4.2 Hunger Strikes mental health personnel.

Prior to 72 hours, staff

may refer a detainee for medical evaluation, and
I. Purpose and Scope when clinically indicated, medical staff may refer
the detainee to a hospital;
This detention standard protects detainees’ health 2. The ICE/ERO Field Office Director shall be
and well-being by monitoring, counseling and immediately notified when a detainee is on a
providing appropriate treatment to any detainee who hunger strike, declared or otherwise;
is on a hunger strike.
3. The detainee’s health shall be carefully monitored
Nothing in this detention standard is intended to and documented, as shall the detainee’s intake of
limit or override the exercise of sound medical foods and liquids. The clinical director,
judgment by the clinical medical authority (CMA) designated physician or treating medical staff
responsible for a detainee’s medical care. Each case shall conduct a full clinical and mental health
must be evaluated on its own merits and specific assessment and evaluation, and recommend a
circumstances, and treatment shall be given in course of treatment, intervention or follow-up;
accordance with accepted medical practice.
4. When medically advisable, a detainee on a hunger
This detention standard applies to the following strike shall be isolated for close supervision,
types of facilities housing ICE/ERO detainees: observation and monitoring;
• Service Processing Centers (SPCs); 5. Medical, mental health or hospital staff shall offer
• Contract Detention Facilities (CDFs); and counseling regarding medical risks and detainees
shall be encouraged to end the hunger strike or
• State or local government facilities used by accept medical treatment;
ERO through Intergovernmental Service
6. Refusal of medical treatment shall be documented
Agreements (IGSAs) to hold detainees for more
in the detainee’s medical file;
than 72 hours.
7. Involuntary medical treatment shall be
Procedures in italics are specifically required for
administered only with medical, psychiatric and
SPCs, CDFs, and Dedicated IGSA facilities. Non-
legal safeguards;
dedicated IGSA facilities must conform to these
procedures or adopt, adapt or establish alternatives, 8. A record of interactions with the striking
provided they meet or exceed the intent represented detainee, the provision of food, attempted and
by these procedures. successfully administered medical treatment, and
communications between the CMA, facility
Various terms used in this standard may be defined
administrator and ICE/ERO regarding the striking
in standard “7.5 Definitions.”
detainee shall be established; and
II. Expected Outcomes 9. The facility shall provide communication
assistance to detainees with disabilities and
The expected outcomes of this detention standard
detainees who are limited in their English
are as follows (specific requirements are defined in
proficiency (LEP). The facility will provide
“V. Expected Practices”).
detainees with disabilities with effective
1. Any detainee who does not eat for 72 hours shall communication, which may include the
be referred to the medical department for provision of auxiliary aids, such as readers,
evaluation and possible treatment by medical and materials in Braille, audio recordings, telephone

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 handset amplifiers, telephones compatible with Procedures for identifying and referring a detainee
hearing aids, telecommunications devices for deaf suspected or announced to be on a hunger strike to
persons (TTYs), interpreters, and note-takers, as medical staff shall include obtaining from qualified
needed. The facility will also provide detainees medical personnel an assessment of whether the
who are LEP with language assistance, including detainee’s action is reasoned and deliberate, or the
bilingual staff or professional interpretation and manifestation of a mental illness.
translation services, to provide them with Facilities shall immediately notify the local Field
meaningful access to its programs and activities. Office Director or his/her designee when an
All written materials provided to detainees shall ICE/ERO detainee begins a hunger strike.
generally be translated into Spanish. Where 1. Staff shall consider any detainee observed to have
practicable, provisions for written translation shall not eaten for 72 hours to be on a hunger strike,
be made for other significant segments of the and shall refer him/her to the CMA for evaluation
population with limited English proficiency. and management.
Oral interpretation or assistance shall be provided 2. Medical personnel shall document the reasons for
to any detainee who speaks another language into placing a detainee in a single occupancy
which written material has not been translated, or observation room. This decision shall be reviewed
who is illiterate. every 72 hours. Medical personnel shall monitor
III. Standards Affected the detainee in a single-occupancy observation
room, when medically advisable and taking into
This detention standard replaces “Hunger Strikes” consideration the detainee’s mental health needs.
dated 12/2/2008. If measuring food and liquid intake/output
becomes necessary, medical personnel shall make
IV. References a decision about appropriate housing placement.
American Correctional Association, Performance- C. Initial Medical Evaluation and
based Standards for Adult Local Detention Management
Facilities, 4th Edition: 4-ALDF-2A-52, 4D-15.
Medical staff shall monitor the health of a detainee
National Commission on Correctional Health Care,
on a hunger strike. If a detainee engaging in a
Standards for Health Services in Jails (2014).
hunger strike has been previously diagnosed with a
ICE/ERO Performance-based National Detention mental condition, or is incapable of giving informed
Standards 2011: “4.3 Medical Care.” consent due to age or illness, appropriate
medical/administrative action shall be taken in the
V. Expected Practices best interest of the detainee.
A. Staff Training 1. During the initial evaluation of a detainee on a
hunger strike, medical staff shall:
All staff shall be trained initially and annually
thereafter to recognize the signs of a hunger strike, a. measure and record height and weight;
and to implement the procedures for referral for b. measure and record vital signs;
medical assessment and for management of a
detainee on a hunger strike. c. perform urinalysis;

