Hunger Strikes

By Elizabeth Franklin-Best, Esq., and Christopher Zoukis, JD, MBA

Program Statement	5562.05
Subject	Hunger Strikes
Current edition	July 29, 2005
Change notices	None
Supersedes	P5562.04, Hunger Strikes, Inmate (6/20/94)
Governing regulation	28 C.F.R. part 549, subpart E — §§ 549.60 through 549.66
Governing statute	None cited in the Program Statement. The Bureau’s general duty is 18 U.S.C. § 4042(a)(2)–(3).
Related BP forms	BP-A358, Refusal of Treatment; BP-S292 (used to document beverages other than drinking water)
Official PDF	https://www.bop.gov/policy/progstat/5562_005.pdf

Checked against the BOP policy set · 2026-09-07 · How we verify

Federal regulations define a hunger strike as refusing food for more than about 72 hours, or telling staff you are refusing food and being observed not eating — and once that definition is met, the Bureau of Prisons moves the person to a single-cell observation room, keeps delivering three meals a day, and begins daily medical monitoring. If the physician later decides that a person’s life or health is in immediate danger, the regulation permits treatment without consent. This page reproduces the rule word for word and explains what the Bureau’s own staff instruction adds on top of it; for how routine health care works day to day, see medical and dental care in federal prison.

Two things are worth understanding before anything else. First, most of what happens is medical rather than disciplinary: the regulation routes the person to health services and mental health staff, not to the disciplinary process. Second, the regulation is old. It was published in 1980 and last amended in 1994; the Program Statement implementing it dates from 2005 and has never been reissued. That combination — a thirty-year-old rule and a twenty-year-old staff instruction — is unusual in a policy set the Bureau has otherwise been rewriting steadily.

The rule itself: hunger strikes

Program Statement 5562.05 prints its own typographic key on its first page: “[Bracketed Bold – Rules] / Regular Type – Implementing Information” (PS 5562.05 at p. 1). Everything in brackets is the regulation. Everything else is the Bureau’s instruction to its own staff. That distinction matters, because a regulation binds the Bureau and a Program Statement is the Bureau’s internal direction for applying it.

Below is the complete regulation — 28 C.F.R. part 549, subpart E, all seven sections — reproduced verbatim from the Code of Federal Regulations, with the paragraph of PS 5562.05 where each one appears.

