A 16-year-old with severe anorexia who refuses to be fed
A 16-year-old girl is admitted to the paediatric ward after her mother found her collapsed at home. She weighs 34 kg and is 1.61 m tall (BMI 13.2). Over nine months she has restricted herself to 'a bowl of soup and an apple' a day and exercises for two hours before school, losing 19 kg. She has had secondary amenorrhoea for six months; her mother reports lanugo hair and constant coldness. Pulse 46 regular, BP 85/50, temperature 35.8 °C, cold peripheries, marked muscle wasting, no oedema. Sodium 128, potassium 2.9, phosphate 0.7, magnesium 0.65, alkaline phosphatase raised, QTc 468 ms. She is articulate, has read about refeeding syndrome, and says she understands she may die but will not eat and will not accept a nasogastric tube. She denies suicidal intent but adds that she 'would rather be dead than fat'. Her mother will agree to any treatment; her father insists she should come home and 'be given a chance'.
1. Is she competent to refuse treatment? Set out the capacity assessment and the legal and ethical route you would take.
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Capacity is decision-specific, not diagnosis-specific. Anorexia nervosa does not automatically remove capacity, but neither does an articulate explanation of risk prove it. Work through the four functional components for this specific decision - accepting nasogastric feeding:
- Understand: can she restate that her potassium is 2.9, her QTc is prolonged, and that starvation or refeeding can kill her?
- Retain: can she hold that information long enough to decide?
- Use and weigh it: can she compare the risks of treatment against the risks of refusal, or does the illness force the conclusion that weight gain is worse than death regardless of the evidence? This is where severe anorexia most often fails - the values used in the weighing are themselves disordered.
- Communicate: clearly intact here.
Record the assessment in the notes with the questions you asked. If she lacks capacity, treat in her best interests. She is 16, so she is a minor in most jurisdictions, including Iraq; her parents can consent to necessary treatment, but her father's refusal creates a conflict, so seek a second independent psychiatric opinion, involve the hospital ethics committee and legal advisers, and use the mental health legislation if it covers treatment of a mental disorder with risk to life. The test is necessity and least restriction: nasogastric feeding with 1:1 nursing, close electrolyte monitoring and sedation only if she physically resists. Involve her in the plan at every stage, keep the therapeutic alliance, and avoid framing food as punishment - coercive feeding saves lives but damages trust if handled without explanation.
2. Design the immediate medical and psychiatric management, including the refeeding plan and the drugs you would consider.
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Environment. Admit to a medical or specialist eating-disorder bed with 1:1 nursing, bed rest, no exercise, blind weighing, and supervision after meals and in the bathroom. Correct the hypothermia with warming and monitor cardiac rhythm given QTc 468 ms.
Refeeding - start low and go slow. She already has hypophosphataemia (0.7), hypokalaemia and hypomagnesaemia, so she is at high risk of refeeding syndrome. Begin at 5–10 kcal/kg/day, increase over 5–7 days, and give thiamine before any carbohydrate load, with a full multivitamin and phosphate, potassium and magnesium replacement according to protocol. Check phosphate, potassium, magnesium, sodium and calcium at least twice daily in the first week and daily thereafter; watch for oedema, tachycardia, confusion and cardiac failure. Fluid restriction is required for the hyponatraemia (128) - correct slowly to avoid osmotic demyelination.
Drugs. Low-dose olanzapine (2.5–5 mg at night) has reasonable evidence for promoting weight gain and reducing the intense anxiety around eating; use it cautiously with a prolonged QTc, monitoring the ECG, and be alert to hypotension and sedation. An SSRI alone does not reverse starvation and is best started after weight restoration if depression persists. Avoid bupropion and any drug that lowers seizure threshold. Treat the hypokalaemia before considering any QT-prolonging drug.
Psychiatric input. Daily review, a clear behavioural contract, family-based (Maudsley-style) work with both parents, and a dietitian-led meal plan. Involve the child and adolescent mental health team and plan a structured transition to specialist outpatient care; relapse after discharge is common.
3. The parents disagree with each other and the nursing staff are split. How would you manage the disagreement and the longer-term plan?
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Bring the conflict into the open rather than letting it obstruct care. Hold a single meeting with both parents, the paediatric team, psychiatry and the dietitian, with the clinical facts written down: BMI 13.2, potassium 2.9, QTc 468 ms, and the documented mortality of severe anorexia. Explain that home care is not a safe option at this weight, that her father's wish to 'give her a chance' is understandable, and that the offer is treatment in hospital, not punishment. Make it clear that the team is not asking permission to feed her but is asking them to support a plan that is medically necessary; if her father continues to object, the legal route and a second opinion are explained to him in advance, not sprung on him.
Manage the staff split. Nurses who feel coercive feeding is abusive need a debrief and a clear explanation of the legal and ethical framework; the plan should specify who does what, what to do if she refuses, and when to call the psychiatric doctor. Avoid splitting by assigning a named nurse and a single consultant.
Longer term
- Restore weight to a BMI of at least 18–19 before discharge; premature discharge predicts readmission.
- Family-based therapy is the best-evidenced treatment for adolescent anorexia; individual therapy focused on the eating disorder should be available if family work is not feasible.
- Treat comorbid depression, anxiety or OCD once nutrition is restored; monitor bone health and consider bone density assessment.
- Agree a written relapse plan with the GP and the family: weight thresholds, who to contact, and rapid re-referral.
- Record the capacity assessment, the disagreement and the reasoning; if the outcome is contested, the notes are the defence.