The ethics consult group at my hospital meets monthly to go over cases and discuss readings. For July, we read a couple of older articles on whether and how to factor a patient’s possible noncompliance into treatment and discharge plans. We also looked at an American Journal of Bioethics “Trending” article by Summer Johnson McGee.

1. “The noncompliant substance abuser”. By: Cassel, C., LaPuma, J., Hastings Center Report, Mar/Apr91, Vol. 21, Issue 2:

JR is a combative, young white female who presents in the Emergency Room disoriented, with a fever, chills, and a cough productive of yellow sputum. She complains of chest pain and shortness of breath.

JR is well known to the medical staff. She has had three previous admissions with endocarditis and interrupted her clinical course on two of those admissions by leaving the hospital against medical advice. On her most recent previous admission, her mitral valve was replaced with a porcine prosthesis. She also tested HIV positive (but was and remains asymptomatic for AIDS).

JR’s social history includes occasional prostitution, IV substance abuse (cocaine), and needle-sharing. Although JR had been referred repeatedly to the substance abuse shelter, she refused counseling.

With a diagnosis of pneumonia, Staphylococcus aureus bacteremia, and a mitral valve vegetation and mild insufficiency, JR is placed on appropriate IV antibiotics and hospitalized.

{noncompliance —> bad things happen}

JR demands another valve, saying it would violate her civil fights to be refused. Would it be wrong to refuse her?

2.”Do cardiologists and cardiac surgeons need ethics? Achieving happiness for a drug user with endocarditis”. By Bromage DI, McLauchlan DJ, Nightingale AK. Heart. 2009 Jun;95(11):885-7. Epub 2009 Jan 23.

Ethical dilemmas are commonplace in clinical cardiology. There has been a recent
focus on ethical behaviour of cardiologists and debate about resource allocation
and cost-effectiveness of new technologies. The case of an intravenous drug
addict, with native aortic valve endocarditis complicated by a cerebral abscess
and severe aortic regurgitation, is presented to illustrate some common ethical
and moral dilemmas. The predominant theories in medical ethics, including the
“Four-Principles Approach,” is discussed, and a model to translate these ethical
theories into a clinical decision-making tool is presented.

3. We did not read this one as a group, but in case you are interested, this third article is relevant:

“Ethical obligation of surgeons to noncompliant patients: can a surgeon refuse to operate on an intravenous drug-abusing patient with recurrent aortic valve prosthesis infection?” By DiMaio JM, Salerno TA, Bernstein R, Araujo K, Ricci M, Sade RM, Ann Thorac Surg. 2009 Jul;88(1):1-8.

4. “To Friend or Not to Friend: Is That the Question for Healthcare?” by Summer Johnson McGee. American Journal of Bioethics 11 (8):2-5, August 2011.

Discussion:

Sometimes I share articles that are relevant to cases we have seen, and the three articles on noncompliance fit that description. It is always difficult to know how to factor probable nonadherence. When a doctor refuses to do a procedure on that basis, our ethics team often gets called. We have a high percentage of substance abusing patients, as the mental health services in our area serve 2/3 of the state.

Lance Stell’s position probably comes closest to my own on the issue and how to address it:

The controversial part of the argument concerns whether noncompliant, self-destructive behavior can be a relevant causal factor in judging efficacy. If it can, how much evidence must one have before the principle justifies refusal? Some ethicists think that a patient’s noncompliant, self-destructive behavior can never serve in an argument to justify refusing an intervention. I think this absolutist position is too strong.

That said, it is of the utmost importance to be sure everyone is on the same page with regard to understanding that this patient is presenting with two or perhaps three chronic (and maybe terminal) conditions: (a) whatever condition got her here, (b) her addiction, and often (c) mental health issues, such as mood disorders. We may have to do some education in the early part of a consult around addiction as an illness, not a moral or personal failing.

It is also vital to be clear on how the assessment of compliance is being made. For one thing, is this patient being supported, for all of her conditions, to the absolute best of our ability? If not, then it is not fair to use her past nonadherence against her. For another, how are we defining “nonadherence”? On what basis, exactly, is the judgment that this particular treatment (say, a heart valve) will be “useless” being made? It helps to substitute another example of nonadherence, like a patient with uncontrolled diabetes, to make sure predictions about a substance abusing patient’s likelihood of adherence are not being influenced by prejudice.

It’s also important in such cases to include the patient in the ethics process from the beginning. This group of patients is highly alert to bias and unfair treatment, often for good reason. The ethics process is for her, just like any other process we undertake on behalf of her health. The last thing we need to do is further disempower this patient, and cut off our most important source of information about who she is and what she wants and what she feels capable of achieving post discharge.

And finally, are clinicians being supported? Such patients, especially if, as so often happens, they are seen again and again by staff, can be very challenging. On some occasions, our consults have benefited the staff as much as anyone else. They needed to vent, to share frustrations, and their feelings of powerlessness. We sometimes set aside a portion of the meeting just for this purpose.

On the “Friending” article, it was short, but we agreed with McGee that the AMA guidelines on the use of social media are unhelpful, and we appreciate her more concrete suggestions, such as rigidly separating an online professional profile from a personal one. Right now, our hospital is trying to figure out how to realize the benefits of social media without suffering the costs. As McGee notes, many hospitals err on the side of caution, and ours, which has, for example, blocked social networking sites from the intranet, may be doing just that. It’s hard to tell from my position, honestly. I’m not privy to what kinds of problems Facebook and other sites may have created. One thing is clear: social media is not going away, and while McGee’s suggestions are a good start, I wonder if anyone with a Blackberry or iPhone can really be said to be able to separate professional from personal lives anymore.