Brigham Clinical Ethics Case Review is published by the Brigham’s Office of Clinical Ethics. Each issue highlights a Brigham case that posed an ethical problem for a patient, family members and/or caregivers, leading to an ethics consultation and Brigham Ethics Committee discussion. Please note that because cases are based on actual ethics consultations, some details may have been altered to protect patient privacy and confidentiality.thinker

“How Can We Discharge This Patient Home?”

Concerns About Home Discharge for a Patient with Injection Drug Use History

This issue of Brigham Clinical Ethics Case Review highlights a case in which the treatment team felt conflicted about discharging a patient with a history of injection drug use who needed ongoing intravenous antibiotic therapy.

The Case

The patient was a middle-aged man with a history of injection drug use who presented with endocarditis, a bacterial infection of the heart valves that is commonly associated with bloodstream infections acquired from injection drug use. The patient was admitted to Brigham and Women’s Hospital and began the first-line intervention for this condition — a prolonged course of antibiotics administered intravenously through a PICC line (peripherally inserted central catheter used to deliver medication directly to a central vein).

After a few weeks in the hospital, the patient was well enough to complete the therapy in a non-acute care setting. The hospital stay had been difficult for him and he wanted to go home. The team was apprehensive about discharging the patient with a PICC line in place. They worried he might be tempted to inject recreational drugs through the PICC portal and contract another infection or suffer a fatal overdose. The nurse director requested an ethics consultation to help address these concerns.

Discussion

Most patients who start a long course of IV antibiotics in the hospital can safely and effectively complete the therapy on an outpatient basis. This option has been considered less safe for people who inject drugs. The fear is they will use the easy access through the PICC portal to inject illicit substances and develop dangerous complications. The alternatives — keeping patients in the hospital or discharging them to a skilled nursing or rehabilitation facility — are also problematic. Not only does a prolonged stay in a health care facility take an emotional toll on patients and distance them from their support systems, but it may be more expensive, less clinically effective and risky for other reasons (D’Couto et al. 2018; Suzuki et al. 2018).

In weighing discharge options for patients who inject drugs and need IV therapy, clinicians may feel ethically torn, especially when the patient wants to go home. They respect the patient’s wishes and want to honor them; at the same time, they feel responsible for ensuring a safe treatment plan. Until recently, there was limited evidence-based information to guide clinicians in making these decisions. Frequently, patients were deemed unsuitable for home discharge based on presumed safety risks and remained hospitalized for the duration of their treatment course (D’Couto et al. 2018; Suzuki et al. 2018).

Two recent developments — the emergence of new research and the opening of the Brigham Health Bridge Clinic — are shifting attitudes about the appropriateness of home discharge for this patient population.

Recent research suggests that home IV therapy may be a safe discharge option for some patients with a history of injection drug use. For example, one study found that rates of therapy completion, mortality and catheter-related complications for this patient population are comparable to rates for those without injection-use history. Moreover, the rate of PICC line misuse is low, despite the widespread perception that it is likely in this scenario (Suzuki et al. 2018). Initiating addiction treatment during hospitalization and transitioning patients to ongoing treatment after discharge may improve outcomes even further (D’Couto et al. 2018; Suzuki et al. 2018).

Patients with a history of injection drug use should be carefully screened to determine whether they are good candidates for home IV therapy. Willingness to engage with addiction treatment is a primary consideration. Other factors to consider are secure housing, ideally with a sober support system, and agreement to infectious disease follow-up care (D’Couto et al. 2018).

With the opening of the Brigham Health Bridge Clinic last April, Brigham patients with a history of injection drug use have a greater likelihood of successfully completing IV therapy at home. The Bridge Clinic is a hospital-based facility that provides a low-barrier, rapid-access approach to substance use disorder treatment to support patients as they transition out of the acute care setting. A dedicated team of multidisciplinary experts in psychiatry, medicine, infectious disease and recovery coaching is available to work with the inpatient care team to assess whether the patient is appropriate for home discharge, and if so, to provide close follow-up care and support throughout the completion of IV therapy.

Data from the first nine months in operation show that care in the Brigham’s Bridge Clinic is improving post-discharge outcomes for patients with injection drug use. Over this time, 15 clinic patients completed intravenous antibiotic therapy at home, thereby avoiding 451 inpatient/rehabilitation days. No patients had complications with the PICC line and all 15 had successful resolution of the original infection. Two patients reported relapse of their illicit drug use; however, they did not use their PICC lines for injection and had resolution of their infections. Despite these promising results, more research is needed to establish protocols and clarify best practices.

In this case, after consulting with Bridge Clinic clinicians, the treatment team reached consensus that the patient was not an appropriate candidate for outpatient IV therapy due to instability in his housing situation and his unwillingness to engage in addiction treatment. The team recommended switching to oral antibiotics for the final weeks of therapy as the best treatment option in these circumstances. The PICC line was removed and the patient was discharged to the home of a relative.

Read more about the Brigham Health Bridge Clinic in Brigham Bulletin and On a Mission.

If you or someone you know would like to seek support for substance use disorder, please contact:

Addiction Recovery Program, an outpatient service in the Department of Psychiatry at Brigham and Women’s Faulkner Hospital that helps patients with substance use disorder, at 617-983-7060, option 2.

Brigham Health Bridge Clinic, an outpatient service in the Department of Psychiatry at the Brigham and Women’s Hospital main campus, at 617-278-0172.

Supporting Literature

D’Couto, H et al. “Outcomes According to Discharge Location for Persons Who Inject Drugs Receiving Outpatient Parenteral Antimicrobial Therapy.” Open Forum Infectious Diseases, Volume 5, Issue 5, 1 May 2018, ofy056, https://doi.org/10.1093/ofid/ofy056

Suzuki, J et al. “Outpatient Parenteral Antimicrobial Therapy Among People Who Inject Drugs: A Review of the Literature.” Open Forum Infectious Diseases, Volume 5, Issue 9, 1 September 2018, ofy194, https://doi.org/10.1093/ofid/ofy194

We welcome your feedback about Brigham Clinical Ethics Case Review. Please email your questions and/or comments to BWHEthicsService@partners.org. The Ethics Service is available 24/7 by pager to all Brigham clinicians without a physician order, as well as any Brigham patient or family member. To learn more about ethics consults, visit the Office of Clinical Ethics website.

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