Section	Heading	Text of the regulation	Where it appears in PS 5562.05
§ 549.60	Purpose and scope.	“The Bureau of Prisons provides guidelines for the medical and administrative management of inmates who engage in hunger strikes. It is the responsibility of the Bureau of Prisons to monitor the health and welfare of individual inmates, and to ensure that procedures are pursued to preserve life.”	¶ 1, p. 1
§ 549.61	Definition.	“As defined in this rule, an inmate is on a hunger strike: (a) When he or she communicates that fact to staff and is observed by staff to be refraining from eating for a period of time, ordinarily in excess of 72 hours; or (b) When staff observe the inmate to be refraining from eating for a period in excess of 72 hours. When staff consider it prudent to do so, a referral for medical evaluation may be made without waiting 72 hours.”	¶ 6, p. 2
§ 549.62	Initial referral.	“(a) Staff shall refer an inmate who is observed to be on a hunger strike to medical or mental health staff for evaluation and, when appropriate, for treatment. (b) Medical staff ordinarily shall place the inmate in a medically appropriate locked room for close monitoring.”	¶ 7, p. 3
§ 549.63	Initial medical evaluation and management.	“(a) Medical staff shall ordinarily perform the following procedures upon initial referral of an inmate on a hunger strike: (1) Measure and record height and weight; (2) Take and record vital signs; (3) Urinalysis; (4) Psychological and/or psychiatric evaluation; (5) General medical evaluation; (6) Radiographs as clinically indicated; (7) Laboratory studies as clinically indicated. (b) Medical staff shall take and record weight and vital signs at least once every 24 hours while the inmate is on a hunger strike. Other procedures identified in paragraph (a) of this section shall be repeated as medically indicated. (c) When valid medical reasons exist, the physician may modify, discontinue, or expand any of the medical procedures described in paragraphs (a) and (b) of this section. (d) When medical staff consider it medically mandatory, an inmate on a hunger strike will be transferred to a Medical Referral Center or to another Bureau institution considered medically appropriate, or to a community hospital.”	¶ 8, p. 4
§ 549.64	Food/liquid intake/output.	“(a) Staff shall prepare and deliver to the inmate’s room three meals per day or as otherwise authorized by the physician. (b) Staff shall provide the inmate an adequate supply of drinking water. Other beverages shall also be offered. (c) Staff shall remove any commissary food items and private food supplies of the inmate while the inmate is on a hunger strike. An inmate may not make commissary food purchases while under hunger strike management.”	¶ 9, p. 5
§ 549.65	Refusal to accept treatment.	“(a) When, as a result of inadequate intake or abnormal output, a physician determines that the inmate’s life or health will be threatened if treatment is not initiated immediately, the physician shall give consideration to forced medical treatment of the inmate. (b) Prior to medical treatment being administered against the inmate’s will, staff shall make reasonable efforts to convince the inmate to voluntarily accept treatment. Medical risks faced by the inmate if treatment is not accepted shall also be explained to the inmate. Staff shall document their treatment efforts in the medical record of the inmate. (c) When, after reasonable efforts, or in an emergency preventing such efforts, a medical necessity for immediate treatment of a life or health threatening situation exists, the physician may order that treatment be administered without the consent of the inmate. Staff shall document their treatment efforts in the medical record of the inmate. (d) Staff shall continue clinical and laboratory monitoring as necessary until the inmate’s life or permanent health is no longer threatened. (e) Staff shall continue medical, psychiatric and/or psychological follow-up as long as necessary.”	¶ 10, pp. 6–7; (e) at p. 8
§ 549.66	Release from treatment.	“Only the physician may order that an inmate be released from hunger strike evaluation and treatment. This order shall be documented in the medical record of the inmate.”	¶ 11, p. 8

Regulation text quoted from 28 C.F.R. part 549, subpart E on ecfr.gov. Bracketed rule text reproduced from Program Statement 5562.05 at pp. 1–8. Every section carries the source note [45 FR 23365, Apr. 4, 1980, as amended at 59 FR 31883, June 20, 1994], except §§ 549.62 and 549.66, which carry [59 FR 31883, June 20, 1994].

The seven-item initial evaluation

The single most liftable item in the rule is the list at § 549.63(a). These are the procedures medical staff are to perform when a person is first referred:

1. Measure and record height and weight
2. Take and record vital signs
3. Urinalysis
4. Psychological and/or psychiatric evaluation
5. General medical evaluation
6. Radiographs as clinically indicated
7. Laboratory studies as clinically indicated

Note item 4. A psychological or psychiatric evaluation is part of the initial workup, not something reserved for later. If your family member was placed on hunger-strike status and no mental health contact appears in the record, that is a documented gap in the required evaluation, and it is the kind of thing counsel asks about. Weight and vital signs then repeat at least once every 24 hours under § 549.63(b) for as long as the status continues.

Two paragraphs that look like regulation but are not

PS 5562.05 numbers its implementing instructions in continuation of the regulation’s lettering, which can mislead a reader comparing the two documents side by side. Two paragraphs in particular sit outside the brackets:

• ¶ 8.e (at p. 5) directs staff to record entries for all the medical procedures in the inmate’s Health Record. There is no § 549.63(e) in the Code of Federal Regulations; § 549.63 ends at (d).
• ¶ 9.d (at p. 5) directs that all food and water intake and output be monitored and recorded, with the Warden making that determination after consulting the physician. There is no § 549.64(d); § 549.64 ends at (c).

Both are real Bureau instructions. Neither is a regulation. If a filing needs to say what binds the Bureau, these two paragraphs are not it.

What the Program Statement adds on top of the regulation

The regulation is six short sections. The Program Statement is where nearly all of the operational detail lives, and it is the part families most often need explained. The following are the Bureau’s instructions to staff — not rules a reader can enforce the way a regulation is enforced.

