The scenario is familiar. A narcotic-using patient is desperately ill with a bacterial infection (endocarditis perhaps) and needs life-saving antibiotics. The patient is admitted through the ED and sent up to a medicine unit. The standard treatment might be a six-week course of antibiotics administered intravenously – often via a PICC line. That treatment could be provided in the community, but because of the fear that the patient might use the PICC line for injecting narcotics, and because of the fear of the patient overdosing using this method, and because of concerns about the ability of home care to provide the treatment in the often precarious living conditions of the patient concerned many physicians would be extremely reluctant to discharge such a patient with the PICC line in place.
So, orders are written that the patient should stay in hospital for the duration of the antibiotic treatment (six weeks.) The course of events that follows is both common and predictable. In the first few days of the admission the patient is both very sick and experiencing withdrawal. But as the patient improves and becomes more mobile and as the patient may well have no particular intention to stop using at this time the patient may continue to use while in hospital. This results in visits from friends (and dealers) drug paraphernalia in the room (including needles) and drug use on the hospital premises, in the washrooms, stairwells, car parks and so on. This, of course, does not exactly sit well with hospital staff – who have legitimate fears for their own safety, and who often find it extremely difficult to deal with patients in these circumstances. As staff and hospitals struggle to retain (or regain) control over the situation they typically seek to impose conditions on the patient’s stay. (The patient “responsibility” part of patient rights and responsibilities.) The patient experiences these conditions as increasingly onerous and so they eventually just leave “AMA.” The PICC line is removed and the patient leaves without complete treatment, without follow up and with a fractured relationship with the health care system.
It is widely accepted that this process does not work – it does not work for patients who end up not receiving treatment that could benefit them, it does not work for hospitals and care providers who struggle to meet their patient’s needs, and it does not work to build trusting relationships between patients and health care providers.
So what are the alternatives?
We would be interested to hear your thoughts and experiences and suggestions for ways forward.