When is enough, enough?

It is my third year of residency, and I have taken care of the same patient on multiple admissions since my intern year. This gentleman, who I will call Rob, is in his mid-30s with two young children. He suffers from active alcohol use disorder and end-stage liver disease. Unfortunately, he continues to have recurrent bloodstream infections, likely due to the multiple prosthetic materials in his liver that were inserted to treat his cirrhosis. Each admission is similar: Rob generally feels unwell and presents to the hospitals with low-grade fevers and malaise, is found to be bacteremic, and is treated with intravenous antibiotics that are transitioned to oral at the time of discharge. During each hospitalization, he is evaluated to determine whether he would survive the removal of his artificial hepatic tubes or be a candidate for a liver transplant. He is offered numerous resources for alcohol recovery, from inpatient medications to rehab facilities, which he repeatedly declines. Rob's liver disease is more advanced, and he is not clearing the bacteria in his blood despite multiple days of intravenous antibiotics. Moreover, he repeatedly disconnects his intravenous catheter to go outside. Recognizing his dire illness, his multiple medical teams have prioritized a harm-reduction approach to his care and have always tried to accommodate him. Harm reduction is a set of strategies aimed at reducing the negative consequences associated with drug use. In Rob's case, this includes allowing him to leave the floor to have a cigarette, eat nonhospital foods, and sometimes even visit his children when they cannot come to the hospital. Except what started out as quick walks outside to have a smoke have evolved. He now frequently returns intoxicated and was once found to have hard liquor in the room. He was also found to have benzodiazepines in his urine, which he has not received during his hospitalization. The nurses and staff who have known him for years, feeling increasingly tricked, scared, and liable, now no longer feel comfortable caring for him. Palliative care, legal services, and ethics all agree. The patient must be administratively discharged for failing to comply with hospital policy. Should he return to the emergency department, clear instructions must be given that similar breaches will result in immediate “administrative discharge.” I had not previously heard this term but soon learned its meaning: the patient would no longer be treated at this hospital. When patients are discharged in this fashion, their current providers are supposed to arrange alternative or outpatient care, though the patient often does not want that help. Different hospital systems use different language for these discharges, making research and discussions around this topic challenging and opaque. At a nearby Boston hospital, for instance, the lingo is whether the patient should be “PNG'ed”—PNG meaning persona non grata, a status that would bar the patient from being able to access the hospital facilities in the future. In almost all cases, there is a legal framework in the background because abandonment is a category of malpractice. These types of discharges and their associated documentation, with phrases like “care was offered and refused” and “the patient was disruptive,” appear to be for the institution's benefit and protection, not the patient's. Rob's family and the medical system have been trying to treat his addiction and co-morbidities for years, yet it still feels like we should and could do more. To do anything else and withhold care when he continues to seek it feels almost antithetical to our role as physicians. Rehabilitation, medications, and family interventions have all been tried multiple times. Can we offer any of these again? Can we discharge him with a central catheter line to receive outpatient intravenous antibiotics, though he remains bacteremic? Can we prescribe oral antibiotics indefinitely, even if they are less effective? And I, the senior medical resident, am unsure what to do. On the one hand, I see it as my job to always advocate for the patient, to help them in any state, and to recognize when a disease like addiction interrupts their judgment. Moreover, I see it as my job to recognize when bias and disparities may exist and do everything I can to counterbalance them. I also fear that part of the patient's plight is our fault—we are the ones who placed the hardware that became infected, the ones who have restricted—even with the best intentions—his ability to see his children while within hospital walls, the ones who have not been able to reach him through addiction resources, both inpatient and outpatient. On the other hand, I understand the legal and ethical importance of boundary-setting and supporting colleagues who feel unsafe and liable when patients repeatedly violate hospital policies and jeopardize their health and that of others. I also understand feeling empty when patients do not reciprocate our efforts or even deceive us. Sometimes, there comes a point when there is simply no more that you can offer without further breaking yourself. It seems impossible to support the patient, our colleagues, and ourselves in what feels like a lose–lose situation. For Rob, a discharge now—voluntary or involuntary—feels very much like it will be his last. Without control of his infection or treatment with intravenous antibiotics, it will only be a matter of time before the bacteria win and shut his body down in septic shock. Even if he returns to the hospital, the cycle will continue, especially if he is forever labeled as an administratively dischargeable patient. In not too long, he will no longer have the strength to return to the place that has become his second home. Rob has the capacity to make his own decisions but is beholden to the bottle—he has repeatedly tried and failed and tried and failed, but now it seems as though he is no longer trying. And yet, he still returns to the hospital for help. Like so many patients who face a debilitating addiction, there appears to be a disconnect between words of wanting to improve and self-destructive actions. We even investigated whether we could interpret his near-suicidal behavior (for example, making it impossible to receive life-saving antibiotics) as grounds for involuntary commitment. However, in many states, including Massachusetts, you cannot make the case—that a patient's mental illness puts his physical health at risk—if the primary psychiatric problem is substance use. Yet, addiction has characterized virtually Rob's whole existence, changed him, and defined him. His substance use disorder has consumed him to a point that it seems impossible to separate the intoxicated and real person. Trying to distinguish the real person from their debilitating disease is one of the hardest tasks of being a physician, and sometimes, it can never be done. That week, our multidisciplinary team meeting to discuss Rob's care feels different. For one, besides the patient's bedside nurse and colleagues from infectious diseases, social work, and palliative care, there are representatives from the office of general counsel and the ethics committee, who have also known Rob for several years. The door closes, and the nursing director shares, “We cannot care more for the patient than he cares for himself.” There are a few nods around the table, and the general counsel passes my attending and me a sheet of paper. I immediately recognize the first line as the introduction to an administrative discharge summary. “Will you both please sign here?” Am I okay with letting Rob die? The author declares no conflict of interest.