Practice dilemma - Anorexia patient refuses referral

A patient's threatening father is critical of your care of his anorexic daughter. What can you do?

The dilemma
I regularly see a 19-year-old patient with anorexia nervosa. She lives at home. She recognises her condition, but refuses to attend with a family member or to be referred. She says she will work it out with my help. She has amenorrhoea and is severely underweight, but does not have electrolyte imbalance and functions well at her job. Her father came to see me alone and told me he knew his daughter has an eating disorder and that she will not discuss it with him or his wife. He was critical of me for not getting her to see a specialist, and demanded I use the Mental Health Act to force her to get help. He threatened 'further action' if I do not. What can I do?

A GP's view

Dr Kamilla Porter is a GP in Rochford, Essex

Reflect on the situation before taking any action in response to the father's hostile meeting with you. Share this situation with your practice manager and if possible, a GP colleague, so they are aware, should the father make a formal complaint or the patient present to other members of the practice team.

The father's discussion with you raises questions about the dynamics of this family and the impact on your patient's condition. Look out for any red flags that might suggest domestic violence or other abuse.

At 19 this young woman is an adult, so her father has no legal right to instruct professionals on how to manage her medical problems.

If you are confident she has the mental capacity to make an informed decision to refuse referral, her choice to remain under the care of her GP must initially be respected.

You are doing your best to manage and monitor a patient who declines further intervention. It is important that at subsequent reviews, you assess and document that she continues to possess mental capacity.

However, she is already amenorrhoeic and severely underweight, and further deterioration could be life-threatening. The CQC has issued guidance on treating anorexia nervosa under the Mental Health Act, but points out that in most cases, detention is unnecessary and compulsory treatment may be counterproductive to the management of anorexics, in whom patient autonomy is a long-term objective.

Nevertheless, in extreme cases of food refusal, patients with anorexia nervosa can be detained under the Mental Health Act 1983.

It may become increasingly difficult to manage this patient on your own. Seek professional guidance from a local psychiatrist and a consultant with a specialist interest in eating disorders. Speak to your medical defence society and consider contacting the BMA.

This patient is aware of her condition and is well enough to earn an income. Her willingness to see you regularly, and your support and monitoring of her condition, suggests her situation is at least stable and unlikely to deteriorate without your knowledge.

A medico-legal response

Dr Sonya McCullough is a medico-legal adviser at MPS

As your patient is an adult, she has the capacity to make decisions about her care and whether to accept a referral.

When an adult lacks capacity (that is, cannot understand, retain, use or weigh up the information needed to make a decision or communicate their wishes), you would need to act in their best interests, which may be to involve the family or to seek help from a specialist.

There is nothing to suggest this patient lacks capacity, given that she is functioning well in her job.

Where it is agreed that the patient has a mental disorder of a nature or degree that warrants detention for assessment, or assessment followed by treatment for the underlying condition, the Mental Health Act could be invoked (feeding can constitute treatment under the Act).

If the patient consents, you could offer a meeting with her and her father to discuss these matters. You should reassure the father that you are taking his concerns seriously, but if he were to make a complaint, you should only provide a response if you have the patient's consent.

A patient's opinion

Elizabeth Brain is an expert patient

Her father's concern is understandable but, as this patient is no longer a minor, he has no right to attend her consultation. Even if she agreed that he could attend, the risk of his hostility towards you could be damaging to his daughter's relationship with you and with himself.

Her relationship with her father could have a positive or a negative impact. Within the limits of patient confidentiality, you could explain to him that any application for detention or treatment under the Mental Health Act would not be appropriate.

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