BMI 14.1, refusal of nasogastric feeding, and no psychiatric bed for five days
Ms Cheung, 19, has had anorexia nervosa for three years and is admitted to a medical ward for 'medical stabilisation'. She is 1.64 m tall and weighs 38.0 kg (BMI 14.1). Observations: pulse 44/min, BP 88/54 mmHg, temperature 35.8 °C, capillary refill 3 seconds. Bloods: potassium 3.0 mmol/L, phosphate 0.72 mmol/L, magnesium 0.68 mmol/L, glucose 3.1 mmol/L, ALT 62 U/L. She refuses all food and the nasogastric feed the team has prescribed, saying, 'I'm fat and I'd rather die than be fat.' She can repeat back the risks of starvation and refeeding but says she does not want treatment. Her parents support treatment; there is no psychiatric bed for five days. The ward has one special nurse available for 1:1 observation and a policy that physical restraint requires a doctor's order and review every 15 minutes. The registrar asks you to 'just get the feed in'.
1. How should the nurse assess Ms Cheung's decision-making capacity, and what should happen if she is found to lack capacity?
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Assess, do not assume. Anorexia nervosa does not automatically remove capacity, and a low BMI does not by itself prove incapacity. Use the functional test for this specific decision (accepting food and nasogastric feeding) at this time:
- Can she understand the information - that starvation risks arrhythmia, refeeding risks a dangerous drop in phosphate, and that she may die?
- Can she retain it long enough to decide?
- Can she weigh it - does she appreciate how it applies to her, rather than reciting facts?
- Can she communicate a choice?
Her answers suggest she can understand and retain, but that her values are overwhelmed by the illness. Record her exact words and the nurse's questions; do not write 'lacks capacity' without evidence. Involve the psychiatrist urgently, and repeat the assessment if her condition changes.
If capacity is lacking: treatment may be given in her best interests, but the authority for feeding without consent must be established by the consultant psychiatrist with legal advice - do not assume that the Mental Health Ordinance or a parent's consent authorises it. Use the least restrictive option, involve her parents as her supporters, and keep her informed at every step.
If she has capacity: her refusal must be respected, and the team must work on engagement, risk management and rapid psychiatric transfer. 'Just get the feed in' is not an instruction a nurse can act on without a lawful basis.
2. Identify the refeeding risks in this patient and describe the nursing monitoring that must accompany any feeding.
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Why she is high risk: BMI 14.1, negligible intake for days, low potassium (3.0), low phosphate (0.72), low magnesium (0.68), bradycardia and hypotension. Refeeding syndrome can cause fatal arrhythmia and cardiac failure in the first days of feeding, even at modest calorie levels.
Start low and go slow. Feeding should begin at a low rate (commonly 5–10 kcal/kg/day in high-risk patients) as prescribed, with daily review; the nurse should question any order that starts at a high rate.
Monitoring:
- Electrolytes, phosphate and magnesium at least daily, and more often in the first week; report phosphate below the reference range immediately.
- Continuous or frequent ECG where available; watch for a prolonged QTc and bradycardia, and for arrhythmia.
- Observations four-hourly or more often: pulse, BP lying and standing, temperature, respirations, oxygen saturation.
- Capillary glucose; she is already at 3.1 mmol/L and needs a hypoglycaemia protocol.
- Daily weight, strict fluid balance, and watch for oedema, which can signal fluid overload and cardiac strain.
- Neurological checks - confusion, weakness, paraesthesia - and abdominal assessment for constipation or ileus.
- Thiamine before or with feeding as prescribed.
Document every refusal, every intake and every observation; the pattern is the evidence used to decide whether capacity and the treatment plan must be reviewed.
3. How should the nurse respond to the registrar's instruction to 'just get the feed in', and how should the next eight hours be managed?
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Respond with the clinical problem, not a refusal to help. For example: 'I can't feed her against her refusal without a documented legal basis. Can we agree the capacity assessment now, decide who is authorising treatment, and start a safe, low-rate feed while the psychiatrist comes?' This keeps the focus on the patient's safety and makes the gap in the plan visible.
Next eight hours:
- 1:1 special nurse as the least restrictive option; explain what she can and cannot do, and involve her in choices that are genuinely open (meal timing, food type, who is present).
- Escalate to the nurse-in-charge and the consultant psychiatrist; request an urgent review and ask what to do if she deteriorates before transfer. Put the request in writing in the notes.
- If restraint or nasogastric feeding is authorised, follow the policy exactly: doctor's order, indication, duration, review every 15 minutes, airway and vital-sign monitoring, dignity, and documentation of her response.
- Continue medical monitoring for hypoglycaemia, arrhythmia and dehydration; she is bradycardic and hypotensive.
- Inform her parents of the plan and of what is still undecided, without breaching confidentiality about the details she has asked to keep private.
- Complete an incident report if she is restrained or if treatment is delayed by bed shortages, and hand over the unresolved legal question explicitly.