Where the person is housed. Placement is ordinarily a determination the institution physician makes. The room “will be a single cell observation room (i.e., dry cell or cell with water shut-off capabilities), where no other inmate contact is possible” (at p. 3). The Program Statement states flatly that “a dry cell must be available for housing hunger strike inmates” (at p. 5). Someone already in Administrative Detention or Disciplinary Segregation “may be retained in this status and remain in the SHU unless the physician determines movement to other quarters is medically necessary” (at p. 3). For what that housing is, see special housing units.

Who watches. The Warden determines the type of observation — “continuous, 15 minute checks, routine” — and the Program Statement adds an unqualified prohibition: “Under no circumstances will inmate companions be used to monitor hunger strike inmates” (at p. 4). That is a meaningful distinction from suicide watch, where trained inmate companions are used; see the suicide prevention program.

Meals keep coming. Under § 549.64(a) staff prepare and deliver three meals a day. The Program Statement adds that “[a] verbal offer of a meal will not suffice,” that food from the tray may be left in the cell, and that perishable items ordinarily will not be left more than two hours (at p. 5).

What can and cannot be bought. Section 549.64(c) removes commissary food and bars commissary food purchases. The Program Statement clarifies the boundary: a person under hunger-strike management “may still purchase non-food items, such as stamps, from the commissary” and “is allowed to have toothpaste in the dry cell” (at p. 5). See trust fund and commissary policy.

Beverages and supplements. Health Services and Food Service staff may offer alternative beverages, including liquid nutritional supplements, if the physician authorizes. Beverages other than drinking water must be documented, and “[a]cceptance of liquids alone should not be documented as accepting a meal” (at p. 6).

Refusing the initial evaluation. If a person refuses the initial medical evaluation, the Program Statement directs that “a signed Refusal of Treatment form (BP-A358) must be obtained and also documented in the Progress Notes (SF-600)” (at p. 4). That form is the record of the refusal; see BP-A0358, Medical Treatment Refusal and the Patient Care Program Statement.

Who gets told when treatment may be forced. This is the part with real legal traction. When medical staff believe intervention “may soon be required, the Regional Counsel must be notified so any legal issues may be addressed” (at p. 6). Regional Counsel decides whether to contact the U.S. Attorney’s Office and, in all such situations, informs the Regional Director. For a pretrial defendant, “institution legal staff or the Regional Counsel must be notified that intervention may be required, in order to determine whether the court should be notified” (at p. 6). And after the fact: “The Warden shall provide prompt notification and any involuntary treatment under this Program Statement to the sentencing judge, with an explanation of the background of and the reasons for the treatment” (at p. 7).

Who may order treatment, and how it is recorded. “Only the physician may order involuntary medical treatment” (at p. 7). The Program Statement states that this normally consists of a nasogastric tube for feeding; that if that is unsuccessful or medically inappropriate, intravenous fluids and intravenous hyperalimentation may be necessary; and that gastrostomy and tube feeding through the stomach is a last resort for which “review by the appropriate court should first be sought before attempting this treatment” (at p. 7). Where the person refuses to comply, “as with any other use-of-force, these events should be videotaped,” and staff wear protective clothing under the use-of-force policy (at p. 7). See use of force and restraints.

Who else this covers. The Program Statement expressly applies to “pretrial and holdover inmates and ICE detainees” (at p. 3), and directs that people who cannot eat or drink because of mental illness or acute medical conditions be monitored under this policy even though they are not intentionally refusing food. It adds that “[m]entally ill inmates who do not eat or drink for more than 30 days, regardless of the apparent reason, should be referred to an MRC for evaluation and treatment of the underlying mental illness” (at p. 5). For those facilities, see federal medical centers and treatment and care of inmates with mental illness.

Medical judgment governs. The final paragraph of the Program Statement states that none of its procedures “are meant to limit or override the exercise of sound medical judgment by the physician responsible for medical care,” and that “[e]ach case must be evaluated on its own merits and individual circumstances” (at p. 8).

What the hunger strike policy means for you

If you are the person inside: the referral under § 549.62(a)

Under § 549.62(a) the referral is to medical or mental health staff. If you are struggling — with pain, with a medication that was stopped, with a psychiatric condition, with a fear about your safety — telling Psychology Services or Health Services directly gets you to the same clinicians without the housing consequences described above. A staff request form is the ordinary route, and Psychology Services is a department you can address one to.

