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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
Are there any long-term success stories among these cases?
Perhaps it’s the price of having a calling. One doesn’t give up on the “hopeless” cases in return for the gift of having the opportunity to help those who will make the most of being healed. Plus there’s always the chance that that the person we think is hopeless will finally, someday, be permanently healed. Hang in there….
It’s hard to say. I’ve had patients that will be clean for several years and then start using again because something terrible happened and they’re trying to cope or they started hanging out with the wrong people again. I heard one of my surgeons say it’s like 10-15% of IV drug users actually stop using.
This reminded me of the man in John 5:14 whom Jesus had healed and warned, saying
This indicates to me that there is a point where God will cease to strive with man.
I don’t know much about dealing with the addicted except that it can be extremely frustrating and sometimes tragic. Thank you for this honest and thought-provoking post.
Thank you for writing this difficult piece – your fatigue and sorrow surrounds your clinical descriptions. What you describe is completely new to me – what I know about the crushing expansion of drug use is the overdoses. The initial reports identify an overdose – typically resulting in death – but rarely speak to followup treatment or recurring problems. The reporting them seems to always emphasize the terrible societal flaws which cause drug use and homelessness. It’s safe to say I Had No Idea……
As to your specific question of what to do: I am not faced daily with the ambiguity you do of having skill and desire to help while having the strong belief that your skill will ultimately not serve its intended purpose. So maybe it’s easier for me to say “Legalize any drug you want but pay your own medical bills that arise.” You give wrenching first person evidence supporting anecdotal suggestion of near 100% recidivism in heroin addicts. In dealing with other types of addictions, it’s clear that the user is never never helped by “helping” them – they alone must decide to stop. I don’t know if heroin is a chemical which makes it physically and mentally impossible to make that decision. I’ve read too many reports of people who have experienced physical rehab for extensive periods – seemingly long enough for the chemical to have been eliminated from the body – who subsequently return to using. Is the brain also transformed?
Regardless, it seems to me we do none of these individuals any fundamental service, nor their community as a whole, by continuity to act as if using is somehow normal enough to be addressed in the same way as if they are say, just clumsy and keep breaking the same arm when they go mountain biking. As to who says no? It seems as if the individuals are already saying no when they resist treatment and are otherwise uncooperative. Treat their symptoms for comfort and let them go on their way. It’s as if they have already executed a DNR.
I am curious. Seems to me that the opioid crisis got worse when the government slammed down the law on the pill mills. This pushed a lot of users into IV drugs from unreliable sources. I have thought that was a mistake. Should have left them on pills which were safer by method and source and treat the issue as a social problem like smoking and not a criminal issue. I can help but feel that a lot of this misery was assisted by bad government policy.
Pills are safer in the sense that they’re coming from a known source. However, those pills have to come from a provider’s prescription, and it is not my job to support people’s opiate addiction. I give my patients pain medication for two weeks after their surgery. After that, you can take Tylenol and ibuprofen.
Here in Ohio there’s a been a big crack down and we are seeing fewer deaths from overdose. If we as providers stop giving patients as many prescription drugs as they want (which was the practice for a while) and the police crack down on the illicit stuff that seems to be a good combo.
There is absolutely rewiring that happens in the brain with persistent use. 100%. So I guess does that suggest that there’s little to no hope? I do know that the provider community did patients a massive disservice by handing out pills like it was water. This whole patient right to have your pain addressed does not mean you have the right to be pain free, which is what it turned into. I try to be very explicit with patients when I see them before surgery that our goal is to make the pain tolerable, not make you free from pain. You should be able to live with 4 or 5/10 pain.
I feel your pain. Frequent fliers in our rural area require first responders and than an ambulance or helicopter transport. We don’t yet have a big problem with frequent Narcan saves but I’m sure it won’t be long. I’ve read about big cities where Narcan is eating up the EMS budgets in a few months. The system is designed around compassionate care; like anything else that 20 percent of problem users drives the system. Our EMS system covers 663 square miles (with about 40,000 people) with three ALS ambulances; the 7 fire departments back them up and in the far rural areas like ours we usually have first patient contact and perform life support until we can get them transported.
The issue is: where does overuse of a medical system become unfair to the people paying the bills? As you can imagine, many of our frequent fliers are basically indigent, so we are all paying. There is no obvious solution.
