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The Royal College of Psychiatrists has commented on the use of palliative care for eating disorder patients following a series of recent reports on the subject in the media and on social media.
Dr Agnes Ayton, Chair of the Eating Disorders Faculty at the Royal College of Psychiatrists, said:
“Anorexia nervosa is not a terminal illness but it is still an extremely serious mental health condition with a higher mortality rate than any other mental illness.
“It’s troubling to learn that eating disorder patients have been offered palliative care, but we don’t have enough evidence to suggest this is becoming a trend.
“Offering palliative care may be appropriate if an individual has a physical co-morbidity; however, we would be deeply concerned if this started to be considered clinical practice for anorexia nervosa, for which treatment can help individuals recover. While some patients are less responsive to treatment than others, that does not mean they cannot recover now or in the future. Emerging research into the biological causes of anorexia may lead to new treatment methods down the line, which is why we urgently need more funding to support this research.
“The College has issued Medical Emergencies in Eating Disorders guidance which is aimed at making preventable deaths a thing of the past. It provides clinicians with the tools they need to effectively manage the physical, nutritional and psychiatric care of eating disorder patients. NHS trusts and ICBs must now make a commitment to implement this guidance. This will involve training and commissioning appropriate services.”
Sean Horstead, assistant coroner for Cambridgeshire and Peterborough, concluded on 6 November 2020 after the inquest of five deaths that NHS treatment for anorexia patients is "not a safe system" and risks "future deaths". Mr Horstead’s statement mirrors the Parliamentary Health Service Ombudsman language in 20171: “Ignoring the alarms: How NHS eating disorder services are failing patients.” The verdict was widely reported in the media, and many patients and campaigners discussed it on Twitter, agreeing that NHS treatment for eating disorders is a postcode lottery and often woefully inadequate for adults.
As the Chair of the Faculty of Eating Disorder Psychiatry and a frontline clinician, who has been working with people with severe eating disorders over the last 20 years, these tragedies and conclusions deeply sadden me.
The PHSO made several helpful recommendations three years ago, including improving medical education, improving the workforce and the funding of services across the age range, and strengthening coordination of care.
Unfortunately, there has been limited progress since. Despite the efforts of the Faculty of Eating disorders working with the General Medical Council (GMC) and the Academy of Medical Royal Colleges (AOMRC), undergraduate and postgraduate training of doctors remains woefully inadequate (0-2 hours of eating disorders teaching in 10-16 years of training for a disorder that affects 6% of the population). Nursing and psychology training similar. We have recently published our position paper about improving medical education,2 and will continue campaigning for improvements.
Scientific papers often start with the sentence that anorexia has the highest mortality of any mental disorder affecting young people and adults.3 4 The truth is that people should not die of anorexia or any eating disorders, and certainly not in hospitals. Malnutrition is safely reversible, even in the most extreme cases. Several countries have reported improved outcomes on a population level, showing that this is achievable.5 The Royal College of Psychiatrists first issued the Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) guidelines to improve patient safety in life threatening emergencies in 2008,6 but their implementation has been inconsistent in acute hospitals. These guidelines are currently under revision with the help of the National Collaborating Centre for Mental Health, with the aim of wider adoption by all relevant stakeholders.
The Faculty of Eating Disorders is committed to securing the best outcome for people with eating disorders by:
- promoting excellent services
- supporting the prevention of eating disorders and ensuring prompt treatment to achieve higher recovery rates and prevent complications
- improving medical training in eating disorders
- promoting quality and research
- setting standards.
We cannot do these alone. We need support from the Department Health through a commitment to fund high-quality services that can deliver prompt NICE-recommended treatment for all patients who need it, and from the GMC, the AOMRC, Health Education England to improve training both for doctors and allied professionals. Improving medical education is the single most cost-effective intervention to improve recognition and managing risks associated with severe eating disorders. Any more delay in medical training and funding services will cost further lives.
- Parliamentary and Health Service Ombudsman. Ignoring the alarms: How NHS eating disorder services are failing patients. London, 2017.
- Ayton A, Nicholls D, Robinson P. Improving core skills and competence in risk assessment and management of people with eating disorders: What all doctors need to know. Royal College of Psychiatrists, 2020.
- Arcelus J, Mitchell AJ, Wales J, et al. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011;68(7):724-31. doi: 10.1001/archgenpsychiatry.2011.74
- Zerwas S, Larsen JT, Petersen L, et al. The incidence of eating disorders in a Danish register study: Associations with suicide risk and mortality. J Psychiatr Res 2015;65:16-22. doi: 10.1016/j.jpsychires.2015.03.003
- Mustelin L, Raevuori A, Bulik CM, et al. Long-term outcome in anorexia nervosa in the community. Int J Eat Disord 2015;48(7):851-9. doi: 10.1002/eat.22415
- RCPsych. MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa CR189. 2014.