ABSTRACT
Chapter 22 takes on the controversial topic of caring for the patient who declines treatment, when there is a significant risk of death. While virtually all patients with eating disorders resist treatment due to the ego syntonicity of these mental illnesses, some patients truly refuse recommended treatments and have a high risk for lethality, usually due to degree of malnutrition or purging. It is always appropriate to work within patients’ stated goals of care and try to motivate voluntary acceptance of recommended treatment. Parents wielding their financial leverage and holding boundaries with young adults can be vital. Guardianship may be pursued in those under 30 years old when patients lack medical decision making capacity and cannot take care of themselves. Civil commitments (or “holds”) and guardianship proceedings vary by state. Colorado’s mental health laws are particularly slanted towards saving lives rather than protecting autonomy. A civil commitment through the court system can be used when a patient is gravely disabled and requires admission to inpatient mental health care against their will. When a patient is older than 30, has been sick a long time, has not resolved their psychiatric symptoms despite high quality care and medications, and no longer wishes to pursue full recovery, various options exist: harm reduction, palliative care, and hospice care. The literature on severe persistent mental illness (SPMI) names anorexia nervosa as one diagnosis that should be considered for such approaches.
