**3. Case presentation**

**2.2. Factors contributing to stigma and the refusal of care**

136 Advanced Concepts in Endocarditis

communities and an already resource-limited health system.

user, which was an unexpected finding and deserves further research [13].

In general, many surgical professionals identify repeat valve replacement surgery as nonbeneficial for patients with IVDU, and thus, refuse or are reluctant to offer this procedure or refer patients to other surgeons who are willing to treat this patient population. Even when the valve replacement surgery may provide some benefit and give a few more years of quality life for patients, surgical professionals and the healthcare team may feel as though the financial burdens to patients and healthcare institutions is a reasonable justification for not replacing infected valves. This is especially true given the high relapse rates for IVDU and readmission with active IVDU. In addition, because the IVDU patient population contributes to increased unemployment and reliance on publicly funded insurance [12], some health care professionals may feel as though they have a duty to the community by not prolonging the lives of patients with IE secondary to IVDU, and thus adding additional financial burdens for

Smyth et al. (2010) conducted a prospective study of patients who were dependent on opioids and admitted to a residential chemical dependency service for treatment. The authors found that 91% of 109 patients interviewed had relapsed; 59% relapsed just within one week of discharge [13]. Those who had earlier relapse were characteristic of our patient population; patients are younger in age, have a history of IVDU, did not complete the recommended length of time in the addiction program, and did not enter in or commit to aftercare programs. The authors also found that delayed relapse occurred among those who completed their entire program, as well as those individuals who were in a relationship with an opiate

Furthermore, given the significant rise of IVDU with the opiate epidemic in the United States, further research on relapse is needed, including the multitude of factors that contribute to relapse. Without addressing the factors that contribute to relapse, the rate will continue to rise, perpetuate stigma, fuel healthcare professionals' reluctance to provide multiple heart valve replacement surgeries, among other medical interventions. A study in China examined heroin addiction relapse and the effects of detoxification medications (methadone) combined with psychological counseling and social support measures, which were found to be essential to ongoing recovery and reduction of relapse rates along with patient compliance [14]. Additional studies have found that patients who recur to IVDU after the initial valve replacement proce-

dure have very high mortality compared to patients who undergo rehabilitation [15].

patients as persons in need of advocacy and support to combat their addictions.

**2.3. Gaps in the literature**

From a medical perspective, the relationship between IE and substance use disorder is no different than nephropathy and diabetes, coronary artery disease and smoking, or the countless other chronic medical problems that are worsened by "life-style" choices. However, the negative connotations and stigma associated with IVDU lead to patients being treated differently in the health care system and among physicians, who deny life-saving care and devalue their

Unfortunately, little research has been done on the value of extensive psychiatric and behavioral health interventions prior to, during, and following surgical treatment and the overall The following two case presentations are based on actual patients with identifying information removed so as to protect their identities. These cases were presented to an ethics committee for an initial recommendation; however, the analysis and discussion presented here extends beyond committee consultation or even those guiding ethical principles that contribute to decision-making and resolution. These cases reveal a need for a narrative ethical approach to best understand individual patients and their medical, psychosocial, and valuebased needs from diagnosis through recovery. The cases presented in this chapter are montages of health care team members' stories about their interactions with patients through medical evidence, patient interviewing, and clinical observation. However, there is an equal need for the medical team and the patient to co-author or construct a joint narrative of illness and medical care [18, 19]. These cases, however, do represent the multiple voices of the multidisciplinary medical team about the patient in a brief, accessible case presentation. The features of these cases serve as valuable starting points for understanding the complexity of medical decision-making, unifying repeat heart valve replacement, post-operative care, and mental health treatment, and the need for ongoing recognition of the patient's story.

transformation, aphasia, and distal limb emboli. He currently reports feeling feverish with body chills, headache, and joint pain; lab results show *Serratia* bacteremia, hypokalemia, transaminitis, anemia, and thrombocytopenia (I do not think we need these labs after *Serratia* bacteremia). An ethics committee is called upon to guide the treating surgeon whether this patient should receive a repeat valve replacement if he medically qualifies for this intervention. Additional ethical guidance is sought to determine what are the ethical obligations of the healthcare team when the patient does not believe he needs chemical dependency treat-

The Ethics in Repeat Heart Valve Replacement Surgery http://dx.doi.org/10.5772/intechopen.76844 139

The above cases are representative of several medical, social, and ethical issues presented when patients are suffering from IE secondary to IVDU and who may require a repeat heart valve surgery and extensive mental health care for addiction and other related mental disorders (e.g., depression). In situations where patients have IE secondary to IVDU and need a new heart valve—their first surgical intervention—surgeons and others are more likely to treat the typical young patient with a probable successful surgical outcome without a need to seek ethical counsel. In our experiences, while most patients receive minimal chemical dependency treatment post-surgery, relapse (as discussed above) is likely, and a comprehensive mental health care program with monitoring, social support, and a recognition of the social