VC,
Outstanding post. In my job, one of our mantras was give the other guy every chance to save his own life, but if he’s determined in his efforts to shuffle off this mortal coil, then drop the hammer hard and fast. If someone wants to get the monkey off his back, we should offer every chance for recovery and renewal. But if the person is determined to be a race horse for that demon jockey, okay.
I can’t help but think that the break down of the family and the hostility toward religion have contributed to the phenomenon of people filling the void in their lives with substance abuse. With a strong family and a religious foundation, one learns that one has the obligation to be as healthy, happy and productive as possible. Without that? Your OP is what we get. This observation comes from one of the worst Christians you’ll ever find. Go figure.
During what was then Desert Shield, I traveled back “to the rear,” for the once-a-month phone call home. About 2 & 1/2 hours travel for 20 minutes huddled up with Ma Bell and mom and dad. Dad picked up the phone, and said, “Hey, kid, the fact that you’re hearing my voice tells you that I’m okay.”
Turns out, couple weeks before, Dad was on the way home from the gym with my baby bro, bro driving, and started feeling pain in his chest. He started rotating his left arm to loosen up, and joked “man, either I pushed too much weight today, or–Hah!–this is the big one!”
Turned out it was the big one. The docs saved him, and they gave the best doctor I can imagine to care for that mean, obstinate old man.
Dad: I don’t get it, Doc. I run, I swim, I lift. How can I have a heart attack?
Doc: Because you smoke. Doesn’t matter what else you do, if you smoke, you will disease your heart.
Dad, with a little attitude: So, I guess now’s the part where you tell me I have to quit, right?
Doc: If you don’t quit, you’ll die. But, hey, I get paid either way.
The Old Man never smoked again.
It becomes unfair right from the start. But this is about more than fairness.
The local sheriff for Barnstable County and the guy who runs the Barnstable House of Corrections talks about drug addiction issues to the public to generate understanding and support for his many very successful programs. He once remarked, paraphrasing, “I wish 80 percent of the inmates would stop taking the drugs they are taking and the other 20 percent would take the drugs they have been prescribed.” Everyone laughed because it is so true.
It resonated with me because I spent a lot of my time helping a paranoid schizophrenic friend who was in the latter 20 percent category. My friend passed away ten years ago, of heart issues in the end, but she had about ten excellent years because of her cardiologist who treated her over those years and who was very sad when she finally passed away.
Schizophrenia often accompanies serious heart issues. It is so common that I would tell anyone who has a friend or relative who is schizophrenic to start with a complete cardio workup. There’s something deadly about not getting enough oxygen to the brain. It causes all kinds of problems.
My paranoid schizophrenic friend got gradually but noticeably worse–depressed, angry, anxious, imagining things–over a period of a few months, even on her low-level maintenance dose of Risperdal. The symptoms weren’t bad enough that her local psychiatrist saw anything wrong, but I saw it. Finally, she became extremely depressed, and one day, she threw all of her belongings out of her second-floor apartment door and windows. Needless to say, she was committed to the local hospital involuntarily.
The doctor at the hospital ran an ECG just as a matter of course, and the test revealed that she had had a heart attack very recently. I called a dear friend of mine, a local cardiologist who was affiliated with Deaconess Hospital in Boston, and because of his connections there, my friend was treated right away there and got an angioplasty, followed by coronary bypass surgery. I’m sure everything has changed over the ten years, but the thing my cardiologist friend did, and the thing that changed my friend’s life, was to assemble a team of psychiatrists and rehab specialists in addition to the cardio care specialists to work with him. It was a joint treatment approach.
I’m trying to make a very long story very short, but my point is that all addiction is mental illness. And top-notch, up-to-date psychiatric care has got to be part of the treatment from beginning to end.
There’s as much happening in mental illness rehab as there is cardiology. For example, there’s a great program at Boston University on rehabilitation for mental illness.
Without the psychiatric component, you might indeed see a relapse into the former self-destructive life patterns. With it, you might really save a person’s life.
Thirty years old is simply too young to write off to the heroin addiction caves.
I just saw a patient in the cath lab who reminds me of your father- fit, tough type who took the news about needing to have bypass surgery with the same grace as being told he had terminal end stage cancer. Got mean as a snake over it, because he just couldn’t believe that the diseases of other people had gotten to him. I gave him a big speech about not smoking and what it does to your vessels. It went over like a lead balloon.
