Compassionate Release
Synopsis
Michele DiTomas, a hospice physician who cares for incarcerated men, races against the clock and slashes through bureaucratic tape to help a dying man go home.
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CREDITS
Hosted by Emily Silverman.
Produced by Emily Silverman and Marina Poole.
Story Development by Adelaide Papazoglou.
Sound Engineering by Alberto Hernandez.
Assistant Producing by Kirk Klocke.
Illustrations by Lindsay Mound.
Original theme music by Yosef Munro. Additional music by Blue Dot Sessions.
TRANSCRIPT
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The Nocturnists: Stories from the World of Medicine
Season 2 | Ep 2 "Compassionate Release"
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
In the United States, our incarcerated population is almost two and a half times the population of San Francisco, where we record this podcast. And like us all, those who are incarcerated get sick, they grow old, and eventually, they die. And often, their final days are complicated.
I'm Emily Silverman, and this is The Nocturnists: Stories from the World of Medicine. Physician Michelle de Thomas takes care of incarcerated men at the end of their lives. Her job is tough, and full of bureaucratic hurdles. In this story, Michelle tells us about a time when she races against the clock to help a dying man go home. After the story, Michelle and I talk about health and the criminal justice system. And how much of our prison population struggles with mental illness. How can we do better? Here's Michelle.
Michelle de Thomas
So about four years ago, my son's second grade teacher came up to me and she said, "I hear you're quitting your job." Now, I know her pretty well, because she also taught my daughters, but I have no idea what she's talking about. So as my son and I are walking across the playground, I asked him, "So why'd you tell Ms. Justino I was quitting my job." And he reminds me of a dinner conversation we had a few weeks ago. "Remember, you told us that story about the man. They put them in a room all by himself for a really long time? And he went crazy? And you said you hated your job, and you were going to quit." "Oh, right. I remember," I said. So for the last 12 years, I've worked as a physician for the California Department of Corrections and Rehabilitation. In my mind, I go back and forth between frustration with the system, guilt for being part of it, and hope that what I'm doing makes some difference. I guess this can be confusing for an 8 year old. Actually, it's a little confusing for me sometimes. And part of how I deal with it is by telling myself that I'm not a prison doctor because I have to be- I have options. I can quit. I can go home anytime I want. So anyway, the next day go to work in a three story cement building surrounded by razor wire that serves as the entire world for some 2500 men. I show my ID to the officer, go through the Sallyport and head down the main line as a couple hundred men in blue come towards me on their way to breakfast. First, I see Mr. Bell. He nods and smiles, as he cruises by with his walker. He's 87 years old and he had a sentence of seven years to life. He always thought if he just followed the rules and served his time he would go home to his wife and kids. So far, he's been a model prisoner for 37 years. Next, I see Ms. Stevens. She's a transgender woman with a great smile. She says, "Good morning!" back. And I smile, but every time I see her I can't believe she's serving life in prison for a third strike of stealing mascara. She got out under Prop 36 actually. So as I get to the end of the hallway, I see a young man that I don't know very well. He has an inkblot shaped scar on his forehead from banging his head against the wall so much. One time I had to remove a toothbrush from his arm. He'd pushed it through the skin and into the muscle and it had gotten stuck. I asked him why he'd done that. And he told me that his grandma had sent him an Easter card, and it made him feel too sad. When I get to the hospice where I'm rounding this morning, the nurse gives me an update on our patients and lets me know that Mr. Turner had died. All he wanted to do before he died was to say goodbye to his daughter. She was in a psychiatric isolation unit at a women's prison in Southern California. And inmates aren't usually allowed to talk to other inmates. But our Warden is kind of used to us pushing the boundaries, and he got the other word into agree. So they took Mr. Turner's schizophrenic daughter and put her in a therapeutic module. That's code for "telephone besides cage," and allowed them a 15 minute phone call to say goodbye. To their credit, they also pulled together her mental health team to help her process her grief afterwards. And one of the officers from the other facility actually sent me an email the next day, thanking me for allowing him to participate. He said in 25 years of service, this was one of the most rewarding things he'd done. The nurse and I are so happy that Mr. Turner got to say goodbye to his daughter. And I'm happy that we have one more person in the system who understands that maintaining safety and security, and allowing people their