Repeat Valve Surgery in Recurrent Drug Use Associated Infective Endocarditis: A Qualitative Study of Provider Attitudes and Approaches and a Normative Analysis of Relevant Bioethical Concepts

Abstract

Background: Despite growing awareness of the infectious complications of opioid use disorder there is little consensus on how to best treat injection drug use associated infective endocarditis (IDU-IE), particularly when patients present with recurrent infections that may require multiple valve surgeries. This is the first study to empirically examine differing attitudes and approaches towards this clinical and bioethical dilemma. Objective: To explore the diversity of attitudes and approaches towards treating patients with recurrent IDU-IE with a focus on surgical decision-making. Design: Qualitative approach with semi-structured interviews with healthcare providers at a single academic medical center. Approach: We used an inductive, grounded theory approach to analyze interview data. Participants: We selected a sample of 19 healthcare providers with experience caring for patients with IDU-IE across a variety of disciplines and departments. Key Results: Three themes emerged from the interviews: 1) caring for patients with IDU-IE is especially challenging, 2) implicit and explicit bias remain pervasive, and 3) criteria for surgical decision-making are not transparent. When discussing surgical decision-making, participants relied on two predominant bioethical concepts: 1) futility and 2) rationing and the efficient use of resources. Conclusions: There was a wide divergence of opinions on how to approach repeat valve surgeries, ranging from those who endorsed strict single surgery policies to those who felt patients should be offered as many surgeries as needed. Creating general principles for the care of recurrent IDU-IE may help provide more reliable, equitable and predictable care to these patients. The creation of reasonable guidelines requires input from an interdisciplinary group and should address not only empirical data but also the appropriateness of futility and rationing of care questions. Further normative analysis reveals that futility is unlikely to be a philosophically rigorous concept in these discussions and more thought must be given to how to discuss rationing with physicians and the public and how to apply its principles in these cases.