But if people don’t have any skin in the game, they abuse the system. My grandmother is kind of guilty of that with Medicare- “well I’m not paying for it so I’ll just go have X procedure/test done.”
It depends on what you mean by “we”.
It (arguably) is Christian virtue for a person to never give up on a “hopeless case”.
It is (arguably) not Christian virtue to force others to pay to treat a “hopeless case”.
(I have zero expertise in this area, but as an engineer I tend to think of solutions to problems, so I’m just throwing this out there…)
This suggests to me that it would be good to have specialized medical clinics, with their own ERs, for drug abuse patients. The number of these patients is, unfortunately, substantial. They can be disruptive to the care of the other patients. They need different procedures and protocols. A more “holistic” approach that addresses the addiction problems at the same time. It needs to be state funded, because it’s going to be outside of any normal medical insurance.
This was a great post. And it’s a very hard question to answer. I understand both sides and probably lean slightly to the side of no repetitive surgeries.
To the comment you made above, I think there is a difference between treating “temporary” pain (as after surgery) and chronic pain. When I had knee surgery, I took the hydrocodone for about three weeks, but began tapering myself off on my own. I could have continued a little longer, but it just got to be too much trouble trying to balance the pain meds and Raisin Bran/Senocot. At that point, my pain probably was around 4-ish.
But I knew that it was temporary. I think that people living daily with 4-5 level pain are an entirely different story. And they need to be helped. Before my knee surgery, my pain daily varied between 2 and 4 with an occasional, momentary 7. I got used to it, but realized over time that it really sapped my energy and affected my mental outlook. I can’t imagine living with 4-5 every day.
I think the reason we are frustrated with drug addicts is that we lose sight of the fact that their biochemistry is screwed up. We understand this fact in other healthcare areas, but we can’t see it sometimes with drug addiction. We need to keep in mind that drug addiction addles the brain the way a computer virus addles a computer. It affects everything it touches. That’s why it is so hard to treat, but it’s not impossible. We also need to remember that there was an underlying psychiatric issue and illness that prompted the addict to begin using the drug in the first place. That underlying issue is what we need to look at in treatment.
There’s an important role for recovered heroin addicts to play in our society right now, and that is in raising public awareness that there is hope, and there is life after addiction. We need to marshal a small army of recovered heroin addicts to talk to communities.
Essentially, addicts are mentally ill people in need of help. I saw a fantastic video on this subject that was posted here on Ricochet, I think by @she . I wish this were required viewing throughout the helping professions. It is excellent.
A core dilemma is that government is a poor vehicle for charity but private charity for drug users at such scale has not been tried.
If we excluded habitual drug users from public hospitals for drug-related problems, private entities would offer assistance but not at the same rate. With budget restrictions (as opposed to Uncle Sam’s magic trick of borrowing from the future), private groups would need to be more selective in patients and treatments. And I’m not sure the few drug addicts willing to break the habit would be identifiable at the moments of emergency.
Christian charity has no limit. Loving a stranger as you would your own dear child or parent means tolerating failure again and again, ever hopeful and ever merciful. But prudence is also a Christian virtue. The Lord’s mercy follows repentance. And we respect free will, without which no act truly expresses charity.
Perhaps the standard should be catheters, handcuffs, and no visitors for drug-related heart surgery recovery. Severe drugs negate free will, so it’s hardly unjust to hold the person we paid for until he is clean.
It’s good to see you back on Ricochet.
Thanks! Thought I would take advantage of the long weekend. Though Mustang just came into the guest room we’re redoing and told me “more taping off, less postsitting.” We’re in a deadline for getting this room done.
We do some of that- can’t leave the unit, place a sitter with the pt, can use the bathroom unattended, restrict visitors. But then they leave and start using and bounce back reinfected. It’s also amazing to me how often times it’s the mothers and boyfriends that enable the drug use. I can’t tell you how many times I see a parent or child bring drugs in for the patient.
As for the free will aspect of it, even God gives us the option of turning away and rejecting him- “How can I give you up? How can I let you go?” But he does if that is our desire. Should we do the same for the patients that admit they’re just going to keep using? I don’t know.
The only way to look at this is you save who you can. I managed to pull a 19 year-old female jumper away from a bridge railing one night. On the way to her 72 hour pysch hold she told me that I couldn’t be there every night. She was right.
