1. Surviving a Large Scale Organized Hunger Strike at your institution
California Correctional Health Care Services
2011

2. Authors Have No Conflict of Interest Disclosures
Alan Frueh MD
Bonnie Gieschen MD
Linda Maclachlan Pharm.D
Jane Robinson RN
Rebecca Yager RD
John Zweifler MD
Douglas Peterson MD

3. Objectives
Distinguish between the handling of an individual hunger strike and a mass hunger strike.
Describe the pathophysiology, stages, and risks of starvation.
Stratify the risk of refeeding and prescribe an appropriate refeeding diet.

4. Outline CCHCS Policy Highlights Challenges of a Mass Hunger Strike
How it usually works
Challenges of a Mass Hunger Strike
What we knew and expected-July 2011
HS 1-July 1-July 21, 2011
Lessons learned
Mass Hunger Strike Policy
HS 2 September 26-October 14, 2011
Starvation and Refeeding Syndrome
Stages of Hunger and Starvation
Refeeding
Risk Stratification
Clinical Guidance

5. CCHCS Policy Highlights

6. CCHCS Medical Services Program P & P: Hunger Strike Policy Chapter 22 (2006)

7. CCHCS Medical Services Program P & P: Hunger Strike Policy Chapter 22 (2006)
Front loaded with work
Intense utilization of resources before most P/I experience adverse effects
Inefficient, but manageable for sporadic strikers who are more likely to:
Have mental health issues
Have individual goals or grievances
Respond to early and intense interventions by healthcare and custody.

8. Challenges of a Mass Hunger Strike

9. CCHCS Medical Services Program P & P: Hunger Strike Policy Chapter 22 (2006)
Existing policy poorly adapted to a mass hunger strike which is likely to:
Have large numbers of participants
Be politically motivated
Less likely participant has mental health condition contributing to strike
Be organized/pre-planned (food storage)
Be pre-announced

10. What we knew and expected July 2011
Strike rumors circulated in June 2011
CDCR Intelligence expected:
1000+ strike participants at Pelican Bay State Prison
Unknown numbers at CSP Corcoran

11. Limitations with existing policy:
CCHCS medical leadership recognized the limitations of existing policy and the difficulties it created:
How to do RN face-face assessments within 2 days
How to do full RN daily assessments thereafter
How to determine which participants are high risk
How to have PCP evaluation within 72 hrs and order labs
How to have Mental Health see every participant
How to keep track of this many participants

12. Limitations with existing policy:
Initial plans
Follow policy whenever possible
Fallback to declaring Emergency and following Emergency Incident Command System if needed

13. HS 1: July 1-July 21, 2011 First day 6553 participants 16 sites
Maximum 9,079 participants
Challenge was much greater than anticipated

14. July 2011 Strike: Number of participants by Institution (Does not include Out of State)

15. Experience July 1-July 21, 2011
Due to large numbers of refusals staff was generally able to follow policy in spite of the large number of strike participants
Of the 9079 participants only 143 were deemed Persistent Hunger Strikers defined as:
Actively striking > 2 weeks and
Had a beginning wt and > one wt recorded during strike
Only 8 participants had weight loss > 15 lbs

16. July Strike: Outcome Weight Loss
Weight Lost
7/20/2011
> 20 lbs lost 4
lbs lost
lbs lost 29
9.9-0 lbs lost
101
> 0 lbs gained 6
Grand Total
143
Note >7700 participants never had a weight done (refused)
Custody did not clear or restrict canteen during HS 1

17. July Strike: Outcome Admissions
37 admissions out of 9079 participants
1/3 of these appeared related to lack of intake
Most were “Persistent Hunger Strikers”
Primary Diagnosis
Muscle weakness (generalized) 3
Dehydration 2
Abdominal pain, unspecified site
Other disorder metabolism 1
Other disorder eating
Except for one patient inmate at PBSP, there was no evidence of refeeding problems at 3 wks.

18. Lessons learned from HS 1
Routine labs are not supported by available data:
Especially electrolytes in the first 3 wks
Glucose (mild hypoglycemia) can be done by FS
UA (does not change management)
Labs may remain normal until refeeding begins

19. Lessons learned from HS 1
Existing Policy not appropriate for a mass event
Need a policy covering a large scale strike
Identify, evaluate and follow high risk participants (underlying illness, meds, underweight etc.)
Institution/provider high risk patient lists
Clinically Complex Registry.
UHR
Mental Health Tracking System for MH patients.
Clinical assessments safely delayed until participant has lost 5% body weight (except for high risk persons)

20. Lessons learned from HS 1
Baseline/periodic weights useful if can be obtained:
Participants status –risk of adverse events
Predicting risk of refeeding
(Daily weights are not necessary)
The large majority of participants refused weights AND evaluations.
Close clinical observation needed for the participants who refuse weight and exam

21. Lessons learned from HS 1
Routine, early AD/POLST completion not useful
Time consuming
Many participants refused
Those who completed chose full resuscitation and Rx
Appropriate for participants who have lost significant weight and are at higher risk.
Participants need education on responsibility to notify staff of need for health care
Participants need education on risks of starvation and refeeding.
Patient education hand-outs
Documentation of informed consent/effective communication once weight loss documented.

