OBJECTIVE:As an emergent secondary analysis of a wider qualitative study, we aimed to understand how paediatricians apply the Medical Emergencies in Eating Disorders (MEED) guidelines in relation to recommending nasogastric tube feeding under physical restraint. SETTING:Paediatric wards in England. METHODS:We recruited clinicians working in acute paediatric settings in England via adverts using three professional networks. Participants were from a variety of professions within the multidisciplinary team involved with caring for those with an eating disorder. Individual interviews using semistructured interviews were conducted. The interviews were recorded and transcribed by Microsoft Teams and checked for accuracy. This secondary analysis applied Braun and Clarke's approach to thematic analysis. RESULTS:20 participants (five males and 15 females) were recruited across 15 National Health Service Trusts. Overlapping themes between participants identified three main themes of 'positives of MEED', 'negatives of MEED' and 'learning how to use MEED well'. Subthemes of 'tolerating risk', 'individualised meal plans', 'second opinion', 'more time' and 'teamworking' were identified. CONCLUSIONS:This research identifies that paediatric clinicians find the MEED guidelines helpful in understanding who needs to be admitted. Additionally, participants reported their learning on how to make these admissions more successful through personalisation of treatment planning.

We examine the ethical and legal challenges of continuing inpatient treatment for individuals with longstanding anorexia nervosa (AN), particularly where treatment effectiveness is uncertain. This legally and ethically contentious issue has been explored in a number of cases, which can be divided into two cohorts. We analysed the first cohort in 2017, identifying three key criticisms and offering corresponding recommendations. We assess a second, ongoing set of cases in light of those recommendations, while also considering new issues, including emergent treatment approaches and the debate surrounding the controversial ‘terminal eating disorder’ framework. Although judges in the Court of Protection do not adopt this framework, they do recognise that prolonged, compulsory life-sustaining treatment may – under certain circumstances – conflict with the patient's best interests. We argue that recent approaches to both mental capacity assessments and determination of best interests indicate a meaningful shift towards a more individualised and ethically responsive approach and suggest ways to augment this approach.

Background Nasogastric tube (NGT) feeding under physical restraint is a clinical intervention that may be required when a child or young person is medically unstable secondary to restrictive eating.Aim To explore the experiences of parents when their child receives NGT feeding under physical restraint and understand the effects of this on them.Method This is a secondary analysis of data from two previous studies on NGT feeding under physical restraint -one in mental health wards and one in children's wards -in which semi-structured interviews had been conducted with patients, staff and parents.For this secondary analysis, the authors thematically analysed 31 transcripts of interviews with parents.Findings Parents reported a range of emotions which could be conflicting in nature, notably relief and shame.In both studies, parents understood the necessity of NGT feeding under physical restraint but experienced the intervention as traumatic.They expressed empathy for staff facilitating the restraint.In the children's wards study, some parents described conflict and damaged relationships with staff, and three parents had participated in physically restraining their child for NGT feeding. ConclusionNursing staff should be aware that NGT feeding under physical restraint is distressing for parents.Adopting a trauma-informed framework may help to mitigate the traumatic effects on parents and, in turn, on their child.

Background Nasogastric tube feeding under physical restraint is an intervention that clinicians working in specialist mental health in-patient units may need to implement. Aims To examine the impact of this intervention on people with lived experience, carers and staff. Method People with lived experience and parents and/or carers were recruited via UK eating disorder charity Beat. Clinicians were recruited via the British Eating Disorders Society's research forum. Qualitative semi-structured interviews were conducted and transcribed, and the results were thematically analysed. Results Thirty-six participants took part, and overlapping themes were identified. All participants spoke in relation to four themes: (a) the short-term impact on the patient; (b) the impact on those around the patient; (c) the long-term impact; and (d) the positive impact. Subthemes were identified and explored. Conclusion This lifesaving intervention can also negatively affect patients, parents and carers, peers and staff. Further research is needed to understand how interactions and environmental modifications can mitigate the negative impacts.

AbstractDecisions about the treatment of eating disorders do not occur in a socio-political vacuum. They are shaped by power relations that produce categories of risk and determine who is worthy of care. This impacts who gets access to care and recognition of rights in mental health services. Globally, there are calls for more human rights-based approaches in mental health services to reduce coercion, improve collaborative decision making and enhance community care. Treating individuals with longstanding, Severe and Enduring Eating Disorders (SEED) or Severe and Enduring Anorexia Nervosa (SE-AN) can be particularly problematic when it involves highly controversial issues such as treatment withdrawal and end-of-life decisions and, where legally permissible, medically assisted dying. In this article, we argue that the socio-political context in which clinical decision making occurs must be accounted for in these ethical considerations. This encompasses considerations of how power and resources are distributed, who controls these decisions, who benefits and who is harmed by these decisions, who is excluded from services, and who is marginalised in decision making processes. The article also presents tools for critically reflective practice and collaborative decision-making that can support clinicians in considering power factors in their practice and assisting individuals with longstanding eating disorders, SEED and SE-AN to attain their rights in mental health services.