Thus, these patients return with IE and in need of a second, third, or more heart valve replacement surgeries. Surgeons and other healthcare professionals, particularly those working in community hospitals with limited financial resources, may question their duties to this patient population while considering their obligations to their medical community and society at large. Heart valve replacement surgeries, post-operative care, and addiction treatment are costly, and the financial burdens to patients, healthcare institutions, and the general community may deter surgeons from moving forward despite the patient's need. We can add the statistic about how the cost is increasing using the data from NC either here or in the paragraph with all the other statistics. Furthermore, the social stigma and biases against drugaddicted patients impact medical decisions, particularly when combined with the potential risk to health outcome measures, which can affect individual health care professional evalua-

The emotional impact of providing surgical care with the likelihood the patient will be back again for repeat heart valves due to IVDU can prompt moral distress, cynicism, and resentment of this patient population regardless of the moral obligations to treat when medically necessary, or beneficial. All of these considerations for repeat heart valve replacement surgeries should not be dismissed. They are essential for building a case for comprehensive just care, which is guided by core ethical principles of beneficence, non-maleficence, and justice, as well as a recognition of the individual patient's story through narrative medicine. Narrative

ment and is likely to have repeated events of IE secondary to IVDU.

**patient illness narratives**

**4. Ethics case analyses: a need for comprehensive just care and** 

determinants that contribute to the relapse are often not sufficiently addressed.

tions, work satisfaction, and trust among the general patient population.

#### **3.1. Case 1: a unified care model**

A 24-year-old homeless, female patient is brought into the emergency department by a family member and presents for sepsis related to IVDA. The patient has a 10-year history of drug use with previous endocarditis, requiring cardiac surgery and debridement of an infected tricuspid valve approximately 14 months prior to the current admission. She has a history of untreated depression. The patient is admitted for complaints of joint pain, swelling, and general malaise. She reports injecting heroin and crack cocaine in her extremities (feet, arms, and hands) daily. The patient was drug-free for a short period of time with the assistance of residential treatment and hospitalization at a nursing facility where she received IV antibiotics for the endocarditis. However, the patient missed a dose of Suboxone (buprenorphine and naloxone) due to lack of transportation, did not seek support from health care professionals, and was unsuccessfully attempting to stop her persistent drug use on her own. Her continued drug use and failure of medical management have resulted in the need for preoperative cardiac surgery for large vegetation in the tricuspid valve. The patient is willing to pursue addiction treatment following surgery and post-operative care and has had a history of taking Suboxone as an effort to stay clean and sober. An ethics consult is called to provide a recommendation on whether it is ethically permissible to re-operate in this patient with infective endocarditis from persistent IVDU. The ethics committee further weighed in on recommendations for achieving a unified care model in which the immediate medical needs namely, heart valve replacement, antibiotic therapy, and acute peri-operative pain management. Critical in the discussion was also providing a pathway that includes comprehensive mental health care for the patient's depression and addiction.

#### **3.2. Case 2: resistance to IVDU treatment**

A 29-year-old married male with a history of depression, multiple suicide attempts, polysubstance intravenous drug use (heroin and methamphetamines), and a history of endocarditis was brought to the emergency department by EMS following a suspected overdose. The patient was unresponsive until EMS delivered multiple doses of naloxone in route to the emergency department. Upon arrival, the patient was alert but had difficulty speaking. The patient's wife, who is a recovering addict, alerted EMS to her husband's overdose. Upon questioning the patient's current drug use, he admits to using methamphetamine cut with Fentanyl over the past week. The patient was drug-free for approximately 1.5 months after a prior hospital admission for septic mitral valve endocarditis due to IVDA, as well as renal failure, which was resolved following treatment. He received a bioprosthetic mitral valve and antibiotic therapy. Aside from his brief period drug-free, he has never been in treatment specifically for his chemical dependency and currently feels like he doesn't need such treatment. The patient suffers from multiple cerebral septic emboli with hemorrhagic transformation, aphasia, and distal limb emboli. He currently reports feeling feverish with body chills, headache, and joint pain; lab results show *Serratia* bacteremia, hypokalemia, transaminitis, anemia, and thrombocytopenia (I do not think we need these labs after *Serratia* bacteremia). An ethics committee is called upon to guide the treating surgeon whether this patient should receive a repeat valve replacement if he medically qualifies for this intervention. Additional ethical guidance is sought to determine what are the ethical obligations of the healthcare team when the patient does not believe he needs chemical dependency treatment and is likely to have repeated events of IE secondary to IVDU.
