Clinical Case - Alcohol Dependence and Liver Failure

RR is a 47 year old gentleman with a long history of alcohol dependence. He comes from a family with a strong history of alcoholism and has completed 4 inpatient and 2 outpatient treatment programs over the years, the last being 9 years ago. His longest period of sobriety, by his report, was 2 years. Both he and his wife indicate that this occurred after his last 21 day chemical dependence program. Seven years ago he chose not to renew the chemical dependence section of his otherwise robust insurance policy.

Despite a long history of alcohol dependence, RR maintained a steady position as an architectural design assistant, got along well at his job, and participated in a number of clubs and organizations. His wife, who gave up trying to change his drinking habits, has remained faithful to him because "He really is a nice person when he's not fall-down drunk." and "He has been pretty reliable about supporting me and the kids."

For the past six months, RR developed a progressive increase in his abdominal girth and his "color" become worse. He was not been able to function as well at work because of increasing fatigue, weakness, and swelling in his extremities. He also noted increased ease of bruising. Last week, his boss encouraged him to see his physician and refused to allow him to work until his health problems were sorted out. His boss has been aware of RR's drinking problem for some time but did not fire him because of the contributions that he made to the company.

For many years, RR was told by his primary care physician that his liver was being damaged by his drinking. He was repeatedly encouraged to stop. Despite this fact, RR continued to drink and liver function continued to deteriorate. No one considered committing him to a chemical dependence treatment facility because of his long history and relatively short periods of sobriety. Furthermore, the patient's insurance did not cover treatment for alcohol dependence.

At the insistence of his wife, RR saw his primary care physician. The visit confirmed that RR's liver failure had progressed to the stage that unless he received a transplant he was likely to die. RR was referred to the liver transplant program at the local academic hospital. They concurred with the general practitioner's assessment but refused to place RR on the list of transplant candidates until he received chemical dependence treatment and had been sober for 6 months.

The local private chemical dependence program refused to accept RR into their program because his insurance did not include benefits for chemical dependence treatment. The waiting period for the public chemical dependence program was 3 months. The patient refused to pay cash for private treatment because his financial resources were very limited and he did not want to burden his family with the cost, particularly since there is a good chance that he would die anyway. Now that he was not working, his drinking increased.

How you would assist the patient and the patient's family as they work through decisions about how to address RR's problems? Should the patient be committed? Should transplant packages include chemical dependence treatment for those with liver failure secondary to alcohol dependence? Have any programs had success in achieving this? What other issues are important in this patient's care?

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