Eating Disorder: Care and Treatment Policy

DOCUMENT CONTROL: Version: Ratified by: Date ratified: Name of originator/author:

Name of responsible committee/individual: Date issued: Review date: Target Audience

1 Clinical Effectiveness Committee 03 June 2014 Advanced Nurse Practitioner/Psychiatrist Advanced Nurse Practitioner Social Work Lead CAMHS Practitioner Clinical Effectiveness Committee 19 June 2014 June 2017 All clinical staff within the Trust

CONTENTS

SECTION

PAGE NO

1.

INTRODUCTION

4

2.

PURPOSE

5

3.

SCOPE

5

4.

RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 The Trust 4.2 Service Managers and Modern Matrons 4.3 All Clinical Staff

5 5 5 6

5.

PROCEDURE/IMPLEMENTATION 5.1 Diagnostic Ranges 5.2 Associated Mental Health Conditions 5.3 How will objectives be achieved 5.4 Patient Experience 5.5 Relatives or carers 5.6 Consent 5.7 Mental Health Legislation 5.7.1 Mental Capacity 5.7.2 Mental Health Act 5.8 Assessment for Eating Disorder 5.8.1 Physical Assessment 5.8.2 Re-feeding Syndrome 5.8.3 Psycho-social Assessment and Intervention 5.8.4 Specialist Groups 5.9 Environmental Considerations 5.10 Staff support 5.11 Care Planning 5.12 Service Transitions

6 6 6 6 7 7 7 8 8 8 9 9 12 13 14 15 15 16 16

6.

TRAINING IMPLICATIONS

17

7

MONITORING ARRANGEMENTS

18

8.

EQUALITY IMPACT ASSESSMENT SCREENING 8.1 Privacy, Dignity and Respect 8.2 Mental Capacity Act

19 19 19

9.

LINKS TO ANY ASSOCIATED DOCUMENTS

20

10.

REFERENCES

21

Page 2 of 29

11.

22

APPENDICES

Appendix 1 Royal College of Psychiatrists and Royal College of 23 Physicians (2010) (page 46) – key points for hospital staff Appendix 2 RCP and RCPsych (2010) – Compulsory admission 24 and treatment Appendix 3 Primary Care Algorithm

25

Appendix 4 Access Team Algorithm

26

Appendix 5 Mental Health Act Request

27

Appendix 6 Inpatient Psychiatry Flowchart

28

Appendix 7 CAMHS Team Algorithm 29

Page 3 of 29

1.

INTRODUCTION Eating Disorder problems are broadly considered within three diagnostic categories: Anorexia Nervosa, Bulimia Nervosa, and Atypical Eating Disorder. In UK research, it is estimated that approximately 1/250 females and 1/2000 males will experience Anorexia Nervosa, over 5 times this number will experience Bulimia Nervosa, and an even greater number will have an atypical Eating Disorder, many of which go untreated (NICE, 2004). An Eating Disorder may be considered a primary problem for a person accessing services, or it may be comorbid with other mental or physical health problems. Whichever the case, untreated Eating Disorders cause significant problems to: (1) The patient/patient’s physical and psychological health, the immediate consequences of which may be life-threatening. (2) Eating Disorder symptoms are researched as resulting in potential longterm damage in regards to: physical disability and illness, negative effects on employment, fertility, relationships, and parenting. (3) The presence of an Eating Disorder will comprise a range of syndromes (i.e Diabetes), encompassing physical, psychological, and social features. (4) The impact of Eating Disorders upon home and family support is significant, and can result in trauma to the whole system, resulting in wider health and social problems of significant others. Recognising and providing support for people with Eating Disorders concerns all RDaSH staff, not just mental health workers. Early recognition and intervention is key to reducing the health costs of these patient’s/patients (Department of Health (DoH) 2011a&e). Within the field of specialist mental health care, the assessment and treatment of the Eating Disorder range is complex. When considering the range of mental health care cluster needs (DoH, 2011e), Eating Disorders are included within the diagnostic range for Care Clusters 1-8, and may be a comorbid factor for people with psychosis and organic mental health needs. The National Institute for Health and Care Excellence (NICE, 2004) published clinical guidelines in relation to assessment and treatment recommendations for the range of Eating Disorders. A more recent report by the Royal College of Psychiatrists and Royal College of Physicians (2010) provided specific focus upon the problem, identifying the assessment/treatment needs for people with Anorexia Nervosa. These publications both emphasise the need for organisations to provide clear clinical policies for staff and patients regarding this specific patient group.

