Brigham Clinical Ethics Case Review is published by the Brigham’s Office of Clinical Ethics. Each issue highlights a Brigham case that posed an ethical problem for a patient, family members and/or caregivers, leading to an ethics consultation and Brigham Ethics Committee discussion. Please note that because cases are based on actual ethics consultations, some details may have been altered to protect patient privacy and confidentiality.thinker

“Do We Have an Ethical Obligation to Continue Treating This Patient?”
Challenges of Caring for Patients Who Repeatedly Ingest Foreign Objects

The Case

The patient was a middle-aged woman with a complex psychiatric history notable for a severe personality disorder and repetitive foreign-body ingestion (RFBI). She presented to the Brigham’s Emergency Department (ED) after intentionally swallowing a sharp object for which she underwent an endoscopic removal (a minimally invasive procedure in which a telescopic device is introduced through the mouth to locate and extract foreign bodies from the gastrointestinal tract). As she was being wheeled out from the procedure room, the patient grabbed a nearby metal object and swallowed it, necessitating a second procedure right after the first one.

The gastroenterologist who had performed the endoscopy paged the Ethics Service, asking whether it would be ethically permissible to refuse to provide the repeat endoscopy. Given the likelihood that the patient would re-engage in this behavior, he wondered whether yet another intervention would be futile. He also worried about diverting ED resources away from other patients who might have equally or more pressing medical needs.

Discussion

Patients who engage in foreign-body ingestion as a method of self-harm present unique challenges. The behavior tends to be recurrent and resistant to psychiatric treatment. Care is complicated and resource-intensive, involving providers from a wide range of disciplines. As it is nearly impossible to prevent access to all ingestible objects, and as patients often know what to swallow to make their potential injury more dangerous, multiple ED presentations and hospital admissions are likely (Gitlin et al. 2007).

Many patients with RFBI suffer from a severe personality disorder, often associated with childhood abuse or deprivation. Characteristics associated with the disorder — affective instability, self-directed aggression, volatility and impulsivity, coupled with limited interpersonal skills and difficulty with care plan adherence — make this patient population among the most challenging to manage. It can feel like the patient is not only rejecting help but is actively trying to sabotage it. This can evoke frustration and anger in providers, resulting in feelings of wanting to blame, punish or withdraw from the patient (Lytle et al. 2013).

The repetitive nature of the self-injury can also instill a sense of futility. While removing a foreign object from the patient’s gastrointestinal tract may be medically beneficial in the short-term, is the long-term outcome so poor that it doesn’t make sense to provide treatment? (Lytle et al. 2013). It is not surprising that clinicians may question their duty to continue to treat in these circumstances.

While it can be frustrating and expensive to care for patients with RFBI, evidence shows that treatment does offer a meaningful chance of recovery. Through a combination of behavioral, cognitive and pharmacological approaches, the drive to self-harm and frequency of self-injury can be diminished (Gitlin et al. 2007). Generally, there is an ethical obligation to provide treatment if it will benefit the patient. “Bedside rationing,” whereby resources are redirected from those for whom care is perceived as futile to those who are more likely to benefit, is not ethically justifiable. As one article advises, “Care for patients who inflict self-harm, particularly by repetitive foreign body ingestion, is not futile. The patients have a right to treatment and are entitled to resources” (Lytle et al. 2013).

It is important to understand that the swallowing behavior is a manifestation of the underlying disorder and is not a voluntary choice; while these patients are aware of their actions, they are not able to control them. For many, a deep and abiding feeling of being uncared for drives the impulse to self-harm. The behavior “has the combined function of self-punishment and the punishment of others, as well as forcing others to provide care.” Ingestion occurs when mounting tension and feelings of emptiness become unbearable, with the act of self-injury bringing momentary relief (Gitlin et al. 2007).

Involving the psychiatric consultation service early on is recommended in these cases. One aspect of treatment entails helping patients develop a skill set to diminish the drive to self-harm. For instance, substituting other intense physical sensations, such as holding ice cubes, can be effective. When medical interventions are required, performing them in the ED and rapidly discharging the patient afterwards can help to avoid regressive behaviors associated with hospital admissions. Applying hand mitts post-procedure and alerting staff of the need to clear the room of ingestible objects can help to deter repeat swallowing behavior as well.

The ethics consultant in this case advised the gastroenterologist that, barring immediate safety concerns, there was a duty to treat the patient. The patient underwent a second procedure and the foreign object was removed. At a subsequent meeting with the patient’s primary clinical team, there was indepth discussion about how to keep the patient safe while providing needed care. The clinical team agreed to develop an acute care plan to address future ED presentations. This would include performing endoscopies in the ED and not admitting the patient to the hospital unless medically necessary.

Supporting Literature

Gitlin, D. et al. “Foreign-Body Ingestion in Patients with Personality Disorders.” Psychosomatics March-April 2007:48;2.
Lytle, S, Stagno, S, Daly, B. “Repetitive Foreign Body Ingestion: Ethical Considerations.” J Clin Ethics 2013:24(2);91-97.

 

We welcome your feedback about Brigham Clinical Ethics Case Review. Please email your questions and/or comments to BWHEthicsService@partners.org. The Ethics Service is available 24/7 by pager to all Brigham clinicians without a physician order, as well as any Brigham patient or family member. To learn more about ethics consults, visit the Office of Clinical Ethics website.