Dora is a patient in her thirties. She is an inpatient on a regular medical/surgical unit at the University hospital. Years ago, she was in a car accident and sustained a spinal-cord injury and she is now a paraplegic. As a result, Dora uses a wheelchair to get around. She is in the hospital for IV antibiotic treatment because of a blood infection the doctors suspect was caused by her opioid use. She began using after the car accident.
Her antibiotic treatment is delivered via a PICC line (peripherally inserted central catheter). Normally, a patient requiring this treatment could receive antibiotics at home. But Dora will not let community health nurses into her house, and due to her IV drug use it is uncertain or unlikely that she will be present at home when she needs to receive her antibiotics. The care team has determined that being an inpatient at the hospital will make it more likely she will receive her treatments. Her care providers want Dora to receive beneficent care since she is at risk of potentially fatal heart complications if the bacterial infection is not cleared from her blood. In other words, receiving antibiotics would be beneficial for her health even though she is not like a typical patient who could receive antibiotics at home.
The source of her infection appears to be a large pressure sore across Dora’s back. The sore has been untreated for a long time and now the bones of her pelvis are exposed when the sore is not appropriately dressed. With her wheelchair, Dora is fully mobile, yet she drips infected blood everywhere she goes throughout the hospital and outside. The nurses must attend to the sore multiple times a day. It weeps liquid through the bandages. Her exposed bones are so sharp that they can cut the nurses’ hands when they are cleaning and bandaging the wound. Dora is also hepatitis C positive with a high viral load, so caring for her poses a risk to her caregivers.
Plastic surgery and orthopedic surgery have been consulted about the possibility of doing surgery to close her wound. But her blood infection must be under control before they would even consider operating. Moreover, the wound might be too big to close with surgery.
Dora continues to use street-acquired opioids (apparently Dilaudid) while in the hospital. The attending physician has prescribed opioid medication as a way to manage the patient’s addiction symptoms and her pain. But the staff believes that her dealer visits her to provide her with additional drugs. Dora’s husband visits regularly and may also be supplying her with opioids. She disappears from the unit frequently and the staff suspects that she leaves the hospital to acquire drugs nearby. Because of this activity, the nurses and physicians do not know the level of her drug use and do not know the appropriate dosage to manage her symptoms.
Recently, the staff have found an unidentified powder that Dora left on her hospital room furniture. The staff fear that it is fentanyl. In spite of the obviousness of her drug use, Dora vehemently denies she is using. Needles have been found hidden in her bed sheets. The staff have given her a yellow “sharps” container to discard her needles, but she refuses to use it because she denies using drugs. The discarded and hidden used needles are a constant worry for the nurses and housekeeping staff.