Compulsory Treatment for Eating Disorders: Understand the Criteria and Safeguards

1. Eating disordersCompulsory Treatment? Dr Yvonne Edmonstone

2. Questions? • Are criteria for compulsory treatment met? • What constitutes medical treatment? • Nutrition by artificial means without consent v Forcible feeding? • Any special safeguards?

3. Ros • 24yr old single unemployed living parents • 11yr hist depression & anorexia nervosa • 7 yrs Rx Eating Disorder Service • 4 episodes BMI < 13 (lowest 10) • BMI currently 20

4. Criteria met? • Mental Disorder • Medical treatment available • Significant risk to health, safety or welfare . • Because of the mental disorder the patient's ability to make decisions about the provision of such medical treatment is significantly impaired; • Necessity

5. Mental Disorder?Mental Health Act Scotland 2003 Mental Disorder: Mental illness, personality disorder & learning disability however caused or manifested NOT sexual orientation, sexual deviancy, alarming or distressing behaviour, dependence on alcohol/drugs, acting as no prudent person would

6. Mental illness?ICD-10 ANOREXIA NERVOSA • Body weight 15% < expected or BMI <17.5 • Self induced weight loss - dietary restriction or other means • Body image distortion - “Fear of fatness” - Low weight threshold imposed • Widespread endocrine disorder - amenorrhoea, decreased libido / impotence •   Delayed puberty

7. Medical treatment for mental disorder Authorized under part 16 for patients subject to most orders: Including • Short term detention certificate • Compulsory treatment order and interim compulsory treatment order (authorized by tribunal under sect 64) Excluding • Nurses holding power & removal orders • Emergency Detention Certificate (urgent treatment only under sect 243)

8. Section 243: Urgent medical treatment • Is authorised by virtue of the act not withstanding that the patient does not give or is not capable of giving consent • Purpose being to • Save the patient’s life • Prevent serious deterioration • Alleviate serious suffering • Or prevent violent or dangerous behaviour • Not likely to entail unfavourable & irreversible physical & psychological consequences • Treatment does not entail significant physical hazard • RMO to give notice to MWC within 7 days of type & purpose of treatment. (non-statutory form T4)

9. 2.What constitutes Medical treatment? Mental Health Act Scotland 2003 Part 16 (Provisions & safeguards for medical treatment of mental disorder) Medical Treatment: Treatment for mental disorder or consequences including Pharmacological / Physical treatments Psychological interventions Nursing Care Habilitation & rehabilitation

10. Artificial Feeding Code of Practice 70 artificial means of feeding might include feeding through a nasogastric tube, an intra venous drip or directly into the stomach through gastrostomy. These methods by pass the patient’s need to swallow food. They all carry risks. Passing a naso-gastric tube can be particularly dangerous if the patient resists or struggles and force should not be used to insert a tube.

11. 3. Nutrition by artificial means without consent v Forcible feeding? (Code of Practice) 71 There is a difference between forcible feeding and these artificial means of feeding someone. Forcible feeding involves using direct force to make an individual swallow food. It may involve methods such as forcibly pushing food into the individual's mouth or forcibly holding his or her mouth open to receive food. Forcible feeding carries the risk of inhalation of food or asphyxiation and is not allowed under the Act and should never be used.

12. 4. SPECIAL SAFEGUARDS? (240: TREATMENTS GIVEN OVER A PERIOD OF TIME) (3)(c)Provision, without the consent of the patient and by artificial means, of nutrition to the patient May be given only in accordance with sect 238 (with consent) or 241(without consent – authorised by DMP)

13. Artificial Nutrition – with consent (sect 238) RMO or DMP must certify • Patient capable of consenting & gives written consent • Treatment authorised by act & • Having regard to the likelihood of its alleviating or preventing a deterioration in the patients condition it is in the patient’s best interests that the treatment should be given • Statutory form T2 must be used for certification • Copy of certificate to MWC within 7days

14. Artificial nutrition – without consent (Sect 241) DMP (not patient’s RMO) must certify • Patient not consenting or not capable of consenting to treatment • Treatment authorised under act • With regard to likelihood of its alleviating or preventing further deterioration in patient’s condition it is in the patient’s best interests that treatment should be given • Statutory form T3 for certification “Designated medical practitioner” Independent opinion from Mental Welfare Commission

15. IMPLICATIONS FOR TREATMENT OF EATING DISORDERS • Eating disorders, are, by definition mental illnesses. Mental Health Act can be applied to patients meeting necessary criteria (including significant impairment in their ability to make decisions about the provision of medical treatment because of the mental disorder) for detention, assessment & treatment • Medical treatments for mental disorder or in consequence of the patient having a mental disorder include “provision, without the consent of the patient and by artificial means, of nutrition to the patient”

16. IMPLICATIONS FOR TREATMENT OF EATING DISORDERS • Ability to give consent to treatment may be diminished by the disorder & compulsory refeeding can be authorised • CAN does not necessarily mean SHOULD! • Significant risk to health, safety or welfare • Necessity – least restrictive option

17. MENTAL HEALTH ACT COMMISSION Guidance Note “When assessing patient with AN, the ASW has the same responsibilities & duties as with any other person said to be suffering from a mental disorder. It recognises that compulsory measures for a person with a diagnosis of anorexia nervosa are not usually necessary. Therefore, when an assessment is requested it is usually in the extreme situation where the person’s health is seriously threatened by food refusal. Opportunities for seeking the least restrictive alternative may be limited by the need to treat the self-imposed starvation in order to ensure the proper care of the patient. However, by bringing own expertise and perspective into the situation, the ASW may be able to secure the voluntary co-operation of the patient with treatment , including normal methods of feeding.”

18. Advance Statement • Specifies the ways the person making it wishes to be treated or not for mental disorder in the event of them becoming mentally disordered and their ability to make decisions about treatment, being significantly impaired. • At the time of making it, the person has the capacity of properly intending the wishes specified in it. • Written & subscribed by the person making it. • Witnessed - Prescribed witness must certify in writing on the statement, that in the witness's opinion, the person making the statement has the capacity of properly intending the wishes specified in it.

19. CAPACITY • Task limited – ability to make decisions about provision of medical treatment Depends on ability to • Comprehend & retain treatment information • Believe in it • Weigh its risks & benefits in balance to arrive at a choice Anorexia nervosa affects capacity to make decisions about nutrition – but could capacity to make decisions about quality of life be retained and therefore refusal to accept life-prolonging treatment respected??

21. Further Reading • Mental Health Act Commission Guidance on the treatment of anorexia nervosa under the mental health act 1983 (issued 1997 – updated 1999) • Compulsory treatment for anorexia nervosa: Compassion or coercion? J tiller, U Schmidt & J Treasure BJPsych (1993) 162, 679 – 680 • Compulsory treatment in anorexia nervosa: Short- term benefits & long-term mortality R Ramsay, A Ward, J Treasure, J Russell, F M Gerald BJPsych (1999) Vol 175(8), 147 – 153 • Anorexia nervosa and respecting a refusal of Life-Prolonging therapy: A Limited Justification H Draper Bioethics 2000 Vol 14 120 - 133