Case Presentation: Mr. A is a 48-year-old male with a past medical history of end-stage heart failure. He was transported from prison due to worsening dyspnea and was admitted to the hospital with acute kidney injury. He rapidly deteriorated, requiring transfer to the Intensive Care Unit (ICU) due to worsening shock requiring vasopressors. Mr. A’s status continued to decline, leading to multiorgan system failure. Because the healthcare providers believed he was dying and would not survive hospitalization, they requested compassionate release, which the courts granted. Mr. A’s treatment plan focused on comfort, and medications that were not related to providing comfort were discontinued. In the following days, Mr. A’s health markedly improved. The team believed he no longer needed hospital care and could be discharged with home health assistance. However, upon release, the team discovered that Mr. A was ineligible for home health services due to his conviction for sexual assault of a minor. His criminal history created a dilemma for the healthcare team as it was noted that Mr. A was able to ambulate, and team members raised concerns regarding the risk of the potential to harm others as there were no further legal constraints due to his compassionate release. Mr. A was ultimately discharged home. Two months after his hospitalization, he passed away. There were no reports of criminal activity during Mr. A’s compassionate release. The healthcare team experienced moral distress upon his discharge, questioning their responsibility to society. Another aspect of the case that merits exploration is the inability of the patient to receive home health services due to his prior conviction and incarceration, which may result in other challenges in receiving end-of-life care.
Discussion: Compassionate release is a process that allows incarcerated individuals to secure early release based on extraordinary circumstances, such as terminal illness, advancing age, and debilitating medical conditions. Mr. A’s case is one of the first reported instances of moral distress related to compassionate release. Moral distress refers to psychological turmoil experienced by individuals when they believe they are involved in morally undesirable or objectionable situations, resulting in internal conflict and negative self-directed emotions. Due to the large and increasing proportion of aging incarcerated individuals in the U.S. prison system, it is vital to acknowledge the potentially morally distressing nature of the compassionate release process, and to identify solutions to prevent the adverse effects of moral distress. Potential solutions include utilizing hospital ethics committees, implementing a moral distress consultation service, providing healthcare providers with time to reflect during the process, using risk assessment instruments, and developing evidence-based compassionate release policies to address challenges.
Conclusions: As the number of older incarcerated adults and those with progressive chronic illnesses increases, opportunities for healthcare providers to interact with the compassionate release process are likely to increase. Healthcare systems must initiate discussions and implement evidence-based policies to address moral distress in compassionate release cases in institutional facilities and hospitals.