**Conflict of interest**

The first step in reducing the need for repeat valve replacement and improving patient health outcomes and survivability is to understand the patient's own unique story that prompted the IVDU, their goals for treatment, and their overall understanding of their own responsibilities toward successful, comprehensive treatment. By motivating them with a behavioral contract that speaks to the healthcare team's responsibility to the patient's care and the patient's

Second, patients will not have a chance for successful recovery if they are not provided with needed resources and appropriate guidance to motivate them to seek long-term treatment. Such treatment should involve methods ranging from psychotherapy to pharmaceutical

Unfortunately, most current care is focused on the infective pathology; in IE patients only the acute problem is addressed, but no effort seems to be placed on preventing readmissions or improving the patient's quality of life. Addressing the lack of care and support IVDU patients are receiving, rather than trying to limit patient access to replacement procedures provides the just treatment these patients deserve, in addition to reducing the financial burden on healthcare systems and society. Health care providers often fail to identify addiction as the significant comorbidity that it is, and do not treat it as aggressively and appropriately using drugs that specifically target opioid use disorders; this results in under-treatment of addiction

Third, surgeons and the healthcare team also require the support of ethics teams when complex social and ethical questions arise with patients. Personal biases lead to social stigmatization of patients with IVDU, influence medical decisions, lead to provider burnout, moral distress, and cynicism among health care providers. Having ongoing team-based discussions about these negative experiences, attitudes, and emotions is one step in the right direction, Recognizing the ethical and social issues that penetrate the medical problems can also help navigate and resolve dilemmas and elicit a deeper understanding of the individual patient and their illness narrative. It is important for healthcare providers to engage in self-care, and to have the opportunity to address issues before they devolve into negative emotions and

Finally, it is critical for the health care team to know when additional treatment is futile. There are limits to justice. However, such limits to therapies must be based upon objective evidence supported by the medical literature rather than poorly grounded assumptions, biases, and

Unless physicians treat the chronic and acute illnesses in patients with IE due to IVDU, their ethical duties toward their patients remain unfulfilled, and they fail to provide just care. This issue becomes more precarious when considering patients who require additional valve

own commitment, this may be a positive step.

[16]. Such a limited care approach needs to change.

attitudes that can be harmful to self and other.

outdated, or erroneous knowledge or datasets.

replacements due to continued IVDU.

**5. Conclusions**

interventions.

144 Advanced Concepts in Endocarditis

The authors have no conflict of interest.
