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Should We Refuse to Treat Patient's who Overtly Abuse the Health Care System? When is Enough, Truly Enough?





One of the most difficult things as a health care provider is giving care to those you feel do not deserve it. We spend countless hours in medical school discussing the ethics of care, and separating our personal feelings from our duties as providers. Especially given the arguments over heath care expenditures (especially in the United States), it is vital that we start discussing when it is ok to refuse using valuable resources and time on patient's who overtly abuse the health care system.

Let's begin with a real life story (of course some minor details have been changed to protect confidentiality)...

Peter is a 54 year old who looks more like he's in his 70s. He has abused his body with decades of severe alcoholism. He is homeless, has no job, and has no family. His alcoholism has caused such a severe encephalopathy (ie: term used to describe global brain dysfunction) that he is able to mutter a few words at a time.

Peter spends most of his time bouncing between stores buying cheap liquor. But perhaps more importantly he bounces, just as frequently, between emergency rooms and trauma bays.

At one hospital alone Peter was "found down" and brought in as a trauma patient 6 times in the course of 3 weeks! Somewhat amusingly (or maybe frighteningly) he was brought in just 2 hours after a previous hospital discharge! He made it to the local liquor store where he imbibed an inordinate amount of booze and was "found down" again by paramedics. He even still had his previous hospital wrist band on...

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Each time he ends up in the ER or trauma bay a work up with CT scans and xrays reveals a small amount of bleeding within his brain, a result of his severe alcoholic liver disease and dysfunctional platelets. Not surprisingly Peter had emergency brain surgery at some point in the past to remove a larger blood clot as evidenced by a bony skull defect seen on the scans. These findings buy him at least a repeat head CT and a night in the intensive care unit.

The doctors, nurses, care coordinators and social workers spend hours educating Peter about avoiding alcohol abuse. He passes his physical therapy sessions. He is set up with homeless shelters and places to stay, but history, as it so often does, repeats itself...

And then, interestingly Peter "disappeared" for a while. He failed to show up in the trauma bays or EDs. Those of us involved in his care thought that maybe he died on the streets, but no one knew for sure. And then he landed up in the ED again... This time he was unable to move his left side. A scan revealed a large bleed in his head that was putting significant pressure on the area of his brain responsible for movement.

He was rushed to surgery emergently for removal of his skull and evacuation of the blood clot. He was transfused numerous units of blood products to slow the bleeding. He spent several days in the intensive care and eventually got a tracheostomy and feeding tube.

This time Peter really did it. He managed to hurt himself just enough that he will spend the rest of his life in a nursing home.

Peter's story is obviously very sad, but also quite infuriating. Over the course of his life Peter racked up hundreds of thousands (if not millions) of dollars in medical expenditures, of which he will not personally pay a dime. Countless resources were thrown at him. And yet every time he disregarded his care and landed right back in the hospital. The very sad thing is that Peter's story is not unique... There are so many patient's who overtly abuse our system and provide nothing in return.

Should we have refused to operate on Peter the last time he came in? If we did not rush him to surgery Peter would probably have died. The answer requires a lot of soul searching, and perhaps there is no "right" answer. I pose the question to the readers of this blog... When is enough, truly enough?

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