Tumba Jenny, Smith Megan, Rodenbach Kyle E
From University of Wisconsin, Department of Psychiatry (Dr. Tumba, Dr. Rodenbach); Adventist Health, Department of Behavioral Health, Clearlake, CA (Dr. Smith).
Harv Rev Psychiatry. 2023;31(1):14-21. doi: 10.1097/HRP.0000000000000355.
After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN.
Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.
完成本活动后，从业者将更有能力：
• 讨论越来越多的文献强调对严重且持续性神经性厌食症（SE-AN）患者采取适度和减少伤害的方法
• 概述并讨论住院治疗提供者在治疗SE-AN患者时面临的法律、伦理和医学挑战。
严重且持续性神经性厌食症（SE-AN）患者给医院精神科医生带来了众多临床和伦理挑战。患者通常在严重的医疗失代偿状态下入院。急性医疗稳定期的常见困难包括对决策能力和拒绝治疗权利的评估，以及在患者反对的情况下给予人工营养方面涉及法律复杂性的决策。急性医疗稳定后，精神科会诊医生必须决定是否需要精神科住院继续治疗，如果需要，是否需要非自愿住院治疗。这些情况下的护理标准尚不清楚。诸如缺乏专门治疗的适当设施等实际问题很常见。如果非自愿住院未获批准或未实施，在确定是否、何时以及如何让姑息治疗会诊医生参与以指导进一步管理方面可能会有困难。这些案例很复杂，很大程度上处于医学法律和伦理的灰色地带。本文讨论了与这些案例相关的困难，并支持越来越多强调对SE-AN患者采取适度和减少伤害方法的文献。同时也讨论了医生协助死亡（PAD）。
