Patient autonomy and doctor’s concern – a case of intravenous drug abuser

Introduction

Drug abuse among youths is a grave concern for society. Injected drug abuse is rare in Nepal and there is little epidemiological data. Cases of intravenous substance abuse may often go unreported as the patient presenting to the hospital attempts to mislead the doctor with a vague and inaccurate history for his illness. Failure on the part of a doctor to identify needle marks/tracks in mainliners may be another reason; these cases go undetected but even when they are recognised managing these patients can be difficult because of the associated complications of drug abuse. Psychotherapy is a priority in managing such cases.

We report a case of a young man who presented with life-threatening complications of intravenous drug abuse, but refused to give details or undertake the proposed treatment, raising concerns for the team of doctors.

Case report

A 35-year-old male of Mongolian origin complained of sudden and severe pain in the anterior aspect of the right knee and reported to the Emergency Department (ED). He stated that the pain radiated towards the hip joint and that the pain was not relieved by over-the-counter medication (Tab Ibuprofen 400 mg). The pain was severe enough to limit ambulation. Blood pressure was 100/70 mmHg and the pulse rate 64 beats regular/minute. On local examination the swollen right foot had only four toes, the second toe being surgically amputated which was evident by the presence of a healed scarred stump. The blackish lateral aspect of the right foot was indicative of gangrenous changes involving the right fifth metatarsal and distal phalanges of fourth and fifth toes (Figure 1). Overlying skin of the right fifth toe was completely absent in the ventral aspect exposing the underlying bone. The nails of the great toe and the third toe were missing with yellowish brown discoloration of the underlying skin. The left foot was swollen too with reddish discoloration, without any gangrenous changes. The right foot was cold to touch without any pulse in dorsalis pedis artery, anterior tibial artery and posterior tibial artery. Anterior tibial pulse was the only palpable pulse in the left foot. Popliteal pulse was not felt behind the right knee but was palpable on the left, while the femoral pulse could be felt on both sides. The patient was reluctant to give a detailed history and undergo investigations. He handed over his previous investigation reports and demanded pain-relieving medications from the doctors. After a lot of convincing the patient underwent computed tomography angiography that revealed lower limb arteries occlusion of anterior and posterior tibial arteries in the right, occlusion of the proximal left posterior tibial and peroneal arteries and mid part of right tibial artery (Figure 2). There was presence of mild calcified plaques in distal abdominal aorta, right common iliac and right internal iliac arteries. The left common iliac artery was occluded at its origin due to chronic hypodense thrombus with reformation of distal left external iliac artery and distal left internal iliac artery. Bilateral carotid arterial spectral Doppler study was normal. Patient was positive for Hepatitis C infection. The echocardiogram showed rheumatic changes in mitral and aortic valves. There was global hypokinesia with poor left ventricular systolic function. Left ventricular ejection fraction was reduced to 35%. Left atrium and left ventricle were dilated. The patient had grade II mitral regurgitation and grade I aortic regurgitation. Other routine and biochemical investigations were unremarkable. OPEN IN VIEWER

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Figure 2.

CT angiography showing occlusion of right anterior and posterior tibial arteries, occlusion of the proximal left posterior tibial and peroneal arteries and mid part of right tibial artery. CT: computed tomography.

On detailed questioning, the patient hesitantly revealed that he was an intravenous drug user and vaguely mentioned “pethidine like” drugs but did not disclose any further details. On persistent probing, the patient was irritable and even scolded the doctor for asking unnecessary details, and for not being able to relieve the pain he was suffering. The patient was given an anti-tetanus prophylaxis and an injected analgesic to overcome the pain. The pain did not completely subside; however, it was partially relieved. An orthopaedician and vascular surgeon were called for consultation. The patient was apprised of the serious nature of his condition and advised below knee amputation. The patient requested discharge from ED stating “he would rather die with both legs than live with one”. Counselling was suggested which the patient refused and he left the hospital against medical advice.

Discussion

Substance abuse is not only a social stigma but a potential health hazard to the individual. Needle sharing among mainliners poses a risk of transmitting life-threatening viral infections ¹ as observed in our patient who tested positive for hepatitis C infection. Such viral infections not only pose a threat to their peer groups but also to caregivers and treating surgeons. Staphylococcus is the most common pathogen responsible for cardiac infections among injecting drug users. ² Ascending infection from the superficial leg veins to the heart gave rise to rheumatic heart disease in the reported case. The patient apparently chose a lower limb as the site for injecting the drug as the area of the body is usually concealed by socks. On developing phlebitis due to septic puncture of the superficial leg veins, the patient opted for the healthy arteries without knowing the impending risks.

The recreational use of intravenous drugs is associated with numerous complications. Apart from transmission of pathogens the morbidity may be from the effects of the drug itself or from localised injury to blood vessels, nerves and tendons.^3,4 The other feared complication is formation of thrombus which may dislodge and obstruct a distant site paving way for ischaemic necrosis.^5–7 It may also give rise to organ failure and end stage renal disease. ⁸

Despite his life-threatening condition, the patient refused to accept the proposed treatment in the reported case, raising concerns for the team of doctors. We regarded him as mentally competent to make this decision so we were not able to prevent him leaving against advice. Medical management or surgical interventions cannot be initiated without the consent of the patient even if these are lifesaving procedures, or a procedure meant to benefit the patient. A medical practitioner can be held liable for assault (criminal law), medical negligence (law of tort), damages (civil action) and even human rights issues may be raised if patient’s autonomy is not respected in this regard. In all such cases, psychiatric evaluation and psychotherapy of the patient becomes mandatory to ensure acceptance of treatment. In case matters turn out badly, informed refusal should be taken from such patients and near relatives be informed in accordance with the approved practices.