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Should We Just Let Them Die?
I just logged onto our computer system at work to see what our patient list is looking like and if there have been any emergency surgeries this weekend. I noticed something peculiar about the bed assignment of one of our young patients. I opened a nurse’s note to discover that just two days after we operated to repair one of the heart valves that had been damaged by this patient’s IV drug use, the patient was discovered using IV drugs while in the bathroom.
Of course, they deny any wrongdoing but the evidence is overwhelming. I have no idea how this young person’s life will turn out after the follow-up visits are done, but I can say the chances are they will end up like so many of our other patients that require open heart surgery because of their drug use — dead.
When I was working as a bedside nurse in the Emergency Department observation area in Portland at a level 1 trauma center, IV drug users made up about one-third of my patients. They were bread and butter for us. Usually, they came in with abscesses at their injection sites or sepsis. This patient group was trying to deal with; initially, they would be cooperative and seem as though they wanted help, but after 24 hours, they would start jonesing for their fix. Sometimes they would ask to be discharged quickly because of a “family emergency,” they would want to go outside for some “fresh air,” or they would just leave when everyone’s back was turned. After a while, you get hip to their tricks.
The most frustrating part of caring for this patient population is their lack of commitment/willingness to get treatment. Their entire lives are ruled by their need to get their next fix, and not even going through open heart surgery is enough of a wake-up call to get them to change. One patient pushed me past my capacity to care when she came into the ED with her second bout of endocarditis. The first time around, she received treatment when she was flown from another state by a religious health care organization to Portland to have one of her valves replaced. When she was discharged from the hospital, she looked around and decided Portland was a pretty awesome place to be homeless and do IV drugs. I could not ask even the most basic of questions without snark, apathy, and contempt dripping from every answer. At one point, she admitted that she was just going to keep using until it killed her, even if Cardiothoracic (CT) surgery decided to do surgery to try and save her. She was admitted to a medicine service for medical treatment of her infection while CT surgery decided what to do; I never found out what happened to her.
When I left the bedside, the Emergency Department, and Portland for the long hours of CT surgery in Ohio, I thought most of my dealings with drug users were over. I was wrong. So, so, so very wrong. Ohio is at the heart of the opioid crisis. Next to West Virginia, it has some of the highest heroin use in the country. That’s most of what I see — heroin, with a little cocaine thrown in every once in a while.
There’s not much in the way of meth here; that’s more of a rural South and Southwestern thing. But regardless of the drug, the method of delivery is the same, as are the effects on the body. People are careless about cleaning their skin and their needles when they inject. Bacteria colonized on the skin enters the body through the venous system and sets up shop on the valves in the heart- mostly the tricuspid and mitral valves, but sometimes the aortic valve too. We can remove the tricuspid valve and leave it out, causing only some mild to moderate symptoms. It is not absolutely essential the way the mitral and aortic valves are.
Endocarditis causes damage to the valves when bacteria form little clusters on the leaflets of the valve — the flaps of tissue that open and close, regulating the flow of blood flow through the heart. The infection can burrow into the wall of the aorta, requiring replacement of the entire aortic root. Left untreated, many of these people will die.
Last year, I assisted on the first 8.5 hours of an 11-hour surgery on a woman not yet 30 years old who was having her third open heart surgery. She almost died on the table and it is truly by the grace of God and the skill of the surgical team that she did not. Every so often, I check the obituaries online to see if she shows up. Sometimes we find out months after their surgery that they died.
Sometimes they use during their post-op stay and arrest in the hospital, which happened to a patient of mine a few months ago. I came in around 6:30 a.m. to discover that she had died in the middle of the night after taking her heart monitor off and overdosing on something someone brought her. The staff did CPR for 20 minutes and called it. She was younger than me.
Often these patients don’t have insurance and their very expensive hospitalizations are courtesy of the dear taxpayer. Fortunately for these patients, we do not yet have a single-payer system that would ration the care they get. Instead, they get chance after chance, surgery after surgery.
I struggle with this. From a pragmatic standpoint, it is ridiculous to ask the taxpayer to foot the bill for multiple open heart surgeries and the subsequent six weeks of skilled nursing care they will need after their surgery for ongoing IV antibiotics. Especially if they just go home, start using again, and die a few months later. But from a Judeo-Christian standpoint, the need to show compassion and try to heal the way the Great Physician heals compels me to want to give these patients a chance … and another … and another.
