A Novel Protocol
Though this protocol was designed and first implemented at Boston Medical Center, the goal is to disseminate this policy across U.S. hospitals. For that reason, a generalizable protocol for shackle removal was designed that could be incorporated into existing hospital policies for the care of patients who are incarcerated. (Figure 1) The protocol parallels existing clinical assessments of any patient who is restrained in the hospital for medical or behavioral reasons and will be incorporated into the electronic health record (EHR). The EHR will identify incarcerated patients, prompt confirmation that the patient is not pregnant, and direct a member of the healthcare team to perform a Recurring Shackle Assessment (RSA) at regular intervals. The RSA functions to determine if a shackled, incarcerated patient meets any Special Circumstances for shackle removal (Figure 1). These include but are not limited to, the patient being sedated, significantly weakened due to age or clinical condition, dependent on life-sustaining treatments or interventions, placed on palliative care protocols, or having lost ambulation due to pharmacologic or neurologic paralysis such as in cases of paraplegia or stroke. If the patient meets any Special Circumstance, the protocol prompts the healthcare team to determine whether shackle removal is appropriate. 
If appropriate, care team members notify hospital public safety leadership. The attending physician will then either (a) speak with the correctional officers who are accompanying the patient to contact their supervisor, or (b) contact the supervising correctional officer directly by utilizing the Correctional Facility Contact List (CFCL). The CFCL is an appendix to the hospital policy and includes direct points of contact for the care team at each local carceral facility. The supervising correctional officer may then order that the shackles be removed by the correctional officers who accompany the incarcerated patient. If there is a disagreement between the care team and the carceral facility about shackle removal, the care team will follow an appeal process, escalating the request to hospital public safety leadership and administration.
This protocol provides a process of regular assessment, systematically identifies incarcerated patients who may be safely unshackled, and provides a framework for restraint modification or removal. It also ensures that the safety of the healthcare team is protected.  This protocol can be integrated into existing policy systems, EHR flowsheets, and healthcare workflows, while also providing individualized care for incarcerated patients. See Box 2.
Box 2: Excerpt from the updated policy on the Care of Incarcerated Patients – Boston Medical Center. In addition to the Care of Prisoners documentation by nurses, any member of the incarcerated person’s interdisciplinary healthcare team shall assess the incarcerated person’s health status to determine if Special Circumstances are present for shackle removal or modification to the least restrictive alternative. This Recurring Shackle Assessment (RSA) shall be documented every twelve hours. If the patient meets criteria for Special Circumstances, the healthcare team will determine whether the patient is eligible for Compassionate Shackle Removal (See “Compassionate Shackle Removal for Hospitalized Patients). If Special Circumstances are discovered at any other time than during a RSA, restraint removal or modification can also occur. Compassionate Shackle Removal for Hospitalized Patients Compassionate Shackle Removal is a concept where, in exceptional cases, the patient’s clinical team may request the patient’s custodial agency to recommend removal of handcuffs and shackles while the patient is receiving care at BMC. Consideration for these requests should be discussed with the patient Care Team to evaluate the patient’s physical ability to cause harm to themselves or others, or attempt escape. If the Care Team agrees the patient meets the criteria for compassionate shackle removal, the Attending Physician is encouraged to advocate to the custodial agency for the removal of the shackling devices outlined in Figure 1 (Appendix A).
Both policy and practice have begun to change. On May 13, 2023, the Massachusetts Medical Society resolved to condemn universal shackling, as well as advocate for individualized assessments for the removal of shackles and the use of the least restrictive alternative; the resolution was authored by SSP leadership.24 Additionally in May 2023, a patient who was incarcerated, sedated, and intubated in Boston Medical Center was unshackled by correctional officers after the care team adhered to the new policy. Next steps include developing a plan in collaboration with the hospital to provide ongoing staff education about the modified policy. This is important because the protocol is driven by the ability of physicians, nurses, and other patient-facing staff to assess and recognize patients in Special Circumstances. EHR flowsheets will be developed by the hospital information technology team. Ongoing and iterative improvement will be important for sustainable implementation.
We encountered obstacles in parsing through patient and physician rights, engrained clinical practices, stigma, and culpability. Determining who can request the modification or removal of shackles, and who wields the practical authority to approve or deny such requests was complex. This stems from limited interactions, often through third-party health care or security contractors, between the carceral system and hospital-based medical care. Clearing the haze required us to identify written policies wherever possible and collaborate with colleagues from across clinical specialties, hospital administration, public safety, and legal services. SSP overcame barriers to change in a stepwise process that can serve as a model for other initiatives at the intersection of human rights and medicine.
The harmful and discriminatory routine shackling of incarcerated patients brazenly continues to occur across the American healthcare system. It is our hope that this model will be adopted by other healthcare institutions nationally to provide for regular assessment and advocacy of all incarcerated patients, ending universal shackling practices. As healthcare professionals, we are obligated to scrutinize entrenched practices that perpetuate harm, and we must humanize the care of incarcerated patients.
References
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  24. Massachusetts Medical Society Resolution A-22 A106: Condemning the Universal Shackling of Every Incarcerated Patient in Hospitals. Adopted May 2023.