Sixteen-year-old with severe anorexia nervosa: refusal, divided parents, no local bed
A 16-year-old schoolgirl is brought to the eating disorders clinic by her parents. She has lost 14 kg over eight months and now weighs 38 kg at 165 cm (BMI 13.9). She restricts to two small meals a day, runs 8 km each morning before school, and vomits after dinner three or four times a week. Pulse is 48/min, temperature 35.8 C, capillary refill 3 seconds, potassium 2.8 mmol/L; she has lanugo hair and cold, mottled hands. She says she is fat and that she will eat at home if she is allowed to leave. She refuses nasogastric feeding and says she will stop speaking to you if her parents are told about the running and vomiting. Her parents disagree with each other: her mother believes the school is to blame, her father wants to take her home and try Ayurvedic treatment, and both say the previous admission three months ago (from which she discharged herself after two weeks) did no good. There is no child and adolescent inpatient bed in your unit and the nearest one is 220 km away.
1. How would you structure the family meeting, and what specifically would you say to the patient and to each parent?
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Structure first, content second otherwise the meeting becomes a blame contest.
- See her alone first. Build an alliance, take her own account, explain exactly what you will share and why. Confidentiality is conditional on safety, and she should hear that from you before her parents do.
- Then a joint meeting with a clear agenda: what everyone agrees on (she is unwell, everyone wants her home), the medical facts with numbers (BMI 13.9, pulse 48, potassium 2.8, temperature 35.8, 14 kg lost), what treatment involves, and what is not negotiable (medical monitoring and electrolyte correction).
- Externalise the illness. Say that the anorexia is driving the running and vomiting, not that she is being difficult; this lowers defensiveness in both her and her parents.
- To the father: Ayurvedic treatment can be discussed as an adjunct, but it cannot substitute for correcting potassium and monitored refeeding; negotiate timing rather than dismissing his belief.
- To the mother: acknowledge that school stress is real without agreeing it caused the illness.
- To her: be explicit that you will not bargain about medical safety, but will give her real choices within it, menu, who sits with her at meals, phone contact with friends, and when her parents are told.
2. What will you disclose to her parents against her wishes, and how do you justify it? Walk through the capacity assessment you would document.
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Disclose the running and the vomiting, and nothing beyond what safety requires. These are core risk information, not gossip: they change the physical risk (arrhythmia, dehydration, refeeding syndrome) and change the treatment plan. Tell her beforehand what you will say, offer to be in the room when she tells them, and do it within the same session so it does not feel like a betrayal discovered later.
Capacity assessment to document: Does she understand that BMI 13.9 with potassium 2.8 can cause a fatal arrhythmia and that refeeding needs monitoring? Can she retain and weigh that information, and does she appreciate it applies to her rather than in the abstract? Can she communicate a consistent choice? Her statement that she will eat at home is a bargaining position, and the previous self-discharge after two weeks is direct evidence that her stated plan does not hold. On that basis, record that she lacks capacity for this particular decision, that her refusal of monitoring cannot override a life-threatening risk, and that her parents consent to admission in her best interests, using the relevant legal route for a minor in your jurisdiction. Record who was consulted, what was offered as the least restrictive option, and the review date.
3. She meets criteria for inpatient medical stabilisation but the only specialist bed is 220 km away. What do you do, and where is your threshold for compulsion?
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Distance is a system problem, not a clinical one, so do not convert it into a discharge decision. Thresholds for admission here: pulse under 50, potassium under 3.0, hypothermia, rapid weight loss, purging, BMI under 15, poor insight and previous disengagement, she meets all of them.
Options in order of preference: admit to a paediatric or medical ward under your liaison cover with a written feeding and electrolyte protocol, cardiac monitoring and one-to-one meal supervision while a specialist bed is found; arrange escorted ambulance transfer if the specialist unit can accept within days; use the bed bureau and child and adolescent mental health escalation to a named person. Sending her home with a follow-up appointment is the one option that is not defensible, and if the family takes her home against advice, that is a child protection matter.
Before any feeding: phosphate, magnesium, potassium, ECG, thiamine, and a low-start, slowly advancing regimen with daily electrolytes, because refeeding syndrome is the predictable iatrogenic death. Document best-interests reasoning and the second opinion you sought, and involve the medical social worker for the transfer and the family's finances.