Is Resistance (N)ever Futile? A Response to "Futility in Chronic Anorexia Nervosa: A Concept Whose Time Has Not Yet Come" by Cynthia Geppert

Ethical concerns in caring for persons with anorexia nervosa: content analysis of a series of documentations from ethics consultations

BACKGROUND

Caring for patients with anorexia nervosa (AN) is associated with high levels of moral distress among healthcare professionals. The main moral conflict has been posited to be between applying coercion to prevent serious complications such as premature death and accepting treatment refusals. However, empirical evidence on this topic is scarce.

METHODS

We identified all 19 documentations of ethics consultations (ECs) in the context of AN from one clinical ethics support service in Switzerland. These documentations were coded with a sequential deductive-inductive approach and the code system was interpreted in a case-based manner. Here, we present findings on patient characteristics and ethical concerns.

FINDINGS

The ECs typically concerned an intensely pretreated, extremely underweight AN patient endangering herself by refusing the proposed treatment. In addition to the justifiability of coercion, frequent ethical concerns were whether further coerced treatment aimed at weight gain would be ineffective or even harmful, evidencing uncertainty about beneficence and non-maleficence and a conflict between these principles. Discussed options included harm reduction (e.g. psychotherapy without weight gain requirements) and palliation (e.g. initiating end-of-life care), the appropriateness of which were ethical concerns in themselves. Overall, nine different types of conflicts between or uncertainties regarding ethical principles were identified with a median of eight per case.

CONCLUSIONS

Ethical concerns in caring for persons with AN are diverse and complex. To deal with uncertainty about and conflict between respect for autonomy, beneficence and non-maleficence, healthcare professionals consider non-curative approaches. However, currently, uncertainty around general justifiability, eligibility criteria, and concrete protocols hinders their adoption.

Assisted death in eating disorders: a systematic review of cases and clinical rationales

Background

Assisted dying for reasons solely related to an eating disorder (ED) has occurred in multiple countries, including those which restrict the practice to individuals with a terminal condition. The aims of this systematic review were to (1) identify all known cases of assisted deaths among patients with EDs and (2) describe the clinical rationales used to grant patients' requests for assisted death.

Methods

We conducted a systematic search of peer-reviewed studies and publicly available government reports to identify cases of assisted death in patients with EDs. In reports that included qualitative data about the case, clinical rationales were extracted and grouped into domains by qualitative content analysis.

Results

We identified 10 peer-reviewed articles and 20 government reports describing at least 60 patients with EDs who underwent assisted dying between 2012 and 2024. Clinical rationales were categorized into three domains: irremediability, terminality, and voluntary request. Reports emphasized that patients with EDs who underwent assisted death had terminal, incurable, and/or untreatable conditions and had adequate decision-making capacity to make a life-ending decision. Most government reports did not include descriptive-enough data to verify psychiatric conditions.

Conclusion

The results of our systematic review underscore considerable gaps in the reporting of assisted death in patients with psychiatric conditions, posing substantial concerns about oversight and public safety. In many cases, the clinical rationales that were used to affirm patients with EDs were eligible for assisted death lack validity and do not cohere with empirical understanding.

Clinical and Ethical Dilemmas in the Involuntary Treatment of Anorexia Nervosa

LEARNING OBJECTIVES

After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN.

ABSTRACT

Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.

Nurses' views on palliative care for those diagnosed with severe persistent mental illness: A Pilot Survey Study in Switzerland

WHAT IS KNOWN ON THE SUBJECT?: In recent years, some have suggested that palliative care approaches be considered for patients diagnosed with severe, persistent mental illness. Palliative care aims to decrease the suffering related to illness rather than focusing on curing the illness. Palliative care approaches for patients diagnosed with severe, persistent mental illness are controversial: Some argue palliative care would improve quality of life while others argue it would negatively affect patients' well-being. A recent survey found that psychiatrists from Switzerland tended to support the idea of palliative care approaches for those diagnosed with severe, persistent mental illness, but little is known about nurses' attitudes or beliefs regarding palliative psychiatry. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Participating nurses tended to agree that palliative care approaches may be appropriate and even important in caring for those diagnosed with severe, persistent mental illness. Participating nurses tended to prioritize quality of life and respect for patient autonomy. Participating nurses tended to agree palliative sedation may be an appropriate intervention. WHAT THE IMPLICATIONS ARE FOR PRACTICE?: For those diagnosed with severe, persistent mental illness, care that aims to increase daily functioning and quality of life rather than care that looks to cure may be appropriate. Palliative psychiatry should be further explored and better defined. ABSTRACT: Introduction In recent years, palliative care approaches for patients diagnosed with severe, persistent mental illness have been proposed, but remain controversial. Aim/Question The central research question of the present study was whether nurses consider palliative psychiatry appropriate in general and for certain patient types in particular. This pilot study is designed to inform future research. Method A quantitative survey that explored attitudes and beliefs regarding palliative care for those with severe, persistent mental illness. Results The responding 38 nurses tended to agree that palliative care approaches are suitable (73%, n = 24) and even important (62%, n = 21) in treating patients diagnosed with severe, persistent mental illness, including interventions such as palliative sedation (73%, n = 24). Discussion Widespread support among respondents regarding palliative care approaches for those diagnosed with severe, persistent mental illness might be an indication that palliative approaches are already implicitly understood and incorporated into patients' care. More research is needed to determine whether these findings represent nurses' views generally. Implications for practice These finding suggest that palliative psychiatry should be further explored and developed.

