Clinical Case Studies card

Bioethics Forum Essay

Should Life-Saving Medicine Be Continued for an Unhoused Patient with an Addiction?

Ms. B is a 45-year-old African American woman who lives in a shelter. She also has a heroin addiction and has end-stage heart failure. She was admitted to the hospital for emergency treatment, including intravenous medications to increase blood pressure and support her failing heart. Two days later, she remained dependent on one of the medications. To be discharged she would need 24-hour supervision in a home or a long-term care facility. The social worker and case manager worked tirelessly to identify a long-term placement, but no facility would admit Ms. B as long as she was on the intravenous medicine. Her heroin use was likely a factor; the intravenous line could be misused for heroin. 

One month after Ms. B’s admission, the hospital’s clinical ethicists were consulted by palliative care to assist in deciding on what care she should receive and where. The crux of the ethical dilemma was balancing Ms. B’s autonomy—she expressed the desire to live, and her life was dependent on the intravenous medication—against the reality that she had no place to be discharged to as long as she remained on the life-saving medication. More fundamentally, however, this case was also about social justice. Systemic racism and inequality contribute to disparities in substance use disorder. Did the hospital have an obligation to keep Ms. B for the next couple of months in order to redress the societal harms that she had gone through? Had she not been woman of color raised in a poor neighborhood it is unlikely that she would have been so seriously ill at such a young age.

Ethics Analysis and Process

Part of the ethical analysis concerned the purpose of the intravenous drug that Ms. B was on. It belongs to a class of drugs called inotropes that are typically used as a bridge therapy to either a mechanical circulatory support device that assists with heart function or a heart transplant. But Ms. B. was not a candidate for these treatments. In some instances, the Heart Failure Society of America supports inotrope therapy for palliative purposes or symptom-management. However, in Ms. B’s case, the drip was a life-sustaining treatment that could prolong her life for 6-to-12 months. Without it, she was expected to die in a matter of days.

The primary care and psychiatry teams agreed that Ms. B had decision-making capacity, and she clearly said that her quality of life with limited mobility, attached to an IV drip, was acceptable.

There were three options. One of them was to keep looking for a long-term care facility that would accept her and explore whether any family members might take her in. The second option was to wean her off the drip and transfer her to in-patient hospice care, given her life expectancy even on the medication. The third option was to keep her hospitalized indefinitely.

The first option had so far been unsuccessful. No facility – skilled nursing, long-term acute care, or any other inpatient settings – would accept Ms. B on the drip. Ms. B had a sister and a brother who expressed love for her and wished they could take care of her, but for financial and other reasons they could not provide the necessary 24 hours of supervision

The second option, weaning Ms. B off the drip over her objection, was legally problematic. In New York State, where Ms. B was, it is illegal to withdraw life-sustaining treatment over a patient’s objection (or, if the patient cannot make decisions, the patient’s surrogate’s objection). There was no legal or ethical problem with weaning her off the drip as part of hospice care. But Ms. B would have to agree to forgo life-sustaining treatment and enter hospice. 

The third option was also problematic. A hospital is an acute-care setting, not a long-term placement. Other patients are waiting in the emergency room for hospital admission, in need of medical attention. When a huge amount of their finite energy, attention, and resources is invested in the care of one patient, health care professionals may inadvertently give less attention to other patients. Ms. B’s case was complicated by pressure that hospital administration exerted on our medical teams to meet financial imperatives and impact utilization metrics—even after the medical teams, along with social workers and clinical ethicists, appealed to the administration to keep Ms. B longer and to explore charity fundings. While resource allocation may play a part in our deliberative process when we deal with scarce resources such as organ for transplantation, in this case our fiduciary duty was primarily towards this patient, rather than the population as a whole.

The Decision

The ethics team asked Ms. B and her family to discuss their goals of care, since it was unclear whether they understood the seriousness of her prognosis. Did she want to spend the next couple of months in the hospital? Softly, I shifted the conversation to what constituted, for her and her family, meaningful time left. For some people, there may be great value in having control over the timing of their death, surrounded by family members, rather than prolonging their life and most likely dying alone. Ms. B was quietly crying. Yes, she understood. Yes, maybe she would want to have some control over when she dies. She could spend her remaining days with her brother and sister.

Over the following week, she was slowly weaned off the drip. Contrary to all predictions, she survived. I felt relieved. We all felt relieved. Had she not re-examined her goals of care and agreed to remove her infusion, she probably would have lived for the rest of her life in the hospital, tethered to an IV. Instead, she chose to return to her shelter without receiving hospice care, where she was regularly visited by her family. As of my last follow-up, eight months after the case, she was still alive.

Lingering Questions

For a case that was destined from the beginning to leave us with some degree of unrest, one thing brought me solace: The ethics team exhausted every possible alternative and we adhered rigorously to the established process for conducting an ethics consultation. Some might say that we tried to achieve the unfeasible — hospital leadership said that keeping Ms. B in the hospital indefinitely was financially impractical and unfeasible. But I am glad we bought Ms. B some time. The additional time spent advocating for her care coincidentally provided her body with the opportunity to gain strength, ultimately enabling her to survive without the need for inotropic support. There is no doubt, though, that our advocacy had a cost: When a huge amount of our energy, attention, and resources is invested in the care of one, are we, perhaps inadvertently, less proactive in advocating for the next patient?