Understand what the rule permits. The physician, and only the physician, may order treatment without your consent, and may do so once a medical necessity for immediate treatment of a life- or health-threatening situation exists — including “in an emergency preventing” the prior efforts described in § 549.65(b). Nothing in the regulation requires a court order first, and nothing in it gives you a right to refuse once that determination is made. Refusing the initial evaluation does not stop the process; it produces a signed refusal form that becomes part of your medical record.

Understand also what the rule requires of the Bureau. Meals must be prepared and delivered, not merely offered verbally. Drinking water must be adequate and other beverages must be offered. Weight and vital signs must be taken and recorded at least every 24 hours. Only a physician may release you from hunger-strike status, and that order must be documented in your medical record. Those are entries that either exist or do not exist, and their absence is provable.

If you are the family: learning about it second-hand

You will usually learn about this second-hand and late. The most useful things you can do are concrete.

Ask, in writing, for the medical record. The regulation requires documented entries at nearly every step — the initial evaluation, the daily weights and vital signs, staff efforts to persuade, the physician’s order, the release order. Those records are requestable; see medical records access. A signed release from your family member is ordinarily needed before the Bureau will send records to you.

Ask whether a mental health evaluation was done at the outset, as § 549.63(a)(4) directs. A hunger strike that is a symptom of untreated psychiatric illness is a different problem with a different route — one that runs through treatment and care of inmates with mental illness and, in the more serious cases, secure mental health units.

Do not assume anyone has told the court. The Program Statement directs the Warden to notify the sentencing judge after involuntary treatment, and directs institution legal staff or Regional Counsel to consider court notification for a pretrial defendant — but those are internal instructions, and whether they were followed is a question of fact.

If you are counsel: hunger strikes

The authority stack is short and worth stating precisely. The regulation at 28 C.F.R. §§ 549.60–549.66 binds the Bureau; PS 5562.05 is the Bureau’s instruction for applying it. The Bureau’s general statutory duty to provide for “safekeeping, care, and subsistence” and for “protection” sits at 18 U.S.C. § 4042(a)(2)–(3). The Program Statement cites no statute of its own; its stated authority is the regulation.

The Eighth Circuit has addressed the regulation directly. In Martinez v. Turner, 977 F.2d 421 (8th Cir. 1992), the court wrote: “Bureau of Prison regulations authorize medical officers to force-feed an inmate if they determine that the inmate’s life or permanent health is in danger. See 28 C.F.R. § 549.60–549.66 (1991),” and held that “[t]he mere allegation of forced-feeding does not describe a constitutional violation.” The court applied the deliberate-indifference standard of Estelle v. Gamble, 429 U.S. 97, 106 (1976), and observed that “an inmate’s mere disagreement with the course of medical treatment does not give rise to a constitutional claim.” It nonetheless reversed in part on a separate segregation claim, so the case is not a general endorsement of everything that happens around a hunger strike.

The practical consequence is that a challenge framed as “they fed him against his will” is unlikely to go anywhere on its own. What can matter is whether the procedures the regulation does require were followed — the initial evaluation and its psychological component, the 24-hour monitoring, the documented efforts to obtain consent, the physician’s order rather than a correctional decision, the videotaping of any use of force, the notifications to Regional Counsel and to the court. Those are records-based questions, and the record either supports the Bureau or it does not.

What has not changed in the hunger strike policy

Very little, for a very long time — and that is itself the finding.

The regulation was published at 45 FR 23365 (Apr. 4, 1980) and amended once, at 59 FR 31883 (June 20, 1994). Sections 549.62 and 549.66 carry only the 1994 note. Nothing in subpart E has been amended in more than thirty years.

The Program Statement was issued July 29, 2005 and rescinded P5562.04, Hunger Strikes, Inmate (6/20/94) (at p. 2). Its own Summary of Changes identifies exactly three changes from the 1994 edition (at p. 1):

“Section 6 has been expanded to include pretrial and holdover inmates and ICE detainees. Section 9 identifies Health Services staff and Food Service staff as those who may offer alternative beverages and nutritional supplements, if authorized by the physician. This section also indicates food and toothpaste may be left in the inmate’s cell. Section 10 describes procedures for notifying the Regional Counsel when an inmate refuses treatment and the initiation of involuntary treatment.”

