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Cited by 32Eating Disorders and BehaviorsPalliative Care and End-of-Life IssuesPalliative and Oncologic Care

Terminal anorexia nervosa is a dangerous term: it cannot, and should not, be defined

Open access
Guarda, Angela S., Hanson, Annette, Mehler, Philip, Westmoreland, Patricia·2022·Journal of Eating Disorders
DOI 10.1186/s40337-022-00599-6PMC PMC9175496
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Abstract

A recent article (JED 10:23, 2022) proposed defining terminal anorexia to improve access to palliative and hospice care, and to medical aid in dying for a minority of patients with severe and enduring anorexia nervosa (SE-AN). The authors presented three cases and, for two, the first author participated in their death. Anorexia nervosa is a treatable psychiatric condition for which recovery may be uncertain. We are greatly concerned however regarding implications of applying the label “terminal” to anorexia nervosa and the risk it will lead to unjustified deaths in individuals whose mental illness impairs their capacity to make a reasoned treatment decision.

AI snapshot

Written from the paper’s full text.

TL;DR

This commentary argues that “terminal anorexia nervosa” cannot and should not be defined, because anorexia nervosa is a treatable psychiatric condition with uncertain recovery and the label risks unjustified deaths and increased demand for physician-assisted suicide/medical aid in dying. It critiques proposed criteria for terminal anorexia and the application of PAS/MAID to severe and enduring anorexia nervosa, especially when adequate inpatient specialty care was not received.

Key findings

  • Guarda argues against proposed criteria for “terminal anorexia” — 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 — because AN is treatable and there are no clear staging criteria comparable to cancer’s estimated survival of six months or less.
  • The commentary states that most individuals with SE-AN who are over age 30, remain ill, and have previously engaged in high-quality care will not die within six months, and that most medical complications are reversible with nutritional rehabilitation and expert care.
  • It notes that two of the cases described by Gaudiani et al. were offered PAS without ever receiving adequate inpatient specialty care: one patient spent 1–2 weeks in intensive treatment before leaving against medical advice, and another was hospitalized for medical stabilization but thereafter declined admission to a residential program.
  • It argues that decision-making capacity in AN is impaired by malnutrition, depressive and obsessional symptoms, eating-disordered cognitions, and ambivalence toward treatment; standardized tests of competence may fail to identify impairment, and consent to MAID/PAS should have a high threshold.

Methods

  • Design: commentary/critical analysis responding to Gaudiani et al.’s proposed criteria for “terminal anorexia” and their three illustrative cases.
  • Data or sample: no original sample; the paper draws on cited literature and the three cases described by Gaudiani et al.
  • Main analysis: narrative argument addressing whether terminal anorexia can be defined, whether decision-making capacity is impaired in AN, and the risks of applying a “terminal” label.

Limitations

  • Not stated in the paper.
  • Evident from the text: this is a commentary/opinion piece without original empirical data, systematic review, or formal methods; its arguments rely on cited literature and interpretation of cases reported by others.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s40337-022-00599-6

Cites

27 of 27 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 36 cited sources checked · 0 supported · 0 flagged

  • Interpretationreasoning

    Most individuals with severe and enduring anorexia nervosa who are over age 30, remain ill, and have previously engaged in high-quality care will not die within six months.

    “Most individuals with SE-AN who are over the age of 30, remain ill and have previously engaged in high-quality care, will not die within six months.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Risk factors for mortality in anorexia nervosa are poorly defined.
    • Rests on an assumption: There are no clear staging criteria for severe and enduring anorexia nervosa comparable to those used for cancer to help define terminal cases.
  • Premisecitation

    In severe anorexia nervosa, when a patient's life is at risk, involuntary treatment provided by a behavioral inpatient specialty program can be lifesaving.

