Clinical scenario

You are a trainee with the local Child and Adolescent Mental Health Service (CAMHS) team and are joining the consultant psychiatrist reviewing a 14-year-old female patient who is currently on a local paediatric ward in England. The patient was referred to her local CAMHS team 9 months ago, presenting with self-harm and anxiety. Initially, she engaged well with CAMHS and was working to reduce her self-harm.

Three months ago, her CAMHS team noted that she was losing weight and voicing anorexic cognitions (such as wanting to be thin and thinking she was fat), and she subsequently was assessed by the eating disorders CAMHS team 2 months ago and diagnosed with atypical anorexia nervosa, as her weight on assessment was above the normal range (115% median body mass index (BMI)). Family-based treatment was started but, over the past 8 weeks, she has continued to lose weight as her parents have found it difficult to engage in this treatment because they view her weight loss positively and do not think her eating is a problem at present. However, in the past week, the patient's family have reported that she is no longer eating at home and has lost more weight, fainted twice and is only drinking a cup of water a day. The patient has lost 8 kg in the past 5 weeks and is now at 92% median BMI (approximately 25th centile). She is saying that she would rather die than eat. Her parents, having previously felt that an admission was not needed, now feel that it is, and she was admitted 3 days ago. She has continued to refuse to eat or drink, pulled out her cannula for intravenous fluids this morning and is refusing nasogastric tube (NGT) feeding.

There are concerns around her deteriorating physical health: her pulse is 39 beats per minute in the day and 29 beats per minute at night, her temperature is 34.7°C, her electrocardiogram shows an elongated corrected QT interval at 460 ms and her biochemistry is showing that her kidney function is compromised owing to dehydration. The eating disorders team have made a referral to the local adolescent mental health unit; however, there is a waiting list for an admission and there are no other beds available nationally. Furthermore, the nurses at the adolescent mental health unit say they cannot nurse anyone who is not medically stable.

Summary box

Questions to consider:

• • How can we safely refeed and rehydrate a young person who is refusing nutrition and fluids?

• • What are the legal and ethical considerations this case brings?

• • What support is needed to safely manage this patient's admission to the paediatric ward?

Current literature

To date, there has been little research regarding NGT feeding under restraint in mental health patients, and there is a significant gap in the research regarding nursing, pharmacological or psychiatric approaches to NGT feeding under physical restraint. Papers have highlighted the patient groups that may require this intervention,^{Reference Clausen and Jones1,Reference Neiderman, Farley, Richardson and Lask2} and there are dietetic guidelines regarding how practice can be modified in line with the legal principle of least restrictive practice.^{Reference Fuller and Philpot3,Reference Falcoski, Philpot, Tan, Hudson and Fuller4} One paper highlights the potential traumatic risks of compulsory treatment, and although it does not specifically focus on NGT feeding under physical restraint, it does reflect that these patients, once fully recovered, are often grateful for compulsory treatment and all that it entailed.^{Reference Tan, Stewart, Fitzpatrick and Hope5} One qualitative paper has focused on trying to understand the meaning of NGT feeding in patients with anorexia nervosa, although again this was not specifically in relation to NGT feeding under physical restraint, and this revealed that it could mean different things for different patients.^{Reference Halse, Broughtwood, Clarke, Honey, Kohn and Madden6} Broadly, NGT feeding could be characterised as an unpleasant experience, a necessary and helpful intervention, a signifier of anorexia nervosa or a reflection of the struggle of control during treatment.^{Reference Halse, Broughtwood, Clarke, Honey, Kohn and Madden6} Research also suggests that NGT feeding as an intervention for patients with anorexia nervosa carries the risk of self-sabotage and non-adherence in up to 30% of patients.^{Reference Kells and Kelly-Weeder7}

Considerations and reflections

Ethical considerations

From an ethical point of view, there are many different considerations that need to be balanced in every decision to feed under restraint. Many young people who are highly distressed may also be impaired in their competence to make treatment decisions, as are some patients with severe eating disorders and malnutrition. In eating disorders, competence is often specific to treatment decisions, which will potentially cause weight gain, with patients otherwise perfectly capable of making other decisions. A calm, considered and compassionate approach can increase the chance of a peaceful resolution, as can patients having trusting relationships with clinicians and families.¹³

Every patient has a right to be heard and express their wishes, irrespective of whether their decisions are made competently.¹⁰ Regardless of competence, the MHA can be used in England and Wales to override treatment refusal. At the same time, care needs to be taken to respect autonomy as much as possible and inform the patient of what is planned, and care is needed to use the least restrictive measures possible and minimise repeated use.