humanity, are not mutually exclusive. On days like this, I think maybe I'll keep this job. So after I complete the death packet and discharge Mr. Turner's body at the morgue, I look across the room and I see my new admission for the day. He's a young man, thin but kind of muscular, not my usual hospice patient. And I wonder why is he here. I opened his chart, and I see he's 33 and in his first year of a 5 year sentence, his childhood cancer returned. He was sent to UCSF, and he got the best possible treatment. But this time the tumor was too aggressive. And now, he has less than six months to live. After I finished his history and physical, we talked about his end of life goals. He's come to hospice because he wants to spend as much time with his family as possible. And he's really hoping to go home on compassionate release. He only has one year left, and he could live with his mother if he got out. The problem is, in order to apply for compassionate release, you have to have less than six months to live. And the process takes three to four months, at best. So most people don't live long enough to get it. And even if you do, less than 10% are approved anyway. So the next day, his mother visits and she asks to speak to the doctor. Between sobs, she tells me that it's her fault he's going to die in prison. It was her car he stole. She was tired of his drug use and his burglaries. Her sister said she was enabling him. So when she woke up that morning and her car was gone, the car she needed to get to work, she was angry and tired, and she called the police. And because of that phone call, she's terrified he's going to die in prison. "Please don't let him die here," she sobs. I fill out the paperwork for compassionate release. And we wait. A month later his cheeks and temples are sunken, his movements are slowing and sometimes the nurse has to help him to the bathroom. His paperwork has made it through a number of hurdles. He's been approved by medical and by local custody. The Secretary of Corrections has reviewed his paperwork and moved it back to the sentencing court, who will make the final decision. His mother visits whenever she can. And we all hear the clock ticking. More time passes. And now his chest looks like a birdcage covered in skin. Sometimes he's too tired to talk. His mother sits at his bedside holding his hand. And I watched them. And I can't believe he's going to die here. I call the court and they tell me that his hearing is set for next week. I've already shared my medical opinion that he has less than a month to live, possibly less than a week. He's completely bed bound. He's clearly not a danger to society. It's Friday afternoon, and the judge makes the decision-approved for compassionate release, and the system must let him go. But they have 14 days to do so. I leave the hospice and go to the administrative building where those who actually have the power to get him out, sit. The Associate Warden is sitting in his Band-Aid colored office with neat stacks of paper on his desk. He looks up from his computer to hear my story. He wants to help. But there are policies and procedures that must be followed. We have to review his custodial factors, we have to be sure that there's not an outstanding warrant for his arrest in another county. These things take time. I'm listening politely, but inside my head, I'm screaming, "Oh my God, he's going to be dead in a couple of days!" But what I say is, "He doesn't have time. He can't die here. His mother can't have him die here. I can't have him die here." And I feel the tears in my eyes. He pauses and looks up. There's a lot of sad things that happen here. And he's never seen me cry. He asked me for my patients CDCR number and he plugs it into the computer. And after a few minutes of typing, he says if I can get the notarized court order this evening, he'll have somebody work on it over the weekend, and we can get him out by 11am on Monday. I thank him. And I go back to the hospice to tell my patient the good news. Monday is so much better than 14 days, and I think he'll be happy. But when I tell him, he doesn't smile. And I can see in his eyes that he doesn't think he'll be alive on Monday. I touch his arm, and I say goodbye. And I go back through the Sallyport out the razor wire fence and back to my other world, where I can have my children anytime I want. At dinner that night my daughter as she often does, asked me to tell them a story about work. Then my son, as he often does, sort of rolls his eyes and says something about inappropriate dinner conversation for an 8 year old. But he looks up ready for a story. I feel my throat tighten, but I tell them the story. I tell them the story for the same reason that I'm telling you this story. Because I need it to be recognized and remembered. As I tell the story at dinner, I realize I'm not going to quit my job. Something about this woman's dying child, her guilt, my need for him to be able to die with dignity, make me realize that it's only because I'm part of the system, that I'm able to play my role in these stories. On Monday morning, all of his papers are in order. And he goes home to a comfortable place, and at least for a little while, set away.
