Is it acceptable to discharge a heroin user with an intravenous line to complete his antibiotic therapy for cellulitis at home under a nurse's supervision? Yes: supervised home care ensures continued treatment at lower cost.

Abstract

We expect physicians to treat patients without doing harm, and we want them to do so at low cost. Therefore, sending this patient home sounds practical. But what about his heroin use? Is the physician condoning the patient's drug addiction by providing an easy means of heroin injection? Four issues need to be addressed. First, the patient needs treatment. Second, to keep costs to a minimum, home nursing is a reasonable option. Third, the patient's addiction may be stigmatizing, and some physicians might behave in a discriminatory way toward him. Finally, the patient's wishes and values need to be considered. The physician cannot deny the patient intravenous antibiotics for a condition that might lead to severe complications or death if left untreated. The physician has a duty of care toward this patient. Treatment with antibiotics prevents complications and the emergence and growth of resistant bacteria, which is of great public health value. Keeping him in hospital costs hundreds, and possibly thousands, of dollars of taxpayers' money that could be spent in other ways. Patients who have a heart transplant are sent home as soon as they are stabilized, and most rehabilitation after acute illness or injury is done at home with the help of a group of community health care workers. Why should a simple infection that can be treated easily with minimal help from a home nurse require inpatient treatment? The patient's physician might want to keep him in the hospital because of the patient's addiction. A patient with cellulitis who does not use heroin would most likely be discharged to finish the antibiotic course. Are we really naive enough to think that we are going to stop heroin use by keeping the patient in the hospital a little bit longer? He is a competent adult, and until he is ready to stop using heroin and to try abstention, treating him as an untrust-worthy second-class citizen is unjust. Perhaps by keeping him in the hospital, the physician is deliberately making a point of frowning on the patient's addiction. However, disapproval of his behavior is not grounds for discrimination. Finally, if the options are explained to this patient, perhaps his wishes could be taken into account. Physicians have this sort of conversation with their patients every day, so why should they treat drug users any differently? It is possible, for example, that the patient's living conditions will not allow for even basic personal hygiene. In this case, perhaps he should be sent to a nursing facility, where he could receive the medical care he needs at a lower cost than staying in the hospital. Talking with the patient and coming up with the best treatment plan is a reasonable option.