Recurrent Intentionnaly Foreign Body Ingestion in Psychiatric Disorderd Patients: An Ethical Issue

Ingestion of foreign bodies occurs either unconsciously in normal people or intentionally in patient with mental health problems. While these episodes are usually self-limited in time, we here report the case of a 24-year-old female suffering from moderate intellectual disability, as well as borderline personality disorder who repeatedly ingested foreign bodies of very dissimilar nature. Because the number of intentionally ingested foreign bodies was so numerous over time and created a huge burden on the medical staff, the multidisciplinary team in charge of the patient decided to end endoscopic removal after a large panel discussion including Ethicians and Forensic doctors. This patient had been abandoned by her biological mother in the first months of life and has been placed in a foster home ever since. Her school career has been marked by psychomotor, behavioral and language disorders, requiring education in specialized institutes. She was subsequently hospitalized on numerous occasions in psychiatric wards due to hetero as well as auto aggressive behavior and suicide attempts.

Her self-aggressive behavior included repeated Deliberate Foreign Body Ingestion (DFBI), for which she underwent numerous endoscopic procedures. A census shows over 130 thoracic and abdominal X-rays to locate ingested foreign bodies over a period three years, as well as 21 upper digestive endoscopies achieved under general anesthetic with orotracheal intubation. The foreign bodies were mainly coins, often located in the esophagus, spoons and lighters (Figure 1 & 2). She has also been treated in the operating room on ten occasions by other medical departments (gynecology, ENT surgery, orthopedics). In addition to foreign body ingestion, there were numerous medical consultations for minor self-mutilation.

Figure 1:Foreign bodies seen during an upper endoscopy in the duodenum (left panel, spoons) and the esophagus (right side, coin). Images from the service of gastroenterology, University Hospital of Geneva, Switzerland.

Figure 2:Foreign bodies seen on abdominal (left panel) and chest (right panel) X-ray. Images from the service of radiology, University Hospital of Geneva, Switzerland.

Because of her psychiatric comorbidities, the patient usually lived at home surrounded by an educational team. Despite all the precautions taken, she ran away many times from home, consuming toxic substances. The patient’s psychiatric team describes a poor adhesion to conventional and pharmacological therapies, and they eventually had to implement coercive measures to protect the patient from herself. Because lack of compliance with medication was associated with increased risk to recurrent inappropriate ingestions, she was being restrained chemically and physically against her consent in psychiatric services. During this period of coerced therapy, there was a marked decrease in foreign body ingestion and endoscopic procedures. This critical condition prompted the medical referents to ask for further assessment by the local clinical Ethics council in order to define the best appropriate care. Surprisingly, the Ethics conclusions emphasized the need for the patient to recover her full autonomy and advised respecting the principle of benevolence, while simultaneously accepting that selfmutilation or recurrent foreign body ingestion that could eventually lead to fatality.

While the patient recovered full autonomy based on the Ethics decisions, endoscopic procedures were subsequently becoming more and more frequent, sometimes taking place less than 24 hours apart. These numerous hospital admissions brought a heavy psychological burden as well as tiredness to the team which completely confused them. The main idea was that doing repeated endoscopies which are accompanied with substantial perioperative complications did not make any more sense. After many discussions, it was agreed by all concerned members of the multidisciplinary staff to not intervene endoscopically anymore if a new episode of foreign body ingestion occurred, applying the principle of benevolence and respect to self-autonomy. While this decision took months to be delivered by the Ethic committee, it nevertheless led to misunderstandings with various medical departments, particularly the Emergency Department. Finally, the patient was found dead shortly after this decision. However, the cause of death was not related to the ingestion of a foreign body.

Foreign bodies ingestion and impaction in the gastrointestinal tract is a common phenomenon [1]. Hopefully, the vast majority of these items will pass spontaneously throughout the digestive tract while 10% or so will finally require specific interventions. Successful removal rate of foreign bodies by endoscopy is high and the recourse to surgery is less than 1% [2]. This medical condition illustrates the difficulty of management of such patients when decisions are based on dissimilar medical and ethical considerations [3]. Medication in psychotic disorders are considered the cornerstone of therapy and lack of compliance with medical treatments is known to induce frequent relapses, some of them resulting eventually in fatalities [4]. Increased risk of the psychotic patient to themselves or other individuals indeed have fortunately provided the legal grounds for detaining psychiatric patients against their will when their full autonomy is over-ridden [5]. Although the use of chemical coercive drug therapy seems apparently less detrimental than strain coercion by force, all these measures should be discussed on a case-to-case basis and implemented only after a multidisciplinary discussion. In this case, a de-escalation strategy was used instead avoiding further coercion. The medical staff explored the risk assessments and examined alternatives to medical coercive measures. Neutral assessment by clinical Ethics committees might help to give new meaning to the management of clinical conditions for which patient care is not unanimous and subject of ample debate [6].

The authors declare no conflict of interest.

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