What is the recommended approach for palliative care in patients with severe and enduring anorexia nervosa?

Palliative Care for Severe and Enduring Anorexia Nervosa

For patients with severe and enduring anorexia nervosa (SE-AN), palliative care should focus on improving quality of life, reducing suffering, and honoring patient goals rather than pursuing aggressive weight restoration when previous high-quality treatments have repeatedly failed.

Patient Identification and Assessment

Patients who may benefit from a palliative approach typically demonstrate:

• Diagnosis of anorexia nervosa that has become severe and enduring (typically present for many years)
• Older age (generally over 30 years)
• History of multiple high-quality treatment attempts without sustained improvement
• Clear and consistent determination that additional intensive treatment would be futile
• Decision-making capacity intact despite malnutrition 1

Palliative Care Framework

Goals of Care

• Focus on patient-defined quality of life rather than weight restoration
• Reduce physical suffering from malnutrition complications
• Support social and emotional functioning
• Honor the whole person and their autonomy 2

Intervention Approach Based on Life Expectancy

Years to Months Life Expectancy:

• Assess the meaning of anorexia/cachexia symptoms to patient and family
• Consider appetite stimulants if increased appetite is important for quality of life:
  • Megestrol acetate (400-800 mg/day)
  • Olanzapine (5 mg/day)
  • Dexamethasone (2-8 mg/day)
  • Consider cannabinoids in appropriate jurisdictions 3
• Treat depression if present (mirtazapine 7.5-30 mg at bedtime may help with both mood and appetite) 3
• Provide education about natural disease progression
• Focus on patient goals and preferences
• Offer emotional support to patient and family 3

Months to Weeks Life Expectancy:

• Recognize that nutritional support may not be metabolized effectively
• Continue monitoring symptoms and quality of life
• Provide family with alternative ways of caring for the patient
• Consider psychiatric consultation for comorbid conditions 3, 4

Weeks to Days Life Expectancy:

• Acknowledge risks of artificial nutrition/hydration (fluid overload, infection)
• Treat symptoms like dry mouth with local measures (mouth care, small amounts of liquids)
• Recognize that withholding or withdrawing nutrition is ethically permissible and may improve some symptoms
• Intensify palliative interventions for symptom control
• Consider specialized palliative care services or hospice 3

Symptom Management

Nausea and Vomiting

• Discontinue unnecessary medications
• Check blood levels of necessary medications
• Consider dopamine receptor antagonists (haloperidol, metoclopramide, prochlorperazine, olanzapine)
• For anxiety-related nausea, add lorazepam 0.5-1 mg every 4 hours as needed 3

Psychological Support

• Provide emotional and spiritual support
• Help strengthen relationships with family/caregivers
• Address existential distress
• Support patient autonomy while maintaining compassionate care 4

Special Considerations

Harm Reduction Approach

• May be appropriate for patients who cannot achieve full recovery but can maintain stable functioning
• Focus on minimizing medical complications while accepting some degree of ongoing illness
• Support social and occupational functioning 5

Ethical Considerations

• Recognize the tension between autonomy and beneficence
• Assess decision-making capacity regularly despite malnutrition
• Consider ethics consultation for complex cases
• Acknowledge that approximately 25% of patients with SE-AN do not benefit from involuntary treatment 5

Pitfalls to Avoid

• Assuming all patients with anorexia nervosa should receive aggressive treatment regardless of illness duration or previous treatment failures
• Confusing palliative care with giving up - this approach aims to improve quality of life, not hasten death
• Failing to reassess goals of care as the condition changes
• Overlooking the emotional needs of family members and caregivers
• Neglecting to provide adequate symptom management for physical complications of malnutrition 4

Palliative care for SE-AN represents a compassionate alternative when traditional treatment approaches have failed, focusing on quality of life and symptom management rather than cure. This approach acknowledges the reality that some patients with long-standing illness may not achieve recovery despite multiple treatment attempts 1, 2.