Do patients addicted to drugs truly have capacity?

Is it time to rethink how we determine the capacity of our patients who are addicted to drugs?  I recently began debating this question after I took care of a young woman with endocarditis.  She had a long history of IV drug abuse that had led to the development of endocarditis.  She had been admitted one week earlier and was being prepared for surgery, but she left against medical advice “to get a second opinion.”  Perhaps not surprisingly, she was now back and, per her, willing to undergo treatment.  I drew basic bloodwork, started antibiotics, and called the internal medicine team to request admission.  She went upstairs, and I felt pretty good about the job I had done.  I did not think about her until a week later when I saw she was in the emergency department waiting room again.  It turns out she had left against medical advice again after I had admitted her.  She was back again.  I did not care for her during the third visit, but I think I know how her story ultimately ended.

Does this story sound familiar to you?  I know my experience is not unique.  In fact, it’s sadly all too common.  We care for patients suffering from addictions every shift and are often the only care providers they can turn to.  Despite our best efforts, we are often forced to watch as these patients continually succumb to their addiction, sacrificing their bodies as collateral damage in the battle.

What frustrates me the most is that every time one of these patients leaves against medical advice, they are deemed to have the capacity to refuse medical treatment.  I suppose in the strictest legal sense they do.  They understand and can repeat back the risks of leaving without proper treatment.  They understand that forgoing this treatment can ultimately lead to their death.

Yet, I think it’s worth asking if these patients are truly making a rational decision. While they may verbalize the consequences of their choices, I question whether they truly have the capacity to understand them.  Drug addiction changes the brain chemically and structurally.  It creates cravings that are more debilitating than acute intoxication.  In fact, the word “addiction” comes from a Latin term that means “enslaved by.”  These patients may not be intoxicated when they see us, but that does not mean that the substances are not exerting their influences.  We would not let a patient who was intoxicated refuse medical care.  Why then do we allow patients whose choices are being driven by something they cannot control walk out of our hospitals?

Other countries have recognized that patients suffering from severe addiction lack the capacity to make informed decisions.  New Zealand passed the Substance Addiction (Compulsory Assessment and Treatment) Act of 2017.  This legislation allows for the involuntary hospitalization and treatment of patients who are considered to have a severe substance addiction.  While the main focus is on drug addiction treatment, the bill also allows for involuntary treatment of medical conditions.  The bill does note, however, that this option should be the last resort after other less coercive options have failed.

I am not sure if what New Zealand has done is feasible in the United States, but something has to be done.  These patients are one of the most vulnerable populations that we treat, and yet we are often forced to watch as their addiction drives them to ruin. We need to rethink whether these patients truly have the capacity or not because the hard truth is, right now, we are failing these patients.

Gregory Jasani is an emergency medicine resident. 

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