Emily Silverman
I am sitting here with Michel de Thomas, thank you so much for coming to talk to me.
Michelle de Thomas
Well, thank you for having me.
Emily Silverman
I'm very excited to talk about the story that you told at our event on health in the criminal justice system. Because I feel you brought a really unique perspective to the table. It's not every day that you meet somebody who works in the criminal justice system as a doctor. So maybe for our audience, you could just introduce yourself and your role and where you work.
Michelle de Thomas
So currently, I'm a chief physician at the California Medical Facility, which is one of 33 prisons in California. I serve as the medical director for the hospice there as well. I'm the chief physician, so my job involves not only clinical care, but helping manage the medical program there and working on systems improvements and quality as well. I'm also the medical director of our hospice. So we have a 17 bed inpatient hospice that serves the men throughout the state of California, who have a terminal illness and opt for comfort measures only at the end of their lives.
Emily Silverman
And it's such a unique job, such a niche in medicine. So I'd love to hear a little bit more about your path to medicine in general, and then how you were kind of funneled down this very specific road.
Michelle de Thomas
You know, I can't actually remember when I didn't want to be a doctor, that's what I was going to be. So after going to undergrad and having an opportunity to learn a bit more about the world and taking political science and the other liberal arts areas, I realized that I did want to go to medical school. But I want an opportunity to spend some time in the world and learn a little bit more about my place in that world. So I actually was in the Peace Corps and I was a high school biology teacher for two years in a small rural area in East Africa. And I loved being a teacher. I loved going to the market and getting cow hearts and having my students dissect the heart to learn how the blood pumped through. But what I really loved about being a teacher was getting that relationship with the students, and getting to the place where they trusted you and would share their stories with you. So this experience as a teacher made me realize that it's not just the science that makes a doctor a good job for me. So after I got back from Africa, I went to med school. And when I did residency, I opted for the UCSF Family Medicine program that specifically has a mission to train doctors to work with an urban underserved population. So I finished residency and was working at a safety net clinic in Berkeley, and there were some prisoners in the state of California who sued the state for not providing a constitutional level of medical care. And they went to court and in 2003, the judge said, "You're right. People are dying unnecessarily. And the medical care is not acceptable." And they gave the California Department of Corrections two years to fix it. So when they came back to the table to the court two years later, the judge said, "You failed. You haven't corrected the problem." And Felton Henderson, the judge, put the State of California's medical care under a federal receivership. At that time, they gave a large grant to UCSF to provide some services and support as the prison system improved. So the woman who was running that called me and said, "You know, I think this is the perfect job for you." So I jumped at it. And I was a consultant there for about a year. And then I was drawn in to the program.
Emily Silverman
And moving on more into your story about going into residency and then hearing about this lawsuit. There was a phrase that you use that that really caught my attention, you said that, "The population in the prison felt that they weren't having their constitutional level of care." And so what would be an example then of a person in need who wasn't getting the type of care that they deserved, as a human being.
Michelle de Thomas
So there were people who would have an asthma attack, and they would be evaluated and sent back to their cell, and then they would die there.
Emily Silverman
Without treatment?
