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Should We Refuse to Treat Patients 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...

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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Please email with your questions, comments, and/or concerns. Any comments about the page will be reviewed and posted in the comments section below. Thanks!


From Compassionate: There has to be a time where people need to take responsibility for their actions, Im sure Peter probably came from a sad upbringing or was hurt in someway, but when we take the burden to care for people like this it infringes on our rights to grow, contribute and help others (grow as we wont be forced to pay for others mistakes, contribute as there will be resources to help others, etc) People need to understand that health care is NOT a right, its a privilege, a right is a god given right (right to free choice and not to be harmed by others) while it is a privilege to receive things like health care and education (as these are resources that cost us all something - and by making these things a right - it actually takes away from some of our own rights) - Alternative? - we could all be socialist and Id definitely give up my medical degree, get paid the same for a low hours - high fun job, and spend my 20's and 30's parting instead of committed to studying medicine to help those who don't appreciate it...

From Brian Hamill: True, Peter the destitute alcoholic gets a free ride. So does Ambev and Foreman and Diagio et al, makers of Bud and Jack Daniels, and other tasty poisons. They spend billions to make their "product" cheap and readily available all around the world and just around the corner. Has any beverage maker ever contributed a dime to alcoholism recovery? No. Why not?

From Mark: Peter's is a sad story. Brian made a good point, indirect, but a good point; the makers of the poison should be contributing to the illness. Nonetheless, Peter was trapped in a cycle of self-injury and destruction. I believe that during his final episode, he should have been given comfort measures and spiritual care; someone sit with him so that he doesn't have to die alone. My story? My wife and I were hit by an inebriated driver while we were out for a spin on our (hog) motorcycle. Amy's leg was severed and my spine was fractured from the one end to the other. I will focus on one issue. I immediately had a severe headache, which has never gone away. It often flares into Migraine like episodes that can last for over 8 hours. After 5 or 6 six hours of sweating through my clothes, nose pouring with mucus from the cranial pressure, confusion, vomiting, and some intense pain; I have to be taken to the ER because I didn't have the tools at home to deal with it. Later, after they get things under control, I ask, "This is something related to the MVA." And no one would investigate the obvious. I start pulling my medical data and the radiology studies. Hmmm,... Partial Atlanto-Occipital Dislocation is noted. Interesting. And all sort of damage at every level; C6/7 is nasty. OK. Right Vertebral Artery is damaged. Nice. And a recent study finds a large cyst, probably from the injury, in the AC region. I point all of this our to my Doctors. Norvasc, Fioricet, and Dilaudid in hand now. BUT,... had I not done my own work, I would still be making frequent trips to the ER and suffering. My marriage failed, in part, to these numerous spells and trips. So please slow down, listen, and stop making quick assumptions.

From sensible: The alcoholic (or any other drug addict) is responsible for his own condition, and there has to be a point beyond which we can say "no more care unless you clean up your act". The makers of alcoholic drinks are not responsible for anyone's addiction or misuse of their product. Millions of people manage to drink responsibly and never harm anyone, so the problem is not the product, nor the maker, but the user. In the given example, he had every opportunity to change his life & chose not to, so leave him to his self-made hell. It would have been kinder all around to get to surgery slowly, or simply decide that he was too big a risk & not do it at all. He wouldn't be trapped in a non-functional body, never having his preferred drug again, and society wouldn't be stuck caring for him for the rest of his life.

From StillHaveHope: I agree with everything sensible says. Alcohol, like guns, fast cars, or Big Macs, can all be abused and hurt a person or some other involved. The maker of the product is not the problem/answer. Bootleggers, shade-tree mechanics, and Wendy's will gladly step in and continue making whatever you try to "limit" with laws/rules/fines. Personal responsibility is an idea far too removed from 80% of Americans. "Get what you can while the getting is good" seems to be the prevalent thought. You can't please all the people all the time, so why are we trying so hard to please the ones who CHOOSE not to contribute to our society? So when do we limit how much we "care for and please" the people who are not productive, abuse themselves and others and take money out of the big health care pot without putting some in? When do the people who do put money into that health care pot get a say?

From Anonymous: Prohibition doesn't work, but alcohol makers and marketers should pay a significant portion of their profits into a major public fund that exclusively pays for greatly increased public education, negative TV ads, accident victim compensation, and medical treatment costs. (All services provided without influence from the alcohol industry.) The industry would try to pass these costs on to consumers, but would be forced to absorb at least some of the cost, if they want any continuing customers. Consumers would be annoyed, but if the full TRUE social costs of alcohol were spelled out for them, the majority would at least grudgingly accept increased costs and just reduce their consumption to compensate. High "start-up" costs would discourage young people from beginning lifelong habits of excessive drinking, and alcohol abuse would become less "normal" as a youth recreation. (Studies have proven that higher cigarette costs have helped reduce smoking rates.) 

This system would maintain “free choice,” reduce the direct harms caused by alcohol, protect taxpayers from at least some of the medical and welfare costs (higher fees = greater taxpayer relief), and shift more of the burden to where it belongs: to the SOURCE of the problem. 

It's popular these days to blame the victims of alcohol pushers, saying alcoholics deserve every bit of their suffering because they chose to become addicted. But did ANY of them consciously PLAN and CHOOSE to be miserable ADDICTS for the rest of their lives? I doubt it. 

Alcohol is so pervasive in our social lives that everyone seems able (even expected) to drink fairly large quantities several times a week. Glamorous, sexy, clever people drink all the time on TV or in the movies. And even potential alcoholics can often drink "normally" for years ... so it becomes a habit, because they think they're in the lucky majority who can handle it. Are they paying attention as they gradually start to exceed sensible limits? Do all these NEW alcoholics recognize the threshold they're crossing at the moment they become addicts? Are they aware and informed enough to see the full dangers of continued drinking? Again, I doubt it. 

As people cross the line into alcoholism, it often ruins many aspects of their work, family and social lives ... quickly ... often before they understand "what hit them." And though they're reeling from this unexpected devastation, they're expected to immediately exert nearly superhuman willpower by themselves, to overcome their new addiction. 

And what about people at the low end of the Intelligence Bell Curve? At what IQ are we willing to “forgive” alcoholism and recognize the person’s fundamental helplessness to overcome their addiction by themselves? At what level of mental illness or brain injury? 

The alcohol industry doesn't care ... their goal is to create and sustain as many addicts as they can. 

The alcoholic in the original story was too far gone to help, so I have mixed feelings about heroic measures to save him. The tragedy is that he got so bad in the first place. It would be far more cost-effective from a medical and humanitarian perspective to use an industry-provided fund to invest a great deal more in AGGRESSIVE alcoholism prevention, EARLY diagnosis, and EARLY interventions with continuous helpful reinforcement ... BEFORE brain and organ damage sets in. 

Sure, a few capable slackers would still ignore the facts, drink too much, and refuse early help ... but MANY others would avoid or escape full hard-core alcoholism. 

The answer is NOT to look the other way and let tens of thousands of alcoholics rot and die on our streets, just because they "deserve" to suffer. The social, economic, and MORAL costs are too high