An adolescent with severe anorexia nervosa refusing admission
A 17-year-old girl is brought to the child and adolescent psychiatry clinic in Sohar by her mother. Over eight months she has reduced intake to "one piece of bread and an apple" daily and exercises for three hours each night. Weight 34 kg, height 1.59 m (BMI 13.4). She has not menstruated for five months. Pulse 46/min, BP 88/54 mmHg, temperature 35.9 °C, capillary refill 3 seconds. Potassium 2.8 mmol/L, phosphate 0.72 mmol/L, and QTc 470 ms on ECG. She is alert, answers every question fully and lists the risks of starvation accurately, but says she "does not care if she dies" and refuses admission. Her father, a well-known local businessman, insists she be treated at home with Qur'anic healing first and does not want a psychiatric diagnosis attached to the family; her mother has signed nothing but privately asks you to admit her daughter. She is in grade 12 with final examinations in six weeks.
1. Assess her decision-making capacity and explain how, if at all, her status as a minor changes your approach in Oman.
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Capacity is decision-specific and assessed on four elements: understanding, retention, weighing in the balance, and communication of choice. She understands the information and retains it, and she can communicate a choice. The failure is at the level of weighing: her statement that she does not care whether she dies is not a values-based preference but a symptom of the illness, which has distorted her appraisal of risk and outcome. A refusal driven by the disorder is not an autonomous refusal, and the standard is not whether the choice seems wise but whether the reasoning process is intact.
Her age matters practically rather than conceptually. In Oman the age of majority is 18, so consent to treatment ordinarily rests with her parents or guardian. However, parental authority is not unlimited: where refusal of treatment carries a real risk of death, the child's best interests override parental preference, and clinicians may treat under emergency and best-interests provisions, seeking authorisation through the hospital ethics committee and, if the parents persist, the appropriate legal authority.
In practice: document the capacity assessment and its reasoning, obtain a second senior psychiatric opinion, record the parents' views, and avoid framing this as a contest of authority. Her mother's support should be recorded as consent from one guardian where the law and hospital policy permit, while continuing to work with the father.
2. State your immediate medical management priorities and give a practical refeeding plan with numbers.
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She is medically unstable: bradycardia 46/min, hypotension, hypothermia, hypokalaemia, hypophosphataemia, QTc 470 ms and BMI 13.4. She needs admission to a paediatric or medical ward with psychiatric liaison, cardiac monitoring, and bed rest with no exercise - not direct admission to a psychiatric ward.
Before feeding: thiamine and a multivitamin, correct potassium and magnesium, obtain baseline phosphate, magnesium, potassium, renal function and ECG, and insert a nasogastric tube only if oral intake cannot be established - in this situation nasogastric feeding is justified as life-saving treatment.
Refeeding: start at 10 kcal/kg/day (about 340 kcal/day) and increase by 5–10 kcal/kg every 2–3 days according to tolerance; target weight gain of 0.5–1 kg per week. Check phosphate, potassium and magnesium at least daily for the first week (twice daily initially), watch for oedema and fluid overload, and keep continuous cardiac monitoring while the QTc is prolonged; a QTc above 500 ms or any arrhythmia requires urgent cardiology input and consideration of higher-level care.
Do not restrict fluids excessively, do not feed by rapid escalation, and treat any fall in phosphate promptly. Refeeding syndrome, not starvation alone, is the commonest early iatrogenic cause of death in this group.
3. How would you manage the disagreement between the parents and plan the least restrictive safe disposition?
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First separate the clinical emergency from the family dispute. Explain to both parents, in simple terms, that their daughter's heart rate, blood pressure, potassium and ECG show she could die suddenly, that this is a medical emergency and not a moral or spiritual failing, and that treatment will begin today. Acknowledge the father's wish for religious healing rather than dismissing it: offer to involve a religious scholar or imam he respects to work alongside the medical team, which often changes the family's stance more effectively than argument, and make clear that spiritual support can continue in parallel with admission.
Record the mother's consent and the father's objection, obtain the second opinion and ethics committee review, and be explicit that if the parents continue to refuse life-saving treatment, the team will act in her best interests and escalate to the relevant legal authority. Do this transparently rather than by covert admission.
Least restrictive safe plan: a medical bed with one-to-one nursing, restricted visiting initially, a named liaison psychiatrist, and a clear explanation that the goal is to stabilise her medically and then begin family-based and individual psychological treatment. Address the examinations explicitly - arrange a school liaison plan so that continuing education is part of the treatment, not a barrier to it. Arrange follow-up for both parents and consider a family meeting with a cultural mediator.