24. Lessons learned from HS 1
Institutions need to stock up on supplies and equipment :
Scales (mark them, digital if possible), BP cuffs
Oral and intravenous rehydration supplies
MVI, thiamine (oral and IV or IM)
Pre-printed documentation templates .

25. Lessons learned from HS 1
Literature based clinical guidance useful for staff
Role of vitamins/mineral supplements
Assessment of risk/management of refeeding
Share with ED doc’s if participant transferred out
Communication and tracking issues:
Daily manual tracking + large # of participants = errors
Participants start and stop eating
Recognize data limitations due to refusals and initial collection and recording errors do not allow firm conclusions

26. Mass Organized Hunger Strike Policy

27. HS 2: Sept. 26-Oct. 17, 2011 Custody had different approach:
Treated HS 2 as a “disturbance”
Separated HS leaders from rest of population
Removed food and canteen items from identified participants’ cells
Disallowed canteen privileges (except for hygiene items) for participants
Coordinated tracking with medical via SharePoint site.

28. HS 2: Experience with new policy
High numbers but:
Resources focused more appropriately
Improved organization and communication
Less staff and leadership stress and fatigue

29. HS 2: Experience with new policy

30. HS 2: Experience with new policy
Weight loss: HS 1 vs HS 2
0-9.9 lbs
lbs
lbs
> 20 lbs
HS 1 10 29 4
HS 2
417 90 40 18

31. HS 2: Experience with new policy
Larger numbers of weights recorded probably due to:
Greater number of inmates consenting to being weighed
Improved tracking on the SharePoint
Increased weight loss could be due to:
More weights taken
Participants did not have access to stored food this time
No deaths or serious morbidity occurred

32. Lessons learned-HS 2 Continue to improve shared tracking
Removal/restriction of canteen helpful
Dis-incentive to participants
More certain of actual intake, clinically more predicable
Mass HS Policy needs improvement
How best to monitor large #’s of participants
Time vs Weight vs Both? Regular direct observation of refusers?
How best to manage starvation- when start vitamins?
How best to address refeeding
Determine risk and control initial intake
Institution and HQ meeting to revise… stay tuned…

33. Starvation and Refeeding Syndrome

34. Effects of Malnutrition

35. Stages of Hunger Strike
4-7 days
Muscle protein  metabolized to glucose
Depletion of K+ Phos, Mg++
8-14 days
Risk of refeeding syndrome begins Day 10
1-3 days
Use up glycogen

36. Stages of Hunger Strike
35-42 d
“oculo-motor “
nystagmus
diplopia
trouble swallowing
extreme vertigo
vomiting
converging strabismus
> 42 days
Loss of > 30% body wt life-threatening
increased confusion
trouble concentrating
somnolent state
incoherent
arrhythmias
15-18 d
ataxia
difficulty standing
bradycardia
orthostasis
“mental sluggishness”
sensation of cold
weakness

37. Clinical Interventions- Early
Initiate applicable CCHCS Hunger Strike Policy
Baseline weight (same scale/digital if possible)
Identify high risk participants
Refer as appropriate to Mental Health
Review medication lists
Stop nonessential mediations
Stop antacids (interfere with phosphate absorption)
Stop diuretics if possible
Offer educational information
Document refusals

38. Clinical Interventions
Offer patients:
Thiamine 100 mg po daily
B complex 1 po daily
Multi-vitamin (e.g. Tab-a-vite) one po daily
Encourage 1.5L or more /day fluid intake
Watch more closely if refusing fluids
If clinically significant dehydration offer:
Oral rehydration Pedialyte- (IV only if refuses)
Symptomatic hypoglycemia treat as clinically indicated:
Food, LNS, Glucose gel, D50 IV
Fall precautions
Before voluntary refeeding assess risk

39. Refeeding Syndrome Definition:
Wide spectrum of biochemical abnormalities and clinical consequences
Hypophosphatemia is the adopted surrogate marker but not pathognomonic.

40. Refeeding Syndrome Physiology
When a malnourished person begins to eat:
Glucose enters blood
Insulin follows
Glucose takes K+, P, Mg++ into the cells
Increased demand for thiamine (cofactor cellular enzymatic reactions)
How to recognize and respond to refeeding syndrome: Yantis, Mary Ann; Velander, Robyn Nursing2011 Critical Care. 4(3):14-20, May 2009.

