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Should People with Anorexia Be Force-Fed?

Doctors and judges walk a fine ethical line when deciding if people with eating disorders should be treated against their wishes.

Last month, a New Jersey judge granted guardianship to the parents of a 20-year-old woman with anorexia nervosa, arguing that the woman is incapable of making her own medical decisions.

This clears the way for the parents to take charge of treatment decisions for their daughter — known in court documents as S.A. — including the option of force-feeding.

This follows on the heels of the death of a 30-year-old New Jersey woman known as Ashley G., who also had severe anorexia and restricted her food intake.

Superior Court Judge Paul Armstrong — the same judge as in S.A.’s case — honored Ashley’s wishes to stop artificial force-feeding.

The judge met with the woman and determined that she seemed to understand the consequences of refusing treatment.

These cases highlight the ethical fine line that doctors and judges must walk in deciding whether someone with anorexia should be treated against their wishes.

But they also show the lengths to which parents will go to save their son or daughter from a much misunderstood disease that has the highest mortality rate of all mental health disorders.

Many treatment options

Cases that involve force-feeding of people with anorexia through a nasal or stomach tube often get the most news attention.

This type of treatment, though, falls at one extreme of a spectrum, from persuasion by family members or healthcare professionals to involuntary, legal action.

Healthcare professionals can use several other coercive treatment strategies to restore a person’s nutrition and help them learn how to eat regular meals again.

Hospitalization itself can be the first step in involuntary treatment.

In some cases — as with S.A. — guardianship, or conservatorship, is required.

Once admitted to a hospital, patients may be fed additional snacks, liquid meal replacements, or servings at meals to increase caloric intake.

They may also be confined to bed or restricted from physical activity to limit the burning of calories. They may even be barred from walking farther than across the room.

Their meals are often supervised to ensure that all food is eaten and not hidden in a pocket or bedsheets.

And hospital staff may monitor a patient’s bathroom use to prevent purging after meals.

Parents who attempt family-based treatment at home use many of the same techniques, other than the feeding tubes.

Trying to do this at home, though, is time-intensive and can be stressful for parents.

Someone has to sit with the child for all meals — breakfast, snack, lunch, snack, dinner, snack — every day for months or years.

And the disease can make people with anorexia act in ways they normally wouldn’t.

“I’ve known moms whose child threw the food at them, threw it on the floor, refused to eat… stories you would not believe,” said Debra Schlesinger, who founded the Facebook group Mothers Against Eating Disorders after her daughter Nicole died from anorexia at age 27.

Ability to make medical decisions

Whatever the approach, involuntary treatment — for any condition — isn’t something that doctors and judges take lightly.

“In our country, we value individual freedom. Psychotherapy is most often a voluntary activity unless a person is court-mandated after breaking a law,” Kristine Luce, PhD, co-director of the Stanford Adult Eating and Weight Disorders Clinic in California, told Healthline.

This is also true for medical treatments.

If you don’t want a potentially life-saving cancer treatment, it’s your right to decline.

And if you have a substance use disorder, no one will make you go to rehab — unless you’re caught breaking the law.

So what does it take for someone to be forced to undergo medical treatment against their wishes?

“You might consider involuntary treatment when a patient’s capacity to consent to treatment is impaired by their illness — a common problem in anorexia nervosa — and the disorder is life-threatening,” Dr. Angela Guarda, an associate professor of eating disorders, psychiatry, and behavioral sciences at Johns Hopkins Medicine in Maryland, told Healthline.

In the New Jersey cases of S.A. and Ashley, it was left to the judge to determine whether the women’s decision-making abilities were impaired, after hearing testimony from doctors, other health professionals, and the patients themselves.

Parents generally have guardianship over their minor teens. But parents will have a harder time forcing an over-18 child into treatment.

Schlesinger’s daughter was already an adult when she was admitted to the hospital the first time for anorexia, about 25 years ago.

“With Nicole, because she was over 18, she walked out every single time,” Schlesinger told Healthline. “She never stayed as long as she was supposed to stay. She just left. So she never had the full treatment at any of the facilities.”

Patient’s rights vs. care needs

Decisions about whether to treat someone against their wishes must balance a person’s right to decide their own care against what their doctor thinks is best for them.

They must also balance the risks and benefits of potential treatments.

If a person is a danger to themselves or to others — such as being suicidal, physically violent, or severely unable to care for themselves — they may be hospitalized and treated against their wishes.

Suicide is a particular concern for people with anorexia.

One study found that this group is five times more likely than the general population to die from suicide.

People may also be admitted to the hospital against their wishes for medical reasons if they refuse voluntary treatment.