    “In severe AN, when a patient’s life is at risk, involuntary treatment provided by a behavioral inpatient specialty program, can be lifesaving”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [17] Tan JOA, Stewart A, Fitzpatrick R, Hope T. Attitudes of patients with anorexia nervosa to compulsory treatment and coercion. Int J Law Psychiatr. 2010;33(1):13–9. source

      Not checked in the free run.

    • cites [18] Tiller J, Schmidt U, Treasure J. Compulsory treatment for anorexia nervosa: compassion or coercion? Br J Psychiatr. 1993;162:679–80. source

      Not checked in the free run.

    • cites [19] Ward A, Ramsay R, Russell G, Treasure J. Follow-up mortality study of compulsorily treated patients with anorexia nervosa. Int J Eat Disord. 2016;49(4):435. source

      Not checked in the free run.

    • cites [20] Westmoreland P, Johnson C, Stafford M, Martinez R, Mehler PS. Involuntary treatment of patients with life-threatening anorexia nervosa. J Am Acad Psychiatr Law. 2017;45(4):419–25.

      Not checked in the free run.

  • Interpretationreasoning

    Anorexia nervosa impairs patients' ability to freely choose to accept the life-saving medicine they need most, food.

    “AN impairs patients’ ability to freely choose to accept the life-saving medicine they need most, food.”
    Quote in the paperSubstantial claim
  • Premisecitation

    The majority of individuals with anorexia nervosa will eventually recover.

    “Evidence suggests the majority of those affected will eventually recover”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] Eddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. J Clin Psychiatr. 2017;78(2):184–9. source

      Not checked in the free run.

  • Premisecitation

    Anorexia nervosa is a treatable psychiatric disorder.

    “AN is a treatable psychiatric disorder.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] Eddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery from anorexia nervosa and bulimia nervosa at 22-year follow-up. J Clin Psychiatr. 2017;78(2):184–9. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. 12
  • May combine two claims. 7

  • Classified as probably not a substantial claim.

    Premisecitation

    For adults with anorexia nervosa who have not responded to outpatient care, inpatient treatment in a behavioral specialty program is recommended.

    “For adults who have not responded to outpatient care, inpatient treatment in a behavioral specialty program is recommended [13]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Hilbert A, Hoek HW, Schmidt R. Evidence-based clinical guidelines for eating disorders: international comparison. Curr Opin Psychiatry. 2017;30(6):423–37. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    When inpatient treatment is inaccessible or has failed, or when repeated intensive weight restoration is followed by rapid weight loss and relapse, other approaches including harm reduction and palliative care can still foster hope in eventual recovery and motivation to reverse malnutrition.

    “When such treatment is inaccessible, or has failed, or when repeated intensive weight restoration is followed by equally rapid weight loss and relapse, other approaches, including harm reduction and palliative care, that focus on improvements in quality of life, can still foster hope in eventual recovery and motivation to reverse malnutrition.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Even seasoned clinicians cannot predict who will recover or when, nor identify those who will not be able to survive.

    “even seasoned clinicians cannot predict who will recover or when, nor identify “those who will not be able to survive””
    Quote in the paperSubstantial claim
    • Rests on an assumption: Risk factors for mortality in anorexia nervosa are poorly defined.
    • Rests on an assumption: There are no clear staging criteria for severe and enduring anorexia nervosa comparable to those used for cancer to help define terminal cases.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    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.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord. 2022;10(1):23. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Malnutrition exacerbates depressive and obsessional symptoms, promotes eating disordered cognitions, and impairs decision making.

    “malnutrition exacerbates depressive and obsessional symptoms, promotes eating disordered cognitions and impairs decision making [10, 11].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [10] van Elburg A, Danner UN, Sternheim LC, Lammers M, Elzakkers I. Mental capacity, decision-making and emotion dysregulation in severe enduring anorexia nervosa. Front Psychiatry. 2021;12: 545317. source

      Not checked in the free run.

