A 43-Year-Old Man With Intravenous Drug Abuse and Recurrent Endocarditis

Abstract

INTRODUCTION: Fungal endocarditis is a rare disease with a high mortality rate that requires treatment with antifungal therapy and valve replacement. Individuals with active intravenous drug addiction are at high risk of failing treatment. CASE PRESENTATION: A 43-year-old man with a history of intravenous drug abuse and bacterial endocarditis requiring mitral valve replacement presented with fever and groin pain. Blood cultures grew Candida albicans, and mitral valve endocarditis was confirmed by echocardiography. Despite medical therapy, his hospital course was complicated by persistent fungemia and septic shock. Further history revealed that he had relapsed on IV drugs of abuse since his prior valve replacement. Two cardiothoracic surgeons independently determined that the patient was not a surgical candidate due to recidivism. The ICU team consulted the Ethics Committee. Ultimately, the patient underwent valve replacement and was discharged to a rehab facility. He left the facility against medical advice and did not complete antifungal therapy. He was re-admitted to the hospital one month later and was diagnosed with bacterial endocarditis. He died one week after hospitalization. DISCUSSION: This case presented an ethical challenge for the ICU team. The surgeons determined that recidivism was a contraindication to re-operation. They implicitly invoked arguments of futility and distributive justice to justify withholding care. This decision left the ICU team in a difficult position, since the patient was unlikely to survive without surgery. The Ethics Committee concluded that the decision to perform surgery should be based on medical necessity, not psychosocial factors. Furthermore, they stated that the procedure was justified despite the possibility that the patient might continue abusing drugs post-operatively. Their decision implied that because the patient's drug addiction was potentially curable, life-saving surgery must be provided. Although the second valve replacement surgery improved the patient's condition, it ultimately failed as a consequence of persistent drug addiction and did not affect the patient's long term prognosis. CONCLUSION(S): This case illustrates the difficulty in rationing costly healthcare resources in patients with drug addiction, where successful intervention requires cure of the addiction. Studies need to be conducted to define public and health professionals' opinions to define appropriate guidelines for ICU physician responsibility in these situations. The failure of the public and health professionals to develop appropriate guidelines in these situations, analogous to those applied in solid organ transplantation, results in every case being considered an isolated ethical dilemma.