Do we continue to give people unlimited treatment, or do we cut them off after a time? Are we being compassionate caregivers, or are we just being crazy by repeating the same action but expecting a different outcome?
There is disagreement amongst the surgeons I work with as to our moral obligation to operate. Some feel operating is a bad idea and call in an ethics consult; others feel that you should always operate even if the patient tells you they have no plans to quit. One large hospital in a neighboring city has a one and done policy — they will not perform redo valve replacements/repairs on people that reinfect themselves with ongoing IV drug use. I truly don’t know what the solution is.
Help me out, folks. My empathy is struggling. And I’m tired from all these long surgeries.
Published in General
We all die. But dying from lung related illness is terrible. You just gradually suffocate to death. That’s a horrible way to go.
The world is full of tragedy. Making unrelated folks pay for the self imposed tragedy of an unknown person is itself tragic. We have to do what we can, but it must be the helper’s choice. People should be responsible for their own behavior and if they are so disposed, for helping those they love or care about, or want to help. I don’t know if it helps to go beyond this but I’ll believe that those who insist that it’s our obligation are serious when they dedicate their own time and money first. I think they’re building power for central authorities and this makes me very skeptical of abstract gifts to failing individuals unless I know those who need help and know the situation that I’m trying to fix or relieve. Anything more is an abstraction being used by folks for other purposes.
As for the original question. Yes. We should let people die. They aren’t worth using the coercive power of the state to save. If we have the state provide for them, I don’t think it will do much good but it will take away our freedom. Freedom means the freedom to choose to die.
Nine years ago I was arrested for several drug related offenses after a year of shooting heroin. The largest sensation I had, outside the onset of withdraw, was relief. Relief that I didn’t have to continue the rat race that was my pathetic existence. Relief that I didn’t have to focus on how to beg/borrow/steal enough cash to line up one more (just one more!) score.
It still took three months in jail, two sessions of rehab, and six months of aftercare to finally slay that particular monster. The persistence of counselors and other medical professionals (and, also important, the instance of the legal system with support from family) is a big reason I am here now as opposed to in prison (one friend), homeless (another) or dead (three more).
From the bottom of my heart, thank you for what you do! It’s not possible to pull all of us back from the abyss but I am glad you try.
Good. Good for you. This made me cry a little bit. Please, stay strong. And when life pummels you (as it will, eventually, whenever/whereever) reach out. Best to you,
What’s that doing to you sugars?
Because beer is about the only fast carbs in which I partake, sugars are good. A1C is good. Daily blood sugar sampling is good. My steady-state reading averages at/about 92. Without fasting and with beers.
Since they want me below 120 with fasting, I figure I’m doing a’ight.
This is the problem with socialism. Who are “we?” Whom does “we” refer to?
The question should be answered, who is paying for this treatment? In a sane world, the entity paying would be able to decide whether to pay, and the doctor/hospital can decide if they wish to perform. However, we have a largely socialist country now where people can demand very expensive treatment paid for by the government.
Yes, these drug abusers should suffer the consequences of their decisions. If they can’t afford to pay, and can’t convince family or friends to pay, then they should deal with the need for a new heart valve the way people have dealt with the need for heart valves for time immemorial. What makes them special?
But in fact, the government is only too eager to pay and the benefee of the government’s largess can be as nasty and ill-mannered as he wants. And can continue to use drugs while under care all he wants because he knows that we have to pay for it.
It’s sick. It needs to stop, but I’m not thinking it will in my lifetime.
So – you can’t fix them if they won’t fix themselves. They are their own responsibility. One and done.
Think of the opportunity cost of the services provided. Is someone else getting less medical treatment or care, or lower quality, because of resources consumed in treating those that refuse to make better choices for themselves? The answer is yes, but hard to measure.
I’ve been up and down this road with family members. It sounds harsh, but after the 1,000th or so “help”, if they don’t get it, 1,001 times will not make the difference.
I don’t see it that way. God has infinite love and mercy. Jesus would continue to love and care for the man even if he continued to sin. Some need more bad things to happen to them before they are able to turn their lives around. Some never do, no matter how bad things get. But God never gives up.
One person has said that Christian charity has no limits. I’m not too sure about that from a practical viewpoint.
Over the last 2000 years, Christianity would not have thrived, or even survived, if people had not made hard choices, including on how charity was doled out.
