Patients with substance use disorders (SUDs) being treated for serious medical conditions are more likely to leave the hospital against medical advice (AMA) than those without addiction. A special type of contract with healthcare providers might enable patients to consent in advance to life-saving medical care—even if they later refuse treatment, according to a commentary 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 greatly improve the current state of treatment for life-threatening comorbid conditions in SUD patients through reducing AMA discharges,” writes Paul Tobias, MD, JD, MBA, of Ohio Health, Columbus.
But in an accompanying commentary, 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 any legal basis for overruling patients if they later decide to refuse treatment: “As long as a patient has capacity, they almost always have the final say in consenting to or refusing care.”
‘Ulysses contracts’ for hospitalized patients with SUDs: Consenting to care in advance
Dr. Tobias describes the case of “Jane,” a young woman with serious infections related to injection drug use, who was repeatedly hospitalized—but each time, left the hospital without completing treatment. It’s a familiar scenario, reflecting the increased rate of AMA discharge among hospitalized patients with SUDs.
Patients always have the right to make decisions about medical treatments, as long as they’re not being coerced. However, the “irrationally self-harming decisions” sometimes made by patients with SUDs “[echo] the patterns seen in cases of coercion,” according to Dr. Tobias. “By acknowledging SUD as an acting force that is beyond the control of the patient, the reason becomes clear: these patients cannot exercise free choice because their SUD coerces them to make unreasonable decisions.”
He proposes SUADs as an option to manage these difficult situations. SUADs are similar to psychiatric advance directives used in patients with psychiatric disorders such as schizophrenia, who know they might lose their decision-making capacity in the future. These specialized instruments are sometimes called “Ulysses contracts”—referring to the story in the Odyssey where Ulysses orders his ship’s crew to tie to him to the mast, instructing them not to release him even if he begs them to.
“Ulysses contracts could be applied to patients like Jane by allowing patients who seek treatment of their life-threatening comorbid conditions to choose if and how their physicians can compel them to complete therapy,” Dr. Tobias writes. Patients and healthcare providers could follow a shared decision-making approach to determining treatments for SUD and other medical conditions—including the conditions under which patients want to be kept in the hospital without the option of AMA discharge.
In her commentary, Dr. Dineen’s key objection to SUADs is that unlike Ulysses contracts used in patients with psychiatric disorders, the proposed SUADs would be applied to people who still have decision-making capacity. She also notes that hospitalized patients with addiction often receive inadequate or no treatment for SUD, including medications 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 out the long history of “moralistic, punitive, and discriminatory attitudes and policies,” leading to “separate but unequal systems of care” for people with SUDs who are at particular risk for having their autonomy removed.
Dr. Tobias acknowledges the complexities of the SUAD approach. He emphasizes the need for evaluation of state policies “to determine whether the use of SUADs would enable better outcomes with improved patient autonomy and clear physician and nurse responsibilities when patient treatment decisions change.”
“Patients with SUD have too long carried the burden of structural and institutional discrimination on the basis of their disease,” Dr. Dineen concludes. “Focusing on correcting those is far more just than inflicting more individual harm under the cloak of beneficence.”
Richard Saitz MD, MPH, FACP, DFASAM, Editor-in-Chief, Journal of Addiction Medicine, also voices reservations about SUADs: “There are serious concerns with an approach that would override a patient’s decision when they have capacity to make it, particularly when that patient (one with addiction) belongs to a class of patients who have been stigmatized, whose autonomy is often taken away, and whose treatment for addiction is often of poor quality.”