Given the interests in how the law should be used in cases of Anorexia
Nervosa, I am putting on the Blog my Chapter in my book: The Cockroach Catcher.
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"This is
the Captain again. I hope you have enjoyed the view of St. Lucia. It is unusual to have so
little cloud. Anyway, in seven minutes
we shall be able to come into view of Barbados. We should be coming in from the north side
where you will be able to see Port
St Charles. Then we shall go round the west coast.
With any luck you will be able to see Sandy
Lane, the best hotel in the world. So, in seven
minutes. Barbados.
The temperature in Barbados:
83 degrees Fahrenheit, with scattered clouds.”
In seven minutes I would start my life
of leisure in this Paradise
Island in the sun.
Seven minutes.
Seven minute cure. My famous seven minute cure. It was the
making of me at the Adolescent Inpatient Unit. It was the pinnacle of my
career. The most defining seven minutes in my career.
And Candy really helped me launch
myself into it.
“It is our view that clinically it was
wrong for Candy to be transferred at this stage. It was wrong for the NHS to
accept her back and in our view Candy is in serious risk of – quite frankly – dying.”
Those were more or less the words said at
the transfer meeting by the nurse from the private hospital where Candy had
been for the past eighteen months. She had been compulsorily detained twice and
she had been put on Olanzapine. Olanzapine
is one of a new group of drugs licensed for Schizophrenia and has been found to
induce a voracious appetite especially the bingeing of carbohydrates. Some
psychiatrists have started using it for this specific effect. In Candy’s case
she managed to fight the biochemical effect of Olanzapine.[1]
Candy was just two days free of
tube-feeding, which apparently was the only way to get her weight to a less
frightening level.
Ethics in medicine has of course
changed because money is now involved and big money too. What was in dispute in
this case was that the private health insurance that sustained Candy through
the last eighteen months had dried out. The private hospital then tried to get
the NHS to continue to pay for the service on the ground that Candy’s life
would otherwise be in danger. The cost was around seven hundred pounds a
night. Some would argue: since we as a
state hospital would not be getting the money, why should we take the
risk? After all, the consultant in
charge would be in the dock if the patient did die. Nowadays, patients and their families are
trigger happy and complain even if the patient becomes better. God help us if
they die.
I argued the case in the opposite
fashion. We shall help the authorities without precondition and who knows, I
may be able to get them to give us something when the time is right.
Cynics at the unit looked at me as if I
had just dropped off another planet. Get something out of the Health Authority?
When were you born?
A quick calculation gave me a figure of
over a quarter of a million pounds per year at the private hospital. No wonder they were not happy to have her
transferred out. Before my taking up the
post, there were at one time seven patients placed by the Health Authorities at
the same private hospital. Not all of them for Anorexia Nervosa, but Anorexia
Nervosa required the longest stay and drained the most money from any Health
Authority. I have seen private clinics springing up for the sole purpose of
admitting anorectic patients and nobody else. It is a multi-million
pound business. Some of these clinics even managed to get into broadsheet
Sunday supplements. I think Anorexia
Nervosa Clinics are fast acquiring the status of private Rehab Centres. Until
the government legislates to prevent health insurers from not funding long term
psychiatric cases, Health Authorities all over the country will continue to
pick up the tabs for such costly treatments.
The poor nurse did not realise what hit
her. That was my first week. I am never threatened. I like the challenge of
difficult cases and definitive statements like – the patient will die. I like to prove it otherwise.
The nurse concerned was not naïve
either. Far from it. She based her judgement not on what she knew about me. It
was only my first week after all.
No, she based her judgement on her
knowledge of the unit, as she used to work here. She was once its lead nurse.
Alas, poor pay and bad conditions coupled with the deteriorating consultant
leadership prompted her to jump ship. I could not blame her for that.
The unit went through a difficult phase
until the last consultant was finally suspended. Even before that, other
consultants started refusing to refer patients here, and the two main Health Authorities
that the clinic served had to fund ECRs (Extra Contractual Referrals in the
then re-organised Health Service lingo) to mainly private hospitals.