    • cites [11] Broomfield C, Stedal K, Touyz S. The neuropsychological profile of severe and enduring anorexia nervosa: a systematic review. Front Psychol. 2021;12: 708536. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    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”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord. 2022;10(1):23. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Ambivalence towards treatment is a hallmark symptom of anorexia nervosa and results in treatment avoidance.

    “Ambivalence towards treatment, a hallmark symptom of AN, results in treatment avoidance [12].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [12] Guarda AS. Treatment of anorexia nervosa: insights and obstacles. Physiol Behav. 2008;94(1):113–20. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Defining terminal anorexia risks colluding with anorectic reasoning that improved quality of life and potential for recovery are hopeless prospects.

    “Defining terminal anorexia risks colluding with anorectic reasoning that improved quality of life and potential for recovery are hopeless prospects.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    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”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord. 2022;10(1):23. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Introducing the diagnosis of terminal anorexia risks countering hope for recovery and increasing demand for PAS by patients with severe and enduring anorexia nervosa.

    “Introducing the diagnosis of “terminal anorexia” risks countering hope for recovery and increasing demand for PAS by patients with SE-AN.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    Defining terminal anorexia inherently conflicts with goals of developing treatments, combating inequalities in care, nurturing hope of recovery, focusing on functional rehabilitation, and improving quality of life for patients with severe and enduring anorexia nervosa.

    “Defining terminal anorexia inherently conflicts with these goals”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Demoralized patients who read about terminal anorexia may self-identify with the label and seek out concierge physicians who offer PAS as an elective treatment.

    “Like social contagion and suicide, demoralized patients who read about terminal AN, may self-identify with the label and seek out concierge physicians, who offer PAS as an elective “treatment”.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    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.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Gaudiani JL, Bogetz A, Yager J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord. 2022;10(1):23. source

      Not checked in the free run.

    • Rests on an assumption: Palliative care does not require a terminal diagnosis and can be prescribed separately or conjointly with curative care.

  • Classified as probably not a substantial claim.

    Premisecitation

    Anorexia nervosa has high mortality.

    “as AN has high mortality [5].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68(7):724–31. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Applying the label terminal to anorexia nervosa risks leading to unjustified deaths in individuals whose mental illness impairs their capacity to make a reasoned treatment decision.

    “We are greatly concerned however regarding implications of applying the label “terminal” to anorexia nervosa and the risk it will lead to unjustified deaths in individuals whose mental illness impairs their capacity to make a reasoned treatment decision.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In a minority of adults with severe and enduring anorexia nervosa who do not respond to expert intensive inpatient behavioral treatment, continued aggressive attempts at weight restoration infringe on patient autonomy, risk harm, and may constitute futile care.

    “and in whom continued, aggressive attempts at weight restoration infringe on patient autonomy, risk harm, and may constitute futile care [6, 7].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [6] Westmoreland P, Mehler PS. Caring for patients with severe and enduring eating disorders (SEED): certification, harm reduction, palliative care, and the question of futility. J Psychiatr Pract. 2016;22(4):313–20. source

      Not checked in the free run.

    • cites [7] Westmoreland P, Parks L, Lohse K, Mehler P. Severe and enduring anorexia nervosa and futility: a time for every purpose? Psychiatr Clin North Am. 2021;44(4):603–11. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    Defining terminal anorexia will lead to unjustified deaths for a treatable condition.

    “we fear will lead to unjustified deaths for a treatable condition.”
    Quote in the paperNot a substantial claim
17 of 17

  • The paper relies on this without support.

    Most general psychiatrists and palliative care specialists have little experience assessing capacity in patients with anorexia nervosa.

    “most general psychiatrists and palliative care specialists have little experience assessing capacity in patients with AN.”

  • The paper relies on this without support.

    High disease burden in severe and enduring anorexia nervosa, including physical, social and financial costs, can contribute to extreme hopelessness and guilt.

    “High disease burden in SE-AN, including physical, social and financial costs can contribute to extreme hopelessness and guilt.”