Excessive vomiting and laxative use associated with anorexia and other eating disorders can lead to low potassium levels in the blood. This can cause abnormal heart rhythms.

Guarda said that if a person shows up at the hospital with extremely low potassium and refuses to be admitted, involuntary treatment “might” be warranted because of the “very high medical risk.”

Danger to self or others isn’t the only consideration.

There also has to be a “reasonable expectation” that the treatment will work — futile care against a patient’s wishes isn’t justified ethically.

Studies are limited, but Guarda said that “there is data to support that involuntary treatment of anorexia is associated with benefit.”

In one study that looked at involuntary treatment for anorexia, patients treated against their wishes gained a similar amount of weight as those treated voluntarily.

“Successful” treatments, though, may not work for every patient. And it’s not always clear why.

Some people with anorexia who aren’t in treatment survive. Others who go into treatment don’t recover or die from the disease.

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Starting treatment earlier, and at a younger age, may increase the chance of recovery. But it’s no guarantee.

“With my daughter, even though I knew something was wrong pretty early into it, treatment just did not work with her,” said Schlesinger.

People with chronic anorexia also face an uphill battle, which can sway a doctor’s decision about involuntary treatment.

“If a patient has already been involuntarily treated once or twice in the local facility — with limited benefit — do you admit her a third time against her will to the same facility?” said Guarda. “That is a very different question from a patient who has never been treated in that facility.”

Role of family in treatment

Guarda also thinks that it’s important for the family to be on board with involuntary treatment — to provide a “unified front” aimed at winning the patient’s cooperation.

She refers to treating anorexia as a “process of conversion” — moving the patient from seeing dieting as the solution to dieting as a problem.

For a patient to get better, you have to shift their perspective, but “it is difficult to do that if the family is split,” said Guarda.

In a 2007 study in the Journal of American Psychiatry, Guarda and her colleagues found that this “shift” can happen soon after hospitalization.

They surveyed patients admitted voluntarily to an inpatient eating disorders program.

Two weeks after admission, about half of the patients who felt pressured to enter the program had changed their mind.

“That also happens with involuntary patients,” said Guarda. “At some point during their admission, the majority of them will say, ‘Well, I know I need to be here.’”

Access to a specialized treatment program is also important.

“There are some states that have no specialty programs for anorexia,” said Guarda. “Just admitting the patient to the local community hospital means they can be evaluated, and maybe their potassium can be fixed for today, but the doctors aren’t really treating the underlying cause.”

Schlesinger said that when her daughter was admitted to a hospital the first time over two decades ago, there weren’t as many dedicated eating disorders treatment programs.

This affected her care. Nicole was put on a feeding tube right away because she wouldn’t eat.

The nurses, though, weren’t experienced in treating eating disorders. So they gave Nicole “too much, too fast, and she ended up throwing up the whole thing,” said Schlesinger.

After that, the doctor had the feeding tube removed.

Access to specialized treatment programs can also be limited by a family’s lack of money or insurance, or by living in rural areas where there are no programs.

And because states have different laws governing involuntary hospitalization, doctors may not be able to transfer a patient who is under guardianship to an out-of-state eating disorders program.

Overcoming the fear of eating

Determining whether involuntary treatment is justified is similar for anorexia as it is for other conditions, like dementia or substance use disorder.

Treating anorexia, though, can be particularly challenging.

“One of the defining characteristics of anorexia is that it’s marked by at least some level — often extreme — of ambivalence about treatment,” said Guarda, “especially about entering treatment that is going to focus on changing weight or changing eating behavior.”

Luce said “part of this is that there becomes this true fear of eating, even though it may not seem rational to people.”

She compares this to other fears, such as a fear of flying. No matter how many statistics you cite that show airplanes are safer than driving, the fear will still be there.

Schlesinger knows the irrationality of the disease well.

“They don’t see themselves as what they really look like,” she said. “When a person with anorexia who is emaciated looks in the mirror, they see fat. They get anxious, and it’s very real for them.”

Even when Nicole was pregnant, she was 5 foot 7 inches and 95 pounds.

Nicole shared some of the anxious thoughts that she experienced on a blog post.

Well-meaning family members or friends often ask, “Why don’t they just eat?” But Schlesinger says eating disorders aren’t a conscious choice.

“Nobody would wake up and choose to starve themselves,” she said. “And nobody would wake up and choose to binge and throw up.”

Long road to recovery

Further complicating recovery, people with anorexia may recognize the need for others with the disease to undergo involuntary treatment, while denying that their own condition is that severe.

“Nicole fought everything,” said Schlesinger. “She didn’t think there was anything wrong.”