Abstract The treatment of eating disorders is often challenging. Clinicians may struggle to engage collaboratively with both patients and their family members. This is because eating disorders can lead to cognitive rigidity, changes of identity, a narrowing of focus, withdrawal inwards, and increasing difficulty in being flexible in thinking, behaving, and expressing oneself. The aesthetic domain of experience, by accessing emotion and making meaning with minimal language, can be immensely helpful in creating opportunities to enable non-judgemental discovery and exploration of meanings, experiences, and desires. It can also potentially help people who have eating disorders to express what is often a ‘felt’ disorder of embodiment, perception, and identity, rather than a ‘thought’ disorder of cognitions, beliefs, and rationality. In this chapter, the authors will focus on exploring how aesthetic experience as a component of engagement with the arts can be encountered in the experience of both living with and treating eating disorders. The authors will illustrate this with a range of examples from research and creative art and poetry. The authors suggest that understanding and acknowledging aesthetic experiences in eating disorders is important in understanding and exploring eating disorders, for both people who have eating disorders and those to seek to treat them.

Background Nasogastric tube (NGT) feeding against a patient's consent is an intervention that clinicians working in specialist mental health in-patient units may need to implement from time to time. Little research has explored clinician, patient and carer perspectives on good practice. Aims To use qualitative data from people with lived experience (PWLE), parents/carers and clinicians, to identify components of best practice when this intervention is required. Method PWLE and parents/carers were recruited via BEAT UK's eating disorder charity. Clinicians were recruited via a post on The British Eating Disorders Society's research page. Semi-structured interviews were administered, transcribed and thematically analysed. Results Thirty-six interviews took place and overlapping themes were identified. Participants spoke in relation to three themes: first, the significance of individualised care; second, the importance of communication; third, the impact of staff relationships. Sub-themes were identified and explored. Conclusions Good care evolved around positive staff relationships and individualised care planning rather than standard processes. The centrality of trust as an important mediator of outcome was identified, and this should be acknowledged in any service that delivers this intervention.

Objective To gain insights into the experience, and impact, of using security staff to facilitate physical restraints for nasogastric tube feeding.Design A cross-sectional design using 39 individual interviews, three online focus groups and three written submissions involving young people with lived experience (PWLE), parents/carers, paediatric staff and security staff involved in nasogastric feeding under restraint in paediatric settings in England. Qualitative semistructured interviews were transcribed and thematically analysed.Participants 53 individuals participated: seven security staff (all men); nine PWLE who experienced the intervention between the ages of 9 and 17 (all female); 20 parents (15 mothers, 5 fathers) and 20 paediatric staff (5 men, 15 women).Results Regarding the involvement of security staff, participants spoke in relation to two primary themes (1) short-term impact and (2) long-term impact. Short-term themes included that the intervention felt inappropriate and traumatic while also recognising its lifesaving nature and the fact that involving security guards preserved positive relationships with nursing staff. Longer-term themes included the development of trauma symptoms, while also acknowledging the skill development and improved professional relationships that could result from delivering the intervention.Conclusions This lifesaving clinical intervention can negatively impact security staff as much as the patient, parents/carers and paediatric staff. A prebrief and debrief should be seen as part of the ‘process’. Further research is needed to better understand what else can mitigate negative impacts.

Nasogastric tube (NGT) feeding is a common medical intervention used to help malnourished patients meet their nutritional needs. Occasionally this is used to help patients with restrictive eating disorders if they are unable to meet their nutritional requirements through oral diet or supplements when appropriate meal support is given. NGT feeding against a patient’s will, requiring physical interventions to maintain their safety, can be used to stabilise a patient medically in lifesaving scenarios. Recent research highlighted the extent of this practice within mental health wards in England, with 622 patients reported to have received this intervention in a one-year period. The length of time for which this intervention was required ranged from a single feed to 17 patients receiving it for over a year, and one patient for six years. These findings have raised ethical and legal concerns regarding the extent of this restrictive intervention and the associated physical, emotional and psychological risks it carries for the patient, as well as the emotional and psychological risk to the inpatient peer group, parents/carers and the staff involved. This paper aims to suggest the best ethical, legal and clinical practice regarding this intervention for those practicing in England and Wales.

Compared with other mental health conditions or psychiatric presentations, such as self-harm, which may be seen in emergency departments, eating disorders can seem relatively rare. However, they have the highest mortality across the spectrum of mental health, with high rates of medical complications and risk, ranging from hypoglycaemia and electrolyte disturbances to cardiac abnormalities. People with eating disorders may not disclose their diagnosis when they see healthcare professionals. This can be due to denial of the condition itself, a wish to avoid treatment for a condition which may be valued, or because of the stigma attached to mental health. As a result their diagnosis can be easily missed by healthcare professionals and thus the prevalence is underappreciated. This article presents eating disorders to emergency and acute medicine practitioners from a new perspective using the combined emergency, psychiatric, nutrition and psychology lens. It focuses on the most serious acute pathology which can develop from the more common presentations; highlights indicators of hidden disease; discusses screening; suggests key acute management considerations and explores the challenge of mental capacity in a group of high-risk patients who, with the right treatment, can make a good recovery.

