Guidelines published by the Royal College of
Psychiatrists (RCPsych) and the Royal College of Physicians (RCP)
hope to reduce the number of avoidable deaths of patients with
severe anorexia nervosa on general medical units.
The guidelines are aimed at all medical, nursing and dietetic
staff working in hospitals to which a patient with severe anorexia
nervosa could be admitted. They provide advice on the physical
assessment of patients, required members of the in-patient medical
team, the use of mental health legislation, and advice for
commissioners on required services for this group of very ill
The guidelines have been produced by the
MARSIPAN working group, which stands for the MAnagement of Really
SIck Patients with Anorexia Nervosa. The group was established in
2008 because of serious concerns over the number of deaths of young
people with severe anorexia on general medical wards. Some died
from medical complications such as pneumonia. Others died from,
re-feeding syndrome (RFS) when food intake is increased too rapidly
after weeks of starvation, or from “underfeeding syndrome” when
nutrition intake is increased too slowly.
Most people with severe anorexia nervosa
should be treated on specialist eating disorder units (SEDU).
However, they may be admitted to a medical ward if a SEDU bed is
not available, or if they need treatments that are not available on
a psychiatric ward such as intravenous infusions or artificial
ventilation. Anorexia nervosa has one of the highest mortalities of
any psychiatric condition, and some deaths are inevitable. But
patients admitted to medical wards are often at high risk and may
not be seen by staff with specialist knowledge.
The guidelines make 9 key recommendations
- Physical risk assessment in
these patients should include body mass index (BMI), physical
examination, including muscle power, blood tests and
- The in-patient medical team
should be supported by a senior psychiatrist, preferably an eating
- The in-patient medical team
should contain a physician and a dietician with specialist
knowledge in eating disorders, preferably within a nutrition
support team, and have ready access to advice from an eating
- Key tasks of the in-patient
medical team are to: safely refeed the patient, avoid re-feeding
syndrome, avoid underfeeding syndrome caused by too cautious rates
of re-feeding; manage, with the help of psychiatric staff, the
behavioural problems common in patients with anorexia nervosa, such
as sabotaging nutrition and arrange transfer to a SEDU without
delay as soon as the patient can be managed safely there.
- Health commissioners should be
aware of the often inadequate local provision for patients, and
ensure medical, nursing and dietetic staff on acute services are
adequately trained and resourced.
The guidelines are accompanied
by a one-page
quick reference guide summarising the key points for hospital
staff to remember when treating people with severe anorexia.
Dr Paul Robinson, executive member of the
RCPsych Eating Disorders Section and chair of the MARSIPAN group,
said: "Tragic deaths of people who are often young, occur too often
in medical wards. Avoiding these events is only possible when
medical and psychiatric teams work together so that the physical
and psychological problems faced by such patients are addressed
simultaneously. The MARSIPAN report represents a very
important initial stage in this process. Disseminating its advice
and providing education to clinical staff in primary care, medical
units and psychiatric, including eating disorder services, are now
necessary to make sure that life threatening complications of
eating disorders are, in future, adequately managed."
RCP Registrar Dr Patrick Cadigan said:
"Doctors working in the acute medical setting need to be aware of
the major challenges posed by this extremely ill group of patients.
These guidelines provide vital information for physicians on how to
manage the physical aspects of care, and remind them of the need to
seek specialist medical, dietetic and psychiatric advice."
The guidelines have been endorsed by four other organisations
including beat, the eating disorders charity. Beat chief executive
Susan Ringwood said: "We welcome these guidelines as we know how
important it is to assess and manage the physical aspects of this
serious mental illness. From our daily contact with families, we
are aware of the risks that arise when someone needs urgent medical
care and no specialist eating disorders support is available –
risks that too often end with tragic results. The MARSIPAN
guidelines will make an important contribution to avoiding
preventable deaths of people seriously ill with eating
For further information, please
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Royal College of Psychiatrists and Royal College of Physicians of London (2010) MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa – Report from the MARSIPAN group (College Report CR162). Royal College of Psychiatrists.
Note to editors:
The MARSIPAN report is published jointly by the Royal College of Psychiatrists and the Royal College of Physicians of London. It is endorsed by: beat; the British Association for Parenteral and Enteral Nutrition; the Intercollegiate Group on Nutrition; the Specialty Advisory Committee on Clinical Biochemistry of the Royal College of Pathologists.