Compulsory treatment in grave circumstances

An update from a regular series written by Mr Robert Wheeler, director, department of clinical law, where he considers various aspects of clinical law that our nursing staff, medical staff and other professions rely on when caring for patients.

The case of D, a 12 year old girl, was recently reported. She had significant difficulty with food. Starting abruptly when she was ten years old, D suffered unremitting symptoms ascribed to gastroenteritis. It had not been possible to identify an organic cause following detailed and extensive investigation.

Whilst much of the multidisciplinary clinical evidence pointed towards a behavioural component to her condition, some of the conventional indicators of anorexia nervosa were not considered to be present, and the court dealing with her case emphasised the necessity to keep an open mind as to her diagnosis. The court report made no reference to the use of the Mental Health Act during the description of her management.

During a one month admission to hospital immediately prior to the court hearing, D had consistently refused to take food, and her life was considered to be at risk. The court initially authorised reasonable and proportionate restraint to achieve ‘force feeding’; it acknowledged just how distressing this was for D, her parents and those whose responsibility it was to achieve feeding in this way. Despite this regime, D continued to lose weight, more than 5 kg during the admission, leaving her at 27 kg.

The behavioural aspect of her condition touched on other areas of her clinical management. D resisted physiotherapy, mobilisation, dressing and toileting. One objective of D’s current hospital was to identify a specialised unit more suited to deal with the totality of her presentation.

Such a unit was found, and the court’s next step was to decide whether compulsory admission to and management within this unit was in D’s best interests. The judge was ‘entirely satisfied that the treatment proposed is in D’s best interests’ and unusually spelt out what ‘treatment’ entailed.

That stark description of the compulsion to be employed in treating this 12 year old, separated from her family, is disheartening, spelling out severe interference with her freedom. D is to be observed ‘at all times’; she will have daily showers; she will be encouraged to use the toilet; she will wear day clothing during the day. She will be fed by nasogastric tube, with restraint if necessary, and have a daily seating plan, prompted to move, and discouraged from remaining for prolonged periods in one position. Regular and frequent physical examination will be necessary, together with observations that monitor her personal care. Alongside all of this will be nursing and medical care, physiotherapy and both individual & family therapy. The overall emphasis, ironically, is to return D to independence.

The court recognised the ‘distraction’ caused by protracted litigation, and the clinical time spent in preparing for it. The judge sought to minimise this legal process, providing a fast track route back to himself, should the need occur.

Most clinicians can recall being twelve years old; we can feel our feet in D’s shoes. Equally, all of us have at some stage been involved in clinical management entailing a degree of restraint or compulsion. So consider for one moment how D must feel, faced with enduring the regime authorised by the court. Those who understand eating disorders, experienced in their management, tell us that this case simply demonstrates the reality faced by those suffering elusive and dangerous disease. And that these measures are necessary, proportionate to the risks D faces if left without treatment, representing the least restrictive option available to provide her with effective therapy.

Whilst that makes sense, it remains difficult for those who have no contact with these diseases to fully grasp their gravity, or the necessary draconian counter measures. One can only hope that D recovers, ultimately believing that the right steps were taken for her.

Robert Wheeler
Department of clinical law
October 2019