Julie Aultman

By Julie M. Aultman, Emanuela Peshel, Cyril Harfouche and Michael S. Firstenberg

The treatment of patients with intravenous drug use (IVDU) has evolved to include a wide range of medications, psychiatric rehabilitation, and surgical interventions, especially for life-threatening complications such as infective endocarditis (IE). These interventions remain at the discretion of physicians, particularly surgeons, whose treatment decisions are influenced by several medical factors, unfortunately not without bias. The stigma associated with substance use disorder is prevalent, which leads to significant biases, even in the healthcare system. This bias is heightened when IVDU patients require repeat valve replacement surgeries for IE due to continued drug use. Patients who receive a valve replacement and continue to use illicit drugs intravenously often return to their medical providers, months to a few years later, with a reinfection of their bioprosthetic valve; such patients require additional surgeries which are at the center of many ethical discussions due to high mortality rates, for many complex medical and social reasons, associated with continuous chemical dependency after surgical interventions. This chapter examines the ethics of repeat heart valve replacement surgery for patients who are struggling with addiction. Considerations of justice, the fiduciary therapeutic relationship, and guiding ethical principles justify medically beneficial repeat heart valve replacement surgeries for IVDU patient populations.

Part of the book: Advanced Concepts in Endocarditis

By Julie Aultman and Michael S. Firstenberg

Extracorporeal membrane oxygenation (ECMO) is an established therapy for the management of acute cardiopulmonary failure. A substantial concern when considering ECMO therapy is whether the patient will recover enough function to be weaned from support and survive to discharge. The concept of “a bridge to nowhere” is where a patient is supported on a therapy for which there is no hope for recovery and would, by definition, immediately die if support is discontinued—a somewhat unique concept in clinical medicine, but often considered when considering short-term mechanical support for acute heart and/or lung failure. Much like initiating mechanical ventilator support in patients who have no chance of meaningful recovery, there are concerns about embarking on or continuing with ECMO support in patients in whom recovery is unlikely. The purpose of this chapter is to review the ethical foundation and principles to support the clinical decision-making process when there are concerns regarding the initiation, continuation, or withdrawal of this highly invasive, resource-intensive life-support technology. Specific attention will be given to well-established principles of the ethical application of advanced life support and how to appropriately limit offering or continuing therapies for which meaningful outcomes are unlikely or further support is considered futile.

Part of the book: Advances in Extracorporeal Membrane Oxygenation