Dilemma that warrants an adult discussion. While I realize this has been a difficult subject to debate without degenerating into heated argument, I am optimistic that will not be the course this thread takes.
I have an example that I feel nicely illustrates a lot of the challenges we face regarding healthcare delivery in the United States. People go to the hospital and are waiting for care in the Emergency Room for hours, overnight even, sorry no beds available. Hospital care is very expensive. People look at their bill and it is eleven bucks for an aspirin, bandaid, or whatever crazy example you care to cite. Bear in mind when considering this, what is billed is not what insurance companies allow, and allowed charges are usually not paid at 100% If you have suggestions for the insurance companies or healthcare providers screwing people out of money, please take them to another thread.
I have been involved in the care of a guy who happens to be about the same age as I, on paper anyway; IRL this is not the case. He is a homeless diabetic crystal meth aficionado. Had a hole that went all the way through his foot that was filled with rotting tissue. Came in septic, where you are over whelmed by infection to the point you are fixin' to die. His situation is complicated by the HIV and Hepatitis C infections he has. Not only that, but he also is being treated for colorectal cancer. Had surgery, done by the local bad ass MFer oncology surgeon. Consequence of this is a colostomy, which is the side exit for the poop, radiation and chemo ongoing, the whole nine yards.
As I said, he has a fetid hole in his foot when I meet him. Initially refused surgery when I talk to him Monday at 0800. I let the doc managing the patient know he said GTFO to me. He gets the ortho hospitalist to go see him, patient told them okay do surgery tomorrow. Tuesday morning he tells the other guy to F** OFF, so they call me to see if I will try and talk some sense into him. I go by and he is all ready to go get this foot fixed, I want to do whatever it takes, don't want to lose this foot. I tell him he needs to do like I say, or the next guy he sees will be cutting off his leg. Clean the rotten stuff out, flush a ton of irrigation through it, put a wound vac on it, and it does surprisingly well post operatively, considering how poorly he followed instructions. He walks down stairs to smoke cigarettes a bit more often than is therapeutic. 
The wound vac did not work out, kept losing the seal when he walked on it. I was apparently unclear when I said, "Pretend like that foot is gone, don't even touch it to the ground, or you won't have to pretend, you lose the leg." Still did pretty well, all things considered, even without the wound vac, which would have healed that thing up far, far more quickly. Typically, the patient goes to a convalescent facility shortly after this sort of surgery, much more economical than a hospital. Nobody will take him though. Any facility that might, knows better because this guy has a habit of walking away from care facilities, or being verbally and physically abusive to the people trying to help him. Due to his diseases, he is in an isolation room. Due to his temperament, he is in a hospital, rather than a convalescent home. A week after surgery, the police came to talk to him, because after he declined assistance changing his colostomy bag(B*tch leave me alone). He was not successful in his efforts to change his colostomy bag, so he shat the bed. Nurse's aid comes in to change the bedding. "I need you to move so I can put clean sheets on your bed." He goes off on her. She could ask him to move, instead of telling him what to do, GTFO B*TCH, leave me alone. He is literally laying in is own feces, that are infectious with HIV and Hep C virus, over and above the basic nastiness of cleaning up crap, and she needs to put clean sheets on the bed for him. He tells her GTFO, I have a gun in that drawer, leave me alone. So she leaves and calls security. Security calls the cops. I get there between the time the cops were called and they arrive. He has his feces on my dressing. I am not okay with that, so I am in the midst of changing the dressing when the security guy comes back from calling the cops, I am just getting started. Security guy is a large young man, and stands in the doorway watching while I am doing my thing, which I found a little unusual. I was not hip to the fact he claimed he had a gun, which I would not believe for a second if he made the claim. If that guy had the dough for a gun, he is going to be a high MFer 10 times out of 10 before he purchases a fire arm, say if he found a gold Krugerrand in his Christmas stocking, he buys a bunch of dope. Patient was griping before we started about how much his foot that is so numb he can walk on a hole in the bottom the