“You Can’t Search Me”: A Story of Consent, Contraband, and Nursing Ethics in the Hospital

I've talked about IV drug use and endocarditis before, mainly about how these patients get a new heart valve and then very often end up ruining it by continued IV drug use after discharge. However, this one night was the first time I saw a patient manage to do drugs in the hospital and get away with it. And it all started with a policy change I'll never understand.

It used to be that patients with a history of IV drug use (IVDU) were mandated to have a one-to-one sitter with them at all times. The sitter would help deter attempts by the patient to smuggle in drugs and use them. We would also search visitors' and the patient's belongings for drugs or drug paraphernalia. It worked, until one day the hospital changed its policy. In our shift change huddle, we were told sitters are no longer required to be assigned to patients with IVDU in their history. Cameras could be installed, but patients now had the right to refuse the cameras as well. Additionally, we could no longer search visitors or patients unless there was clear reason to suspect they were smuggling something illegal in, and even then the patient or visitor could refuse. The policy change was announced under the guise of "fostering an environment of trust between caregivers and patients", but I'm pretty sure it was to reduce the demand for sitters. Regardless of the motivation, it happened.

From my last post on this topic, I mentioned how we've started limiting the number of times we're willing to give a patient a new heart valve for endocarditis related to IVDU. At some point, it becomes a huge amount of time, money, resources, and energy spent repeatedly on something that almost never lasts. It's extremely sad because, while IVDU starts with a choice, it ends with something biological that is almost impossible to cure. I'll be the first to admit it's very hard not to be frustrated and, frankly, judgmental of these patients. Without experiencing IVDU addiction personally, it's hard to really grasp how difficult it is to stop. The important part is remembering they are our patients that need help, just like the patients with diabetes or heart disease. We must care for them like we would for anyone else.

However, I have to draw the line at deceiving and lying to nurses and doctors while voluntarily under their care in the hospital in order to continue their drug use. It puts us in an ethically and legally murky situation, where we are caught between respecting patient privacy and keeping ourselves and our patients safe. One night, we got a new patient who was admitted for infective endocarditis due to active IVDU. He had a planned valve replacement the upcoming week. Per the new policy, he had no sitter but did have a camera in the room. He also had a visitor who came and went often, and we were not allowed to search her each time she went in. The first night he was there started out normal until the person monitoring him on the camera called. She reported to us that she saw the patient using some kind of torch lighter to melt something on his spoon, but could not see what he then did with it. As the primary nurse, Michelle, discussed this with charge, a nearby nurse jumped in.

"That's used for melting drugs for drug use. I've seen it before." This was, for multiple reasons, alarming and dangerous, particularly because oxygen supply to the room could be ignited by a flame and because this patient was already getting narcotic pain meds from us, which can be dangerous when mixed with his own drug use. Michelle told the patient about the seriousness of this and confiscated the lighter, and then asked if security could search him for other contraband. The visitor who came and went was also in the room nearby, both acting like they were clueless about all of it.

"Sure, I have nothing to hide. But you cannot search her," the patient said, gesturing to his visitor. Reconvening outside the room, Michelle, charge, and myself realized there was a decent chance the visitor had smuggled drugs in, and that's why he wasn't letting us search her. Other than suspicious behavior, we had no evidence of this, so security told us their hands were tied and they could not search her. Needless to say, they found nothing further on the patient.

Fast forward two uneventful days to day three, when things got a little wild. Michelle was still his primary nurse. She got a call from the person monitoring the patient through the camera.

"I just saw him crush something with a small cup and mix it in water and draw it up into a syringe. His arms then went under the blanket, so I did not see what he did after that." Horrified, Michelle ran into the room and found the small cup with traces of crushed powder on the rim. She again asked to search him, but this time he refused entirely and got angry. He started raising his voice and swearing, so we backed off. We called security and the administrative director on duty asking what we could do, as it was fairly obvious the patient was secretly doing drugs. We were told we could do nothing.

That man went on to get his new heart valve the following week, and I've struggled to wrap my mind around the whole situation. I know the addiction itself is a disease, but the deceiving us and putting himself and the people around him in danger while yelling at us and expecting us to continue with the surgery and narcotics floors me to this day. It would have been way less frustrating if he was honest about it when we caught him. I struggle internally with this story because I want to keep my prejudices in check, but I think it is also understandable to be frustrated by his actions and the fact he walked out of the hospital with a new heart valve and will definitely immediately damage it again so that he has to come back for another. The saddest part is that, by then, he will most likely be told no.

Moral of the story: Drug addiction starts with a choice but ends with chemical changes that are nearly impossible to battle. For that reason, it is still something we must pay attention to and treat as caregivers, but I believe there is nothing wrong with feeling frustrated about it. It's just a frustrating situation.

• Bella, RN

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