Michelle de Thomas
Well, they might have been treated. But it may have only been partial. I don't know the details of the cases that were brought forward. But it was estimated by some outside observers that there was probably one person dying unnecessarily in the system per week. There were some physician training issues. Correctional medicine historically may be a place that has attracted people who couldn't be hired elsewhere. So after the receiver took over, all of these things were addressed, like physician salaries. They wanted to attract people who were actually qualified to be working in that type of primary care setting with all of the mental health and other complexities. They created primary care teams so that each patient actually had continuity of care. Because as people get older, their medical conditions become more complex and coming in for a sick call, or just coming in when you feel sick, isn't an adequate way to take care of an elderly man with prostate cancer, diabetes, hypertension, and hyperlipidemia. So the whole system was restructured. Part of what makes me able to work in a place that I think has some ethical issues that I disagree with is by seeing those moments where as an individual, I see a cultural shift. I think you can force things by making systems changes. But if you want to really change attitudes, you need to have it done more slowly. And I think with our hospice is one place where it's easy to allow people to see little small changes, and seeing people's humanity at the end of their life is sort of a time when many people are able to see that. So in the story I mentioned, one of the patients I called Mr. Turner wanted to speak to his daughter before he died, but she was incarcerated in another prison. And one of the correctional officers that allowed us to get the two of them together to speak, contacted us afterwards and said that this was a really moving experience for him. And it's really important to me that he was able to see that, and that I suspect, if he moves up through the ranks, he becomes an Associate Warden or a Warden, he'll remember that experience. And then next time something will come up where you have opportunity to treat people more humanely.
Emily Silverman
It's interesting to me what you said about the prison population aging. And just makes me think about all of the overlap that there is with these people, with these patients. For instance, somebody may have landed in jail or prison because of something that they did because of their mental illness. And then the question is, do they belong in jail or prison, or do they belong in a psychiatric facility? And you even mentioned in your story, this person with depression who had put the toothbrush into his arm, you know, and that was not in a psychiatric facility, that was right there in prison. And so that line blurring between where does this person belong?
Michelle de Thomas
In television, there's this idea of not guilty by reason of insanity. 50% of people within the United States prison system have serious mental illness. New York city county jail, Cook County, LA County, are the largest inpatient psychiatric wards in this country. This is where we take care of our mentally ill people. We don't have enough resources on the outside. So you know, it's not a question of whether they should be there or not. They are there and we have to treat them there. At our facility we have a very large mental health program and many of the facilities throughout the state do. But the problem is that no matter how many good psychiatrists, no matter how many programs, no matter how many groups and support you give people, prison will never be an appropriate place to treat people with mental illness. It's inherently anxiety provoking. It's inherently a place where you can't build trusting relationships. It's inherently a place without privacy. There is nothing about the mileu of prison, that's going to allow people to be successfully treated from a mental health perspective. So as a society, all of those people, you know, should probably be in some sort of other setting. There are people who've done bad things, and we have to protect the greater society. But you protect them by taking away that person's liberty. And once they go into corrections, we should be doing something to help correct them so that when they go back out into society, we are protecting future victims.
Emily Silverman
And then, aside from just the mental illness, also just thinking about it as an aging population with multiple diseases and terminal diseases, who are just aging and requiring complex care. Potentially to the point where they're so debilitated that they're clearly as was the patient in your story, no longer a harm to society. And so then a similar question comes up, which is, where do they belong? Do we keep them in custody, or is there some sort of exit door or way to transition out, once their medical problems become so much that the point of prison to begin with is no longer really being served and is just hindering their care?
Michelle de Thomas
So, you know, the ACLU estimates that with current trends, by 2030, we'll have almost a half a million geriatric patients within the prison system in the United States. We incarcerate more people in the United States than any other country in the world. So if we keep incarcerating large numbers of people, and giving them very long sentences, we will end up with this huge burden that nobody is prepared to deal with: neither logistically-with hearing impaired people, blind people, people in wheelchairs- nor financially, let alone the emotional difficulties for those people in their families. So you know, there is a point where people are very unlikely to recommit. There are three things actually, well, there's probably more than that. But three things that lower recidivism are allowing a higher education, maintaining connections in the community, and being older. People over 50, are much, much, much less likely to recommit than other people. And part of why I wanted to tell that story was not just the story of the young man dying in prison, but including the story of the older man who went in at 50, and now he's 87. He had a sentence of seven to life. He thought he was going to go home. And he didn't do anything wrong the whole time he was in prison. Why didn't he go home? And part of it is, I think that the media likes to portray people who are incarcerated sort of in a monolithic way. And when I have stories that I hear from my patients, it just creates such a complexity. The people inside are as complex as the people outside. They're not monolithic. They have children and parents and stories and they've made mistakes. And I think if there was a way to have people hear more of these stories, we will be able to move the conversation forward in a different way.
