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Brief Oral Papers

Integrative Medicine & Whole Person Health

Brief Oral Papers Session 14 - C-L Subspecialties

Severe Anorexia: A Case of Treatment Over Objection vs. the Right to Die

Friday, November 8, 2024
3:10 PM – 4:25 PM EST
Location: Merrick
Abstract:

Background:
Anorexia nervosa (AN) is characterized by harmful restrictive eating patterns in patients who are often ambivalent about potential life-threatening physical complications (Bloomberg, et al., 2023). Recent literature proposes criteria for terminal anorexia, which introduces ethical challenges in cases of patients refusing treatment (Gaudiani, et al., 2022). These criteria are controversial and evolving. We aim to contribute to this discussion by presenting a case of severe AN and treatment over objection.

Case:
A 24-year-old female presented to our hospital from home with hospice care for a recurrent small bowel obstruction. She was hospitalized 9 times in the last year for similar presentations. On admission, she had a body mass index of 13 and severe acute-on-chronic metabolic, hematologic, cardiac, and gastrointestinal abnormalities. Psychiatry was consulted to manage her AN and assess her capacity to refuse total parenteral nutrition (TPN). She declined this treatment and threatened to remove her central venous line, if placed. She verbalized her goal to decline life-sustaining treatment, discharge home, and die naturally from her illness. In addition to diagnosing her with extreme AN and major depressive disorder, we assessed that she did not demonstrate capacity to refuse TPN. Ethics was consulted to address the use of physical restraints to facilitate life-sustaining treatment. They also concluded that she lacked capacity, determined there was no active role for hospice or palliative care, and that she should be treated with TPN over her objection with the use of physical restraints.

Discussion:
These cases cause moral and ethical distress for teams managing acute complications of severe AN. Some authors propose criteria for when psychiatrists should consider AN a terminal illness and when end-of-life care is appropriate (Gaudiani et al., 2022). Two controversial criteria required to classify AN as a terminal illness are failure in prior eating disorder treatments and the patient’s capacity to choose death over living with AN. Experts argue that severe AN is a chronic illness that often requires multiple rounds of treatment before remission is achieved. Consequently, assessing capacity to refuse life-saving treatment is critical and challenging, as thought distortions are ego-syntonic and impair patients’ self-determination (Riddle, et al., 2022).

Conclusion:
We present this case of severe AN and treatment over objection to highlight the ongoing debate surrounding terminal AN. We compare assessments from our ethics board with Gaudiani’s criteria to emphasize the discrepancy of opinion on this evolving topic. As described, the proposed criteria fail to appreciate AN’s chronologic and psychological course. General consensus in the field is to provide compassion-focused treatment over objection, and this case demonstrates the need for continued discussion.