My partner and I were sent to breakup a teen age house party on another night. The young man that opened the door wasn’t going to let us in. I knocked him down, and we went in anyway. There was a 16 year-old female passed out on the floor. More than passed out, she was comatose. She had been given a fifth of bourbon as a birthday gift. The bottle was almost empty. We took her to the hospital. My partner sat in the back seat on the trip to hold her upright so if she vomited she wouldn’t aspirate. The ER docs and nurses saved her.
I found a guy that had OD’d. He was breathing, but when I shined my flashlight on his opened eyes there was no reaction, to include his eyelids closing to avoid the light. The paramedics stabilized him, but he refused to go to the hospital, he walked off into the night.
You do what you can. In the case of the female jumper I was asked if I followed up on what happened to her. I didn’t. I wasn’t going to go looking for heartbreak, it came often enough on a shift without having to chase it.
Maybe, in that it stops pill abuse and pushes people into IV drug abuse. I am more inclined to believe addiction is a part of life. Maybe we should push people that abuse toward safe abusing as opposed to more problematic ones.
One of my patients, a 35ish fellow with no endogenous medical issues, regularly attempts suicide with opiates or other drugs. This time it was a meth derivative. Amphetamines, benzos and cannabinoids were in his urine. He’s been on a ventilator in the ICU, deeply sedated and paralyzed, since May 16, when he was found unresponsive with his injection paraphernalia. Temperature was 106, I had trouble believing that but it’s in the records. He’s suffering rhabdomyolysis, acute renal renal failure, acute respiratory distress syndrome.
This is his fourth ICU admission in 3 years, his third bout of a medically-induced coma. He’s had pulmonary emboli, septic injection sites, you name it, but no valvular lesions yet. My colleagues work really hard to save him each time and we all have a bit of a soft spot for him, behind his demons he’s a sweet guy. By the time he awakens, he will be completely withdrawn from all of his addictions.
But he means to die, so he goes back to his drugs and eventually he will die from them. Perhaps he needs not to be found unresponsive next time.
Pathetic.
We do lots of serious medical interventions where we buy the patient a day or two in the hospital; it’s sad but we gave their family members time to say goodbye, and there is no way to put a value on that. That jumper at the very least lived a while longer, and that’s all on you. Take a win when you can.
We are being crazy, but we sometimes must. A question. Transplantable organs are a rare commodity. Do we allow heavy drinkers to get liver transplants, IV drug users to get heart transplants? One suspects not. If not, should the same logic not apply here?
There’s so much here. @fakejohnjanegalt, I don’t buy this theory. First, heroin isn’t an opioid. It’s an opiate. The really meteoric rise in the use of opiates began well before the government restrictions on opioid prescriptions. Indeed, I believe that was the greatest source of increase of opioid / opiate deaths in the first place. Based on my personal observations, I believe the increase in heroin use would be even greater were it not for the percentage of potential heroin users out there who opt for meth instead (that is not an endorsement of meth. Actually, I consider meth to be worse). The problem is that I have yet to find reliable statistics that distinguish between opioid and opiate deaths, no doubt because to do so is not convenient to those who always strive for more government control.
And with that I need to leave for a Memorial Day ceremony.
That’s a very good point. We certainly have very strict guidelines for getting transplants; strict standards for using other people’s organs but not our own.
Addictions are brutal. We all have various forms of coping mechanisms for when life gets messy. Some are benign(ish), some are not. Some of us eat when stressed, or smoke. But the drugs are the worst because the withdrawal is itself horrendously stressful. You don’t get DTs from holding off of donuts for a while, and while breaking a smoking habit is hard, it’s not impossible (and using a step down plan with vaping I’ve seen help multiple people – far more than patches or gum).
As I heard one recovering heroin addict put it, getting off heroin was brutal not just for the DTs, but because he had to face up to just why he started using heroin in the first place, and why it had become such a crutch – that meant taking a very long look at himself in the mirror and seeing who he really was. Not easy.
The other thing people need to know with heroin is this: you don’t start with needles and injecting. You start by snorting it like cocaine. You only move to needles when you’re so deep into it that you cannot get enough of a fix just by snorting anymore. By the time you get to the needle stage, though, you’re so deep in that you don’t care anymore.