  • The paper relies on this without support.

    Palliative care does not require a terminal diagnosis and can be prescribed separately or conjointly with curative care.

    “it does not require a terminal diagnosis and can be prescribed separately or conjointly with curative care.”

  • The paper relies on this without support.

    Persuasion and encouragement of a vulnerable individual is coercive.

    “as persuasion and encouragement of a vulnerable individual is coercive.”

  • The paper relies on this without support.

    PAS is neither a curative nor a reversible intervention.

    “As PAS is neither a curative nor a reversible intervention”

  • The paper relies on this without support.

    Risk factors for mortality in anorexia nervosa are poorly defined.

    “Risk factors for mortality are poorly defined”

  • The paper relies on this without support.

    There are no clear staging criteria for severe and enduring anorexia nervosa comparable to those used for cancer to help define terminal cases.

    “there are no clear staging criteria for SE-AN comparable to those used for cancer to help define terminal cases”
7 of 7

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Unlike cancer or Alzheimer's disease, most medical complications associated with anorexia can be treated with adequate nutritional intake and weight restoration, even in severely emaciated patients.

    “Unlike cancer or Alzheimer’s disease, most medical complications associated with anorexia can be treated with adequate nutritional intake and weight restoration, even in severely emaciated patients (3, 146).”

    From Assisted death in eating disorders: a systematic review of cases and clinical rationales (2024) · cites this paper as [3]

    The section “Terminal anorexia cannot be defined” says most medical complications of anorexia nervosa are reversible with nutritional rehabilitation and expert care. It discusses severe and enduring anorexia and contrasts its lack of terminal staging criteria with cancer, but does not make the claimed comparison with Alzheimer’s disease or explicitly establish reversibility in severely emaciated patients. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • 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”

    From Assisted death in eating disorders: a systematic review of cases and clinical rationales (2024) · cites this paper as [3]

    The section “The danger of a label” reports increased demand for physician-assisted suicide for psychiatric illnesses in Europe following legalization of medical assistance in dying. It does not specify which jurisdictions permit it or establish that a psychiatric disorder alone qualifies. (LLM, conf=0.79)

    Experimental — accuracy not yet measured

  • Clinicians who treat anorexia nervosa cannot predict who will recover or when, nor identify those who will not be able to survive.

    “This critical appraisal rightly asserts that clinicians who treat AN cannot predict who will recover or when, nor identify “those who will not be able to survive”, as most medical complications are reversible with nutritional rehabilitation and expert care.”

    From Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward (2022) · cites this paper as [5]

  • Most medical complications of anorexia nervosa are reversible with nutritional rehabilitation and expert care.

    “This critical appraisal rightly asserts that clinicians who treat AN cannot predict who will recover or when, nor identify “those who will not be able to survive”, as most medical complications are reversible with nutritional rehabilitation and expert care.”

    From Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward (2022) · cites this paper as [5]

Cites

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Related

Authors
Guarda, A. S., Hanson, A., Mehler, P., & Westmoreland, P.
Affiliations
University of Colorado Anschutz (US)
ORCID
Mehler, Philip
Venue
Journal of Eating Disorders
Publisher
Springer Science and Business Media LLC
Published
2022-06-07
Volume
10
Issue
1
Pages
79-79
ISSN
2050-2974 (ISSN-L)
DOI
10.1186/s40337-022-00599-6
PMC
PMC9175496
OpenAlex
W4281791196
Semantic Scholar
3d04f4293d0776548158429f7b9ae59f64aa5929
Cited by
32
References
27
Citations by year
2026: 9 · 2025: 3 · 2024: 10 · 2023: 9 · 2022: 1
FWCI
5.25
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Eating Disorders (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Eating Disorders and Behaviors
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
Keywords
severe and enduring anorexia nervosa, medical assistance in dying, palliative care, hospice care, end-of-life decisions, decision-making capacity, mental illness, treatment decision-making

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