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Westermair AL, Reiter-Theil S, Wäscher S, Trachsel M. Ethical concerns in caring for persons with anorexia nervosa: content analysis of a series of documentations from ethics consultations. BMC Med Ethics 2024; 25:102. [PMID: 39354548 PMCID: PMC11443878 DOI: 10.1186/s12910-024-01101-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/12/2024] [Indexed: 10/03/2024] Open
Abstract
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.
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Affiliation(s)
- Anna Lisa Westermair
- Clinical Ethics Unit, University Hospital Basel (USB), University Psychiatric Clinics (UPK) Basel, University Children's Hospital Basel (UKBB), Geriatric University Medicine Felix Platter (UAFP), Spitalstrasse 22, Basel, CH-4031, Switzerland.
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich (UZH), Zurich, Switzerland.
| | | | - Sebastian Wäscher
- Institute of Biomedical Ethics and History of Medicine (IBME), University of Zurich (UZH), Zurich, Switzerland
| | - Manuel Trachsel
- Clinical Ethics Unit, University Hospital Basel (USB), University Psychiatric Clinics (UPK) Basel, University Children's Hospital Basel (UKBB), Geriatric University Medicine Felix Platter (UAFP), Spitalstrasse 22, Basel, CH-4031, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
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Zugai JS, Gill K, Ramjan L. Clinicians' power in the inpatient care of anorexia nervosa: A qualitative investigation of consumer perspectives. Int J Ment Health Nurs 2024; 33:885-893. [PMID: 38183348 DOI: 10.1111/inm.13287] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 11/20/2023] [Accepted: 12/19/2023] [Indexed: 01/08/2024]
Abstract
Medically compromised people with anorexia nervosa are cared for in inpatient settings where clinicians closely monitor health and safety. Clinicians are in a position of power, with the capacity to impose mandated weight gain to achieve medical stabilisation. Consumers are in a vulnerable position, compelled to temporarily relinquish autonomy and to accept coercive practices that often diminish the quality of the therapeutic relationship. Clinicians' position of power in mental healthcare has a dual potential for both healing and harm, and limited attention has been given to consumers' views of clinicians' power. The aim of this qualitative descriptive study was to investigate the consumer perspective of clinicians' power in the inpatient care of anorexia nervosa, establishing insight into the beneficence and maleficence of the power asymmetry. Ten women with anorexia nervosa in the community participated in semi-structured interviews online. The COREQ checklist was used to ensure accuracy and completeness of reporting. Thematic analysis revealed that abuses of power were common in the course of inpatient AN care, however life-saving measures were regarded as defensible. The perception of clinicians' power was determined by the strength of interpersonal relationships and clinicians' clinical competence. To mitigate the potential for harmful experiences, clinicians' use of power must be exercised with close consideration for consumer perspectives, with the integration of person-centred care and trauma-informed care principles.
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Affiliation(s)
- Joel Sebastian Zugai
- School of Nursing, University of Wollongong, Liverpool, New South Wales, Australia
| | - Katherine Gill
- Consumer Led Research Network, The University of Sydney, Sydney, New South Wales, Australia
| | - Lucie Ramjan
- School of Nursing, University of Wollongong, Liverpool, New South Wales, Australia
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
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Steinert T. Using coercion in mental disorders or risking the patient's death? An analysis of the protocols of a clinical ethics committee and a derived decision algorithm. JOURNAL OF MEDICAL ETHICS 2024; 50:552-556. [PMID: 38050143 DOI: 10.1136/jme-2023-109578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/12/2023] [Indexed: 12/06/2023]
Abstract
While principle-based ethics is well known and widely accepted in psychiatry, much less is known about how decisions are made in clinical practice, which case scenarios exist, and which challenges exist for decision-making. Protocols of the central ethics committee responsible for four psychiatric hospitals over 7 years (N=17) were analysed. While four cases concerned suicide risk in the case of intended hospital discharge, the vast majority (N=13) concerned questions of whether the responsible physician should or should not initiate the use of coercion in patients lacking mental capacity. The committee's recommendations were non-uniform. Forced feeding and electroconvulsive therapy were endorsed in each one case. In two cases of intermittent loss of capacity due to heavy drinking or intermittent severe suicidal ideation, a self-binding contract was recommended and the use of coercion was considered as justified for a very limited period. In all other cases, most of which involved involuntary treatment, the use of coercion was not endorsed. Without exception, the recommendations were accepted with relief by the physicians and their treatment teams, who feared liability in the event of harm to the patient. Eventually, a model of a decision algorithm was derived from the ethical arguments in the protocols.
