Ethicists at Massachusetts General Hospital noticed opioid use disorder was the reason for many consults. “Our hunch was that there was a great deal of emotion in decision-making in these clinical-ethical tragedies,” says Ellen M. Robinson, PhD, RN, HEC-C, nurse ethicist.
Most cases involved one of two scenarios: patients with infected heart valves, where the ethical question was about decision-making for cardiac surgery, or patients with severe anoxic brain damage due to drug overdose who were unlikely to regain cognitive or physical function.
“This presented tremendous complexity for families, who found themselves in a decision-making quandary,” Robinson explains. Some families had been estranged from the patient with addiction, adding to the emotional complexity.
To learn more about the cases, ethicists analyzed 1,061 ethics consults that occurred between 1993 and 2017 at Massachusetts General Hospital.1 Opioid use disorder (OUD) played a central role in 43 of these cases. Consult requests involving opioids increased from 1.4% in 2009 to 6.8% by 2017. Data from 2018 and 2019 have not been analyzed yet, but the upward trend appears to be continuing.
“Conducting this retrospective review was quite helpful,” Robinson reports. “We affirmed our hunches, yet also identified more themes in the cases.”
Patients in consults where OUD was a factor were much younger than those in other cases. About one-third were homeless, compared to about 2% in non-OUD cases. Most (73%) were either underinsured or uninsured, compared to 22% of non-OUD cases. In the 43 consults where OUD played a central role, these scenarios arose repeatedly:
• Decisions had to be made regarding continuation of life-sustaining treatment for overdose patients with neurological injury or severe infection.
• Clinicians were unsure if surgical intervention, such as repeat valve replacement or organ transplant, was appropriate. The concern is that ongoing drug use would adversely affect the patient’s outcome. “We aim for all patients to receive high-quality care — if the surgeon believes it is indicated, and the patient can benefit from it,” Robinson explains. No patients would be denied surgery because they are addicted to drugs if the procedure would be beneficial. However, poor general health, stubborn infection, pneumonia, and other conditions are considered. “Longstanding addiction is not kind to the body,” Robinson notes. “Each and every case must be given a 360-degree evaluation laced with compassion but also with realism.”
• Discharge planning became complicated. “Concerns about relapse were central in clinical-ethical decision-making,” says Julia Bandini, PhD, the study’s lead author and an associate behavioral and social scientist at the RAND Corporation.
Patients struggling with addiction may frustrate easily. Providers aim to set them up with care that is as hassle-free as possible. Sometimes, this means setting up daily transportation to the methadone clinic or for outpatient antibiotics.
• There were some patients who were unrepresented. Social workers and nurses immediately begin trying to locate any family member who could come to the patient’s bedside, or at least be available by phone. Once they are found, “physicians, social workers, nurses, and ethics consultants aim to support the family in understanding the patient’s prognosis,” Robinson says.
• Some patients asked to be discharged against medical advice (AMA). These patients are ambivalent about receiving any medical care at all. “Presumably, this is due to an impulsive desire to return to illicit drugs,” Robinson observes. In these tough cases, the team uses a consultation service that specializes in working with patients with addictions. Ethics often intervene if a patient wants to leave AMA. Psychiatry also is called to assess decision-making capacity. “We frequently aim to de-escalate the patient and persuade them to stay,” Robinson reports.
• Some patients with infectious endocarditis were at high risk for relapse. This made decision-making more ethically complex. “Ethics consultants worked with multidisciplinary teams,” Robinson says.
Psychiatry, social work, and outpatient substance abuse treatment facilities crafted the best possible plan for successful long-term outcomes. It was not always possible. “In some cases, such a strategy did not seem feasible due to poor health from long-standing disease and poor self-care,” Robinson says. Ethics consultants worked with patients and surrogates to move to a palliative care approach. Overall, the findings demonstrate how much ethics can help with these highly emotional cases. “An ethics consult offers a kind of objectivity that can be challenging for both clinicians and families to maintain in these complex and tragic cases,” Robinson adds.