Practically speaking, generosity has its limits. So when the question comes up on whether “we should let them die”, the answer is, eventually yes.
Give someone a chance. But then after that, let the person die.
I’m better than I used to be. Honest.
Congratulations on reclaiming your life. After winding up in a series of bad places, you were still able to climb into the light.
It can be done. It requires help, but it requires a decision from the substance abuser. A “no going back” decision. To go back is to die (or worse), and if you’ve figured out that life is worth living, that becomes, eventually, an easy decision to make, every day.
Vicryl, Martin Scorsese has a criminally neglected film called Bringing Out the Dead, which, if you haven’t seen, I’d recommend.
I worked at a funeral home in south Florida for a number of years where fentanyl and other prescription drugs have actually brought the life expectancy down by a number of years. The families that I worked for ranged considerably, but typically I found them to be the sort who could not have anticipated the struggles that they’d be put though. I suppose it’s them that you’re really fighting for.
As for the Judeo-Christian standpoint you mentioned, maybe it would be of some value to paraphrase Michael Walsh, who said that God needs souls and Satan wants corpses. So I guess by depriving the latter of the death he desires you’re doing all of us a service.
Thank you!
If I may ask, why are drugs so fun? It sounds like a miserable life to me. The people I know on drugs don’t seem very happy. Why are drugs so popular when they don’t seem to lead to good results? Is being high really that good?
Feel free not to respond if this subject is too painful. I just don’t get the whole drug thing and I feel like I should because it is a very big deal in America and I’m an American.
How about this for a solution, we combine implantable drug delivery with Naloxone (aka Narcan). That will prevent any treated user from getting a high off of heroin. Problem solved. I am sure it could be sized to last for 3+ years. Get someone sober for 3 years and you are off to a good start.
I find the question to be naive, or maybe wilful ignorance.
Misbehavior in general is always fun at first, until the consequences are paid. I have never been addicted to drugs, nor a heavy sustained user.
Yet, I’ve been drunk from time to time and still drink from time to time.
Those are fairly common vices, and most people do keep them under control. But even for those that don’t become addicted, they are still vices and do inflict some harm.
Tell me that you haven’t done anything you knew was bad for you, but was still fun when you did it. Drugs or no drugs.
Okay, I’ll bite:
The sensation I can’t describe, but the story…
On my thirteenth birthday, my brother woke me up at 2 in the morning to take me to a party near the local university. This was the first time that I smoked pot, and I thought I was super-cool for having done so. By the time I was sixteen, I had gotten into all sorts of trouble – LSD, ecstasy, cocaine, and various pharmaceuticals. At the time, it seemed like a blast and it was only after the long, painful process of retreating from it all that I realized how it wasn’t all it’s cracked up to be.
I think a lot of it has to do with the environment one grows up around. At some point after high school, I realized that the majority of my circle of friends came from households where their parents had divorced. The few exceptions were the kids whose parents would take off during the weekends – these were the houses where our wild bunch were…. wild – I remember a number of times that I found kids passed out on the bathroom floor. There were plenty of parents who decided that the “responsible” thing to do was to supervise the party, though I don’t recall a single one stopping me from driving home when I wasn’t fit to do so. And most of us also had older siblings in college, giving us a misguided inkling of what “adulthood” was like.
I consider myself incredibly lucky. Most of my old friends have drug problems to this day – and you’re right about it being a miserable life. I had moved out to New Orleans, which, (go figure) is not the best place for someone with a substance abuse problem to go. After a few years of pretty serious depression, I had a psychotic break, and finally decided I needed to get my life together; not that this sort of turn-around comes easy. Thankfully, shortly thereafter, I came across this little web series hosted by a guy named Peter Robinson (maybe you’ve heard of him) and it really lit a fire under me – which, eventually brought me here.
Unfortunately, I’m not sure that there is much to get (though terrible influences seem to be a common theme throughout my story).
I won’t be dishonest and pretend that getting high isn’t fun; it is a little bit. It’s just that the long-term price is stiff. Having said that: even today, I probably drink too much.
The biggest problem that we have is meth. So much meth. It’s never just meth, though. It’s meth and coke. Meth and opiates. Meth and benzos (because if you have an upper, you need a downer).