PS 5562.05 carries no Change Notice. It was not among the twenty-three Program Statements the Bureau reissued effective June 22, 2026, nor among the dozens reissued between February and May 2026. As of the date stamped at the top of this page, the 2005 edition remains the operative one, and the Bureau’s directives it cross-references have since moved on: PS 6031.01 Patient Care (1/15/05) and PS 6090.01 Health Information Management (1/15/05), both named at page 2, have been superseded by later editions, and PS 5566.05 Use of Force (7/25/96) has likewise been replaced. The cross-references in the 2005 document therefore point at editions that no longer exist. That does not invalidate the hunger-strike rules, but it means anyone working from PS 5562.05 must check the current edition of every policy it sends them to.

One wording difference is worth knowing about. The Code of Federal Regulations at § 549.65(a) says the physician “shall give consideration to forced medical treatment of the inmate.” PS 5562.05, in the bracketed text it presents as the rule, prints “involuntary medical treatment” (at p. 6). The Program Statement uses “involuntary” throughout, including in its Summary of Changes. For any purpose where the operative language matters — a filing, an administrative remedy, a records request — quote the regulation, not the Program Statement’s rendering of it.

Where people get stuck on the 72-hour definition

Being told the 72 hours has not run. The definition at § 549.61 uses “ordinarily in excess of 72 hours,” and the same section provides that “[w]hen staff consider it prudent to do so, a referral for medical evaluation may be made without waiting 72 hours.” The Program Statement is more explicit: “staff may consult Health Services anytime they observe an inmate refraining from consuming food and/or liquids prior to 72 hours” (at p. 3). Where someone with a diabetic, cardiac, metabolic or psychiatric condition is not eating, the 72-hour figure is not a waiting period the Bureau must observe before doing anything. Route: an Inmate Request to Staff to Health Services, then the administrative remedy program — informal resolution (BP-8), then BP-9 to the Warden, BP-10 to the Region, BP-11 to the Office of National Inmate Appeals. Where the delay is urgent and medical, say so on the face of the filing and ask for the sensitive-issue or expedited handling the remedy policy provides for.

Property, mail and phone treated as if hunger-strike status were a sanction. The regulation removes commissary food and bars commissary food purchases. It says nothing about stamps, phone access, correspondence, legal calls or visits, and the Program Statement expressly preserves non-food commissary purchases and toothpaste. When restrictions travel beyond what § 549.64(c) authorizes, the question is what independent authority the institution is relying on — a disciplinary sanction, a special housing status, or nothing. Route: BP-8 identifying the specific item and asking which policy authorizes its removal; then BP-9. Keep the dry-cell placement and the added restrictions as separate issues, because they rest on different authority.

No mental health contact in the record. Section 549.63(a)(4) puts a psychological and/or psychiatric evaluation in the initial workup. In practice it is the item most often missing when the placement was handled as a security matter rather than a clinical one. Route: a request to Psychology Services, then BP-9 if there is no response, attaching the medical record if you have it. For a person with a serious mental illness who is not eating, the Program Statement’s own 30-day referral instruction for evaluation at a Medical Referral Center (at p. 5) is the specific relief to ask for.

Finding out afterward that no one told the court. The Warden’s notification to the sentencing judge, and the pretrial notification through institution legal staff or Regional Counsel, are Program Statement instructions rather than regulatory commands, and there is no form that proves they happened. Route: this one is usually not an administrative-remedy problem. Where a person is in active litigation — a pending case, a supervised-release proceeding, a § 2255 or § 2241 matter — counsel raising it directly with the court is faster than the remedy chain, and the Bureau’s obligation to notify is a fact the court can inquire into.

Applied Insight — Christopher Zoukis, JD, MBA, Managing Director: When a family calls about this, the first thing we ask for is not the incident report — it is the medical record and the housing record for the same dates. The regulation generates a documentary trail at almost every step: an initial evaluation with seven named components, a weight and a set of vital signs every twenty-four hours, written efforts to obtain consent, a physician’s order, a release order. Where the Bureau followed its rule, that record exists and the picture is clinical. Where it does not exist, the gap is specific enough to name in a BP-9, and specific enough for counsel to put in front of a court. What we do not do is treat the presence of forced treatment as the problem by itself; the Eighth Circuit has said plainly that it is not.