Then the unit had a locum and the operation
was scaled down drastically. Bed availability dropped to less than half the
normal capacity and the waiting list for admission grew. Unlike elective
surgery, some patients in psychiatry cannot wait. Beds had to be found and
often they were placed with adult psychiatric patients. It was not ideal even
for the psychotics and certainly inappropriate for Anorexia Nervosa. Private
Hospitals had to be used.
My first task as the new consultant in
charge was to ask the Charge Nurse what would limit our ability to admit to
full capacity.
“Your time,” was his reply.
So we aimed to move to full capacity,
not overnight but within the following three months. The shock on the faces of
the managers as this was announced at a meeting gave me such an adrenaline
rush.
Or, did they think, “What a fool!”
Fool or no fool, one needs to enjoy
one’s work, even in the NHS.
This perhaps is one thing that the
government has conveniently forgotten. Many of us do what we do because we
enjoy it. Otherwise why should anyone want to teach in universities when they
can earn ten or twenty times more in industry? We may also decide to dedicate more
time to work for personal pride and satisfaction. During the few years I worked
at the inpatient units I spent in excess of a hundred hours a week there, one
man doing the job of at least two. In
addition to that, I was still looking after two outpatient clinics.
With increased capacity, we were ready
to take on transfers. At that time the Health Authorities still had decent
managers not yet blinded by directives and performance targets. For a start
these managers did not interfere with clinical matters. For our part we were
free to exercise our clinical judgment.
Unfortunately many consultants abuse this privilege of clinical independence, often
making excessive demands for treatments and investigations, and managers have
learnt to ignore them. Worse the
government set up this organisation called NICE (National Institute for Health
and Clinical Excellence) to try to deal with such behaviour.
“It is our view that clinically it was
wrong for Candy to be transferred at this stage. It was wrong for the NHS to
accept her back and in our view Candy is in serious risk of – quite frankly – dying.”
The nurse was probably unwise to make
such a declaration, as my mind was already made up to take on Candy regardless.
What if the private hospital did not
exist? It would have been down to us
then. So to me that was no big deal. After all, most private hospitals are
notorious for transferring their dying patients to NHS hospitals so as not to
mess up their pristine mortality figures. What was so different here?
“Shall we meet the family?” I said,
trying to break the ice.
There had of course been a pre-visit by
our Charge Nurse and his team.
“This one is difficult and I think you may
have a problem with father.”
Candy led the three-some. She gave me
such a look as if to say, “Wait till I give you all the trouble.” She looked out of the window for the rest of
the time. Mother was warm but worn. Eighteen months had taken its toll and she
was gracious enough to be pleased to meet me. Father on the other hand seemed
to show some anxiety. In fact, he was a quite a powerful negotiator, and had
managed to persuade the insurers to agree to extend the private medical care
for another six weeks on a shared cost basis, either with the parents or with
the Health Authority. He was still quite
keen on the private treatment, and was half hoping that I would refuse to take Candy
on clinical grounds and then the Health Authority would pick up the bill from
then on.
To be fair, eighteen months was a long
time even for Anorexia Nervosa. Perhaps
someone else should have a go. NICE had
not yet come up with a standard treatment and I certainly would challenge them
to do so. Tube feed everybody? That
would be the day.
Mother was more intuitive and I think
she got the measure of me very quickly. “Darling, perhaps we should give Candy
a new start. The new doctor might work in a different way.”
“It is the nurses that did most of the
work.” A final and desperate attempt by the nurse from the private hospital to
set the record straight was missed by the nervous family. The rest of the world
still looked up to the consultant, perhaps not for much longer but until
Armageddon, I was going to enjoy it.
“I will give it my best shot.”
So on a rather unusually beautiful
sunny Tuesday morning, we received a soon to be dead Anorexia Nervosa patient
who had been abandoned by her insurer to the unsafe NHS.
What a challenge! Some
of those at the meeting must have considered that I was delusional.
I believed that money should not be part of
the consideration for the best health care and I was determined to make sure
that my delusions should remain true for me.
I had to maintain a good service in my little corner of the NHS.
Perhaps I was able to capture mother’s
heart and gain her confidence through mine. She decided that they should give
us a try.
Do I tube feed her straightaway or do I
wait?