Patient dignity and respect must be prioritised, especially in carrying out such intrusive and uncomfortable procedures. This can take the form of giving the patient adequate warning of each impending feed, and maximal choice and support to decide to eat or drink to avoid feeding under restraint altogether; ensuring it happens in a private place away from other patients; careful explanation of each step of the process before it is done; using minimal force or restraint, and provision of sedation if this is helpful to reduce distress or the patient wishes it.

There must always be enough trained staff to carry out the process safely, competently and kindly, and they should work well together to deliver it. NGT feeding under restraint must never be punitive or routine; it should always be the last resort in a situation of necessity, done calmly and efficiently to minimise restraint. Although this intervention is a highly distressing event for all, it can be necessary to save life, and protecting life is a paramount consideration enshrined in the European Convention of Human Rights as the right to life, which is particularly important in legal minors for whom welfare is paramount.^10,14–16

Parents can be distressed and may feel helpless or angry in situations where there is refusal of food and drink and coercive feeding is needed, and experience a mixture of fear for their child's life and horror at the use of coercive feeding. Use of the MHA and delivery of the feeding by competent clinicians can be a relief to parents, and indeed patients themselves, if the message that is conveyed is ‘we care, and we will not let a young person die’, which can relieve the young person and parents of the responsibility for the decision to eat or not eat. Patients and parents do appreciate compulsory treatment, despite objections, when they understand that treatment is being done to save life and is in their best interests.^{Reference Tan, Stewart, Fitzpatrick and Hope5} The intrusiveness of the process means that it can be unfair for parents to be asked to make decisions that may earn them the lasting resentment of their child or damage relationships. If coercion is needed, it is more appropriate that this is done dispassionately by clinicians under direction of a psychiatrist or paediatrician who can assume the role of the ‘bad guy’, by taking responsibility for the compulsion in this emotionally fraught scenario. For restrictive and coercive measures such as NGT feeding under restraint, honest acknowledgement should be made of the traumatic and distressing experience it can be for patients, parents and staff. All three groups may need support and the opportunity to debrief and address their feelings both at the time and after.

Expert by experience reflection

Informed and written consent has been obtained from our expert by experience: ‘Although I don't remember the event clearly, I was NGT fed under resistant as a 17-year-old on an eating disorders unit. It was horrible to have part of my free will stripped away from me, but looking back, there were no alternatives. I was too unwell to think logically, I'd completely given up and didn't understand or care what the consequences were. Eight years on, I'm grateful. I'm in my second year of studying medicine and have been fully recovered from anorexia for years.

It terrifies me to think of how bad the situation now is that children are being NGT fed under resistant on paediatric wards, which must make an already traumatic experience even worse.’

Clinician reflection from a specialist eating disorders dietitian

‘Previously, we had never needed to NGT feed a patient under physical restraint on our paediatric wards, thinking it was something that only happened in mental health in-patient units. Sadly, during the COVID-19 pandemic, we have experienced this with an increased number of patients.

As a team, we felt a shared sense of relief that our patient was finally receiving the appropriate, lifesaving nutrition and fluids that they needed. This gave us hope. Hope that it would help the patient break out of the starved state and be able to engage in treatment. At the back of everyone's mind is the concern that our patient may die.

The decision-making process, however, would often take time and cause anxiety among our team, the paediatric team, the patient and their family. There are risk frameworks to help identify who may need admission to the wards, but this does not state at what point a patient's life is at such risk that we need to consider this lifesaving intervention.¹⁷ Different clinicians have different thresholds of when to act. Once the decision was made, having the patient assessed under the MHA takes time, leading to further anxiety around the patient's deteriorating medical state. Then, the logistics become an issue, resulting in frantic calls to agency staff who are trained in physical restraint, to ensure the intervention was carried out safely.

Physically restraining children and young people is not common practice on paediatric wards, and the staff often report how difficult the experience was for them’.

Practical considerations