Related BOP policy on hunger strikes

The Program Statement names three Bureau directives at page 2 — Use of Force and Application of Restraints on Inmates, Patient Care, and Health Information Management — and the practical questions around a hunger strike usually run through a wider set than that.

• Patient Care (Program Statement) — the general framework for medical treatment, including refusals of treatment and the BP-A358 form
• Use of Force and Restraints — governs the videotaping and protective-clothing requirements when treatment is administered over refusal
• Special Housing Units and solitary confinement and SHUs — the housing status a person may already be in, and may remain in
• Treatment and Care of Inmates With Mental Illness and Psychology Services — where the § 549.63(a)(4) evaluation comes from
• Suicide Prevention Program — a separate policy with a separate watch structure; the two are not interchangeable
• Secure Mental Health Units — the units that house people with serious mental illness in a secure setting
• Health Services Administration and Medical Records Access — how the department is run and how to get the file
• Federal Medical Centers — the Medical Referral Centers § 549.63(d) refers to
• Administrative Remedy Program — the BP-8 through BP-11 route for every complaint above
• Medical and dental care in federal prison — the paired page: how routine care actually works
• Federal prison consulting services — where the issue is medical designation, care level, or an administrative remedy that has stalled

Frequently Asked Questions About Hunger Strikes

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Program Statement 5562.05 — full text

The full text below is the Bureau of Prisons’ own document, reproduced in full and without edit from its published PDF. Source: Program Statement 5562.05 (PDF).

Program Statement U.S. Department of Justice Federal Bureau of Prisons OPI: HSD/HSS NUMBER: P5562.05 DATE: 7/29/2005 SUBJECT: Hunger Strikes 1. [PURPOSE AND SCOPE §549.60. The Bureau of Prisons provides guidelines for the medical and administrative management of inmates who engage in hunger strikes. It is the responsibility of the Bureau of Prisons to monitor the health and welfare of individual inmates, and to ensure that procedures are pursued to preserve life.] 2. SUMMARY OF CHANGES. Section 6 has been expanded to include pretrial and holdover inmates and ICE detainees. Section 9 identifies Health Services staff and Food Service staff as those who may offer alternative beverages and nutritional supplements, if authorized by the physician. This section also indicates food and toothpaste may be left in the inmate’s cell. Section 10 describes procedures for notifying the Regional Counsel when an inmate refuses treatment and the initiation of involuntary treatment. 3. PROGRAM OBJECTIVES. The expected results of this program are:

a. The health and welfare of any inmate on a hunger strike

will be monitored.

b. Food and beverages will be offered to inmates regularly.

c. When an inmate’s life or health is threatened, involuntary

medical treatment will be administered. [Bracketed Bold – Rules] Regular Type – Implementing Information

7/29/2005 Page 2

d. Every incident of an inmate on a hunger strike will be

properly reviewed, documented, and reported.

4. DIRECTIVES AFFECTED

a. Directive Rescinded

b. Directives Referenced

Inmates (7/25/96)

c. Rules cited in this Program Statement are contained in

28 CFR § 549.60-66.

5. STANDARDS REFERENCED

a. American Correctional Association 4 Edition Standards forth

Adult Correctional Institutions: 4-4257 and 4-4397(M)

b. American Correctional Association 4 Edition Standards forth

Adult Local Detention Facilities: 4-ALDF-4D-15(M) and 4-ALDF-2A-52 6. [DEFINITION §549.61. As defined in this rule, an inmate is on a hunger strike:

a. When he or she communicates that fact to staff and is

observed by staff to be refraining from eating for a period of time, ordinarily in excess of 72 hours; or

b. When staff observe the inmate to be refraining from eating

for a period in excess of 72 hours. When staff consider it prudent to do so, a referral for medical evaluation may be made without waiting 72 hours.] A hunger strike may be announced by the inmate, or observed by staff, even though the inmate may be taking liquids.

strike, but merely make a bid to gain attention.

