Jerome Murdough was a 56-year-old former Marine being treated with antipsychotics and mind stabilizers. One day, he was found dead in his cell on Rikers Island, where the temperature reached 100 degrees Fahrenheit (37.7 degrees Celsius). A preliminary autopsy was inconclusive, but evidence strongly suggested that Murdough died of severe dehydration and heat stroke. murdough was not charged with a crime: law enforcement arrested him for trespassing for sleeping in a stairwell of a public building.
Unable to post bail, Murdough was sent to the Rikers Island jail, where he was locked in his cell around 10:30 p.m. on Feb. 14, 2014; he died about six hours later. His mother reported that Murdough suffered from a severe chronic mental illness.
Heat stroke is a life-threatening clinical condition that often occurs during the summer months, and the high incidence of mental disorders is particularly noteworthy in patients with mental disorders. Patients in prison face an even more challenging situation because they do not have the freedom to change their environment.
Thermoregulation and heat stroke
Body temperature is regulated by the dynamic balance of heat production and heat loss. Heat is a byproduct of metabolism, and the rate of heat loss is determined by the time it takes for heat to be transferred from the body to the skin and back again.
Heat stroke is possible when the body temperature rises to 105°F (40.6°C) and is characterized by a core body temperature exceeding 104°F (40.0°C) with abnormalities in central nervous system function, including delirium, convulsions and coma, leading to multi-organ damage and tissue destruction. Symptoms indicative of heat stroke include dizziness, abdominal discomfort, followed by vomiting, confusion and loss of consciousness. Given the destructive nature of hyperthermia on organs and tissues, it can be life-threatening even if it lasts only a few minutes.
Thermoregulation and psychiatric medications
Anticholinergic drugs can affect thermoregulation by inhibiting the parasympathetic pathway, suppressing sweating and leading to a decrease in the body’s ability to dissipate heat. The antidopamine effect of antipsychotics can elevate the thermoregulatory point and reduce certain behaviors that contribute to thermoregulation, including increased water intake and removal of excessive clothing.
Phenothiazine antipsychotics, including chlorpromazine, thioridazine, fluphenazine, and endorphin, have anticholinergic and central thermoregulatory effects. For example, endorphin inhibits hypothalamic nerve impulse afferents and attenuates the latter’s compensatory effect of increasing cutaneous blood flow to enhance heat dissipation. Other commonly used psychiatric medications can also disrupt thermoregulation, including atypical antipsychotics, 5-HT agonists, and beta-blockers; some psychiatric medications can reduce water intake by reducing thirst, thereby increasing the risk of dehydration and heat stroke, including SSRIs, colistin, carbamazepine, and valproic acid.
Abnormal thermoregulation in patients with schizophrenia
Evidence suggests that thermoregulatory function may be abnormal in patients with schizophrenia. However, the role of CNS pathology and medications in this is not well understood. The biochemical and physiological explanations for this phenomenon in the literature are not very convincing, but certain peripheral and central abnormalities may play some role. The peripheral abnormality theory suggests that peripheral niacin and prostaglandin E1 are abnormal in schizophrenic patients, affecting vasodilation and leading to impaired heat dissipation, while the central abnormality theory suggests that the midbrain limbic dopamine system is the culprit.
Shiloh and colleagues compared unmedicated outpatients with schizophrenia with healthy controls. All subjects participated in a standardized plate test of thermal exercise tolerance. Results showed that patients with schizophrenia had higher baseline and exercise-related body temperatures than healthy controls.
Heat waves and death in psychiatric patients
A heat wave (heat wave) is usually defined as a temperature above 89.96 degrees Fahrenheit (32.2 degrees Celsius) for 3 or more consecutive days. Studies have shown a strong correlation between heat waves and emergency department visits for psychiatric symptoms. In a study of deaths from heat waves in France in 2003, researchers concluded that medication side effects can affect the body’s ability to adapt to high temperatures, especially psychiatric medications.
Bouchama A and colleagues had conducted a Meta-analysis of the included observational studies examining risk and protective factors for heat wave-related deaths. The results showed that a history of prior psychiatric illness could increase the risk of death in heat waves by more than 2-fold in individuals. Researchers also found that taking psychiatric medications nearly doubled the risk of related deaths.
An Australian study looked at hospitalization rates during heat waves, spanning 13 years. The results showed that for patients with schizophrenia, schizotypal disorders and delusional disorders, heat-related deaths were more than 1-fold higher than for others.
Another study compared deaths among inpatients in New York psychiatric hospitals with those in the general population between 1950 and 1984. The researchers found that the risk of death among inpatients in heat waves was twice that of the general population. The risk of death was highest in the 1970s; in fact, patients were often taking higher doses of antipsychotics at that time. In addition, mortality rates were also higher before patients took antipsychotics, suggesting that mental illness itself may be an important risk factor for death in heat waves.
Kaiser and colleagues found that psychiatric disorders elevated the risk of death during the 1999 Cincinnati heat wave. Eighteen deaths were included in the case-control study, which showed that eight of them had psychiatric disorders, including four with schizophrenia, and four were taking psychiatric medications, including amitriptyline, clozapine and olanzapine.