She was also in a premed program at university, so “she felt she knew how far she could push this illness,” said Schlesinger. “Unfortunately, it turned out the opposite way.”

Because a person’s reasoning is only impaired in this one specific area, it can make it more difficult for judges to rule in favor of treatment against the person’s wishes.

Some people with anorexia will voluntarily seek treatment on their own — or at the urging of their family. But they may avoid any treatments that involve restoring their weight or changing the amount or types of food they eat.

Without these treatments, success is unlikely.

“It’s not enough to just gain weight, but without that you’re not making any progress in treatment, no matter how much insight you have,” said Guarda.

She compares it to trying to stop drinking alcohol just by understanding why you first began binge drinking in college.

In addition, the conditions that keep an eating disorder going may not be the ones that led to someone restricting their food intake in the first place.

There are also many factors that may contribute to eating disorders, including family distress, sexual abuse, history of dieting, and a preoccupation with having a thin body.

Even participating in weight-obsessed activities — like ballet or gymnastics — can be a trigger for people who carry the genetic “load” for an eating disorder.

Some studies estimate that genetics account for about 50 percent of a person’s susceptibility to the disease.

Although the lack of food intake is one of the most noticeable outward signs of anorexia, this condition is more than just a problem of nutrition.

“Other people don’t understand that it’s not just about the food,” said Schlesinger. “Actually, it’s not about the food at all. It’s a mental illness. People do not see it that way.”

Restoring nutrition can get people with anorexia part way to recovery, but the road is a long one.

“After renourishment, if a patient doesn’t participate in psychotherapy or follow-up outpatient care, they often lose the weight again,” said Luce. “That’s when you start seeing repetitive inpatient stays.”

Schlesinger said Nicole was hospitalized around eight times. During her last treatment, her feeding tube became infected. It had to be taken out.

She ended up leaving the treatment center. There wasn’t anything Schlesinger could do about it.

Schlesinger describes her daughter’s death as many other parents do — as “devastating.” But she’s also thankful that she was able to see her daughter marry and have a child.

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Other mothers of children with eating disorders aren’t as fortunate.

Much has changed since Schlesinger’s daughter was first hospitalized for anorexia.

There were no support groups. And few resources, like the Mothers Against Eating Disorders group, to help parents educate themselves.

At the time, Schlesinger didn’t even know enough about eating disorders to consider requesting guardianship.

While parents now have more ways to help their children recover, this one legal option is sometimes the best choice.

“You have to do everything and anything to try to save your child,” said Schlesinger. “Even if it means getting a conservatorship to make sure that they get the proper treatment.”

Feeding Tubes for Severe Anorexia and ARFID

When utilized as a supplement to or in place of normal oral refeeding, feeding tubes for severe anorexia and ARFID can help facilitate nutritional rehabilitation for these extremely ill patients.

Eating disorder experts agree that effective treatment for anorexia nervosa begins with nutritional rehabilitation to restore body weight and reverse the cognitive deficits of prolonged starvation.

While simple in concept, this philosophy can be rather complicated in the practice of treating patients with severe anorexia and ARFID. Increasing caloric intake with proper blood monitoring too quickly can result in refeeding syndrome, a dangerous metabolic imbalance that can lead to heart failure. Gastrointestinal medical complications like gastroparesis and slowed colonic transit can cause physical discomfort associated with ingesting food, while psychological distress from increasing caloric intake can be overwhelming to patients. Taken together, these considerations may necessitate the use of feeding tubes for treatment of patients with severe anorexia and ARFID. While not necessary for most patients, these adjunct methods of refeeding can be valuable interventions in patients for whom oral nutritional rehabilitation alone is insufficient or intolerable.

Nasogastric (NG) tube feeding offers a temporary means of supplementing normal oral feeding for individuals whose medical stability and/or body weight continue to decline despite refeeding efforts. A form of enteral feeding, the NG tube is inserted through the nostril, down the esophagus and into the stomach, where nutrition is delivered directly at a volume and frequency based on the metabolic needs of the patient.

Early in recovery, supplemental caloric intake via NG tube feeding supports medical stabilization, weight gain and improved cognitive function in severely malnourished individuals, promoting readiness for the psychological aspects of treatment. As treatment progresses, tube feeding can augment oral feeding when caloric need is especially high as ideal body weight is approaching.

NG tube feeding can also alleviate some distress associated with GI complications related to restriction, purging, laxative abuse and other eating disorder behaviors. Liquid nutrition is well-tolerated compared to solid nutrition in patients with impaired GI function, and limits physical discomfort associated with increased food intake. NG tube feeding rates can be reduced and eliminated as necessary as eating becomes normalized, patients adjust to the physical sensations of eating and they develop coping skills for anxiety related to caloric intake.