Paola Nicolas, PhD, MS, HEC-C, is a bioethics consultant and assistant director of graduate education programs at Montefiore Einstein Center for Bioethics in the Bronx.

Series Editors’ Comment: Discharge Planning and Social Injustices

The case of Ms. B demonstrates the role of clinical ethicists in reasoning through complex medical decisions that reflect the social determinants of health and the limitations of institutional and societal resources. It is an example of clinical ethicists having insights into the ways in which our society routinely fails those who are unhoused. These injustices are often compounded for minoritized populations, whose medical vulnerabilities can be interwoven with structural inequities.

Ms. B and the health care team were faced with a set of far-from-ideal options: a) wait for a medically safe discharge plan to materialize, b) transfer the patient to in-patient hospice, which would have required first weaning her off the intravenous medication, or c) let the patient stay in the hospital indefinitely. Discharge is a common source of moral distress and ethical concern for which clinical ethics services may be tapped. The resource allocation and utilization process described by the author are among the relevant considerations, but so are procedural fairness and maintaining patient-centered care.

A resolution in this case was possible because Ms. B agreed to transition to comfort care. She made this decision with the care and support of her family. But we have seen similar patients choose instead to stay in the hospital and maintain the intravenous medication. The author remarks that under New York State law “unilateral withdrawing of life-sustaining treatments over patient’s objection is not allowed.” Still, this case raises the issue of shared societal responsibility for patients who no longer need acute care but stay in the hospital when there are no medically safe alternatives.

The lack of safe discharge options is far neither to patients nor to the greater community served by the hospital. Although some ethics services have “reduced length of stay” as a metric for the value of their service, this kind of metric has the potential to backfire in cases like Ms. B’s. Moreover, ethics services strive to avoid incentives or pressures from hospital administration to reduce the length of stay. In tricky cases like this one, ethicists are put in the difficult position of determining the ethical justification for extending a patient’s stay in the hospital based on societal injustices rather than acute medical need, such as when housing insecurity creates a barrier to maintaining life-sustaining medical therapies outside of the hospital. Given the hospital’s responsibility to maintaining financial solvency to continue to serve the acute needs of the whole community, extending the length of stay for one patient can be a challenging recommendation for a clinical ethicist to make. Nonetheless, it may indeed be ethically justifiable when the alternative involves the harm and injustice of withdrawing life-saving interventions over the objections of the patient.

– Laura Guidry-Grimes and Gina Campelia

Read More Like This

Hastings Bioethics Forum essays are the opinions of the authors, not of The Hastings Center.

  1. You know, I find this really sad as her being a woman of color, when I was going through radiation therapy for cancer. I was on my 31st round of radiation and caught a pneumonia. I went to the hospital and they put me in the room with a white gal who had a massive staff infection from shooting up., I talked with a night nurse because her boyfriend had shown up and they were smoking in the same shared room. There was just a curtain between us, but I had a pneumonia and it was making me cough because I could smell the smoke. I believe they were doing meth or heroin, I went back out to the desk and I said I can’t handle the smoke in here and she told me, honey it’s the wildfires going on! I’ve asked them to transfer me out of the room because I couldn’t be in a room with someone that sick and another nurse told me that her infection was so bad that she was in the hospital on a antibiotic drip for the last three months to get rid of her infection because it was so bad.
    All I have to say is why was she allowed to live in the hospital for 3 to 6 months on this IV drip while still using drugs, why would they put a cancer patient in the room with her when obviously if it took that long to get rid of the infection, she still had it and I was susceptible to her infection and third why would you even put me in the room with her, putting my life at risk? Did y’all think that my life was worse less than hers I had insurance and a job and what is honestly going through the hardest thing I’ve ever been through in my life and I had to worry about that.! When the sun came up the next morning I went out to the charge nurse desk and I told them I don’t care what you have to do. Get me the hell out of this place and do it now.! And they sent me home on a bunch of medication and steroids and by gosh within a week I was feeling better but I was so thankful that I didn’t pick up whatever she had. Hospitals really need to think about the patients that they commingle because I was not comfortable with any of that.

  2. Why wasn’t this patient eligible for In Home Support Services at her family members’ homes, or even a shelter, to cover the supervision she needed? I’ve known a few people at shelters who had IHSS, with a trusted friend who lived there too and got training.

  3. Excellent articulation of a complex case that examines many, many issues. Much to say, but I’d like to focus on the laudable persistent pressure-testing by the clinical ethicist of the components/perceived barriers to each potential option. AND for the time spent ensuring that the patient fully understood their condition, their prognosis, and the many variables associated with continuation (or weaning) from being inotrope-bound. The act of continuing to check in with the patient on their values in these differing contexts was one of the keys to finding a path forward in a heavily forested scenario.

  4. I think that addictions are a field of specialized medical care. This pathology is the original and main cause of the illness. Treatment cannot ignore this primary task. The hospital stay must include the solutions that can be given to the addiction.

Leave a Reply

Your email address will not be published. Required fields are marked *