Treating anorexia in intensive care

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.

LV was twenty, an inpatient for more than two years in a unit specialising in eating disorders. An ‘…academically ambitious and intelligent’ woman, she was detained under s3 of the Mental Health Act 1983. Her diagnoses included anorexia nervosa, severe depression; and anxiety. By the time of the court hearing she was ‘extremely unwell.’ She had to be restrained for nasogastric feeding twice a day, a process requiring seven staff. However, she had learnt to regurgitate her feed as it was being delivered; and vomit the remainder of the feed once the forced feeding ended. Her body mass index was 11. The court was told that in the absence of an effective intervention, she would soon die. Set out graphically in court; ‘Is she at risk of collapse by heart attack and death if she walks from one end of the ward to the other briskly? Yes.’

‘Could that happen this afternoon? Yes.’

The hospital sought orders from the court providing ‘…for LV to be admitted to an intensive care for a period of feeding under sedation.’ The judge was told that LV ‘…lacks capacity to make a decision between the options for life-saving treatment, as she is not able to weigh the information for the decision that needed to be made.’ Furthermore, that ‘…In combination both the anorexic cognition and the effects of starvation on her brain are such that LV is affected by an impairment of her mind.’ The court noted that feeding under sedation was ‘…most unusual and there is good reason why it is regarded as an option of last resort…a long period of deep sedation or anaesthesia is not a benign experience.’ The judge acknowledged that the experience of ‘ICU delirium’ associated with the proposed treatment might add to the overall burden of LV’s illness.

Reviewing LV’s engagement with home and family, Mrs Justice Morgan found that LV had been planting seeds and completing projects for her family; and asking for more materials for future ventures; ‘Planting seeds to grow plants and, more significantly, returning to water and check on growth on future visits is entirely irreconcilable with someone with no interest in the future.’ Acknowledging that these were small indicators of optimism for the future, capable of being over interpreted, these nevertheless provided some context when considering LV’s repeated expressions of a wish to die. Ultimately, an ‘…intolerable affront to her autonomy had to be balanced… against imminent death.’ For this reason, it was held that it was in LV’s best interests to proceed with treatment.

The nature of the application by the two hospital Trusts, seeking declarations that LV lacked capacity, and that forced feeding was in her interests reflected their anxiety that this might not be a clinical situation that could be legitimised by treatment within the Mental Health Act 1983. Nasogastric feeding, along with necessary restraint, is often provided under Part 4 of the MHA; this arrangement has not been displaced by the advent of the Mental Capacity Act 2005 and could in principle have been provided within an intensive care setting. But the question as to whether in LV’s grievous situation, the MHA 1983 provided the most appropriate framework, was entirely different. Legal commentators have welcomed the opportunity given to the Court of Protection to review this case. To ensure that LV’s interests were protected by the State.

St George’s University Hospital NHSFT & Anor v LV [2025] EWCOP 9 (T3)

Mr Robert Wheeler
Department of clinical law
March 2025