Navigating life-sustaining treatment decisions in anorexia cases

Cases involving life-sustaining medical treatment for patients with anorexia are amongst the most difficult for individuals, families, healthcare professionals, and judges alike. The recent case of Patricia, a young woman with severe anorexia, is the first eating disorder case in the Court of Protection where the court overturned an order preventing clinicians from administering compulsory treatment under the Mental Health Act 1983.

In this article, we consider Leeds and York Partnership NHS Foundation Trust v FF & Anor, a decision that provides a guide for future cases involving life-sustaining treatment in patients with severe, enduring psychiatric disorders, such as patients with anorexia. It sets out a framework for determining when enforced treatment should be withdrawn, particularly when it becomes psychologically damaging and clinically futile, emphasising patient dignity and autonomy alongside physical survival.

Case summary

This case centred around FF, a profoundly vulnerable young woman diagnosed with severe and enduring anorexia nervosa, coupled with an emotionally unstable personality disorder (EUPD). The Trust sought judicial approval to withdraw enforced clinical artificial hydration and nutrition (CANH), a form of life-sustaining medical treatment. The Trust’s position was that enforced treatment was no longer clinically indicated and was instead causing severe psychological trauma, presenting no realistic prospect of improving FF’s condition.

FF lacked the capacity to consent to or refuse medical treatment, and her condition had significantly deteriorated despite prolonged periods of enforced interventions, including physical restraint and chemical sedation. The clinical team, supported by FF's father (GG) and her litigation friend (the Official Solicitor), argued that continuing forced treatment caused extreme psychological distress and harm, negating any possible therapeutic benefit. The hearing focused on a request for authorisation of the cessation of enforced life-sustaining treatment, understanding that the consequence of this authorisation could realistically be FF’s death.

Legal analysis

The case addressed two crucial questions:

1. Best Interests under the Mental Capacity Act 2005

Under the MCA, the court evaluated whether continuing enforced CANH treatment was in FF's best interests. Guided by Aintree University Hospitals NHS Foundation Trust v James [2013], the court stressed that treatment must offer a realistic prospect of restoring or improving the patient's quality of life. While acknowledging the critical presumption of preserving life, the court also recognised circumstances where treatment might be excessively burdensome or futile.

In FF’s case, the court found that forced feeding involved severe psychological and physical trauma. The evidence highlighted FF’s clear opposition, and the profound distress caused, including her characterisation of enforced treatment as akin to sexual assault. The judge concluded that ongoing enforced treatment failed to provide meaningful therapeutic benefit, instead significantly exacerbating psychological harm. Consequently, despite the possibility that withdrawing CANH could lead to FF’s death, the court held that it was in her best interests to end enforced treatment.

2. Section 63, Mental Health Act 1983

The court conducted a full merits review regarding enforced treatment under Section 63 of the MHA, which ordinarily permits compulsory medical treatment without patient consent. Referring to established case law, such as Nottinghamshire Healthcare NHS Trust v RC [2014], the court emphasised the necessity of parties applying for a "full merits review" when decisions potentially impact a patient’s right to life under Article 2 of the European Convention on Human Rights.

The court concluded that enforced treatment under section 63 was inappropriate and no longer justified, given the substantial psychological harm it caused and its failure to provide a beneficial therapeutic outcome. This review was particularly important as there were no significant disagreements between the parties, yet it was essential for the court to independently verify the appropriateness of ceasing enforced treatment due to the grave potential consequences.

Roadmap for similar cases

This case offers a clear and essential roadmap for similar cases, outlining important principles and practical guidance:

1. Comprehensive assessment of futility and harm

Clinicians and Trusts must rigorously assess whether enforced life-sustaining treatment truly serves the patient's interests beyond mere survival. Treatments that cause profound psychological harm without significant prospects of improvement must be critically reviewed.

2. Patient dignity and autonomy

Even in cases where patients lack the capacity to consent, preserving dignity and autonomy remains central. Forcing treatment can infringe these fundamental human rights if it leads to significant psychological trauma, outweighing physical benefits.

3. Early and independent expert involvement

Prompt involvement of an independent psychiatric expert is strongly encouraged. Early expert advice can significantly assist the court in objectively evaluating complex clinical decisions, particularly in cases involving prolonged mental health treatments with limited success.

4. Procedural clarity

When judicial review of enforced treatment decisions under the MHA intersects with best-interest evaluations under the MCA, clear procedural distinctions should be maintained. MCA issues should be addressed through Court of Protection proceedings, while MHA declarations should ideally be pursued via Part 8 Civil Procedure Rules.The judge explained that:

“whilst the Court of Protection application is issued to deal with capacity or best interest issues, a Part 8 claim form is also issued to deal with the declaration separately in respect of section 63 of the Mental Health Act 1983.  There is no need for anything further to be done other than that claim form to be served, and for that Part 8 claim form to note the evidence and background set out in the Court of Protection.”

Key takeaways

This case reinforces several learning points for mental health providers operating in the NHS and private sector managing similar clinical scenarios, including:

• Assessing treatment futility: Clinical futility should be evaluated holistically, incorporating psychological harm alongside physical impacts. Sustaining life alone does not justify treatments causing severe psychological trauma.
• Human rights integration: Treatment decisions must thoroughly consider and integrate fundamental human rights, notably Article 2 (Right to Life), Article 3 (Prohibition of Inhumane Treatment), and Article 8 (Right to Respect for Private Life), ensuring patient rights and welfare are protected comprehensively.
• Supporting staff and patients: Recognising the intense psychological toll cases can have on clinical staff is critical. Providers should proactively manage staff welfare, particularly when treatment involves repeated physical or chemical restraint and generates high stress levels.
• Ethical decision-making: Ethical considerations must be explicitly documented, transparently debated, and thoroughly evaluated, particularly when decisions could result in the patient's death. Dedicated best-interest meetings, clearly documented, assist in ensuring decisions are carefully considered and justified.

Comment

This case reinforces the need to carefully balance the imperative to preserve life with the responsibility to prevent serious psychological harm. By advocating for a patient-centred approach that avoids futile and harmful interventions, the court provides a clear legal framework for similar cases.

If you’d like to discuss any of the issues raised here or have a similar case you require support with, please contact Leah Selkirk.