Bio medical ethics

Overview: W, a 17-year-old male high school junior, has been admitted to a local hospital with endocarditis. He has been injecting heroin for the past three months. The ethical issues of this case deal with W’s discharge planning.

Medical Indications

Presenting Problem:

Admitted to community hospital with endocarditis. Endocarditis is an infection of the endocardium, which is the inner lining of the heart chambers and heart valves.

Salient History:

W is a 17-year-old that lives with his parents and has been a heroin IV drug user for the past three months. His endocarditis was contracted from the injection of heroin with contaminated needles/syringes. The treatment of endocarditis is 6 weeks of IV antibiotic. His physician has inserted an IV access port to receive the antibiotics. While hospitalized, W’s friends brought him heroin, and they used his port to inject the drug.

Diagnosis:

1o – Endocarditis 2o – IV drug addiction (heroin)

Prognosis:

With regards to the endocarditis, he risks the infection going septic (traveling throughout the body) or developing other chronic medical conditions, if not treated with six-weeks of antibiotics. Substance abuse disorder must be addressed, otherwise he risks death from overdose or complications with his endocarditis. Endocarditis could permanently cause several chronic heart problems such as 1) heart problems- heart murmur, heart valve damage, heart failure 2) stroke 3) seizure 4) paralysis 5) abscesses in heart, brain, lungs & other organs 6) pulmonary embolism 7) kidney damage.

Patient’s Condition:

Pt’s current condition is “urgent” and “critical”. Refer to “prognosis” for reasoning behind the patient’s critical status.

Care Goals:

First care goal is to ensure that W completes the 6 weeks of antibiotics to successfully treat the endocarditis. Medical staff needs to assess W’s willingness to overcome his drug addiction due to the fear that if discharged, he may inject heroin through his central line. If he is ready, willing and able, medical staff need to find him a rehabilitation facility/program to begin his journey on becoming drug-free.

Summary:

Initial concern for W is to treat the acute endocarditis with the 6-week regimen of antibiotics. Another concern for the medical staff is to ensure a safe discharge for W due to his history of drug use while hospitalized. If he is sent home with a central line still in place, there is a high chance that he will continue to use. Addressing the substance abuse disorder is another concern for his physician.

Patient Preferences

Competency:

When W. arrived at the hospital, he was considered to be incompetent because he was 17 years old and legally considered a minor.

Decisional Capacity:

Although the patient was not considered competent in a legal sense, due to being nearly 18 (adult age), state law would likely allow him to make some healthcare decisions for himself. In the state of Tennessee, W is allowed to consent to his own drug rehabilitation because he is over 16-years-old. However, W cannot consent to advanced medical procedures such as placement of a central line. That would require his parents’ permission to do so.

Stated Preference:

W. made it very clear that he did not want to be hospitalized for 6 weeks in order to receive long term intravenous antibiotics as he did not want to be away from his friends during the time.

Surrogate:

Due to W. being 17 years old upon time of admittance to the hospital, his parents would act as Common-law surrogates for him until he reaches the age of 18.

Summary:

W. was not considered competent when he was admitted to the hospital due to his age (see Competency). W would not be allowed to make decisions for himself for certain medically procedures such as the placement of his central line, however, he could have the decisional capacity to consent to drug rehabilitation. It was made clear to the physician, family, and hospital staff that W did not want to remain in the hospital for 6 weeks in order to receive intravenous antibiotics. At the time of his admittance, his parents acted as his common-law surrogates.

Quality of Life

Characterization:

Pt’s current condition may suffer functional deficits as a result of the endocarditis diagnosis and his drug use. His quality of life is “restricted”, due to W being in the hospital, not in school and not being able to socialize with his friends.

Normal Life:

If W receives the full 6-week antibiotic regimen, he should be able to return to normal life. Once the infection is clear, the medical staff can determine if he has any secondary results from the condition (see Pt’s Condition for examples). If he does not receive treatment for his drug addiction, he will not be able to return to normal life.

Likely Deficits:

W’s endocarditis can cause possible damage to his heart or other medical conditions that could severely affect his baseball career. His continued drug abuse will impair his cognitive functioning and prevent him from being successful in his educational endeavors.

