Does a patient with an eating disorder and a body mass index (BMI) indicating severe malnutrition, bradycardia, have the capacity to make informed decisions regarding refusal of eating disorder treatment?

From the Guidelines

The person described likely lacks capacity to refuse eating disorder treatment due to their severely compromised physical state. With a BMI of 16.9 (significantly underweight) and a heart rate of 33 (dangerously low, indicating severe bradycardia), they are at imminent risk of serious cardiac complications including sudden death. While the question states their physical compromise isn't impacting capacity, this assessment is questionable given the physiological effects of starvation on brain function. Severe malnutrition impairs cognitive function and decision-making abilities, even when patients appear lucid. Their stated reason for refusing treatment (not wanting to gain weight) suggests the eating disorder is influencing their decision-making, which is a hallmark of these conditions.

According to the American Psychiatric Association practice guideline for the treatment of patients with eating disorders 1, patients with anorexia nervosa who require nutritional rehabilitation and weight restoration should have individualized goals set for weekly weight gain and target weight. The guideline also recommends that adults with anorexia nervosa be treated with an eating disorder-focused psychotherapy, which should include normalizing eating and weight control behaviors, restoring weight, and addressing psychological aspects of the disorder.

In such cases, healthcare providers would typically consider involuntary treatment under mental health legislation, as the immediate risk to life outweighs patient autonomy. Treatment would involve medical stabilization (cardiac monitoring, careful refeeding to avoid refeeding syndrome), followed by nutritional rehabilitation and psychological interventions. This situation represents a medical emergency requiring immediate intervention regardless of the patient's stated preferences.

Key considerations in the treatment plan include:

• Medical stabilization to address the immediate risks associated with severe malnutrition and bradycardia
• Careful refeeding to avoid refeeding syndrome, which is a potentially fatal condition
• Nutritional rehabilitation to restore a healthy weight and improve overall nutritional status
• Psychological interventions to address the underlying eating disorder, including cognitive-behavioral therapy or family-based treatment, as recommended by the APA guideline 1.

Given the severity of the patient's condition and the potential for severe complications or death without treatment, involuntary treatment should be considered to ensure the patient's safety and well-being.

From the Research

Capacity to Make Decisions

• The question of whether someone with an eating disorder has the capacity to make a decision regarding declining eating disorder treatment is complex and multifaceted.
• According to 2, when patients refuse recommended treatment, it can carry increased risks for their well-being, and therefore, requires more emphatic disclosure without imposing pressure.
• In the context of eating disorders, the physical compromise from the disorder may not necessarily impact on the individual's capacity to make decisions, as stated in the scenario.

Eating Disorder Treatment

• The provided studies primarily focus on the pharmacological treatment of eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder 3, 4, 5, 6.
• These studies discuss various medications that can be used to treat eating disorders, such as fluoxetine, lisdexamfetamine, and olanzapine, but do not directly address the issue of capacity to make decisions regarding treatment.
• The studies suggest that olanzapine may be effective in promoting weight gain among individuals with anorexia nervosa 3, 4, 5, 6.

Decision-Making Capacity

• The study 2 highlights the importance of considering the level of disclosure and capacity required for patients to refuse medical treatment.
• It suggests that consenting to and refusing medical treatments may not be the same sorts of decisions and could require different levels of disclosure and capacity.
• However, the studies do not provide direct evidence to support or refute the idea that an individual with an eating disorder and a BMI of 16.9, heart rate of 33, and a desire not to gain weight, has the capacity to make a decision regarding declining eating disorder treatment.