Tube feeding for severe anorexia and ARFID should only be used when medically necessary and, in most cases, as a supplement to oral feeding. It should be continuously monitored by experienced medical, nursing and nutritional professionals, and involve a thoughtful initiation of caloric intake reflecting each patient’s unique metabolic needs and medical complications. Using these guidelines in an inpatient medical setting or residential setting with experience in addressing the complications of refeeding seriously underweight patients, NG tube feeding can be a valuable tool facilitating both physical and psychological eating disorder recovery.

For more information about the use of feeding tubes for severe anorexia and ARFID, contact us.

I didn’t believe I had an eating disorder. But the threat of forced feeding saved my life

By Carrie Arnold

January 18, 2017

Eros Dervishi for STAT

M y therapist told me I was running out of time. She had been recommending I sign myself into the hospital for several weeks. Each time, I said I was fine, that such drastic measures weren’t necessary, especially considering that I was acing all my college classes at my small liberal arts school in western Michigan. I didn’t think I needed to gain weight — in fact, I wasn’t even positive I had an eating disorder, despite weighing less than I had as a fourth-grader. I wrote off my falling-out hair and diminishing body temperature as mere coincidences to my steadily declining weight.

“If you don’t voluntarily sign yourself in, we might have to start thinking about forced commitment. You could die,” she said.

I tried not to laugh in her face. But as her words sunk in, I realized where any court would send me. I had heard stories about that psychiatric unit, and it frankly terrified me. I realized I would have far more control over my care if I signed myself in. So, two days after Christmas, at age 21, I did.

Looking back, it’s obvious the hospital stay saved my life, although it didn’t lead to immediate recovery or any overt psychological changes. I would bounce in and out of treatment facilities and hospitals for nearly a decade before any sort of recovery finally stuck.

In that I’m not unique. “One of the diagnostic criteria of anorexia includes a fear of weight gain or a failure to recognize the seriousness of the illness,” said Evelyn Attia, director of the Columbia & Weill Cornell Center for Eating Disorders. “By definition, treating anorexia comes with a lot of challenges.”

Those challenges were starkly evident in the recent New Jersey court case of a 29-year-old, 60-something-pound young woman known simply as A.G. The woman had been a ward of the state since 2014 after being found passed out in her hotel room and refusing treatment. Kept alive with a nasogastric feeding tube, A.G. wanted the right to refuse further forced feedings and subsist on black coffee, Diet Coke, and what little food she managed to absorb while binge eating and vomiting. She argued that future treatment would be futile, and that she wanted to die in peace. Her mother agreed, but the state of New Jersey took her to court to continue the tube feedings. In late November, a judge ruled that A.G. had made a “forthright, responsive, knowing, intelligent, voluntary, steadfast and credible” argument and said New Jersey couldn’t feed her against her will.

Judge: Severely anorexic patient can refuse forced feedings

The case has set off a firestorm in the eating disorder community, with advocates, clinicians, and people with eating disorders divided. In a Huffington Post article, eating disorder advocate Laura Collins Lyster-Mensh argues that “there is no such thing as ‘late terminal anorexia nervosa,’” and that A.G. was not refusing to eat as much as she was unable to feed herself due to her eating disorder. On Twitter and Facebook, however, many eating disorder sufferers countered that low weight itself does not make someone incompetent in the eyes of the law and that A.G. should be allowed to direct her own care.

Answers in ethical cases like this are rarely straightforward, even for someone like me who knows the potential stakes all too well. I don’t know what I would want done if I were A.G., nor do I know enough about her case and her history to render any judgments on her behalf. What I do know is that without significant changes to the way we treat eating disorders, there will only be more A.G.s in court.

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‘World’s deadliest game of hot potato’

Treating a disease that involves self-starvation seems relatively straightforward. “Just eat” seems to be the obvious solution. If only it were that simple. Just as someone with schizophrenia can’t will themselves out of psychosis and a person with bipolar disorder can’t wave a wand to eliminate mania, those with anorexia can’t just eat. Malnutrition accompanies eating disorders, which has been shown to shrink the brain and affect cognitive function, potentially interfering with a person’s ability to see the necessity of treatment. Many with anorexia also don’t find the weight loss alarming or disconcerting. As my illness tightened its grip and my weight dropped, I didn’t find the prospect of dying nearly as terrifying as the thought of having to face a plate of food five times a day. I wanted to get well, just as long as it didn’t involve eating or gaining weight.

