If evaluation shows that the patient lacks capacity, however, the findings that support this conclusion should be documented clearly. The team then should consult the hospital attorney to determine how to best proceed. The attorney might recommend that a physician on the primary treatment team initiate a “medical hold”—an order that the patient may not leave against medical advice (AMA)—and then seek an emergency guardianship to permit medical treatment, such as refeeding.
To treat or not to treat?
What are the legal risks of allowing Ms. Q to leave AMA before she reaches medical stability?
Powers and Cloak11 describe a case of a 26-year-old woman with anorexia nervosa who came to the hospital with dizziness, weakness, and a very low blood glucose level. She was discharged after 6 days without having received any feeding, only to return to the emergency department 2 days later. This time, she had a letter from her physician stating that she needed medical supervision to start refeeding, yet she was discharged from the emergency department within a few hours. She was re-admitted to the hospital the next day.
Powers and Cloak11 do not report this woman’s medical outcome. But what if she had suffered a fatal cardiac arrhythmia before her third presentation to the emergency department or suffered another injury attributable to her nutritional state: Could her physicians be found at fault?
On Cohen & Associates’ Web site, they essentially answer, “Yes.” They describe a case of “Miss McIntosh,” who had anorexia nervosa and was discharged home from a hospital despite “chronic metabolic problems and not eating properly.” She went into a “hypoglycemic encephalopathic coma” and “suffered irreversible brain damage.” A subsequent lawsuit against the hospital resulted in a 7-figure settlement,12 illustrating the potential for adverse medicolegal consequences if failure to treat a patient with anorexia nervosa could be linked to subsequent physical harm. On the other hand, could a patient with anorexia who is being force-fed take legal action against her providers? At least 3 recent British cases suggest that this is possible.13-15 A British medical student with anorexia, E, made an emergency application to the Court of Protection in London, claiming that being fed against her will was akin to reliving her past experience of sexual abuse. In E’s case, the judge ruled “that the balance tips slowly but unmistakably in the direction of life preserving treatment” and authorized feeding over her objection.6 In 2 other cases, however, British courts have ruled that force-feeding anorexic patients would be futile and disallowed the practice.14,15
Faced with possible legal action, no matter what course you take, how should you respond? Getting legal and ethical consultation is prudent if time allows. In many cases, hospital attorneys might prefer that physicians err on the side of preserving life(D. Vanderpool, MBA, JD, personal communication, February 3, 2016)—even if that means detaining a patient without clear legal authorization to do so—because attorneys would prefer to defend a doctor who acted to save someone’s life than to defend a doctor who knowingly allowed a patient to die.
When might persons with an eating disorder be civilly committed?
Suppose that Ms. Q does not need urgent nonpsychiatric medical care, or that her life-threatening physical problems now have been addressed. Her physicians strongly recommend that she undergo inpatient psychiatric treatment for her eating disorder, but she wants to leave. Would it now be appropriate to fill out paperwork to initiate a psychiatric hold?
All U.S. jurisdictions authorize “civil commitment” proceedings that can lead to involuntary psychiatric hospitalization of people who have a mental disorder and pose a risk to themselves or others because of the disorder.16
In general, to be subject to civil commitment, a person must have a substantial disorder of thought, mood, perception, orientation, or memory. In addition, that disorder must grossly impair her (his) judgment, behavior, reality testing, or ability to meet the demands of everyday life.17
People with psychosis, a severe mood disorder, or dementia often meet these criteria. However, psychiatrists do not usually consider anorexia nervosa to be a thought disorder, mood disorder, or memory disorder. Does this mean that people with anorexia nervosa cannot meet the “substantial” mental disorder criterion?
It does not. Courts interpret the words in statutes based on their “ordinary and natural meaning.”18 If Ms. Q perceived herself as fat, despite having a BMI that was far below the healthy range, most people would regard her thinking to be disordered. If, in addition, her mental disorder impaired her “judgment, behavior, and capacity to meet the ordinary demands of sustaining existence,” then her anorexia nervosa “would qualify as a mental disorder for commitment purposes.”19