Edward Dunn, MD, has seen a recent surge of ethical consults involving opioids in some way. He shares some issues that come up in these cases:
• Overdose patients were resuscitated, but are now in a vegetative state due to anoxic brain injury. At some point, the decision on whether to withdraw life support needs to be made. This may call for an ethics consult.
• Physicians prescribe opioids appropriately, but patients cannot obtain the medications. “We have an ethical responsibility of beneficence, but we have difficulty getting the medication to the people who need it,” says Dunn, medical director, palliative medicine service at Norton Healthcare in Louisville, KY.
As a palliative medicine physician, Dunn administers opioids to people with intractable pain due to cancer, end-stage chronic disease, or heart failure, often at the end of life. “They need opioids just to have some kind of quality of life for whatever amount of time they have remaining,” Dunn explains.
Clinicians want to give patients enough relief to live in less discomfort, but there are obstacles in their way. Insurance companies may refuse to cover the drugs unless authorization is obtained first. Sometimes, hospital pharmacies cannot fill the prescription regardless.
“Because of the backlash against opioids, we have trouble getting the drugs to people who need them,” Dunn laments. “Pharmacies don’t have the drugs. That’s an ethical dilemma for me as a physician.”
Further complicating the situation are strict caps on prescribing imposed by many state laws. “These limits may curb misuse, but they also create access barriers to those to who have legitimate needs,” says Thaddeus Mason Pope, JD, PhD, director of the Health Law Institute and professor of law at Mitchell Hamline School of Law in St. Paul, MN.
Clinicians feel forced to choose between helping their patient and following the law. Some experience moral distress. “The physician is seeing a patient who needs their services, but they can’t meet the patient’s needs,” Dunn notes.
• Sometimes, the backlash against opioids affects physicians’ prescribing practices. “The medical community doesn’t want to be scrutinized for giving opioids,” Dunn says. That is true even when there are no actual legal constraints.
Certain clinicians, afraid of legal oversight by the Drug Enforcement Administration or their state medical board, underprescribe to avoid raising red flags. “It is unfortunate that legal incentives appear to misalign with the standard of care,” Pope laments. “But clinicians should not allow ill-founded fears to corrupt their professional judgment.” In reality, says Pope, careful documentation of the basis for dosing is nearly always an adequate response to regulators’ inquiries. Still, he says, “some clinicians are avoiding patients with opioid needs — or even worse, firing current patients with high opioid needs.”
Physicians can terminate the treatment relationship, but they must give the patient adequate notice and opportunity to obtain another physician. “Otherwise, the physician commits patient abandonment, which is medical malpractice, a licensing violation, and a breach of standards in most professional codes of ethics,” Pope cautions.
• Some patients present with a history of OUD, but their need for the drugs is valid. It is unethical to send people who are addicted to street drugs home with a bottle of pain pills. “They don’t take them as directed or prescribed. It’s unsafe,” Dunn says.
What options are appropriate for these challenging patients? “We still have a responsibility to see them, and we’ve got to be able to manage their pain,” Dunn says. One option is to use buprenorphine, a semisynthetic opioid that is much safer than any other opioids. “It is very effective in treating pain and preventing withdrawal symptoms,” Dunn explains. “Overdose death from respiratory depression is rare, regardless of how high the dose.”
Another is to ask patients to agree to periodic urine checks. “We do that with the understanding that opioid addiction is a chronically relapsing disease,” Dunn notes. This means that, inevitably, some patients are going to violate their agreements. “But we can’t punish them for the disease they have. We don’t treat any other disease that way,” Dunn stresses.
If someone misses all appointments and refuses drug screens, the patient/physician relationship may have to end. But that happens only in extreme cases. “Nobody else is going to take care of these people,” Dunn adds. “That is an ethical dilemma.”
- Bandini JI, Courtwright AM, Rubin E, et al. Ethics consultations related to opioid use disorder. Psychosomatics 2019; Nov 4. pii: S0033-3182(19)30214-2. doi: 10.1016/j.psym.2019.10.003. [Epub ahead of print].