"The death squad." Or, "the executioners."
That's what many inmates used to call the inmate-volunteers who work the Graterford state prison hospice unit, a bleak row of isolation rooms — each, one part hospital room, one part jail cell — where inmates with terminal illnesses are placed to die.
Then, they saw how the inmates cared for dying men in shifts, undertaking the intimate tasks of feeding, cleaning, and comforting them. For many, it is a calling.
Over time, attitudes changed, said James, a 51-year-old inmate who volunteers to do this work. "There's a lot of progress in this place. There is more humanity here now."
It's needed, given that far more people are dying in prison than ever before.
In Pennsylvania, 483 state inmates have died since January 2015. That's about 180 deaths in prison each year. From 2005 to 2014, the average was 150 deaths per year.
That increase is a byproduct, officials say, of the extraordinarily fast-growing elderly population in prison. In 2001, there were 1,892 geriatric inmates in Pennsylvania (ages 55 or older). Today, that's more than tripled to 6,458. The leading causes of death in the state's prisons are heart disease, cancer, and liver disease. Caring for this population is extraordinarily expensive: It's estimated that elderly inmates cost three to nine times more than young ones. Compassionate release, meanwhile, is granted to just a few inmates each year.
But since 2004, families of dying inmates at Graterford have had the small comfort of knowing they will not die alone. There is just one nurse on staff at the 23-bed infirmary, and visitors are allowed only an hour a day, but volunteers man the hospice on 24-hour vigils, sometimes caring for two or three inmates at once.
A year ago, a statewide memo ordered that all Pennsylvania prisons establish hospice programs, but there's no set format for those programs to follow, said Annette Kowalewski, who runs the hospice program at Laurel Highlands state prison, which contains a skilled-nursing facility. Staff at five or six institutions have contacted her for guidance.
According to Brie Williams, a professor at University of California-San Francisco who studies geriatric care in prison, some type of hospice care is offered at around 80 prisons nationwide.
"Hospices in the correctional setting are a critically needed response to the extraordinarily long sentences and minimum mandatory sentences that were handed down over the past decades," she said.
She noted that prisons are constitutionally required to provide appropriate care — though interpretations of what's appropriate vary. (For example, Kowalewski said at Laurel Highlands, inmates providing hands-on personal care would be out of the question, but it's standard at Graterford.) There's no standardized protocol for assessing prison hospice care. Typical challenges include a lack of staff trained in palliative care, insufficient access to pain medications, and inconsistent systems for creating advance directives.
Still, for Miriam Rodriguez, whose brother Frank was in the Graterford hospice for 10 weeks before his death in August, the hospice team was her one source of comfort. The inmates sat with her brother in four-hour shifts, brushed his teeth, bathed him, shaved him, massaged his back and legs, read him the Bible. They cooked for him, approximating his favorite foods: fish soup, sausage with rice.
Barb March, a nurse and Graterford's hospice-care coordinator, supervises 22 inmate caregivers in the hospice, a narrow cinderblock room in the infirmary with a hospital bed and a mural of the ocean at sunset.
Most are lifers, keenly aware that they, too, may one day die in that room.
(A reporter was granted access on the condition that inmates involved not be identified by last names or the details of their crimes.)
Elias, 58, said as longtimers, the lifers know many of the older inmates personally and feel an obligation. "This is how we pay our rent here on Earth."
"I got into this to give back for the wrong that I done," said Arthur, 57.
To participate, inmates must apply and be vetted, based on their prison records and crimes. Some are sent for a psychological evaluation. Then, they go through a weeklong training.
"We go over everything they'll see," March said. "We go over signs of impending death."
James, a hospice volunteer since 2010, is the team's de facto record keeper. He maintains a spreadsheet, and keeps a printout in the pocket of his maroon prison uniform.
So far, he's worked 37 hospice vigils. The youngest patient was 28; most are older than 50. He has personally watched five lives fade into stillness.
Hazards of the job include changing colostomy bags and convincing resistant patients they need to be repositioned to prevent bedsores.
"If we don't do that work for them, sometimes they'd be in bad, bad condition," said Francisco, 55. "I don't want to bash the system, but it's the reality. They could be laying on poop. Not taking a shower. We do all the stuff for them, if they allow us."
The most difficult part of this work, for many, is watching patients suffer. Some refuse medication for religious reasons, or for fear of reawakening old addictions. "Some feel they need to go through that suffering because of the crime they committed," James said.
Even with medication, said Francisco, "The majority of the time it seems like the pain is not controllable. At times patients ask us to help them. You think it's, 'Help me move to the side,' or something. But sometimes they mean, 'Help me. Kill me. Finish this misery for me.' "
Chaplains, corrections officers, even the prison superintendent will stop in to visit.
But often it falls to the hospice team to counsel patients and families. Some patients ask the hospice workers to break bad news to relatives. Other times, families decline to visit, or they come but can't bring themselves to stay.
The inmates can't always offer relatives much comfort.
"One man's sister said, 'Did he accept the Bible before he passed?' That's all she wanted," Elias recalled. "His family wanted me to read to him from the Bible, and I did. But he never said anything."
As for the volunteers, they said this work has made them kinder, humbler, more compassionate.
"I care more," Elias said. "Before, I didn't care about what the other person was going through most of the time. Now, I do. I see how other people are living."
It's painful, too, though.
Bruce, 63, said he struggles most after a death, when he's faced with an empty hospital bed.
"I go through a tough time, because I'd like to see an individual get out of here in a different way," he said. "Not that way."