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Substance use disorders (SUDs) treated for serious medical conditions are more likely to leave the hospital against medical advice (AMA) than non-addictive patients. A special contract with health care providers could allow patients to agree to life-saving medical care in advance – even if they later decline treatment, according to a comment in the Journal of Addiction Medicine, the official journal of the American Society of Addiction Medicine (ASAM).
The Substance Use Advance Directive (SUAD) “has the potential to significantly improve the current status of treatment for life-threatening comorbid conditions in SUD patients by reducing AMA discharges,” writes Dr. Paul Tobias, JD, MBA, Ohio Health, Columbus.
In an accompanying comment, Kelly K. Dineen, JD, Ph.D., of Creighton University, Omaha, Neb., Cites “Obvious Practical and Ethical Challenges” to the SUAD concept, including the lack of a legal basis to overcome Patients If they later decide to decline treatment: “As long as a patient has the capacity, they almost always have the final say in whether or not they agree to care.”
“Ulysses Contracts” for Hospital Patients with SUDs: Approval for Advance Care
Dr. Tobias describes the case of “Jane”, a young woman with severe infections related to injecting drug use who was repeatedly hospitalized – but each time left the hospital without completing treatment. It is a well-known scenario that reflects the increased rate of AMA discharge in hospitalized patients with SUDs.
Patients always have the right to make decisions about medical treatments as long as they are not forced. The “irrational self-harming decisions” sometimes made by patients with SUDs[echo] The patterns that occur with compulsion, “says Dr. Tobias.” By recognizing SUD as an operating force beyond the patient’s control, the reason becomes clear: These patients cannot make free choices because their SUD forces them to make unreasonable decisions. “
He suggests SUADs as an option to deal with these difficult situations. SUADs are similar to the guidelines for psychiatric advancement for patients with psychiatric disorders such as schizophrenia, who know they may lose their decision-making ability in the future. These special instruments are sometimes referred to as “Ulysses contracts”. This refers to the story in the Odyssey where Ulysses orders the crew of his ship to tie him to the mast and instructs them not to release him even if he asks them to.
“Ulysses contracts could be applied to patients like Jane, letting patients seeking treatment for their life-threatening comorbid conditions decide whether and how their doctors can force them to complete therapy,” writes Dr. Tobias. Patients and healthcare providers could share a common decision-making approach to determining treatments for SUD and other conditions – including the conditions under which patients would like to stay in hospital without the option of an AMA discharge.
In her comment, Dr. Dineen’s key objection to SUADs is that, unlike Ulysses contracts, which are used on patients with psychiatric disorders, the proposed SUADs would be applied to those who still have decision-making skills. She also notes that hospital patients with addiction often receive inadequate or no treatment for SUD, including drugs for withdrawal symptoms – despite the documented improvement in outcomes – and that this inadequate care is often the cause of AMA discharges. Dr. Dineen also points to the long history of “moral, punitive, and discriminatory attitudes and policies” that lead to “segregated but unequal care systems” for people with SUDs who are at particular risk of being deprived of their autonomy.
Dr. Tobias recognizes the complexity of the SUAD approach. He stressed the need to evaluate government policies “to determine whether the use of SUADs would enable better outcomes with improved patient autonomy and clear responsibilities of doctors and nurses as patients’ treatment choices change”.
“For too long, patients with SUD have borne the burden of structural and institutional discrimination based on their illness,” concludes Dr. Dineen. “Focusing on correcting these is far more equitable than doing more individual harm under the guise of charity.”
Richard Saitz, MD, MPH, FACP, DFASAM, Editor-in-Chief of the Journal of Addiction Medicine, also has reservations about SUADs: “There are serious concerns about an approach that would override a patient’s decision if they are able to to do so if that patient (one with addiction) belongs to a class of patients who have been stigmatized, whose autonomy is often deprived, and whose addiction treatment is often of poor quality. ”
Established nursing principles for young adults with substance use disorders
Tobias, Paul. How advance guidelines help when patients refuse life-saving treatment because of their substance use. Journal of Addiction Medicine (2021) Courtesy of Wolters Kluwer Health
Quote: Advance consent to treatment to reduce hospital leaving against medical advice in addiction patients (2021, January 22) was granted on January 22, 2021 from https://medicalxpress.com/news/2021-01-consenting -treatment-advance-hospital retrieved -medical.html
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