Page 4 of 29

2.

PURPOSE The purpose of this policy is to provide a flexible and reflective approach to the assessment and management of patients who present with Eating Disorder within primary, secondary, and tertiary mental health care services. The policy supports the implementation of NICE Clinical Guidelines No. 9. Eating Disorders: Core interventions in the treatment and management of Anorexia Nervosa, Bulimia Nervosa and related Eating Disorders, and is informed by the MARSIPAN Report (Royal College of Psychiatrists (RCP) and Royal College of Physicians (RCPsych), 2010). This policy, like the NICE (2004) guideline, is relevant to people 8 years and older who have an Eating Disorder.

3.

SCOPE This policy relates to: • •

4.

All clinical staff within the Trust All patients in receipt of care and treatment from the Trust. The guideline is relevant to all people aged 8 years and older who present with an Eating Disorder, and it addresses all health and social care professionals who come into contact with them. Where it refers to children and young people, this applies to all people who are between 8 and 17 years inclusive.

RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1

The Trust The Chief Executive and Directors of the Trust are responsible for the provision of clinical care which is safe and follows good practice/national guidelines .They are also responsible for having training in place for clinical staff in relation to the care and treatment of patients who access RDaSH services, who have an Eating Disorder.

4.2

Service Managers/Modern Matrons Service Managers and Modern Matrons are responsible for: • The dissemination of this policy to their staff. • Highlighting the training needs of their staff in relation to this policy. • Releasing staff to attend for training. • Supporting staff who care for patients with Eating Disorders.

Page 5 of 29

4.3

All Clinical Staff All staff who have contact, in an urgent medical situation, with people who have Eating Disorders, should be adequately trained to assess mental capacity, and to make decisions about when treatment and care can be given without consent. Staff should give full information, and make all efforts necessary to allow someone who has an Eating Disorder the opportunity to give meaningful and informed consent. Staff working with those who have an Eating Disorder should understand when and how the Mental Health Act can be used to treat the physical consequences of the Eating Disorder. Staff who have emergency contact with children and young people who have an Eating Disorder must understand how issues of capacity and consent apply to this group. The clinical staff must also be aware of other guidance, including: • The Mental Health Act (1983) • The Children Act (1989) • The Human Rights Act (1998, amended 2005) • The Mental Capacity Act (2005)

5.

PROCEDURE/IMPLEMENTATION 5.1

Diagnostic Ranges This policy provides guidance upon the management of: Anorexia Nervosa Bulimia Nervosa (please note that Bulimia can transcend to Anorexia) Eating Disorder Not Otherwise Specified (EDNOS)

5.2

Associated Mental Health Conditions NICE recommend that psychological, pharmacological, and psychosocial interventions for any associated conditions, must consider the most appropriate NICE guideline (examples would concern: NICE 90 – Depression, NICE 82 – Schizophrenia and NICE 78: Borderline Personality Disorder).

5.3

How will objectives be achieved The NICE Clinical Guidelines outline a number of standards to achieve aims and objectives for people with Eating Disorders.. The implementation of the policy will be monitored directly by the Clinical Leads, Modern Matrons and Social Work Leads through staff supervision. Page 6 of 29

Patient Experience 5.4 People who have an Eating Disorder should be treated with the same care, respect, and privacy, as any patient. In addition, healthcare professionals should take full account of the potential shame and secrecy associated with Eating Disorders. Providing treatment and care for people who have an Eating Disorder is emotionally demanding, and requires a high level of communication skills. Therefore it is imperative that all staff working in this field have regular clinical supervision, to allow them the opportunity to reflect on their practice. Relatives or Carers 5.5 People who have an Eating Disorder should be allowed, if they wish, to be accompanied by a member of their family, friend, or advocate, during assessment and treatment. However, for the initial psychosocial assessment, the interview should take place in private, to maintain confidentiality. Family members of people with Eating Disorders may be very distressed, specifically when patient’s Eating Disorders have progressed to potentially life-threatening stages. Family and significant others can present with guilt, anger, and distress, due to the issues related to the complex Eating Disorder process. Staff should also be ready to offer support and help to the relatives/carers of people who have an Eating Disorder. Family and system-focused psychotherapeutic intervention is evidenced as advantageous in achieving and maintaining recovery for patients with Eating Disorders. Family interventions that directly address the Eating Disorder should be offered to children and adolescents with Anorexia Nervosa (NICE, 2004). Consent 5.6 Staff frequently face difficult decisions about whether they should intervene to provide treatment and care to a person who presents to mental health services with an Eating Disorder and then refuses help. Not only are these decisions difficult, but they can provoke disagreements between staff who may interpret differently the legal framework that underpins them.

