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Ethics Roundtable: Autonomy and Delusion

KJ is a 32-year-old male patient and previous avid longdistance runner who presented with failure to thrive and cachexia which warranted hospitalization. At that time, exam findings included profound weakness, cachexia, apathy, fatigue and 2þ dependent edema. BMI was 12. Past medical history was significant for anorexia nervosa which, after years of therapy, had been sufficiently managed by “eating to relieve hunger.” Eighteen months prior, KJ had been involved in a severe motor vehicle accident which impaired his ability to run. KJ stated that due to his inability to run, he had also ceased “eating to hunger” and desired no nutritional support. The hospital chaplain was consulted and learned that KJ believed running to be his “calling from God” to be a “witness for fitness”. He did not want to “put anything unhealthy in [his] ‘temple’ (body)” in order to “be an example for others with poor health due to poor eating.” Since he could no longer run, he stated, “there’s no longer any reason for me to eat.” The chaplain stated concerns related to hyper-religiosity and obsessive exercise behaviors and ideations. KJ’s mother had been his primary caregiver at home, but he stated that he wanted to make his own healthcare decisions. There was concern regarding KJ’s decision-making capacity, and serial psychiatric evaluations were requested, all of which determined that KJ did indeed have full understanding of his condition and the consequences of his decisions. The medical team felt in-patient psychiatric placement would be appropriate for treatment of his eating disorder. Despite his ability to express understanding of his condition, the primary attending felt his physical decline was due to a delusional disorder and that involuntary admission would be ethical. KJ refused to consider a psychiatric admission and refused enteral feeding. He then produced a previously signed advance directive declaring DNR status and “no tube feedings if my condition is terminal.” An order for an ethics consult was placed.