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Affiliation(s)
- Tilman Steinert
- Centers for Psychiatry Suedwuerttemberg, Ravensburg, Germany
- Ulm University, Ulm, Germany
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Abry F, Gorwood P, Hanachi M, Di Lodovico L. Longitudinal investigation of patients receiving involuntary treatment for extremely severe anorexia nervosa. EUROPEAN EATING DISORDERS REVIEW 2024; 32:179-187. [PMID: 37690079 DOI: 10.1002/erv.3033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/05/2023] [Accepted: 08/29/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Involuntary treatment may be a life-saving option for extremely severe anorexia nervosa (AN) in the context of life-threatening conditions and refusal of care. The long-term outcomes of patients undergoing involuntary treatment for AN are poorly understood. This study aims to explore quality of life, long-term outcomes and attitudes towards involuntary treatment in patients involuntarily treated for extremely severe AN. METHODS 23 patients involuntarily admitted for extremely severe AN (I-AN), and 25 voluntarily admitted patients (V-AN) were compared for body mass index (BMI), residual symptoms, quality of life, and attitudes towards treatment almost four years after discharge. In I-AN, clinical variables were also compared between admission and follow-up. RESULTS At follow-up, weight restoration was higher in V-AN (p = 0.01), while differences in quality of life, BMI, and mortality rates were not significant between I-AN and V-AN (p > 0.05). In I-AN, BMI increased and weight-controlling strategies decreased at follow-up (p < 0.05). Despite negative experiences of involuntary treatment, the perception of the necessity of treatment increased from admission to follow-up (p < 0.01) and became comparable to V-AN (p > 0.05). DISCUSSION Involuntary treatment for AN does not appear to be a barrier to weight gain and clinical improvement, nor to long-term attitudes towards treatment.
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Affiliation(s)
- Florent Abry
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
| | - Philip Gorwood
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Institute of Psychiatry and Neuroscience of Paris (IPNP), INSERM U1266, Paris, France
| | - Mouna Hanachi
- Clinical Nutrition Unit, Paul Brousse University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Villejuif, France
- UMR Micalis Institute, INRA, Paris-Saclay University, Jouy-En-Josas, France
| | - Laura Di Lodovico
- Clinique des Maladies Mentales et de l'Encéphale, Hôpital Sainte-Anne, GHU Paris Psychiatrie et Neurosciences, Paris, France
- NeuroCentre Magendie, INSERM U1215, Bordeaux, France
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Kiely L, Conti J, Hay P. Anorexia nervosa through the lens of a severe and enduring experience: 'lost in a big world'. J Eat Disord 2024; 12:12. [PMID: 38254163 PMCID: PMC10804804 DOI: 10.1186/s40337-023-00953-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/11/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Severe and enduring anorexia nervosa (SE-AN), is a serious and persistent illness, despite 'state of the art' treatment. Criteria have been theoretically proposed, but not tested, and may not adequately capture illness complexity, which potentially inhibits treatment refinements. The clinical reality of death as an outcome for some people who experience SE-AN (1 in 20) and broadening access to voluntary assisted dying, further complicates the field, which is undeveloped regarding more fundamental concepts such as nosology, treatment, recovery definitions and alternative conceptualisations of SE-AN. The present paper is in response to this and aims to build upon qualitative literature to enhance phenomenological understandings of fatal SE-AN. METHOD A published book, being the legacy of a 32-year-old professional artist offers a rich account of a life lived with AN, for 18 years with continuous treatment. A polysemous narrative via the interrelationship between the languages of the artist's words and visual art is translated via interpretative phenomenological analysis (IPA), offering rich insight into the SE-AN experience. FINDINGS The process of analysis induced three superordinate themes (1) Disappearing Self (2) Dialectical Dilemma (3) Death and Dying: Finding Meaning. Two cross cutting themes traversed these themes: (a) Colour and (b) Shifting Hope, where the former produced a visual representation via the 'SE-AN Kaleidoscope'. Collectively the themes produce a concept of SE-AN, grounded in the data and depicted visually through the artist's paintings. CONCLUSIONS The picture of SE-AN revealed in the analysis extends upon conceptualisations of SE-AN, highlighting key processes which are thus far under explored. These factors are implicated in illness persistence eliciting opportunities for further research testing including diagnostic considerations and treatment directions. In SE-AN, distorted body image extends to a global distortion in the perception of self. Additional criteria for the severe and enduring stages of illness related to (1) self and identity processes (2) measures of 'global impoverishment' across life domains are proposed for consideration in the future testing of putative defining features of SE-AN.