Emily Silverman
Clearly, this is a flawed system. And I'm wondering, as a physician operating in this system, clearly you have a lot of influence with your individual patients. You have the individual, you know, doctor patient interaction. Do you, as a physician in your job, have any control over reforming the system or changing the conversation around the system, less just one on one with patients but more just being a voice that's resounding within the system?
Michelle de Thomas
So, as a supervisor/manager type, I do have opportunities to influence my staff. One area that we've worked really hard as a team is with our older patients, and trying to ensure that doctors and nurses understand that just because you're incarcerated and a ward of the state, doesn't mean that you lose your autonomy in terms of your medical decision making. And that patients truly do have the right to accept treatment, to decline treatment, just as you would in the community. So allowing people to really come to terms with what they want at the end of their lives, and how they're going to fill out their advanced directive and communicate with their families, and getting them to name their decision maker is something that we've really worked towards as an institution. There's certainly a lot of room to grow as there is in most places. But I think it's really important to keep that in mind, especially with our older, and you know, the inpatient people.
Emily Silverman
Have you had a lot of patients who ended up being released from custody to die at home?
Michelle de Thomas
So I talked about the compassionate release process as a big part of the story, and you know, the process is very, very logistically complex. There are process steps along the entire pathway that make it difficult to achieve. So there's a paper that was put out by Families Against Mandatory Minimums, FAMM, and it's called Everywhere and Nowhere. There are processes in every state and the District of Columbia to allow people to be released for medical illness- it's medical parole, compassionate release, these sorts of programs. But the reality is, it's nowhere, because the logistics of these processes are so hard, and California is no different than the other states. The legislature has all agreed, everybody's agreed, that people like the man and my story should get out. And yet he came so close to almost dying in prison, which would have, you know, altered the course of his family's life. And it would have been wrong, because nobody intended for him to die in prison. So there needs to be a systematic review of this legislation to make it logistically feasible. And as part of that, I've worked with UCSF a bit on a number of training programs, where we've gone and trained doctors in Hawaii and New York State about how to prognosticate, how to identify people earlier in the process. Then we can put in our request for compassionate release sooner. We train them in how to phrase your request for compassionate release. Just saying "I think somebody has less than six months to live, can they please get out?" isn't going to be enough for a judge to make that decision. So really putting in the details that a judge might need to be able to fully make that decision.
Emily Silverman
So are there other countries that we can look to for inspiration on how to improve our criminal justice system?
Michelle de Thomas
So I think that's a great question. There's only so much we can do with our current system. And there's a lot of countries in Europe who have taken a really different perspective on how to manage criminal justice issues. One that comes to mind is Norway, in the 90s, they were having a lot of trouble inside, they had 60 to 70% recidivism, similar to the United States. They're a small system, but they had two officers killed in a year, a lot of inmate-on-inmate fighting. And they realize that the way they're doing things isn't working. And instead of continuing to do that same thing, they decided to undergo a pretty massive reform. So one of the major things that changed was, they started thinking of these people as your future neighbor. In Europe, the vast majority of people returned to society, life sentences are not common. 15 years would be a very long sentence. So they're really looking to prepare people to be good citizens, and to be their neighbor, potentially their neighbor. So what they did was they shifted to a system where they're looking a lot more at getting to know people. It's called "dynamic security." So in the United States, we do something called "static security," where we lock people up, we put them in cuffs, we put them behind bars. They don't use the chains, cuffs, and bars to the degree that they did in the past. In fact, it's very minimal. They're maintaining security by getting to know people. By forming relationships. The officers will play volleyball with the group, the men are allowed to have rooms that look similar to a college dorm, so they have privacy. They can reflect. They can grow and become the people that we want them to be. So Norway is really reimagined the way that they rehabilitate people. And it seems like something that we have to think about in this country. This whole idea of you take away somebody's liberty, but you don't take away their humanity, because our goal is to bring them back into society. So I think we could definitely look to Europe for some ideas on how we could be better.
