A 32-year-old man with opioid use disorder comes to the emergency department with a temperature of 39.4 C (103 F) and is diagnosed with tricuspid valve endocarditis due to Staphylococcus aureus. A 6-week course of intravenous (IV) antibiotics is initiated. On hospital day 3, the patient develops diaphoresis, tachycardia, and diarrhea consistent with opioid withdrawal and requests to leave the hospital. He says, "I know IV antibiotics are the best treatment and that I could die without them, but I gotta get out of here. Can you at least give me some antibiotic pills to take?" Which of the following is the most appropriate response to this patient's question?

Question

A 32-year-old man with opioid use disorder comes to the emergency department with a temperature of 39.4 C (103 F) and is diagnosed with tricuspid valve endocarditis due to Staphylococcus aureus.  A 6-week course of intravenous (IV) antibiotics is initiated.  On hospital day 3, the patient develops diaphoresis, tachycardia, and diarrhea consistent with opioid withdrawal and requests to leave the hospital.  He says, "I know IV antibiotics are the best treatment and that I could die without them, but I gotta get out of here.  Can you at least give me some antibiotic pills to take?"  Which of the following is the most appropriate response to this patient's question?

Quizplus · Accepted Answer

11ec25c8_d52d_d40c_bc81_8df35dd8befa_MD0003_00 This patient has acute, right-sided infective endocarditis (IE) due to Staphylococcus aureus, possibly acquired from intravenous (IV) drug use. Treatment of right-sided IE generally requires an extended course of parenteral antibiotics. Although some patients with IE who show clinical improvement can be transitioned to outpatient therapy via placement of a venous access catheter, this strategy is problematic in patients with a history of IV drug use due to the potential for misuse of the catheter. According to principles of patient autonomy, adult patients have the right to both decline initiation of treatment and terminate treatment already underway. In either case, the provider should advise the patient of the potential risks of refusing care but may not mandate that a competent patient submit to treatment. In cases in which a patient chooses to prematurely discontinue treatment (eg, leaving a hospital against medical advice [AMA]), the provider should ensure that the patient has been clearly informed of the risks of doing so. If the patient still insists on discontinuing treatment, the principle of beneficence mandates that the provider continue to act in the patient's best interest. Although the effectiveness of oral antibiotics for IE is not well studied, and oral antibiotics are likely inferior to parenteral therapy, oral therapy is not likely harmful or clearly futile and should be offered to this patient (Choice A). (Choice C) Patients terminating care AMA should be advised of the associated risks (with all such discussions documented in the patient chart) but do not need to sign a liability waiver. Furthermore, such waivers do not absolve the provider of the legal obligation to advise appropriate care. (Choice D) In most cases, third-party payors will cover otherwise appropriate hospital care, even if the patient chooses to leave AMA. Threatening financial consequences for leaving AMA is neither necessary nor appropriate. (Choice E) This patient is not acutely intoxicated and voices an understanding of the primary risks of refusing care. He is therefore competent to make decisions regarding his care and may not be restrained against his will. Educational objective: When a patient chooses to prematurely discontinue treatment (eg, leaving a hospital against medical advice), the provider should clearly inform the patient of the risks of doing so. If the patient insists on discontinuing treatment, the provider should continue to act in the patient's best interest, including offering appropriate (even if less effective) alternate treatment options. References: Discharges against medical advice at a county hospital: provider perceptions and practice. (http://www.ncbi.nlm.nih.gov/pubmed/28125826)

A 32-Year-Old Man with Opioid Use Disorder Comes to the Emergency