Anorexia nervosa is not, by itself, a terminal illness. The vast majority of people with anorexia ultimately recover, or at least make vast improvements in their well-being and quality of life, even if some symptoms remain. (I consider myself in that last group.) Treatments — good treatments, effective treatments — exist, especially when people are diagnosed quickly and treated rapidly. Despite this, it remains the most lethal psychiatric disorder, with up to 20 percent of all people who have had anorexia for 20 years dying of the condition. Many die of the direct physical effects of long-term starvation. Without any external fuel, the body cannibalizes itself, eating fat and skeletal muscle before turning to vital organs. Hearts stop, livers and kidneys fail. Others die by suicide, worn down by years of struggle and an illness that seems to offer them no valid way out.

More men are developing eating disorders. Why are we treating it as only a women’s disease?

I came all too close to becoming one of those statistics. No matter how sick I got, however, insurance almost always denied care for “lack of medical necessity.” Other countries set absurdly low BMI thresholds for accessing even the most basic of care. What we hear is: You’re not sick enough. Psychiatric wards don’t want to handle eating disorder patients because they aren’t equipped to deal with the extensive medical complications that anorexia brings. Medical units don’t want to handle the difficult behaviors that also accompany an eating disorder. The result is the world’s deadliest game of hot potato, where many anorexia patients are bounced around from place to place, being kept alive but not actually treated. It’s not surprising, then, that many with long-term eating disorders begin to lose hope in the possibility of recovery.

I was lucky — I cobbled together the support I needed as an outpatient that ultimately helped me turn the corner. Relearning how to eat and returning to a normal weight was agonizing, and I often became combative as primal fear morphed into anger. While maintaining a small set of non-negotiables, my treatment team worked with me to instill a sense of hope that improvement was possible and to help me get there, bite by bite.

The author in 2016 at Suomenlinna, Finland. Courtesy Carrie Arnold

What treatment means

When treatment fails, clinicians often blame patients for being “difficult” or “treatment-resistant.” But in those cases the problem, according to Stephen Touyz, a psychologist at the University of Sydney in Australia, isn’t the patient but rather a lack of effective approaches.

If this were cancer with a list of established therapies, making the decision that treatment options had run out would be relatively straightforward. With eating disorders, it’s much less so. Experts remain divided on what the key outcome of treatment should be, and how much distress a patient should go through to achieve it. Compounding the troubles, the type of long-term, community-based support that adults with anorexia often need simply doesn’t exist. Residential treatment can cost upward of $40,000 per month, and insurance generally doesn’t cover it.

Treating a disease that involves self-starvation seems relatively straightforward. “Just eat” seems to be the obvious solution. If only it were that simple.

A new approach to treating the most severe form of the disease — severe and enduring anorexia nervosa, for which no treatment currently works — calls for moving the goalposts. Instead of requiring these individuals to gain weight, a select few clinicians instead emphasize improving quality of life. A study of this approach found that, although these patients may not recover, their depression decreased and they were able to make important strides in other areas of their life, such as returning to school or starting a family.

“If you don’t help a person help themselves, all the decisions end up in the hands of the disorder,” said Touyz.

But that way of thinking about the disorder remains highly controversial. Angela Guarda, director of the eating disorders program at Johns Hopkins University, disagrees with this approach, as well as the ruling in A.G.’s court case.

“Severe anorexia impairs judgment specifically in the area of decision making about what is the right treatment. Those of us who have treated 1,000 plus patients know that we are bad at predicting who will recover and have seen recovery in some of the most severely ill and chronic cases, even in cases who failed multiple treatments,” Guarda said in an email. “There is much danger in viewing anorexia as a terminal illness. Instilling hope and helping patients find a path to recovery should always be our goal.”

Guarda’s own work showed that weight gain was often a necessary precursor to emotional recovery. Once admitted to a hospital and partially re-fed, many patients who felt strong-armed into treatment realized their loved ones had done the right thing.

Not all that long ago, I would have come down strongly on the side for using forced feeding, but now I’m not so sure. I think that force feeding is and will continue to be a lifesaving tool for many with eating disorders, but when it’s used alone on a long-term patient in a non-specialist eating disorders unit, I have begun to question its usefulness.

A court order for forced feeding will never last long enough for that person to achieve wellness, and it’s almost certain he or she would return to the eating disorder the second the order was lifted. What’s more, it’s unlikely individuals would regain trust in a medical system that pitted itself against them, leaving them to live out their illness alone, without any support. For these types of patients, it could very well be more humane to help them engage with treatment on whatever level possible and improve what life they have left, even if it’s significantly shorter than anyone would like it to be.

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