(PO-014) (PO-014) Ethical Dilemmas in Patients with Intentional Foreign Body Ingestion: Is There a Role For Standardized Policies?

Background:
Patients who present with recurrent, intentional foreign body ingestions (FBI) often require repeat endoscopic and surgical interventions that necessitate the use of substantial medical resources via multidisciplinary management and prolonged hospitalizations¹. These behaviors can often be divided into four categories: malingering, psychosis, pica, and personality disorder. Regardless of the behavioral etiology, these patients can be behaviorally challenging for staff². This may result in a conscious or unconscious bias towards what accommodations, safety precautions, or even treatments are made available to these patients. Staff at an academic hospital have suggested developing blanket protocols for all FBI patients that enter the Correctional Care Medical Facility (CCMF; a specialized medical unit dedicated to the needs of corrections patients). We will examine the case of a patient with intentional FBI and focus on the ethical implications of instituting a standardized protocol meant to address patient safety, but which may be influenced by unconscious bias.

Case:
RD is a 30-year-old man with a history of Borderline Personality Disorder, Post-Traumatic Stress Disorder, polysubstance dependence, and multiple past admissions for FBI who presented to the CCMF after having ingested a pulse oximeter probe and cord while in jail. He had an urgent esophagogastroduodenoscopy (EGD) done with successful retrieval of the probe and cord. Our team determined he was not at imminent risk of suicide, did not need a 1:1 sitter for suicide precautions and he returned to jail. After the patient’s third visit to the hospital in three days, requiring two EGDs, psychiatry was approached by CCMF staff about developing a standard protocol for FBI admissions regarding environmental restrictions, 1:1 sitter protocols, and treatment restrictions (access to IVs/tubing, whether EGD should not be offered if there’s suspicion that there was no ingestion).

Discussion:
From the ethical perspective of justice, FBI patients present unique challenges in balancing autonomy vs. medical beneficence. Furthermore, there is a lack of literature addressing clinical decision-making within the bounds of these ethical dilemmas. Here we discuss this delicate balance of restricting means to self-harm vs. impinging on patient autonomy and extend this discussion to the role standardized treatment interventions might play in lightening this ethical burden.

Conclusion:
Through an ethical lens, we believe standard protocols should not be universally made for all FBI patients. This poster intends to provoke discussion regarding well-intentioned standardized interventions aimed to respect beneficence that may infringe on a patient’s autonomy.

References:

1. Atluri, D., Veluru, C., Chopra, A., & Mullen, K. D. (2012). Recurrent Intentional Foreign Body Ingestion: An Endoscopist’s Dilemma. Gastroenterology & Hepatology, 8(7), 482–484.

2. Gitlin, D. F., Caplan, J. P., Rogers, M. P., Avni-Barron, O., Braun, I., & Barsky, A. J. (2007). Foreign-Body Ingestion in Patients With Personality Disorders. Psychosomatics, 48(2), 162–166.