Desirable Quality of Life:

W’s current attitude is ambivalence however, he does not want to stay in the hospital for 6 weeks for the IV antibiotics. He does feel ashamed and disappointed that he has let his parents down. He desires to stop the drug abuse and have a higher quality of life.

Double Effect Issues:

The IV access port was beneficial because it provided a high functioning access for the repeated IV antibiotics. However, it also provided an easy access for W to continue heroin use during his hospital stay. This patient safety issue needs to be addressed and prevented. When medical staff discovered the issue, they restricted visitors.

Comfort Care Plans:

Due to W’s heroin use, he may be experiencing withdrawal. Medical staff needs to evaluate if W’s substance abuse is due to physical and/or emotional dependence. If emotional, the physician should consult with a therapist. If physical, he may be experiencing symptoms of withdrawal which may have led to his continued drug use while in care. In this case, the physician may consider using some type of weaning with another opioid that does not cause a high, such as methadone.

Contextual Features

Family Issues:

W’s family was shocked and upset to hear about his frequent heroin use over the last 3 months. Refer to “Salient History” for continued use. W’s parents are willing to do whatever it takes to help in their son’s recovery in regard to the endocarditis and the heroin use. They will not be able to provide 24-hour supervision.

Provider Issues:

The physician and W’s parents understand that he does not want to remain in the hospital for 6 weeks but know that forcing treatment on him against his will is not a realistic option. Although W could be considered a “mature minor”, the physician and family know that by making his own decisions, W. would not receive treatment for his endocarditis and heroin addiction and would put himself at risk for more serious health issues.

Financial/Cultural/Allocated/Legal issues:

There was no mention of financial or cultural issues in this case, however, there were allocated and legal issues. Legally, his parents are considered his common law surrogates and could push for forced treatment. In addition, the physician and hospital staff could be considered legally liable, if W was discharged with the central line still in place and continued to inject heroin through it leading to injury or death.

Summary:

W. comes from a loving family and his parents are willing to do anything to get their son physically and emotionally well. The provider, allocated, and legal issues revolve around his “minor” status and not being allowed to make treatment decisions on his own. As well, he does not agree with his physician and surrogate decision makers (parents) on his medical treatment.

Problem Solving

Problem:

The issue in this case is that W needs long-term antibiotic treatment which would require a 6 week stay in the hospital. Due to his recurrent drug use he required 24-hour supervision but refuses to stay in the hospital for the full duration and cannot legally make his own decision.

Alternatives:

1. The family and hospital staff could look into a home health professional (RN/LPN/CAN) to administer the IV antibiotics to W. while providing supervision during the times that his parents cannot be with him. Some positives are that W. would be treated for both endocarditis and his heroin abuse. This is an alternative that W. would likely support, and hospital staff would be recognizing W’s wishes of not being hospital bound for 6 weeks. A negative of this alternative is that W. may be able to access heroin easily.

2. The parents could take legal action as a common-law surrogate to force the treatment requiring him to stay in the hospital for 6 weeks. The positive of this alternative is that W. would receive thorough treatment for his endocarditis as well as allowing his body to recover from the substance abuse. This would significantly decrease his access to heroin. The negative of this alternative is that forcing treatment upon W could have a significant negative impact on his mental health and relationship with his parents and may increase his likelihood of future drug use.

3. The patient could be placed in a facility such as a nursing home where he could be treated for both his endocarditis and drug use in a socially segregated and supervised setting. By doing this W’s preferences would be met as well as providing quality care for both of his conditions.

4. W. could be sent to a drug rehabilitation center for immediate treatment of his heroin use, then be treated afterwards for his endocarditis. A positive in this scenario is that W would receive immediate for his heroin use and this would decrease his chances of suffering from endocarditis in the future. The negative is that, by putting off treatment of his endocarditis for 6 weeks, W. would be at risk of serious injury or death. Untreated endocarditis could lead to severe damage of the heart valves which would result in a stroke, seizure, pulmonary embolism, paralysis, and death.

Recommendation:

Although W. would have access to better healthcare by staying in the hospital for 6 weeks, we recommend that W receive treatment in a nursing home where he can be socially segregated to monitor his drug while also being able to receive medical treatment for his endocarditis. In this scenario his wishes would still be respected, and he would receive care for both of his presenting conditions.