Some thoughts from an eating disorders specialist who regularly consults to emergency departments
By Warren Ward, Director Eating Disorders Service, Metro North Mental Health Service - RBWH
Eating disorders can be associated with significant medical complications resulting in morbidity and mortality. Anorexia Nervosa, especially, has a high mortality rate, with the risk of death increased by purging behaviours.
For many people with eating disorders and their families, the first step to recovery is often the increased awareness in the patient, or others, of the problems associated with the eating disorder as a result of medical complications such as weakness, fainting or collapse.
It is therefore critical for people suffering from eating disorders, their families, general practitioners and other clinicians involved in their care, that staff working in emergency departments have a good understanding of the medical complications of eating disorders and their management. It is also important that emergency department staff have a good understanding of when admission to hospital is indicated and required for patient safety.
To assist emergency department staff in the above tasks, the Qld Eating Disorders Outreach Service (EDOS) has developed access pathways. These access pathways were developed following a review of the literature including the Royal Australia and New Zealand College of Psychiatry Clinical Practice Guidelines for the management of Anorexia Nervosa. In addition, EDOS consulted with Directors of Medicine, Emergency Departments and Mental Health; as well as drawing on its experience of many years of providing consultation-liaison services to emergency departments and general medical and mental health inpatient units treating patients with eating disorders.
The access pathways provide guidelines to emergency department clinicians as to what should be assessed when patients with eating disorders present, when patients with eating disorders require admission, and whether admission to a medical or mental health setting is indicated. The pathways also provide recommendations as to when patients could safely be transferred from a medical to a mental health setting. A general overriding principle of the pathways is that most patients require close co-operation between medical, mental health and specialist eating disorder clinicians to ensure medical safety as well as help with the cognitive, emotional and behavioural symptoms of eating disorders. Most jurisdictions in Australia unfortunately do not always have access to adequate specialist inpatient eating disorder settings, so the access pathways provide guidance to generalist clinicians including emergency department staff as to the safe medical management of life-threatening complications of eating disorders including malnutrition, effects of purging, and re-feeding syndrome.
Another issue that emergency department clinicians often require assistance with is the use of the mental health act, guardianship or other legislation which may need to be used if the patient’s eating disorder is impairing their decision-making capacity and resulting in great risk to themselves. EDOS has developed a guide to the use of the mental health act in Queensland with patients with eating disorders. Although legislation differs in different jurisdictions, the principles are quite similar in that for the use of such legislation to be considered there must be impaired decision-making capacity due to mental illness, imminent risk to self or others due to the mental illness, and no less restrictive way to help the patient access treatment.
Perhaps the most important thing to consider with respect to emergency department clinicians, is that such clinicians have a very busy, stressful job in which they are expected to assesses and manage a wide range of medical conditions. Therefore specialist eating disorders services and clinicians have an important role in providing guidance, support, advice, consultation and education and training to their emergency department colleagues.
The related guides may assist eating disorders specialists in their efforts to provide education and support to their local emergency department.