Does a patient with anorexia nervosa, a body mass index (BMI) of 16.9, and bradycardia (heart rate (HR) of 33 beats per minute (bpm)), who is aware of the risks, have the capacity to refuse emergency department attendance?

From the Guidelines

This individual likely lacks capacity to refuse emergency medical care due to the severe and life-threatening complications of anorexia, as indicated by a critically low heart rate and severely low BMI, which are impairing her judgment and decision-making capacity. The patient's heart rate of 33 beats per minute and BMI of 16.9 are significantly below normal ranges, posing an immediate risk to her life 1. Despite acknowledging the risk of death, her decision to refuse emergency medical care appears to be influenced by her eating disorder, which is affecting her insight into the severity of her condition. The American Psychiatric Association practice guideline for the treatment of patients with eating disorders recommends a comprehensive evaluation, including assessment of vital signs, laboratory tests, and electrocardiogram, to identify potential life-threatening complications 1. In this case, the patient's claim that her low heart rate is her "baseline" demonstrates poor insight into the abnormal and dangerous nature of her cardiac status. Healthcare providers should prioritize the patient's safety and well-being, and consider pursuing emergency treatment under mental health legislation or emergency treatment provisions to protect her life. Key considerations in determining capacity include:

• The patient's ability to understand the risks and benefits of refusing emergency medical care
• The impact of her eating disorder on her judgment and decision-making capacity
• The presence of any co-occurring health conditions or psychiatric disorders that may be contributing to her decision
• The need for a comprehensive and multidisciplinary treatment plan to address her eating disorder and related health issues 1.

From the Research

Capacity to Make Decisions

The patient in question has a diagnosis of anorexia, a BMI of 16.9, a heart rate of 33bpm, and no desire to lose more weight, being happy at a stable weight. Despite being advised to attend A&E due to a low heart rate, she refuses, citing it as her baseline heart rate and previous uneventful visits. The question arises whether she has the capacity to make this decision.

Understanding the Risks

• The patient is aware of the risk of death associated with not going to A&E, as indicated by studies such as 2, which highlights the cardiac complications of anorexia nervosa, including structural, functional, and rhythm-type changes that can be life-threatening.
• Another study, 3, notes that patients with severe malnutrition due to anorexia nervosa have a higher mortality rate, with predictors of mortality including older age, occurrence of in-hospital suicide attempts, and somatic complications like cardiac issues.
• The awareness of these risks is crucial in assessing her capacity to make informed decisions about her health.

Capacity Assessment

• To determine if the patient has the capacity to make this decision, it's essential to evaluate her understanding of the situation, the potential consequences of not seeking medical attention, and her ability to appreciate the risks involved.
• Study 4 emphasizes the importance of evaluating and managing cardiovascular complications in patients with anorexia nervosa, given the high mortality rate associated with the condition.
• The patient's refusal to seek medical attention despite being aware of the risks may indicate a lack of appreciation for the severity of her condition or the potential consequences of her decision.

Medical Complications and Decision-Making

• The medical complications associated with anorexia nervosa, including cardiac dysfunction, as described in 5, can have a significant impact on the patient's ability to make informed decisions.
• Study 6 provides a comprehensive review of the cardiovascular complications of anorexia nervosa, highlighting the importance of monitoring and managing these issues to prevent severe outcomes.
• The patient's decision to refuse medical attention may be influenced by her medical condition, and it is crucial to consider this when assessing her capacity to make decisions about her health.

Conclusion is not allowed, so the response will be ended here.