Changing direction in severe anorexia

An update from a regular series written by Mr Robert Wheeler, director, department of clinical law, where he considers various aspects of clinical law that our nursing and medical staff rely on when caring for patients.

We are accustomed to the situation where it may be better to prioritise the quality rather than the quantity of a patient’s remaining life. This shift in emphasis is made only in conjunction with the patient, or her family; but for the management of physical illness, this is rarely controversial.

The same cannot be said of mental illness. The state is bound by the Mental Health Act 1983 (MHA), which does not envisage palliation. For patients with anorexia nervosa, the English courts view that the interests of these patients as being best served by ensuring that their lives are sustained by insisting they are nourished. This law is explicitly and solely directed at treating disease of the mind rather than physical illness. But it has been interpreted over the last 20 years as regarding the need to nourish anorexic patients as ‘ancillary’ to the treatment of their mental illness; this physical need is duly provided for, compulsorily if necessary, via the MHA.

But since 2012, the approach of the courts is changing in the severest of cases. A 28 year old woman, W, who had suffered anorexia for 20 years, (having spent 10 of these as an inpatient, mainly in specialist eating disorder units) had a BMI of 12.6. During her final 30 month admission, her weight loss continued, despite intensive support. Her clinicians supported their patient’s request to be released into her family’s care. (i) The court accepted that W understood that her life was in danger, noting she was ‘not overly concerned’ by this prospect. Her history showed that she would only eat when she had deteriorated to the extent when she believed her death was imminent. But the court recognised that W’s hospitalisation was no longer therapeutic; it had become ‘a place for talking about eating;… not (a place) for eating’.

Ten months later, in front of a different judge, the case of Ms Z was considered. A 46 year old lady whose anorexia nervosa had been diagnosed at 15, Z lacked capacity to make decisions as to whether to undergo treatment for her anorexia; including whether to refuse or accept nasogastric feeding. The clinicians treating her had concluded that only three options existed. To continue detention with forced nasogastric feeding, which would be hampered by Z’s tendency to pull out the tube; she could control her swallowing to prevent its replacement. This first option risked death and injury, due to the severest osteoporosis, and ‘metabolic’ cardiac failure. Her BMI was 9.5. An alternative was to feed her under continuous sedation, risking cardio-respiratory arrest.

Finally, to discharge Z from the compulsion of the MHA 1983, and offer treatment only on a voluntary basis. The latter programme depended (only) on support and encouragement. The court noted that it was a pious hope that Z could effectively manage her illness if left to her own devices. The judge was acutely aware that all of the options, taken at their best, were palliative; the latter being the ‘least bad’.

In both cases, the courts allowed the patients to go home, released from compulsory feeding. In neither case could the court identify a better therapeutic option.

We have rarely seen courts acknowledge the impracticalities of compulsory treatment of patients with the most severe anorexia; let alone allow them to elect for the palliation of their choice.

The withdrawal of compulsory life preservation in the severest anorexic patients, when the burden of treatment outweighs the benefit they would accrue entails them facing a daunting future. But these patients have now been given the same opportunity for palliative care that is already afforded to countless others suffering from physical disease.

(i) Anorexia Betsi Cadwaladr YLHB v Miss W 2016 EWCOP 13 (see in court reports)

Robert Wheeler
Department of clinical law, March 2017