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In part II of this Psychcast Masterclass, Patricia Westmoreland, MD, returns to discuss severe, enduring eating disorders, including management and ethical questions.
In Dr. RK this week, Renee Kohanksi explores the impact of censorship and self-censorship.
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By Jacqueline Posada, MD, 4th-year resident in the department of psychiatry & behavioral sciences at George Washington University, Washington.
Patricia Westmoreland, MD, forensic psychiatrist at the University of Colorado Denver, Aurora; attending psychiatrist for Eating Recovery Center, Denver; adjunct assistant professor of psychiatry at the University of Colorado Denver.
Dr. Westmoreland spoke at the American Academy of Clinical Psychiatrists 2019 annual meeting in Chicago, sponsored by Global Academy for Medical Education (GAME). GAME and the MDedge Psychcast are owned by the same company.
Harm reduction, palliative care, and futility
- Harm reduction model: A focus on returning to reasonable level of functioning without focus on full weight restoration, especially if full weight restoration has not proven sustainable with previous treatment.
- Harm reduction is managed an as outpatient with regular check-ups. Team collaborates for attainable, mutual treatment goals.
- Patients are allowed to stay at a lower body mass index (BMI) and are able to partially function and do things they enjoy, such as living with family and working part time.
- Patients maintain an agreed-upon weight and regularly check labs.
- Inpatient hospitalization is pursued only to restore weight back to previously agreed-upon goal:
- BMI is a marker of risk; BMI greater than 15 kg/m2 is lower risk, and BMI less than 13 kg/m2 is higher risk (lower BMI is tied to higher immunocompromised risk, more fractures, and other illnesses, as well as a greater risk of suicide, etc.)
- Palliative care is offered when patients have failed harm reduction and cannot sustain an acceptable body weight (not weight restored):
- Palliative care is NOT hospice, and therefore, there are no specific expectations.
- Treatment goal is comfort care, i.e., analgesics for fractures and decubitus ulcers, anxiolytics for refractory anxiety.
Ethics and futility:
When to say “enough is enough”? In anorexia nervosa (AN), frequently, many treatments have been implemented, and there may be no cure.
- Some think that anorexia should never be an end-stage diagnosis.
Cynthia Geppert, MD, MPH, a health care ethicist and a professor of psychiatry and internal medicine at the University of New Mexico, Albuquerque, who wrote in the American Journal of Bioethics: “Futility and chronic anorexia nervosa: A concept whose time has not yet come,” argues against futility:
- AN does not meet the definition of a terminal illness:
- The patient’s depleted weight renders a patient as having a life-threatening illness.
- Can a patient be terminal and is care futile if there is hope for long-term recovery?
- Legally: Cognitive distortions make up the core of AN as an illness. Do patients with AN have the capacity to decide that further treatment is futile?
- Cognitive impairments often normalize with treatment. Are physicians obligated to treat first in order to restore a patient’s decision-making capacity before allowing them to choose palliative care?
- People with AN may lack capacity because they cannot appreciate the consequences of their decision, which is one of the four components of capacity.
In support of futility, Cushla McKinney, PhD, of the biochemistry department at University of Otago (New Zealand), argues against the complete rejection of the concept of futility, saying it risks forcing a small and chronic group of patients into an intolerable situation.
- Arguments for futility: Not EVERY individual with AN lacks capacity.
- Some argue for futility and allowing patients to make choices in line with what they value in life.
- Prognosis, even with treatment, is poor, especially for older individuals with years of failed treatments and medical comorbidities.
- Are we doing harm by forcing an invasive treatment that patients don't want – especially after much treatment?
Illustrative case of AG, a 29-year-old female with chronic AN, who had a guardian for medical decision making:
- The guardian had decided in favor of tube feedings many times; AG had suffered complications such as heart failure.
- AG wanted to enter palliative care, arguing that she did not want to die, but if death were the result of AN, then “so be it.”
- The judge ruled she could refuse treatment. He did not comment on capacity, but ruled she could make this decision to die on her terms.
Is anorexia nervosa an end-stage illness or not? How will physician aid-in-dying overlap with AN? Do eating disorder patients have the capacity to request aid-in-dying, and what is the physician obligation?
Eddy J. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. Clin Psychiatry. 2017 Feb;78(2):184-9.
Sjostrand M et al. Ethical deliberations about involuntary treatment: Interviews with Swedish psychiatrists. BMC Med Ethics. 2015;16:37.
Geppert C. Futility in chronic anorexia nervosa: A concept whose time has not yet come. Am J Bioethics. 2015. 15(17):34-43.
Cushla M. Is resistance (n)ever futile? A response to “Futility in chronic anorexia nervosa: A concept whose time has not yet come,” by Cynthia Geppert. Am J Bioethics. 2015 Jul 6. 15(7):53-4.