41. Refeeding Syndrome Clinical Manifestations: Symptoms: Unpredictable
Deterioration can be rapid
May occur late.
Variable
Mild derangements may have no symptoms.
Spectrum: N/V, lethargyrespiratory insufficiency, cardiac failure, hypotension, arrhythmias, delirium, coma death.

42. Evaluation and Management
Clinical Evaluation:
Screening exam, review medications
Risk assessment based on:
BMI, wt loss , length of fasting
What if no baseline weight?
ECG (if irregular pulse, abnormal HR, ↓ K+ or Phos)
If cardiac abnormalities-monitoring recommended

43. Evaluation and Management
Clinical Evaluation: (cont)
Labs:
Baseline Phos +, Mg + +, Ca + +, K +, Na +, urea, Cr
before refeeding
During refeeding monitor electrolytes daily (as indicated based upon refeeding risk assessment)
Life-threatening changes usually seen in the first 3 days
Watch fluid intake/output and weight
If gain > ½ lb per day or 3.3 lbs/wk likely fluid retention

44. Risk Stratification: adapted from

45. Risk Stratification Negligible risk:
Fasting < 7-9 days, with BMI>18.5 kg/m2
Modest risk:
Any one of the following criteria:
a BMI > 16 but <18.5 kg/m2 or
loss of >10% body weight (but < 15%)
High risk: (either)
Major risk factors (any one of the following)
a BMI <16 kg/m2
weight loss >15%
Low K+, Mg++,Phos
Lesser risk factors: (two or more of the following)
a BMI <18.5 kg/m2
weight loss >10%
H/O ETOH, co-morbid/meds
Extreme risk:
More than one of the following:
BMI <16 kg/m2
Low K+, Mg++, Phos
No food > 21 days
ChemoRx, other significant comorbidity

46. Refeeding Guidance adapted…

47. Refeeding Risk- Modest
Level of Risk
Management of Patient
Negligible risk:
Fasting < 7-9 days, with BMI>18.5 kg/m2
Eat and drink freely and no monitoring is necessary.
Watch hydration if have not been taking fluids
Modest risk:
BMI > 16 but <18.5 kg/m2 or
loss of >10% body weight
(but < 15%)
Strongly consider giving thiamine 100 mg prior to refeeding
Add to D5NS or given IM.
<20 kcals/kg/day for the first 2 days
CDCR Heart Healthy Diet tray (Provides 2750 kcal)
½ of each meal tray the first 2 days
Fluid limited to around 30ml/kg/day
(Example 170 lb man= 2310 ml/day)
Blood tests above before refeeding starts
Repeated at approximately 24 and 48 hours of refeeding
Daily multi-vitamin and trace element supplement.

48. Refeeding with “Food”

49. Refeeding Risk- High Level of Risk Management of Patient High risk:
Major risk factors :
(any one of the following)
a BMI <16 kg/m2
weight loss >15%
Low K+, Mg++,Phos
Lesser risk factors:
(two or more of the following)
a BMI <18.5 kg/m2
weight loss >10%
H/O ETOH, co-morbid/meds
Refeeding in clinical setting with careful observation ( In most cases community hospital)
Monitor closely-transfer to higher level of care if:
K+ <3.0 mmol/l
Mg++ <0.5 mmol/l
Phos <0.5 mmol/l
Strongly consider Phos, K+, Mg++ even if baseline ok
Strongly consider thiamine 100 mg prior to refeeding.
Intake 10 kcal/kg/day for the first 24 hours, taking either:
CDCR Heart Healthy or
Carnation Instant Breakfast Lactose Free
Increase by 5-10 kcal/kg/day.
Fluid < 30ml/kg/day. (zero” fluid balance x 1 wk)
Blood test daily x 1 week (LFT’s 2x/wk)
Daily multi-vitamin and trace element supplement.

50. Refeeding Risk- Extreme
Level of Risk
Management of Patient
Extreme risk:
More than one of the following:
BMI <16 kg/m2
weight loss >15%
Low K+, Mg++, Phos
No food > 21 days
H/O ETOH, co-morbid/meds
ChemoRx, other significant comorbidity
Admit to hospital
Restore volume, fluid balance and electrolytes.
IV Thiamine
Supplementation of K+, Phos, Mg++
5 kcal/kg/day for Day 1
NG continuous or intermittent LNS if can’t eat
Carnation Instant Breakfast Lactose or
If pt can eat CDCR Heart Healthy diet
Monitoring of the ECG for at least the first 48 hours
Blood test daily x 1 week (LFT’s 2x/wk)
Normal labs- can have TOTAL body depletion low
Even if high or renal failure may need supplements
If low need to give supplements WITH low levels of feeding
Once po well established begin daily MVI & trace element

51. Refeeding with LNS

52. Questions? Terra.Rasmussen@cdcr.ca.gov
For copies of Policy, Clinical Guidance and Decision Support