P3.I169: Employing Primary Palliative Care Skills in Treatment of Hospitalized Patients with Anorexia Nervosa

Introduction: Anorexia nervosa (AN) is associated with high mortality rate with medical complications accounting for more than half of all deaths. Due to potential for severe medical complications, patients may require hospitalization for medical stabilization. Eating disorder (ED) behaviors can create challenges for medical care. Introduction of “terminal anorexia” to ED literature and news media has brought new attention to the importance of using primary palliative care (PC) skills to navigate goals of care (GOC) and decision making.

Case Description: 18-year-old female with history of AN and BMI of 12 was admitted for medical management of AN associated complications. NG feeds were initiated with management for severe refeeding syndrome. During admission, the patient objected to NG feeds and ethics was consulted for question of continuing NG feeds over patient’s objection with additional question of patient capacity for decision making. PC consulted to evaluate for decision making and in response to recent news media portrayal of PC involvement for “terminal anorexia.” Medical team also expressed concern for provider burn out in the setting of complex and challenging patient management.

Discussion: Ethics consult concluded it is ethically justifiable to provide feeding over patient objection when it is medically necessary to prevent imminent threat to health and life. The question of capacity for young adult patients with ED is difficult to navigate. Recent literature challenges the paradigm of involuntary treatment and emphasizes a role for harm reduction, acknowledging that some ED behaviors will likely continue, and focus should be on minimizing harm. Despite “terminal anorexia” appearing in ED literature, there is lack of consensus over what clinical characteristics would determine a patient to have terminal ED. Proponents argue that tenants of PC with focus on recovery “in” and not recovery “from” ED may improve quality of life, bolster resiliency and improve engagement with treatment. PC team supported pediatric providers to engage in primary PC skills of exploring GOC supporting the patient with a decision to allow NG feeds. Exploring GOC helps to create a therapeutic holding space, containing a patient’s oscillating feelings about the extremes of their illness, providing normalization and validation.

Conclusion: PC in psychiatry including ED treatment is still being defined. Efforts have been made to recognize the benefits of a PC approach more formally for patients with ED including, creation of a therapeutic holding space. This allows providers to empathize with patients and allows patients to face developmental tasks of trust and control. If patients can be treated without fear of threat or abandonment, they may integrate that trust and engage in more mature defenses and coping mechanisms even when hospitalized for exacerbation of their ED. This approach will also mitigate provider burn out in caring for complex patients.