Heat Stroke and Legal Liability
The risk of heat stroke and death for people with mental disorders has led to numerous lawsuits, often against certain places of residence or hospitals. For example, in Kotler v. Alma Lodge, a California court held the owner and manager of Alma Lodge liable for the wrongful deaths of two schizophrenic patients. The two patients died during a heat wave when temperatures in Los Angeles approached 100 degrees Fahrenheit (37.8 degrees Celsius) or higher for five consecutive days. The medical examiner noted after autopsy that both patients died of hypothermia caused by high ambient temperatures. The jury found that Alma Lodge was negligent in this matter and awarded $600,000 in damages.
The case, Trisdale v. Ohio Department of Mental Health, was related to intense physical activity. on June 22, 1993, Ms. Trisdale’s 30-year-old son, Dawayne Colyer, died. Mr. Colyer suffered from schizophrenia and was taking 2,000 mg/d of chlorpromazine, 30 mg/d of fluphenazine, and 2 mg/d of benztropine, an anticholinergic. The latter was an anticholinergic. Although there is disagreement over the exact temperature on the day of Colyer’s death, the National Weather Service has posted a temperature of 84 degrees Fahrenheit (28.9 degrees Celsius) and a relative humidity of 46 percent.
Colyer was playing basketball with staff and other patients when he experienced confusion and disorientation, then fell to the ground and lost consciousness. He was taken to a local hospital for treatment and died several hours later. When he arrived at the hospital, his body temperature was 108 degrees Fahrenheit (42.2 degrees Celsius). The verdict was in favor of the plaintiff: Colyer’s physician was negligent and specifically noted that the physician did not mark restrictions in Colyer’s medical records that addressed physical activity and exposure to heat.
Heat-Related Deaths During Incarceration
Determining liability for heat-related deaths in the course of incarceration is complicated because medical personnel can face two types of liability: civil rights violations (deliberate indifference) and negligence. Deliberate indifference is often used in cases where necessary medical treatment is intentionally denied or delayed, and where reasonable business judgment is not exercised. Given that inmates’ medical needs are entirely dependent on the controlling agency, failure to provide those needs may rise to the level of cruelty in the eyes of a judge, and often results in unusually harsh penalties.
Charges of deliberate indifference can arise either alone or in conjunction with negligence. The challenge with a deliberate indifference charge is that the plaintiff must show that the regulatory agency, while aware of the risks, ignored them and failed to take effective action. It has been argued that this requirement sets an unattainably high bar for plaintiffs. As a result, litigation often develops over whether staff were aware of the relevant risks and whether they took action to mitigate such risks. The result has been that in many cases staff members have not taken adequate medical measures without violating the Eighth Amendment, especially when staff members have more or less done something.
In Willis v. Barksdale, Ms. Willis sought compensation for the death of her 26-year-old brother, Michael Lott, who was charged with a misdemeanor for carrying a handgun and whose autopsy revealed that the cause of death was heat stroke. When Lott was found, the temperature in his cell was 96 degrees Fahrenheit (35.6 degrees Celsius), while the high temperature that day was 40.6 degrees Celsius.
The cell Mr. Lott was in was reserved for patients with physical and mental illnesses, and the area had two electric fans; inmates had access to ice and water, and prison staff were aware of how to handle patients with exhaustion and heat stroke.
Mr. Lott had been admitted to the psychiatric unit several times. Prior to his death, the medications he took included 60 mg of haloperidol at bedtime and benztropine 2 mg twice daily. Although the court was aware that these medications can affect thermoregulation, it ultimately ruled in favor of the defendant. The court held that prison administrators were not obligated to emphasize the special medical needs of a particular inmate, and that it was the medical staff that was truly responsible. The decision successfully distinguished between deliberate indifference and negligence. The facts further demonstrate that prison administrators did not show signs of deliberate indifference to Lott’s medical needs.
The 2006 case of Scarver v. Litscher is “interesting” in part because Mr. Scarver was the man who killed Jeffrey Dahmer, a notorious cannibal who killed 17 people and was sentenced to 1,070 years in prison. Mr. Scarver claims to have been subjected to cruel and unusual punishment by being placed in a small, windowless and air-conditioned cell. He noted that the antipsychotic medication he was taking interacted with the heat in his cell in the summer, which may have had a negative effect on him.
Mr. Scarver was not allowed to use a tape recorder or have access to other sources of sound, and Scarver believed that outside sounds could help him control the voices in his head. This condition led Scarver to develop suicidal ideation and to overdose on medication twice a day in order to attempt suicide. In addition, he banged his head against the wall for long periods of time, slit his throat with a razor, and slit his wrists. Concerned about heat-drug interactions, Scarver stopped taking his medication, which led to a worsening of his psychiatric symptoms.
The judge acknowledged Scarver’s claim that the condition he was in worsened his psychiatric symptoms, which in turn led to physical and mental suffering. However, following the tradition of safe sex, the court ruled in favor of the defendant: “Prison authorities must be entrusted with a higher level of authority to act to control manic with homicidal tendencies ……”
Prevention and treatment of heat stroke
In the literature, heat stroke is considered a “preventable disease”. However, prevention requires effective identification of risk factors and careful measures. Psychiatric patients should be educated and prepared for heat waves, including reducing heat exposure, increasing fluid intake, and being alert to signs and symptoms of dehydration and heat stroke. Particular attention needs to be paid to those with severe mental disorders, especially those taking antipsychotics and anticholinergics. Other useful measures include monitoring body temperature, dressing freshly, and allowing additional cool showers. As soon as symptoms suggest the possibility of heat stroke (e.g., vomiting, confusion, elevated body temperature, etc.), the patient should be taken to the emergency room for consultation and treatment.