Emily Silverman
Yeah that's really fascinating. I'm just thinking about what you said about fear. And that crime came to mind that took place in Norway of that man, who I think, it was a massive shooting, and I think it was children. And I remember hearing in the news that his sentence was something like you said, like 15 years, which in Norway is a really long sentence. But for us, we're like, "What? 15 years for a crime that was that heinous?" If you were going to explain this to somebody who say falls on the more conservative side of the spectrum and painting this image of prison as a place where you're playing volleyball with the with the security guard, and that kind of thing. I feel like somebody might smirk at that.
Michelle de Thomas
So I think that the main reason to think about doing things in a different way is because what we're doing currently isn't working. We put people in solitary confinement, and then we release them to the streets. I'm not sure we're making people safer, you can be punished and still be allowed to go to groups that actually support you, or help you reduce your substance use issues. In the United States, 50% of incarcerated people have mental illness, or substance abuse disorders. And those are things that by being compassionate, and allowing them to be treated for these problems, we will make society safer.
Emily Silverman
I want to pivot a little bit to your conversation with your son. You describe sort of this internal struggle about your job, and how on the one hand, it feels good to be doing this good work, and it gives your life meaning. But then on the other hand, it's very emotionally challenging and incredibly frustrating for all the reasons that you just described. And you know, perhaps not the best fit for someone who's seeking a job that is smooth or easy, or amounts to a good state of mental health and work life balance and those sorts of things. And so I'm wondering, how does that tension affect you? How often do you get to that place where you're like, "Maybe I'll quit," and then come back and say, "No, I can't." Where are you in that dialogue?
Michelle de Thomas
Yeah, early on, I would have that dialogue daily, I think. But at this point, I tell the story like it was that one moment, but it was a combination of all those moments that made me get to the place where I am, 12-13 years later. I'm sort of at peace with the tension between working for this organization, and being able to feel what I'm doing makes a difference. And for the work life balance part, I think I've sought out things outside of the department like this, like telling a story. It's cathartic to be able to tell a story about all of these challenges, to have other people relate to them and hear them, and also to have this relationship with UCSF where we're doing these trainings. You know, one of the trainings we did was in Hawaii, and it was teaching parole officers to have more empathy for their older parolees, and how challenging it can be to get to a parole appointment. So, the training the parole officers put on glasses that simulate macular degeneration or cataracts. They put on gloves to have a little bit of peripheral neuropathy. They have bungee cords to make their gait altered. And then they're supposed to take you know, beans and put them into a Monday through Sunday pill kits, so they can remember to take their anti-psychotic medication, so they can get on the bus and get to their parole appointment on time. And one of the officers was putting her beans in the container and she finally just is dropping beans all over the floor. And she says, "God damn it, now I have to be more empathic." And she was joking a little bit, but she also was seeing, "Wow, I didn't realize how hard and how complicated it can be for an older person with common problems that older people have to get to the appointment." And in many places, if you miss your parole appointment, you go back to prison for 12-18 months. So it's very common and, you know, that all plays into not just with older people, but with younger people, these ideas of very high recidivism. Some of the recidivism is parole violations- when you don't have resources, it can be very hard to get yourself where you need to be. I teach classes whenever I'm asked for the same reason. Maybe some of these stories will compel them to go forward and do research, or work towards improving the compassionate release process, or address some of the troubles with solitary confinement. It gives me some sense that that I have that work life balance that I'm not just slogging away inside the prison walls every day.
Emily Silverman
Well, I'm really glad that you are speaking out about the work that you're doing and teaching and that you came to share your story with us. We're so grateful to have had you come and speak, and come here for this interview.
Michelle de Thomas
Thank you. Thank you so much for having me.