Download Eating disorders Compulsory Treatment?

Eating disorders
Compulsory Treatment?
Dr Yvonne Edmonstone
Questions?
1. Are criteria for compulsory treatment
met?
2. What constitutes medical treatment?
3. Nutrition by artificial means without
consent v Forcible feeding?
4. Any special safeguards?
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
1.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
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
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
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)
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)
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
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.
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.
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)
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
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
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”
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
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.”
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.
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??
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: Shortterm 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 LifeProlonging therapy: A Limited Justification
H Draper Bioethics 2000 Vol 14 120 - 133