    - The RHCE shall consult with the CEO, and their leadership team, regarding options for resolving the hunger strike or food refusal.
  - Day 14 of Hunger Strike or Food Refusal
    - By calendar day 14 of the hunger strike or food refusal, the institution CME, or designee, shall request a Care Team Enhanced Conference (CTEC) to take place no later than calendar day 21 of the hunger strike or food refusal to assist with the resolution and clinical management of the hunger strike or food refusal.
    - The CME, or designee, may decide at any time based on a patient’s health care condition, to rehouse the patient to a HLOC bed. The patient(s) may not refuse placement or housing for medical or mental health needs. HLOC options include, but are not limited to, the following:
      - Skilled Nursing Facility.
      - Medical Correctional Treatment Center.
      - Mental Health Crisis Bed.
      - Psychiatric Inpatient Program.
  - Day 15-until Resolution
    - Licensed health care staff shall continue daily rounds, observation, and documentation.
    - The PCP shall continue weekly evaluations pursuant to the CCHCS Hunger Strike, Fasting, and Refeeding Care Guide.
  - CTEC Intervention
    - The CTEC shall:
      - Occur no later than calendar day 21 of the hunger strike or food refusal.
      - Meet weekly as outlined in the Health Care Department Operations Manual, Section 3.1.21, Clinical Team Enhanced Conference, until the hunger strike or food refusal has been resolved.
      - Consider all factors concerning the hunger strike or food refusal including:
        
        The stated and likely underlying reason(s) for the hunger strike or food refusal and efforts taken to resolve the stated or potential causes for the hunger strike or food refusal by custody or licensed health care staff.
        
        The current medical and mental health status of the patient including weight, BMI, and other vital signs, activity level and the results of nursing, medical, and mental health assessments during the hunger strike or food refusal.
        
        The patient’s medical decision-making capacity.
        
        Past or pending actions to seek orders pursuant to PC 2602 or PC 2604.
        
        Whether the patient has engaged in past hunger strikes or food refusals and the dates, duration, and any known reasons for past hunger strikes or food refusals.
        
        Any mental health factors that have an impact on the patient’s decision-making.
        
        The appropriateness of the patient’s current housing.
    - Based on the above factors, the CTEC shall develop a treatment plan that includes, but is not limited to:
      - Determination of any additional steps that can be offered to resolve grievance related hunger strikes or food refusals.
      - Determination of any additional medical or mental health treatments that can be offered.
      - Collection of current lab and weight values to inform ongoing care.
      - A recommendation regarding appropriate housing and whether the patient would benefit from a HLOC.
      - An assessment of whether the patient is able to communicate their wishes with respect to written advance directives and the CDCR 7465, Physicians Orders for Life Sustaining Treatment, and if so, an opportunity to do so.
      - A legal, clinical, and ethical assessment of whether sufficient grounds exist to seek a court order for involuntary care and treatment in cases where there is a risk of permanent morbidity or risk of death, regardless of the patient’s medical decision-making capacity.
    - If a court order is to be pursued:
      - During the CTEC, a decision shall be made regarding which clinical and custody staff shall serve as declarants and follow the process pursuant to the DOM, Chapter 5, Adult Custody and Security Operations, Article 10, Hunger Strike.
      - If the patient is to be transferred, this shall be coordinated with the receiving institution’s Warden, CEO, CME, CMH, and Chief Psychiatrist.
- Resolution of Hunger Strike or Food Refusal Event
  - Once a patient has resumed eating, the staff member who observed the patient eat shall document the conclusion of the hunger strike or food refusal on a CDC 128-B including observation of what was consumed, what actions were taken to resolve the hunger strike or food refusal, and current weight (if available), and notify their supervisor and the Facility (or Unit) Sergeant or Lieutenant, and the clinic RN or licensed health care designee. The clinic RN shall notify the other treatment team members.
    - A copy of the CDC 128-B shall be sent to the CEO and the patient’s facility, yard, or unit clinic RN or licensed health care designee. In the event of a hunger strike, a copy of the CDC 128-B shall also be sent to the Facility (or Unit) Captain or AW, and Warden.
    - A copy of the CDC 128-B shall be filed in the health record if it is a hunger strike or food refusal. If it is a hunger strike, it shall be also filed in CDCR’s repository.
  - Patients who have participated in a hunger strike or food refusal for less than five to six days are at low risk of refeeding problems and may end their hunger strike by resuming their regular diet, provided their BMI>18.5 and they have not experienced a weight loss of >10% in the last three to six months.
  - If the patient has fasted for longer than seven days or is otherwise determined to be high risk as determined by licensed health care staff, refeeding shall be conducted as per the CCHCS Hunger Strike, Fasting, and Refeeding Care Guide.
- Mass Hunger Strike
  - During a mass hunger strike, the institution shall follow Section(d)(1)(A)-(I) detailed above.
  - In addition, the institution’s CEO, or designee, shall notify the Director, Health Care Services.
  - The institution’s Warden, or designee, shall notify the Office of the Inspector General of all mass hunger strikes as per the DOM, Chapter 5, Adult Custody and Security Operations, Article 10, Hunger Strike.
  - If the mass hunger strike disrupts institution operations, the institution Warden, or designee, and the CEO, or designee, shall determine if it becomes necessary to implement modified programing as defined in the California Code of Regulations (CCR), Title 15, Section 3000, the institution emergency operations plan as detailed in the CCR, Title 15, Section 3301, and activate the Incident Command Posts.
References
- California Probate Code, Division 4, Part 7, Sections 3200-3212
- California Penal Code, Part 3, Title 1, Chapter 3, Article 1, Section 2602
- California Penal Code, Part 3, Title 1, Chapter 3, Article 1, Section 2604
- California Code of Regulations, Title 8, Division 1, Chapter 4, Subchapter 7, Article 6, Section 3298, Operations
- California Code of Regulations, Title 15, Division 3, Chapter 1, Article 1, Section 3000, Definitions
- California Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 4, Article 4, Section 3301, Emergency Operations Plan
- California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 2, Article 1, Section 3999.203, Capacity for Informed Consent
- California Code of Regulations, Title 22, Division 5, Chapter 3, Article 5, Section 72527, Patients’ Rights
- California Code of Regulations, Title 22, Division 5, Chapter 3, Article 5, Section 72528, Informed Consent Requirements
- California Code of Regulations, Title 22, Division 5, Chapter 12, Article 5, Section 79799, Inmate-Patients’ Rights
- California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 5, Adult Custody and Security Operations, Article 10, Hunger Strike
- Health Care Department Operations Manual, Chapter 2, Article 4, Section 2.4.2, Physician Orders for Life Sustaining Treatment
- Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.21, Care Team Enhanced Conference
- California Correctional Health Care Services, Hunger Strike, Fasting, and Refeeding Care Guide
Revision History
- Effective: 01/2006
  Revised: 12/16/2024