We have a hard time seeing these people. Somehow they end up on our unit and we see them. I do wonder what the limits of medicine are. As a state, we treat patients. We do. Somehow, we’re willing to take care of septic drug users, but we can’t pay for a stroke patient to go to 5 days in ARU for their stroke. Somehow, we’re willing to do major surgery and 6 weeks of antibiotics, but we can’t manage to take care of people who need to go home and have 24 hour care for a few days while their family get it together.
It just amazes me what people are willing to pay for and what they sometimes won’t.
I’m as big a sinner as everybody else. I’m not trying to pretty myself up in any way I just want to know why everybody loves drugs so much.
I don’t think it’s naive, Al. Some people just are not drawn to the experience at all. It’s like someone saying they don’t understand what the appeal is in watching sports. Yes, lots of people love it, but for some of us the appeal is a complete mystery.
The honest, and caring answer, as I see it, is to strip them of their liberty. They are no longer rational actors. As such, monitoring and restrictions are what are needed to help them. I have seen Drug and Mental Health Courts work wonders. But, it takes the force of the State, and treatment for 18-24 months to get a great success rate.
Now, do we as a society want to do this? It is not cheap, though maybe cheaper than ongoing medical bills and the other costs of chronic drug use. It would be more effective than interdicting the supply. And some people would not enter recovery, and they would never be at liberty again. That has costs too.
Of course, this is radical. I am not making a Swiftian argument though. Until we have a way to change neural pathways in the brain, we are left with helping people make hard changes manually as it were.
It is a pity we are so scared of things like DMT. There is some evidence that it can be used to help people change those pathways, if used right, and in the right way.
Here’s a little example. About 5 years ago, I needed to have a good night’s sleep so I could get up early the next morning for something relatively important. I had a couple of Norco left over from a surgery. When I had been in pain, it had helped me sleep. So I took 1/2 a caplet.
Well, half an hour later that 1/2 caplet made me feel warm, fuzzy, and happy. I cuddled down into my bed and even when I woke during the night, I went back to sleep immediately still feeling warm and fuzzy. (I had never had those feelings when I was taking it for pain.)
I can only assume that the serious drugs like cocaine, heroin, etc. feel waaaaaay better. For someone with an addictive personality or a grim life or the judgement of a teenager, with little or no knowledge of the dangers drug addiction, it would be very easy to go down that road.
The key here is: “As a state we treat patients.” By law, hospitals are not allowed to turn patients away. A different set of regulations control coverage after hospital discharge. Changing priorities requires changing (largely federal) regulations and statutes. Like trying to turn an aircraft carrier.
You are right that drug courts have been effective. You are also right that they are not cheap. Drug courts are paid out of the criminal justice budget, from state and local general funds. Hospital bills for the uninsured are paid largely by federal money, or by other paying customers driven by federal regulation. Trying to change the systems is very difficult.
This has inspired a lot of thoughts… posting a new thread to explore them!
My older son was an alcoholic from age 16 to 26. What saved him was an outfit called “Impact” in Pasadena. He had good insurance and that involved 3 months of inpatient care, 3 months half way house, and long term counseling by former addicts. Most people in that programs were not alcoholics but cocaine addicts. He went to law school and has been practicing law now for 20 years. Married with two kids. Both his grandfathers were alcoholics. My father was also an alcoholic, as well as smoker. His mother’s father came back from the War an alcoholic after his job of going up the Bataan Death March route and identifying bodies in 1945. He commanded the mortuary detail. He joined AA in 1946 and stuck to it. His grandson joined him in about 1991.
Hey Henry, others above have good answers but I’ll see if I can chip in my two cents. I’m probably an atypical example of an addict. I don’t come from a broken home, I went to good schools, no childhood trauma, etc. However, after high school I was directionless. The group of friends I had were all similar to me in these regards.
There is a form of reinforcement that can happen in a group like that. You look around and everyone knows they can, and should, be doing something with their lives but hitting the snooze button, so to speak, is easier. Actually improving your lot would be met with some form of derision, no one wants to be the last screw up.
Adding something like heroin to that mix is catastrophic. The effect of opiates, if you are not in pain, is euphoric apathy. Nothing else matters in that moment because all is right in the universe. Conversely, when you are not high everything is wrong and you will move mountains to get back to Nirvana.
So, for me, and those like me, finding a drug that allows you to live in the perpetual, blissful now is often a kiss of death.
I wrote an essay about that kinda thing awhile ago.
@henrycastaigne, my vote goes to Macbeth. Romeo and Juliet were both too stupid to live.