B. Initial Referral d. conduct psychological/psychiatric evaluation;

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 e. examine general physical condition; and treatment, and communications between the
CMA, facility administrator, and ICE/ERO
f. if clinically indicated, proceed with other
regarding the striking detainee.
necessary studies.
2. Medical staff shall measure and record weight and D. Food and Liquid Intake and Output
vital signs at least once every 24 hours during the After consultation with the CMA, the facility
hunger strike and repeat other procedures as administrator may require staff to measure and
medically indicated. record food and water intake and output as follows:
3. Qualified medical personnel may modify or 1. Record intake and output in the medical record
augment standard treatment protocols when using an IHSC “Hunger Strike Form” or
medically indicated. equivalent;
4. Medical staff shall record all examination results 2. Deliver three meals per day to the detainee’s
in the detainee’s medical file. room unless otherwise directed by the CMA—
5. If the detainee refuses the initial medical staff shall physically deliver each meal regardless
evaluation or any treatment or other medical of the detainee’s response to an offered meal;
procedures, medical staff must attempt to secure 3. Provide an adequate supply of drinking water or
the detainee’s signature on a “Refusal of other beverages; and
Treatment” form. If the detainee will not
cooperate by signing, staff shall note this on the 4. Remove from the detainee’s room all food items
“Refusal of Treatment” form. not authorized by the CMA. During the hunger
strike, the detainee may not purchase
6. Any detainee refusing medical treatment shall be commissary/vending machine food.
monitored by medical staff to evaluate whether
the hunger strike poses a risk to the detainee’s life E. Refusal to Accept Treatment
or permanent health. See “Section V,” “E, Refusal An individual has a right to refuse medical treatment.
to Accept Treatment” below in this standard. Before involuntary medical treatment is
7. If medically necessary, the detainee may be administered, staff shall make reasonable efforts to
transferred to a community hospital or a educate and encourage the detainee to accept
detention facility appropriately equipped for treatment voluntarily. Involuntary medical treatment
treatment. shall be administered in accordance with established
guidelines and applicable laws and only after the
8. After the hunger strike, medical staff shall
CMA determines the detainee’s life or health is at
continue to provide appropriate medical and
risk.
mental health follow-up. Only a physician may
order a detainee’s release from hunger strike 1. Medical staff shall explain to the detainee the
treatment and shall document that order in the medical risks associated with refusal of treatment,
detainee’s medical record. A notation shall be and shall document treatment efforts in the
made in the detention file when the detainee has detainee’s medical record.
ended the hunger strike. 2. The physician may recommend involuntary
9. Records shall be kept of all interactions with the treatment when clinical assessment and laboratory
striking detainee, the provision of food, results indicate the detainee’s weakening
attempted and successfully administered medical condition threatens the life or long-term health of

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 the detainee. court order, ICE/ERO may consider other
action if the hunger strike continues.
a. The facility administrator shall notify ICE/ERO
if a detainee is refusing treatment, and the 1) If a court order is to be pursued, ICE/ERO
health services administrator shall notify the shall work with the local ICE Office of Chief
respective ICE/ERO Field Office Director in Counsel to work with the U.S. Attorney’s
writing of any proposed plan to involuntarily Office to make the arrangements for a court
feed the detainee if the hunger strike hearing.
continues. Under no circumstances may a 3. Medical staff shall:
facility administer involuntary medical
treatment without authorization from a. document all treatment efforts and each
ICE/ERO. treatment refusal in the detainee’s medical
record;
b. The Field Office Director, in consultation with
the CMA, shall then contact the respective ICE b. continue clinical and laboratory monitoring as
Office of Chief Counsel and the U.S. Attorney’s necessary until the detainee’s life or health is
Office with jurisdiction. After discussing the out of danger; and
case, the attorneys shall recommend whether or c. continue medical and mental health follow-up
not to pursue a court order. ICE policy is to seek as necessary.
a court order to obtain authorization for
involuntary medical treatment. If a court F. Release from Treatment
determines that it does not have jurisdiction to Only the physician may order the termination of
issue such an order, or a hospital refuses to hunger strike treatment; the order shall be
administer involuntary sustenance pursuant to a documented in the detainee’s medical record.

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