Terminal anorexia nervosa: three cases and proposed clinical characteristics

There were no mentions of EDs in Colorado and California's reports, despite cases involving patients with EDs having been previously reported in the literature.

“There were no mentions of EDs in Colorado and California’s reports, despite cases involving patients with EDs having been previously reported in the literature (2).”

This may progress from an initial diagnosis of an ED to identification with a term like SEED or SE-AN, culminating in the perception of their condition as irremediable, and in some cases terminal.

“This may progress from an initial diagnosis of an ED to identification with a term like SEED or SE-AN, culminating in the perception of their condition as irremediable, and in some cases terminal (2).”

At least two of the patients who underwent assisted dying identified in this review had been previously rejected from treatment or discharged early.

“At least two of the patients who underwent assisted dying identified in this review had been previously rejected from treatment or discharged early (2022–85) (2).”

Some jurisdictions now allow assisted dying for reasons solely related to a psychiatric disorder.

“Some jurisdictions now allow assisted dying for reasons solely related to a psychiatric disorder”

In at least one case involving a person with an ED, a Colorado-based physician prescribed MAiD across state lines to a patient in California.

“In at least one case involving a person with an ED, a Colorado-based physician prescribed MAiD across state lines to a patient in California (2).”

One case study has been published in the United States, which described three patients, two of whom were prescribed MAiD - one in Colorado, and another who resided in California and received a prescription from a Colorado-based physician.

“One case study has been published in the United States (2), which described three patients, two of whom were prescribed MAiD — one in Colorado, and another who resided in California and received a prescription from a Colorado-based physician.”

In the United States, at least four cases of assisted death in persons with EDs were identified.

“In the United States, where terminality is a legal criterion for MAiD, at least four cases of assisted death in persons with EDs were identified (2, 44)”

The nuance that futility refers to a specific treatment rather than any treatment was lost in the cases described by Gaudiani et al., which emphasized that to be eligible for MAiD, patients must 'understand further treatment to be futile'.

“This nuance was lost in the cases described by Gaudiani et al. (2), which emphasized that to be eligible for MAiD, patients must “understand further treatment to be futile” (p. 11).”

Cases of assisted dying in patients with eating disorders have been documented in the United States, the Netherlands, and Belgium.

“cases have been documented in the United States (2), the Netherlands (6–10), and Belgium (11–13).”

Treatment futility was only cited in the two United States cases.

“Treatment futility was only cited in the two United States cases (2).”

Gaudiani et al. proposed that these patients represent a clinical subcategory of severe and enduring anorexia nervosa: terminal anorexia.

“Specifically, Gaudiani et al. (2) proposed these patients represent a clinical subcategory of SE-AN: terminal anorexia.”

In cases in the United States, where a terminal prognosis is a legal prerequisite for assisted death, authors asserted that eating disorder patients prescribed MAiD had terminal conditions.

“In cases in the United States, where a terminal prognosis is a legal prerequisite for assisted death, authors asserted that ED patients prescribed MAiD had terminal conditions (2, 5).”

Gaudiani et al. suggested that two women with anorexia who were prescribed MAiD were eligible in part because they 'understand further treatment to be futile'.

“For instance, Gaudiani et al. (2) suggested that two women with anorexia who were prescribed MAiD were eligible in part because they “understand further treatment to be futile” (p. 11).”

California and Colorado's annual reports showed no record of the two deaths described by Gaudiani et al.

“Notably, California and Colorado’s annual reports showed no record of the two aforementioned deaths described by Gaudiani et al. (2).”

In another of Gaudiani et al.'s cases, the patient was hospitalized for medical stabilization but thereafter declined admission to a residential program.

“another was hospitalized for medical stabilization but thereafter declined admission to a residential program.”

In one of Gaudiani et al.'s cases, the patient spent 1-2 weeks in intensive treatment before leaving against medical advice.

“One patient spent 1–2 weeks in intensive treatment before leaving against medical advice”

Two of the cases described by Gaudiani et al. were offered PAS without ever receiving adequate inpatient specialty care.

“Concerningly, two of the cases described by Gaudiani et al.[1], were offered PAS without ever receiving adequate inpatient specialty care.”

In one case mentioned by Gaudiani et al., PAS was suggested by the treating author.

“In one case mentioned by Gaudiani et al.[1], PAS was suggested by the treating author”

The first case presented by Gaudiani et al. appears to meet the standard for palliative care.

“The first case presented by the authors appears to meet this standard.”

In another case mentioned by Gaudiani et al., the idea of treatment futility was reinforced despite the patient not completing a full course of intensive treatment.

“in another case the idea of treatment futility was reinforced despite the patient not completing a full course of intensive treatment.”

The proposed characteristics for 'terminal' AN include AN diagnosis, age over 30, prior persistent engagement in high-quality multidisciplinary eating disorders care, and decision-making capacity to understand further treatment is futile, the wish not to prolong life, and acceptance of death.

“The proposed characteristics for ‘terminal’ AN included: (1) AN diagnosis (2) Age over 30, (3) Prior persistent engagement in high-quality, multidisciplinary eating disorders care, and (4) decision-making capacity to understand further treatment is futile, the wish not to prolong life and acceptance of death [1].”

Gaudiani et al. recently proposed preliminary criteria for 'terminal' anorexia nervosa, with three cases used to illustrate the defining criteria.

“Preliminary criteria for ‘terminal’ anorexia nervosa (AN) was recently proposed by Gaudiani et al. [1], with three cases used to illustrate the defining criteria.”

The logic of the proposed terminal diagnostic criteria becomes circular: if one has not had access to 'good quality' treatment, treatment inequity cannot exempt an individual from the criterion of prior persistent engagement in high-quality, multidisciplinary eating disorders care.

“This logic and argument becomes circular with regard to the proposed terminal diagnostic criteria—if one has not had access to ‘good quality’ treatment, how can treatment inequity exempt an individual from the terminal AN criterion: Prior persistent engagement in high-quality, multidisciplinary eating disorders care [1]?”

If an individual with a proposed terminal AN diagnosis changes their expression or wish for treatment, a diagnosis of terminal AN would no longer be justified.

“As Gaudiani et al. [1] have proposed a terminal AN diagnosis to have a fourth criterion for ‘consistent, clear expression by an individual who possesses decision-making capacity that they understand further treatment to be futile’, if an individual should change in their expression or wish for treatment, a diagnosis of terminal AN would no longer be justified.”