Eating disorders have the highest mortality rate of any psychiatric condition. Since the COVID-19 pandemic, the number of patients who have required medical stabilisation on paediatric wards has increased significantly. Likewise, the number of patients who have required medical stabilisation against their will as a lifesaving intervention has increased. This paper highlights a fictional case study aiming to explore the legal, ethical and practical considerations a trainee should be aware of. By the end of this article, readers will be more aware of this complex issue and how it might be managed, as well as the impact it can have on the patient, their family and ward staff.

ObjectivesTo determine whether clinically extremely vulnerable (CEV) children or children living with a CEV person in Wales were at greater risk of presenting with anxiety or depression in primary or secondary care during the COVID-19 pandemic compared with children in the general population and to compare patterns of anxiety and depression during the pandemic (23 March 2020-31 January 2021, referred to as 2020/2021) and before the pandemic (23 March 2019-31 January 2020, referred to as 2019/2020), between CEV children and the general population.DesignPopulation-based cross-sectional cohort study using anonymised, linked, routinely collected health and administrative data held in the Secure Anonymised Information Linkage Databank. CEV individuals were identified using the COVID-19 shielded patient list.SettingPrimary and secondary healthcare settings covering 80% of the population of Wales.ParticipantsChildren aged 2-17 in Wales: CEV (3769); living with a CEV person (20 033); or neither (415 009).Primary outcome measureFirst record of anxiety or depression in primary or secondary healthcare in 2019/2020 and 2020/2021, identified using Read and International Classification of Diseases V.10 codes.ResultsA Cox regression model adjusted for demographics and history of anxiety or depression revealed that only CEV children were at greater risk of presenting with anxiety or depression during the pandemic compared with the general population (HR=2.27, 95% CI=1.94 to 2.66, p<0.001). Compared with the general population, the risk among CEV children was higher in 2020/2021 (risk ratio 3.04) compared with 2019/2020 (risk ratio 1.90). In 2020/2021, the period prevalence of anxiety or depression increased slightly among CEV children, but declined among the general population.ConclusionsDifferences in the period prevalence of recorded anxiety or depression in healthcare between CEV children and the general population were largely driven by a reduction in presentations to healthcare services by children in the general population during the pandemic.

Mental disorders in children and adolescents have an impact on

BACKGROUND:Clinicians working in mental health in-patient settings may have to use nasogastric tube feeding under physical restraint to reverse the life-threatening consequences of malnutrition when this is driven by a psychiatric condition such as a restrictive eating disorder.AIMS:To understand the decision-making process when nasogastric tube feeding under restraint is initiated in mental health in-patient settings.METHOD:People with lived experience of nasogastric tube feeding under restraint and parents/carers were recruited via the website of the UK's eating disorder charity BEAT. Eating disorder clinicians were recruited via an online post by the British Eating Disorders Society. Semi-structured interviews were administered to all participants.RESULTS:Themes overlapped between the participant groups and were integrated in the final analysis. Two main themes were generated: first, 'quick decisions', with the subthemes of 'medical risk', 'impact of not eating' and 'limited discussions'; second, 'slow decisions', with subthemes of 'threats', 'discussions with patient', 'not giving up' and 'advanced directives'. Benefits and harms of both quick and slow decisions were identified.CONCLUSIONS:This research offers a new perspective regarding how clinical teams can make best practice decisions regarding initiating nasogastric feeding under restraint. In-patient mental health teams facilitating this clinical intervention should consider discussing it with the patient at the beginning of their admission in anticipation of the need for emergency intervention and in full collaboration with the multidisciplinary team.

Aims and method To identify the clinical characteristics of patients receiving nasogastric tube (NGT) feeding under physical restraint. Clinicians participated via professional networks and subsequent telephone contact. In addition to completing a survey, participants were invited to submit up to ten case studies. Results The survey response rate from in-patient units was 100% and 143 case studies were submitted. An estimated 622 patients received NGT feeding under restraint in England in 2020–2021. The most common diagnosis was anorexia nervosa (68.5–75.7%), with depression, anxiety and autism spectrum disorder the most frequent comorbidities. Patients receiving the intervention ranged from 11 to 60 years in age (mean 19.02 years). There was wide variation in duration of use, from once to daily for 312 weeks (mode 1 week; mean 29.1 weeks, s.d. = 50.8 weeks). Clinical implications NGT feeding under restraint is not uncommon in England, with variation in implementation. Further research is needed to understand how the high comorbidity and complexity contribute to initiation and termination of the intervention.

The number of children and young people admitted to children's wards with an eating disorder has increased significantly since the start of the coronavirus disease 2019 (COVID-19) pandemic. In the most extreme cases, those with severe malnutrition may need to be fed via a nasogastric tube without their consent. Children's nurses working on hospital wards may therefore care for children and young people who need to receive nasogastric tube feeding under physical restraint. This article offers an overview of eating disorders and their detrimental effects as well as practical advice for children's nurses, supporting them to provide safe, compassionate and person-centred care to their patients.