size of a silver dollar and not bat an eye, is going to hurt when we change his dressing. I did not tell him the nurse had morphine she is about to give him, more so he is less unpleasant after I leave, than for any pain he is going to claim to feel. I am starting to wrap things up when John Law arrives. He asks the guy why he is threatening people trying to help him. Guy denies it, she did not hear what I said, there is gum in the drawer. I say, "You threatened her with a stick of gum, really?" He does not need any assistance, holds his hand out like a traffic cop would and gives me the please don't try to help me look. Guy claims has not been abusive or threatening, which is a lie, because he does not want to get handcuffed to the bed. It probably would not occur to you that you might get handcuffed to a hospital bed, unless that sort of thing has happened to you in the past. Cop asks if he has any warrants, he says no, I have not been arrested in 35 years, which I am confident is also a lie. Cop tells him he does not want to have to come back here again, talks to the guy a bit, then takes off. 5 minutes later, cop returns, to stress that he does not want to hear any more abuse complaints, or he will make life rough when he gets out of the hospital. Patient asks if he really walked all the way back up just to tell him that. Yes, it is that important, so I came back. These people are trying to help you, don't give them a hard time, or I will give you a hard time when you get out of here.
Day after the stick of gum incident, he tells his nurse he is going to leave in two days, and will then return, rather than stay in the hospital and get IV antibiotics. Few days later, he is gone.
Police bring him back a few days after he left. Report read disheveled, incoherent man stumbling around leaking something from his side. A cop sees that and is thinking, "That guy got shot." Turns out it was not a GSW or blood, fecal material, remember the colostomy thing. Foot got a lot worse while he was off smoking crystal meth, bone sort of disintegrates with infection, radiographs are quite impressive compared to the prior to going walkabout views. He currently has osteomyelitis(bone infection) in his first and second metatarsal heads. To get it to heal, and stay healed, would need to take off his forefoot, right behind where the toes attach to the foot. He declines, if it was only the toe, okay, but he does not want half his foot cut off. I read him what the infectious disease specialist had to say, which is pretty much what I have been telling him. He has spent about 42 or 43 of the last 50 days admitted to the hospital. He is going to be in a hospital isolation room for the foreseeable future. He has left AMA(against medical advice) from an acute care facility at least 4 times in the last couple months. His care for the last few months has cost literally millions of dollars. He is not going to "get better" as long as he keeps bailing in the middle of treatment. Taking care of this guy is like Sisyphus pushing a rock up a hill.
I suggested we have him arrested for assaulting the staff, which would apply when he is flinging his infectious poo. If he is incarcerated, he can't very well leave AMA. I was told this would not fly.
This guy is not unique, and this sort of thing takes up inpatient beds from people that would almost certainly benefit more than this guy, who technically does not need to be admitted to the hospital, but no other facility will accept the patient as a transfer, so he stays in an isolation room in the hospital. I am not that interested in operating on this guy, but would because it is the best shot to salvage the leg. If he loses the leg, odds are he spends the rest of his days in some sort of facility, a hospital, given past experience. That would be pretty messed up, and very expensive.
What do you do with a patient like this? His past and current actions have had a significant negative impact on his health. Should this color the decisions made on his care? Should you you take his abusive and assaultive behavior into consideration? Do you continue to do everything possible to try and help them, despite their self destructiveness and non-compliance? Should you somehow try to compel their compliance, cuff them to the bed and refuse to let them walk around, smoke cigarettes? Should their care be somehow reduced or restricted? Resources are not limitless. This guy's pharmacy bill alone is sky high, Daptomycin ain't cheap. I don't know what anti-retrovirals cost for HIV, or the going rate for chemotherapy for the cancer is, but they are pricey, no doubt.
I don't know that an answer is even possible. I am talking about one guy, but it is not one guy, it is maybe thousands of guys and gals.
Sorry this post is like War and Peace long, but it has been on my mind.