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Affiliation(s)
- Laura Kiely
- School of Medicine, Translational Health Research Institute, Western Sydney University, Sydney, Australia.
| | - Janet Conti
- School of Psychology, Translational Health Research Institute, Western Sydney University, Sydney, Australia
| | - Phillipa Hay
- School of Medicine, Translational Health Research Institute, Western Sydney University, Sydney, Australia
- Mental Health Services, Camden and Campbelltown Hospitals, SWSLHD, Campbeltown, NSW, 2560, Australia
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Zielinski-Gussen IM, Herpertz-Dahlmann B, Dahmen B. Involuntary Treatment for Child and Adolescent Anorexia Nervosa-A Narrative Review and Possible Advances to Move Away from Coercion. Healthcare (Basel) 2023; 11:3149. [PMID: 38132039 PMCID: PMC10742854 DOI: 10.3390/healthcare11243149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Children and adolescents with psychiatric disorders frequently experience hospital treatment as coercive. In particular, for patients with severe anorexia nervosa (AN), clinical and ethical challenges often arise if they do not voluntarily agree to hospital admission, often due to the ego-syntonic nature of the disorder. In these cases, involuntary treatment (IVT) might be life-saving. However, coercion can cause patients to experience excruciating feelings of pressure and guilt and might have long-term consequences. METHODS This narrative review aimed to summarize the current empirical findings regarding IVT for child and adolescent AN. Furthermore, it aimed to present alternative treatment programs to find a collaborative method of treatment for young AN patients and their families. RESULTS Empirical data on IVT show that even though no inferiority of IVT has been reported regarding treatment outcomes, involuntary hospital treatment takes longer, and IVT patients seem to struggle significantly more with weight restoration. We argue that more patient- and family-oriented treatment options, such as home treatment, might offer a promising approach to shorten or even avoid involuntary hospital admissions and further IVT. Different home treatment approaches, either aiming at preventing hospitalization or at shortening hospital stays, and the results of pilot studies are summarized in this article.
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Affiliation(s)
- Ingar M. Zielinski-Gussen
- Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, University Hospital RWTH Aachen, 52074 Aachen, Germany
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Baile JI, González-Calderón MJ, Rabito-Alcón MF. [Non-voluntary internment in patients with anorexia nervosa in Spain]. Med Clin (Barc) 2023; 160:85-89. [PMID: 36283852 DOI: 10.1016/j.medcli.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/05/2022]
Affiliation(s)
- José I Baile
- Departamento de Psicología y Salud, Facultad de Ciencias de la Salud y la Educación, Universidad a Distancia de Madrid (Udima), Collado Villalba, Madrid, España.
| | - María J González-Calderón
- Departamento de Psicología y Salud, Facultad de Ciencias de la Salud y la Educación, Universidad a Distancia de Madrid (Udima), Collado Villalba, Madrid, España
| | - María F Rabito-Alcón
- Departamento de Psicología y Salud, Facultad de Ciencias de la Salud y la Educación, Universidad a Distancia de Madrid (Udima), Collado Villalba, Madrid, España
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Abstract
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.
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Tsiandoulas K, McSheffrey G, Fleming L, Rawal V, Fadel MP, Katzman DK, McCradden MD. Ethical tensions in the treatment of youth with severe anorexia nervosa. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:69-76. [PMID: 36206789 DOI: 10.1016/s2352-4642(22)00236-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/23/2022]
Abstract
Treatment of anorexia nervosa poses a moral quandary for clinicians, particularly in paediatrics. The challenges of appropriately individualising treatment while balancing prospective benefits against concomitant harms are best highlighted through exploration and discussion of the ethical issues. The purpose of this Viewpoint is to explore the ethical tensions in treating young patients (around ages 10-18 years) with severe anorexia nervosa who are not capable of making treatment-based decisions and describe how harm reduction can reasonably be applied. We propose the term AN-PLUS to refer to the subset of patients with a particularly concerning clinical presentation-poor quality of life, lack of treatment response, medically severe and unstable, and severe symptomatology-who might benefit from a harm reduction approach. From ethics literature, qualitative studies, and our clinical experience, we identify three core ethical themes in making treatment decisions for young people with AN-PLUS: capacity and autonomy, best interests, and person-centred care. Finally, we consider how a harm reduction approach can provide direction for developing a personalised treatment plan that retains a focus on best interests while attempting to mitigate the harms of involuntary treatment. We conclude with recommendations to operationalise a harm reduction approach in young people with AN-PLUS.
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Affiliation(s)
- Kate Tsiandoulas
- Department of Bioethics, The Hospital for Sick Children, Toronto, ON, Canada; Health Science Research Program, University of Toronto, Toronto, ON, Canada
| | - Gordon McSheffrey
- Department of Pediatrics, Scarborough Health Network, Toronto, ON, Canada; Child, Youth, Family Services, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Lindsay Fleming
- Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Vandana Rawal
- Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Marc P Fadel
- Department of Psychiatry, The Hospital for Sick Children, Toronto, ON, Canada; Division of Child and Youth Mental Health, Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Debra K Katzman
- Division of Adolescent Medicine, The Hospital for Sick Children, Toronto, ON, Canada; The Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Melissa D McCradden
- Department of Bioethics, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Genetics & Genome Biology, Peter Gilgan Centre for Research & Learning, Toronto, ON, Canada.
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