Refusal of Food and Dialysis-Level Dehydration in a Depressed Patient
A 68-year-old retired teacher with bipolar I disorder, currently in a severe depressive episode with psychotic features, has eaten almost nothing for three weeks. He has lost 9 kg over two months and now weighs 48 kg at 1.72 m (BMI 16.2). He refuses blood tests and says that food and water are contaminated and that God intends him to fast. When you ask him about the risks, he can repeat back that he may die and that his kidneys may fail, but he insists the contamination is real. He scores 27/30 on the Mini-Mental State Examination. Sodium 128 mmol/L, creatinine 1.5 mg/dL (baseline 0.9), urea 14 mmol/L, glucose 5.1 mmol/L. He is alert, afebrile and haemodynamically stable. His daughter wants 'everything done' and is asking about tube feeding and electroconvulsive therapy; his son says his father has always been independent and should be left alone. There is no advance directive and no appointed substitute decision-maker.
1. Assess decision-making capacity for refusing nutrition and fluids, applying the four abilities to these facts.
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Capacity is decision-specific, so assess his ability to decide about feeding and investigations, not global competence. Understanding is intact: he can paraphrase that refusal may lead to death and renal failure. Expressing a choice is also intact: he consistently declines. The failure is in appreciation and reasoning. Appreciation means applying the facts to oneself, and he does not: he holds a fixed, false belief that his food is contaminated, which is congruent with his psychotic depression and is not corrected by evidence or reassurance. His reasoning therefore rests on a delusion rather than on weighing risks and benefits, so he cannot use the information to reach a decision that reflects his own long-standing values. A Mini-Mental State score of 27 does not settle the question; cognition can be preserved while delusional content drives the decision. Conclude that he lacks capacity for this specific decision. Note what this does and does not mean: it does not erase his values, and it does not automatically authorise every intervention, but it does remove his refusal as an absolute barrier.
2. On what ethical and legal basis would you treat him, and what is the least restrictive option? Consider the disagreement between his children.
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The ethical basis is beneficence and non-maleficence, applied proportionately, because a treatable psychotic depression is driving a choice that will shortly kill him. The refusal is not autonomous in the substantive sense because it is produced by the illness, and his prior self would almost certainly not have endorsed it. Legally, most jurisdictions permit emergency treatment without consent when there is imminent risk to life and the situation cannot wait for a formal hearing; if his condition were not immediately life-threatening, you would need the statutory mental health or guardianship route and, in many countries, a court order for involuntary medical or electroconvulsive treatment. His children cannot consent or refuse on his behalf in the absence of a legal appointment, and their disagreement has no legal weight; hear both, explain the reasoning, and document it. Choose the least restrictive effective option: a short period of supervised oral feeding and nasogastric feeding under mental health law, with rapid progression to electroconvulsive therapy if his depression does not lift, since ECT is definitive here and avoiding intubation and restraint wherever possible.
3. What are the physiological risks of refeeding him, and how would you mitigate them?
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He is at high risk of refeeding syndrome: BMI 16.2, minimal intake for three weeks, weight loss over 10% in two months, hyponatraemia and acute kidney injury. Reintroducing carbohydrate drives an insulin surge that shifts phosphate, potassium and magnesium intracellularly, causing hypophosphataemia, arrhythmia, rhabdomyolysis, respiratory failure and cardiac failure. Give thiamine before feeding, typically 200-300 mg intravenously daily for the first days, and correct potassium, magnesium and phosphate proactively. Start at roughly 10 kcal/kg/day for the first 24 hours, with cautious protein, and increase over 4-7 days as electrolytes allow; do not chase weight gain quickly. Monitor phosphate, potassium, magnesium, sodium and creatinine at least daily, and more often if abnormal, during the first week. Recheck his sodium correction rate, since his chronic hyponatraemia must not be corrected rapidly. If electroconvulsive therapy proceeds, remember that anaesthesia adds its own fasting and electrolyte considerations, and coordinate with the anaesthetist and dietician before the first treatment.