When Is Enough Enough? The Dilemma of Valve Replacement in a Recidivist Intravenous Drug User

s we continue to make advances in medicine that Apromise to treat more people more effectively, we face rising pressures of cost containment and the imperative to allocate resources judiciously. Accordingly, physicians are increasingly confronted with the challenge of where to draw the line at providing care. At first glance this idea may seem akin to Hippocratic blasphemy; as physicians we are never supposed to stop caring for our patients. Nonetheless, it may not always be medically or ethically appropriate to provide ever-escalating care to patients whose illnesses continue to ravage them despite our best efforts, especially when self-destructive behavior lies at the root of their disease. Mr X was a longstanding intravenous heroin user who initially presented with bacterial endocarditis requiring mitral valve replacement. Six months later, he re-presented with severe sepsis and prosthetic fungal endocarditis leading to severe mitral stenosis. Another valve replacement was deemed necessary to achieve cure given the level of valve destruction and persistent positive blood cultures despite appropriate antifungal therapy. However, three consultations with three different cardiothoracic surgeons yielded three nearly identical assessments: Mr X’s recidivism was a contraindication to repeat valve replacement. In case there had been any doubt as to whether he was still using, a nurse found used needles hidden in his clothes. Despite his worsening mental status in the setting of multiple embolic strokes, Mr X expressed that he did not want to die. The ethics committee was consulted and found no medical contraindication to surgery, and in the absence of guidelines they deferred to a senior cardiothoracic surgeon. Although he reinforced the precedent that recurrent prosthetic endocarditis associated with continued active intravenous drug use sufficiently justified his colleagues’ declining to offer a reoperation, he agreed to perform one. After a predictably complicated postoperative course, Mr X was discharged to a physical rehabilitation facility. It was not clear whether there was an effort to enroll him in substance rehabilitation as well. Shortly thereafter, his family brought him to the emergency department after finding him confused and disheveled at home. He had reportedly signed out of