Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We present an ethical dilemma in patient care; you vote on your decisions in the case. Next week, we'll reveal how you all made the call. And stay tuned -- Gregory Dolin, MD, JD, will weigh in next week with an ethical framework to help you learn and prepare.
Mr. X, a 31-year-old man, has a longstanding history of intravenous heroin addiction. His injection drug use caused a bloodstream infection that invaded his heart valve with bacterial overgrowth. Mr. X required open-heart surgery to replace the damaged valve.
This type of infection, known as injection drug use-related infective endocarditis (IDU-IE), has soared in the opioid epidemic since IDU often starts after abusing prescription painkillers. Prosthetic valves are even more prone to endocarditis than native ones, so if patients continue using IV drugs after initial cardiac surgery, they frequently develop recurrent IDU-IE.
This is exactly what happened to Mr. X six months after his initial surgery. Mr. X had signed out of his physical rehabilitation center against medical advice. He developed congestive heart failure and suffered several strokes. His cardiac ultrasound revealed a large infection that destroyed his first prosthetic valve.
Mr. X would likely die without another valve replacement, and he was adamant that he did not want to die. But several surgeons declined to operate, citing his prohibitively high risk for yet another endocarditis recurrence from ongoing IV drug use. In fact, a nurse found dirty needles in his pocket.
His family pleads for another valve replacement.
This Ethics Consult was based on a case as told by Sarah C. Hull, MD.
is associate professor of law and co-director, Center for Medicine and Law at the University of Baltimore, where he also studies biopharmaceutical patent law. His work includes a number of scholarly articles, presentations, amicus briefs, and congressional testimony.
And check out some of our past Ethics Consult cases: Should Sperm Donor Support Autistic Offspring?, 'Freeze' Little Girl in 6-Year-Old Body?, Deaf Couple Only Wants Deaf Baby, or Critical Patient With DNR Tattoo.