The case of Cheshire & Wirral Partnership NHS Foundation Trust v Z recently considered this issue. It is the second such case in 12 months.
Patients who have a diagnosis of anorexia, may well refuse treatment which would be aimed at increasing their BMI. Detention under the MHA enables a clinical team, to treat anorexic patients by force (using restraint) if it is deemed necessary. This case considered this issue in more detail.
From the age of 15 Z had been diagnosed with severe anorexia. For 31 years she had not engaged with treatment in any substantive way so had a very low BMI. She had also developed severe osteoporosis and had a low white blood cell count. Her condition was described as “severe and unremitting” and at times “life threatening”.
Mr Justice Hayden had to consider what the most appropriate treatment plan was for Z, given that she lacked capacity to be able to make any decisions around treatment for her anorexia.
Options before the court included:
- Treatment under section 3 MHA – this would involve naso-gastric feeding under physical restraint to enable her weight and physical health to improve, to a point where she could be discharged.
- Treatment under section 3 MHA – given Z’s likely objections, the feeding could be undertaken under chemical sedation.
- Treatment as a voluntary patient, if Z were to engage in the treatment plan.
The court was assisted with expert evidence from Dr Glover to consider all three options. Dr Glover considered that this level of eating disorder fell at the most serious end of the spectrum of gravity: so, if zero was the least serious and ten the most, this case was a ten.
Disadvantages of each option were considered:
Option 1: Extremely difficult to deliver, Z would seek to pull the tube out, three members of staff needed to carry out the necessary restraint, psychological distress and significant musculoskeletal injury.
Option 2: Risk of respiratory or cardiac arrest with sedation and still a risk that Z would seek to pull the tube out.
Option 3: A palliative care option too.
Z had been under the care of her responsible clinician, Dr Cahill since 2011 so the court was provided with a very detailed knowledge of Z, her presentation and how she engaged with her treating team and in what circumstances. The evidence before the court, from the Trust and the Official Solicitor was that Z wanted to go home to live with her parents where she felt she would be able to survive. The Trust also indicated that Z’s emotional well-being would benefit from not feeling as though she were being subjected to treatment and that this may enable her to engage in some way.
The court sat on 30 December 2016 to consider the case. Option three was concluded to be the least worst option. It was the only option to carry any vestige of hope and most effectively preserved Z’s dignity and autonomy.
What to take away
We have seen a shift in the way courts approach such treatment cases. They do not just focus on clinical evidence but also consider the broader picture of the individual’s life, family involvement and wider interactions with others in order to make their decision. It is important, where you are faced with patients who present with similar treatment issues, that you undertake a full and detailed review of how each option would be managed. As well as ensuring the treating team are involved, you should include the patient, advocate on behalf of the patient, family members and/or carers in discussions and, if necessary, obtain a second opinion or expert opinion to assist in developing a treatment plan.
If you would like any advice in relation to treatment under the MHA, issues around the Mental Capacity Act or applications to the Court of Protection, please contact me or a member of the team.