31st January 2024

Legal aspects

A person with an eating disorder can and often will consent to refeeding, as insight is often intact. Sympathy, negotiation and avoiding arguments are key to finding a treatment plan that allows a patient to regain a healthy weight without resorting to restrictive measures. A key part of negotiation is finding food that is initially acceptable to the patient (though returning to these foods later is a key part of treatment) and addressing the person’s life goals and how treatment allows them to achieve goals (whereas continuation of the eating disorder could stop them) could help with motivation with treatment plan adherence. However, for some who lack insight or are overwhelmed by the compulsion to not eat or to purge, then feeding against their will is necessary to save their lives. There may also be need for other restrictions on liberties, including admission to hospital against their will, to restrict exercise, advising to be on complete bed rest, use of a wheelchair for mobilising to the bathroom, and supervision of toilet and bathroom use (to avoid purging) and constant nursing observation to help the patient from sabotaging their treatment, including by doing disguised exercise such as muscle clenching.

The tools available to legally deprive someone of their liberties would be the Mental Capacity Act or Mental Health Act. Whilst it can be argued a patient’s inability to weigh up a decision is influenced by the presence of the eating disorder, usually the Mental Health Act is used, as there are provisions for force-feeding as a treatment. Indeed, this is the only time the Mental Health Act can be used to treat a physical illness or physical manifestations of a mental illness. That is because feeding, even against the patient’s wishes, can improve the patient’s anorexic cognitions. Often, a medical SHO will be tasked with placing a patient on a section 5(2) of the Mental Health Act as the hospital’s ‘nominated deputy’. This allows them to keep the patient admitted to an inpatient ward (i.e. not A&E or outpatient clinic) against the patient’s consent for 72 hours. This does not allow for treatment against the person’s wishes; it will trigger a full Mental Health Act assessment, and the resulting section the patient moves to – either section 2 or section 3 – allows force-feeding, and only if all other methods (referred to in the act as least restrictive options) have been exhausted, i.e. negotiation and adaptation. Only when compliance with treatment plans ends and negotiation and discussion are exhausted, are the skills of mental health nurses required, who are trained in restraint. Often, psychiatric medications, including benzodiazepines and the antipsychotic medication Olanzapine, are helpful for anxiety around refeeding. 

 A patient with an eating disorder does not require a medical bed for the entirety of their refeeding. Decision to transfer to a psychiatric unit is often made based on what facilities are available within the psychiatric unit. This usually means that if a patient requires daily or two daily blood tests, frequent monitoring of physical observations, IV fluids and electrolytes, this is beyond the capacity of most psychiatric inpatient units, although available in some eating disorder specialist units. Care needs to be given with IV fluids, as overhydration is common, and use of 5% dextrose can trigger refeeding syndrome.