7/29/2005 Page 3 Other types of inmates (not on inpatient status in a Bureau of Prisons Medical Referral Center or hospitalized in the community) who should be monitored according to this policy include:

by virtue of mental illness or acute medical conditions. Although not intentionally on a hunger strike, these inmates are either unwilling or unable to eat or drink sufficiently to prevent complications.

illnesses, who deviate from normal eating habits or intake of fluid, could experience an immediate, significant hazard to their health and well-being. In any case, it is also recognized that after long-term deprivation of food and shorter term deprivation of fluid, serious irreversible changes can occur, and sudden death can occur. Procedures required in this Program Statement apply to pretrial and holdover inmates and ICE detainees. 7. [INITIAL REFERRAL §549.62

a. Staff shall refer an inmate who is observed to be on a

hunger strike to medical or mental health staff for evaluation and, when appropriate, for treatment.] Each Warden shall establish referral arrangements for the institution. In addition, staff may consult Health Services anytime they observe an inmate refraining from consuming food and/or liquids prior to 72 hours. [b. Medical staff ordinarily shall place the inmate in a medically appropriate locked room for close monitoring.] Ordinarily, placement in the medically appropriate room is a determination the institution physician makes. This room will be a single cell observation room (i.e., dry cell or cell with water shut-off capabilities), where no other inmate contact is possible (i.e., other inmates can’t pass food or liquid items to the inmate on hunger strike status). Inmates in Administrative Detention or Disciplinary Segregation may be retained in this status and remain in the SHU unless the physician determines movement to other quarters is medically necessary.

7/29/2005 Page 4 The Warden is to determine the type of observation for hunger strike inmates (e.g. continuous, 15 minute checks, routine).

to monitor hunger strike inmates. 8. [INITIAL MEDICAL EVALUATION AND MANAGEMENT §549.63

a. Medical staff shall ordinarily perform the following

procedures upon initial referral of an inmate on a hunger strike: (1) Measure and record height and weight; (2) Take and record vital signs; (3) Urinalysis; (4) Psychological and/or psychiatric evaluation; (5) General medical evaluation; (6) Radiographs as clinically indicated; (7) Laboratory studies as clinically indicated.] If an inmate refuses the initial medical evaluation, a signed Refusal of Treatment form (BP-A358) must be obtained and also documented in the Progress Notes (SF-600) of the Inmate’s Health Record. (Refer to the Program Statement on Patient Care) [b. Medical staff shall take and record weight and vital signs at least once every 24 hours while the inmate is on a hunger strike. Other procedures identified in paragraph (a) of this section shall be repeated as medically indicated.

c. When valid medical reasons exist, the physician may modify,

discontinue, or expand any of the medical procedures described in paragraphs (a) and (b) of this section.

d. When medical staff consider it medically mandatory, an

inmate on a hunger strike will be transferred to a Medical Referral Center or to another Bureau institution considered medically appropriate, or to a community hospital.] The decision to transfer an inmate on a hunger strike for medical reasons should only be made after consultation with a physician.

7/29/2005 Page 5

if his medical condition warrants continuous enteral (oral) or intravenous support.

hunger strike to a Medical Referral Center (MRC) unless an MRC’s specific services are required.

than 30 days, regardless of the apparent reason, should be referred to an MRC for evaluation and treatment of the underlying mental illness.

e. Medical staff shall record in the appropriate section of

the inmate’s Health Record, entries for all the medical procedures described in this section. (Refer to the Program Statement on Health Information Management.) 9. [FOOD/LIQUID INTAKE/OUTPUT §549.64

a. Staff shall prepare and deliver to the inmate’s room three

meals per day or as otherwise authorized by the physician.] A verbal offer of a meal will not suffice. Food from the food tray may be left in the inmate’s cell. Ordinarily, when the food tray is left in the inmate’s cell, perishable food items will not be left for more than two hours. [b. Staff shall provide the inmate an adequate supply of drinking water. Other beverages shall also be offered.

c. Staff shall remove any commissary food items and private

food supplies of the inmate while the inmate is on a hunger strike. An inmate may not make commissary food purchases while under hunger strike management.] An inmate under hunger strike management may still purchase non-food items, such as stamps, from the commissary. The inmate is allowed to have toothpaste in the dry cell.

d. All food and water intake and output will be monitored and

recorded as needed or to the extent possible. The Warden shall make this determination after consultation with the physician. This procedure is to continue until ended by a physician.

hunger strike inmates.