Palliative Psychiatry for Patients With Severe and Persistent Mental Illness: A Survey on the Attitudes of Psychiatrists in India Compared to Psychiatrists in Switzerland

OBJECTIVES

Palliative psychiatry is a new approach for the care of patients with severe and persistent mental illness (SPMI) which systematically considers biological, psychological, social, and existential factors of care. To assess the attitudes of psychiatrists in India toward palliative psychiatry for patients with SPMI and to compare these to the attitudes of psychiatrists in Switzerland.

METHODS

In an online survey, data from 206 psychiatrists in India were collected and compared with data from a previous survey among 457 psychiatrists in Switzerland.

RESULTS

Psychiatrists in India generally considered it very important to prevent suicide in SPMI patients (97.6%). At the same time, they considered it very important to reduce suffering (98.1%) and to ensure functionality in everyday life (95.6%). They agreed that palliative psychiatry is important for providing optimal care to SPMI patients without life-limiting illness (79.6%) and considered palliative psychiatry as indicated for patients with SPMI (78.2%). By contrast, curing the illness was considered very important by only 39.8 % of respondents. Relative to psychiatrists in Switzerland, psychiatrists in India were significantly more concerned about preventing suicide and less willing to accept a reduction in life expectancy, even at the expense of quality of life in patients with severe and persistent schizophrenia and recurrent major depressive disorder. At the same time, they were significantly more likely to advocate palliative psychiatry.

CONCLUSION

Most of the participating psychiatrists in India agreed that palliative psychiatry can be indicated for patients with SPMI. The comparison with psychiatrists in Switzerland highlights the need to take account of cultural differences in future studies of this kind. In summary, this study shows the potential of palliative psychiatry as a genuine biopsychosocio-existential approach which systematically integrates biological, psychological, social, and existential factors of care.

Severe and Enduring Anorexia Nervosa and Futility: A Time for Every Purpose?

The concept of futility in the treatment of individuals with severe and enduring anorexia nervosa remains controversial and has significant legal and ethical considerations. For those who have been unremittingly ill for 8 to 12 years, full recovery, although possible, is unlikely, and alternatives to traditional, active treatment must be explored. The harm reduction model, palliative care, and end-of-life care are explored as meaningful and reasonable treatments for this population. Landmark cases demonstrating the legal and ethical controversy of such treatment are explored.

Acceptability of palliative care approaches for patients with severe and persistent mental illness: a survey of psychiatrists in Switzerland

BACKGROUND

Some patients develop severe and persistent mental illness (SPMI) which is therapy-refractory. The needs of these patients sometimes remain unmet by therapeutic interventions and they are at high risk of receiving care that is inconsistent with their life goals. Scholarly discourse has recently begun to address the suitability of palliative care approaches targeting at enhancing quality of life for these patients, but remains to be developed.

METHOD

A cross-sectional survey asked 1311 German-speaking psychiatrists in Switzerland (the total number of German-speaking members of the Swiss Society for Psychiatry and Psychotherapy) about the care of SPMI patients in general, and about palliative care approaches in particular. 457 (34.9%) returned the completed survey. In addition, participants were asked to evaluate three case vignettes of patients with SPMI.

RESULTS

The reduction of suffering and maintaining daily life functioning of the patient were rated as considerably more important in the treatment of SPMI than impeding suicide and curing the underlying illness. There was broad agreement that SPMI can be terminal (93.7%), and that curative approaches may sometimes be futile (e.g. 72.4% for the anorexia nervosa case vignette). Furthermore, more than 75% of the participating psychiatrists were in favour of palliative care approaches for SPMI.

CONCLUSIONS

The results of the present study suggest that the participating psychiatrists in Switzerland regard certain forms of SPMI as posing high risk of death. Additionally, a majority of respondents consider palliative care approaches appropriate for this vulnerable group of patients. However, the generalizability of the results to all psychiatrists in Switzerland or other mental health professionals involved in the care of SPMI is limited. This limitation is important considering the reservations towards palliative care in the context of psychiatric illness, mainly because of the association with death and futility. Palliative care approaches, however, are applicable in conjunction with other therapies intended to prolong life. A next step could be to involve service users and develop a consensus of what palliative care might encompass in SPMI. A framework for identifying which patients might benefit from palliative care, should be explored for the future development of care for SPMI patients.

Caring for Patients With Severe and Enduring Eating Disorders (SEED): Certification, Harm Reduction, Palliative Care, and the Question of Futility

Anorexia nervosa is a serious mental illness with a high mortality rate. The body image distortion inherent to this disorder and the impaired judgment and cognition due to malnutrition frequently result in patients refusing treatment. Treatment is most effective if patients are treated early in the course of their illness and undergo a full course of treatment. Involuntary treatment may therefore be both life-saving and critical to recovery. Between April 2012 and March 2016, 109 patients (5.2% of patients admitted to the Eating Recovery Center in Denver, CO) were certified, 39% of whom were transferred from the ACUTE Center for Eating Disorders at Denver Health Medical Center. Of these 109 certified patients, 31% successfully completed treatment, and 42% returned for a further episode of care; 24% of the certifications were terminated as involuntary treatment was not found to be helpful. Conclusions supported by these data are that patients with anorexia nervosa who are the most medically ill often require involuntary treatment. In addition, although many patients who are certified successfully complete treatment, involuntary treatment is not helpful approximately 25% of the time. Many of the patients for whom certification is ineffective are those who suffer from a lifetime of illness that is severe and enduring. Patients with severe and enduring eating disorders (SEED) typically undergo cyclical weight restoration and weight loss. Many of these patients question the value of serial treatments, especially when they have few (if any) illness-free intervals. Patients, families, and treating physicians often wish to explore other models of care, including harm reduction and palliative care. In addition, patients with SEED may also contemplate whether a compassionate death would be better than an ongoing lifetime of suffering. In this review, we outline arguments for and against the concept of futility in SEED, and explore whether (or when) patients are competent to make the decision to die.