Mental Health Legislation Page 7 of 29

5.7 Mental Capacity 5.7.1 The concept of Mental Capacity is central to determining whether treatment and care can be given to a person who refuses it. The Mental Capacity Act (2005) gives clear definition of capacity and “best interests”, and how to measure and record decisions, and will not be dealt with explicitly within this policy. Staff should refer to the Mental Capacity Act 2005 Code of Practice for guidance. A person may lack capacity to make the decision in question because of either long-term mental disability, or because of temporary factors, such as unconsciousness, confusion, or the effects of fatigue, shock, pain, anxiety, anger, alcohol, or drugs and lack of food. Under the Mental Capacity Act, if a person has capacity to make the decision, then this decision must be respected; even if a refusal may risk permanent injury or death to that person. Compulsory treatment can include medical treatment for the physical consequences of the Eating Disorder, which is categorised as either the consequence of, or a symptom of, a patient’s mental disorder, providing it can be shown (and recorded) that the person lacks capacity and that the treatment satisfies the conditions of best interests, as defined by the Mental Capacity Act (2005). Treatment and care should take into account patient’s needs and preferences. People who have an Eating Disorder should have the opportunity to make informed decisions about their care and treatment, in partnership with health and social care professionals. If patients do not have the capacity to make decisions, health and social care professionals should follow the guidance in the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government. If the patient is under 16, health and social care professionals should follow the guidelines in 'Seeking consent: working with children'. Mental Health Act 5.7.2

Please refer to Appendix 5 (page 27) of this policy which provides a clinical algorithm concerning Mental Health Act assessments for people with Eating Disorder.

Assessment for Eating Disorder Page 8 of 29

5.8 A full physical assessment is an essential component of assessment with any patient presenting with an Eating Disorder. Patient’s risks in relation to their physical health condition may be complex and also not immediately obvious in the consultation. Therefore it is essential that physical assessments are conducted alongside of exploratory assessments concerning the individual’s associated Eating Disordered behaviours. Associated behaviours may include: • • • • • • •

Binge Eating. Purging. Misusing medication (i.e. laxatives or diuretics). Using illicit drugs or alcohol. Eating non-foodstuffs. Drinking excessive fluids. Excessive exercise.

For patients with Anorexia, physical assessment is essential and must be structured: “Patients with Anorexia Nervosa can seem deceptively well. They may have an extremely powerful drive to exercise which sometimes needs to override their lack of nutritional reserve, so that they may appear to be very energetic right up until a physical collapse.... Moreover, patients with Eating Disorders can falsify their weight by drinking water, or wearing weights or other objects, and it is acceptable that assessment needs to include a range of measures in order to have a chance at detecting those patients whose state is deteriorating, but who are attempting to conceal that fact” (RCP and RCPsych, 2010, page 14). Physical Assessment 5.8.1 When patients with Eating Disorders make contact with health services, they may or may not be able to recognise that their difficulties form a part of an Eating Disorder. The National Institute for Health and Care Excellence (NICE) Clinical Guideline 32 Nutrition Support in Adults (NICE, 2006), recommends that all hospital in-patients, on admission, and all out-patients at their first clinic appointment, should receive screening for malnutrition or the risk of malnutrition, by professionals with the appropriate skills and training (RDaSH Nutrition Policy).

Primary Care: Page 9 of 29

Physical assessment as a part of mental health assessment and intervention is essential with someone with an Eating Disorder. Patients with Bulimia Nervosa who are vomiting frequently, or taking large quantities of laxatives (especially if they are also underweight), should have their fluid and electrolyte balance assessed. Patients with Anorexia can deteriorate very quickly. BMI indications should not be the sole measure of need, and are not a reliable measure for adolescents or children. Primary care assessment of a person with an Eating Disorder must include: a general physical examination and baseline blood tests, with an ECG for those with a BMI of