I am no coward. So let us wait.
Adolescent units are notorious for
making life difficult for authority figures. This is perhaps due to severe
professional rivalry. To most of the nursing staff, the only difference between
the psychiatrist and them is that the psychiatrist is licensed to
prescribe. If a patient is not on
medication a psychiatrist would barely be needed. Over time various mechanisms
have been introduced to minimize the input of the psychiatrist even when he is
supposed to be in charge. Many psychiatrists gave up the fight a long time ago
just to survive. A patient’s stay in hospital involves a large number of
multidisciplinary meetings that often lead to half-baked treatment plans that
have little hope of success. Surprises
are unwelcome and generally discouraged.
I have found this kind of “consensus”
approach a serious problem. It is simply
not my style. Perhaps one of the reasons
I stayed as an outpatient consultant all these years was to continue to enjoy
the independence from such approach.
Now all eyes were on me.
On that Tuesday I felt as though the
whole unit was putting me through a trial. It was like living through a reality
show. Everybody was watching me, and I
would have to deliver or perish. My
reputation, the reputation of an alien psychiatrist, was at stake. I needed to
act fast and I did not have eighteen months. Otherwise I would be packing and
leaving this jungle, house or whatever reality show I was in.
Apart from true madness, Anorexia is
the only condition where one can use the Mental Health Act to detain and if
necessary force feed against the patient’s wishes, although little is known
about how effective this aspect of our law is.
There is still a rather high mortality rate, even in acknowledged
centres of excellence like the Maudsley[2]. Tube feeding does not seem to be saving lives. It also hurts our pride if we have to succumb
to tube-feeding. It means that we have
failed as psychiatrists.
Then I remembered my own golden rule
about parenting. When all else fails, try bribery. And that is what I did, but not with Candy.
Any nurse that could get Candy to start
eating would get three bottles of nice wine or two cases of beer. It might not be strictly against the rule,
but I am sure a few eyebrows were raised.
Candy refused to eat or even drink.
I had to be in London
for a Royal College meeting that Friday. My mobile rang. Day 4: Candy was still
refusing to eat or drink.
“No tube feeding, just check her blood
chemistry” was what I decided should be done.
People do not die so easily even with committed fasting. We had got
time, and nobody was going to get my wine or beer, I told myself.
By Sunday, there was a major concern
that Candy, having not eaten for five days, might be at some risk. A quick electrolyte check showed normal
sodium and potassium levels. I left
instructions again not to jump up and down and worry too much. I was quite sure she must have been secretly
drinking, perhaps not from her own jug. Often other patients would “help”, not
quite comprehending how their “help” might indeed be a “hindrance”. I have even seen nurses “helping” to dispose
of patient’s food or even eat it. Anorexia stirs up funny emotions.
By the time I got in on Monday, Sophie,
Candy’s nurse said to me, “I think you had better see Candy. There has been no
change at all.” This was in some ways
quite unusual as most of the time the consultant in charge only gets involved
in family meetings and reviews that are pre-planned. Junior doctors deal with
the day to day checking on patients.
Perhaps she was somehow hoping that I would give in and put Candy back
on tube-feeding.
I think if there had been a NICE guideline[3], I might not have been
given this chance. Instead some on-call
doctor over the weekend would have put her on tube-feeding as per protocol.
After all, that had been her mode of feeding for weeks.
We would use the law if and when it
became necessary.
However, that would have defeated the whole
point, as she would have been stuck with the old ways forever.
Stubborn patients deserve stubborn
doctors.
Candy came in.
“Aren’t you going to tube feed me?”
“No.”
“Then I will die.”
“So I will be very sad but we do not
tube feed here.” At least I don’t.
“You can’t do that. I want to be discharged.”
These are more or less verbatim
reports. My mind was racing fast trying to come up with an answer.
“I want to be discharged!”
“Candy, it is actually possible.”
I can still remember the look of horror
on Sophie’s face: “Is this doctor for real?”
“You mean discharged today?”
“Yes. I mean today.”
I could see Sophie was in complete
shock. “What planet did this consultant drop out of and how is he going to pull
this one off?”