7/29/2005 Page 6 Health Services and Food Service staff may offer alternative beverages, including liquid nutritional supplements, if authorized by the physicians. Any beverages other than drinking water must be documented (e.g. BP-S292) and that information relayed to Health Services staff. Acceptance of liquids alone should not be documented as accepting a meal. 10. [REFUSAL TO ACCEPT TREATMENT §549.65

a. When, as a result of inadequate intake or abnormal output,

a physician determines that the inmate’s life or health will be threatened if treatment is not initiated immediately, the physician shall give consideration to involuntary medical treatment of the inmate.] The decision to force treatment upon the inmate is a medical decision, preferably by a written physician’s order, with potential legal implications. When it appears to medical staff that the inmate’s condition is deteriorating to the extent that intervention may soon be required, the Regional Counsel must be notified so any legal issues may be addressed. Although legal counsel has been notified, medical staff should not suspend or delay involuntary treatment if the physician is convinced to a reasonable medical certainty that there is an immediate threat to the inmate’s life, or permanent damage to the inmate’s health. Regional Counsel will determine whether it is appropriate to contact the local U.S. Attorney’s Office.

pretrial inmate, institution legal staff or the Regional Counsel must be notified that intervention may be required, in order to determine whether the court should be notified.

inform the Regional Director. [b. Prior to medical treatment being administered against the inmate’s will, staff shall make reasonable efforts to convince the inmate to voluntarily accept treatment. Medical risks faced by the inmate if treatment is not accepted shall also be explained to the inmate. Staff shall document their treatment efforts in the medical record of the inmate.

7/29/2005 Page 7

c. When, after reasonable efforts, or in an emergency

preventing such efforts, a medical necessity for immediate treatment of a life or health threatening situation exists, the physician may order that treatment be administered without the consent of the inmate. Staff shall document their treatment efforts in the medical record of the inmates.] Written reports of such treatment shall be submitted to the Medical Director and Regional Director. The Warden shall provide prompt notification and any involuntary treatment under this Program Statement to the sentencing judge, with an explanation of the background of and the reasons for the treatment. The outcome of the hunger strike and the treatment administered shall also be reported. When a physician orders involuntary medical treatment, to include placing a nasogastric tube for feeding, and the inmate refuses to comply, as with any other use-of-force, these events should be videotaped. All staff involved in the use of force shall wear appropriate protective clothing as outlined in the Use of Force Program Statement. Only the physician may order involuntary medical treatment.

feeding.

intravenous fluids and hyperalimentations intravenously may be necessary.

the stomach may be required, however, review by the appropriate court should first be sought before attempting this treatment.

however, hyperalimentations or gastrostomy tube feeding must be performed in a hospital or an MRC (see Clinical Treatment Guidelines or Medical Management of Inmates). [d. Staff shall continue clinical and laboratory monitoring as necessary until the inmate’s life or permanent health is no longer threatened.]

7/29/2005 Page 8 Normally, treatment must continue until adequate oral intake of food and liquid is achieved. Medical monitoring for severe or life-threatening complications of malnutrition may continue, at the physician’s discretion, beyond the point at which the inmate resumes adequate oral intake. [e. Staff shall continue medical, psychiatric and/or psychological follow-up as long as necessary.] 11. [RELEASE FROM TREATMENT §549.66. Only the physician may order that an inmate be released from hunger strike evaluation and treatment. This order shall be documented in the medical record of the inmate.] Documentation is to be made in the Progress Notes section of the Inmate’s Health Record. 12. MEDICAL JUDGMENT. None of the procedures or guidelines in this Program Statement are meant to limit or override the exercise of sound medical judgment by the physician responsible for medical care.

individual circumstances.

with accepted medical practice. /s/ Harley G. Lappin Director

Reviewed for legal accuracy by Elizabeth Franklin-Best, Esq., Principal Attorney·September 2026