“Well. If you start off by drinking one
carton of Ensure Plus and some squash, then eat your lunch and have another
Ensure Plus in the afternoon, you will be discharged home and you can come back
daily.”
When I used this case in my teaching
sessions with junior doctors, they invariably showed incredulity that I offered
this to Candy just like that, without consulting her parents or her nurse. I knew that if there had been any discussion
it would never have happened. There would have been objections from somewhere. That is the trouble with consensus.
But you see, it was important for Candy
to know that I had authority. Many adolescent units have
gone too far the other way, and they really are a reflection of dysfunctional
families where the adolescent rules the roost.
A totally democratic approach will never produce the thunderbolt and
deliver the sustainable therapeutic effect.
A strange bond was developing between
me and Candy. I gave her a way out and she would oblige. I had no doubt at all she would be compliant.
Sophie then went to fetch exactly what
I told Candy she needed to
consume. When Sophie came back, the drinks went down
in seconds. I could see the relief and
disbelief in Sophie’s eyes.
That took seven minutes.
And now the real work began: the
details. I told Candy she would be discharged
as an inpatient and would need to come in every day as a day-patient. A trick
you might say.
She did not object.
She never expected to be discharged in
her state. The important thing was that I took control. For her it was a
relief. She never protested that I perhaps tricked her. It too was a relief for
her to have something in her stomach.
What was more important was I saved her face and she, mine.
I was to stay on in the show.
How could I justify sending a fragile
fasting patient home on the first day of resumption of eating?
For five days we achieved nothing when
she was in hospital.
What about the parents?
In fact I phoned mother in front of
Candy straight away. I played a trick on
her. I just said, “Candy is coming home.” A long silence indicated how shocked
she was. Then I told her of our seven minutes.
“I knew you could do something. That was what I told my husband, but I did
not know it was going to be this quick. I did tell him you were OK.”
You can wait for years for a case like
this. It is like a hole-in-one. You just know the moment the ball leaves the
tee. With one such case, I could now put up with anything anyone cared to throw
at me.
At least for a while.
To Candy, it was like a heart
transplant. She had been stuck for too long and was probably pleased to get
out. Hospital was not like home and she had not been home for a long long
time.
So where is Candy now?
She was eventually discharged to attend
a state school but that did not work. She eventually went to an agricultural
college where she worked mainly with horses and did extremely well. Her weight
was well maintained. That took another fourteen months.
But she remained a day patient
throughout except for a long weekend when her parents went away for their
anniversary. At Candy’s request, she stayed in the hospital that weekend.
[1]
Olanzapine – (Zyprexa-Lilly) Anti-psychotic drug. Eli Lilly agreed on Jan. 4,
2007 to pay up to $500 million to settle 18,000 lawsuits from people who
claimed they had developed diabetes or other diseases after taking the drug.
Lilly denied any wrongdoing. In its statement, Lilly said the settlement did
not change its view that Zyprexa is a safe and effective treatment for mental
illness.
Lilly’s internal documents show that in Lilly's clinical trials, 16
percent of people taking Zyprexa gained more than 66 pounds after a year on the
drug, a far higher figure than the company disclosed to doctors.
Olanzapine-induced weight gain may be secondary to excessive ingestion
of food due probably to an inability to increase plasma glucose and leptin
following a glucose challenge.
The
F.D.A. added a warning in 2003 to the label of Zyprexa and other new
antipsychotic drugs about their tendency to cause high blood sugar.
[2]
Anorexia mortality: http://bjp.rcpsych.org/cgi/content/abstract/175/2/147
Anorexia nervosa is a mental disorder with a
high long-term mortality. Detained patients gained as much weight during
admission as voluntary patients, but took longer. More deaths among compulsory
than voluntary patients (10/79 v. 2/78) were found 5.7 years (mean) after
admission. CONCLUSIONS: Compulsory treatment is effective in the short term.
The higher long-term mortality in the detained patients is due to selection
factors associated with an intractable illness.
The British Journal of Psychiatry 175: 147-153
(1999)
© 1999 The Royal College
of Psychiatrists.
[3] NICE guidelines for eating disorders were not issued until January
2004, some years after this case.
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Email: cockroachcatcher (at) gmail (dot) com.
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