Eating disorders on medical wards: breaching clinical standards, patient rights and scopes of practice

Eating disorders (EDs) are psychiatric disorders with high morbidity and mortality. Their management is complex and requires specialist care. There is a lack of ED units in New Zealand and hence people with EDs are frequently defaulted to general medical wards for prolonged periods; a practice that has been invisible in terms of the mental health crisis. Medical wards are not resourced to provide the care needed. The practice breaches the rights of the ED patient, undermines the rights of general medical patients and introduces medico-legal risk for physicians working outside their scope of practice. Given the bed shortages on medical wards, the medical needs of the ageing population and the increasing prevalence of EDs this practice is untenable.

Eating disorders are complex psychiatric conditions

The Diagnostic and Statistical Manual of Mental Illnesses (DSM-5) defines several EDs, including: anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), among other rarer subtypes.¹ ED prevalence has gone up considerably in the last 50 years. Five to 10% of young people have an ED and of these 50% will have disordered eating for over 5 years.² COVID-19 resulted in increased ED diagnoses globally with new admissions for care for New Zealand youth doubling during this time.¹

EDs frequently co-occur with other mental disorders with estimates ranging from 58 to 98% of patients.^3,4 They are also strongly associated with temperamental traits, developmental and personality disorders such as attention-deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and autism spectrum disorder (ASD).² AN in particular is difficult and complex to manage. It is associated with challenging behaviours (e.g., excessive exercise), emotional dysregulation, anxiety and depression and has one of the highest mortality rates of all mental illness. Suicide risk is high—it is estimated to be the cause of death in 25% of cases.⁵ Mortality in ED patients goes up significantly when co-existing psychiatric disorders are present. ^5–7

International guidelines highlight psychological management as the cornerstone of treatment for AN with a focus on causal and maintenance factors.⁸ Treatment has a focus on family therapy for adolescents and individualised psychotherapy for adults.⁸ Relapse rates are high and many individuals develop a chronic course; one-third never recover.^2,9 Pharmacotherapy has a limited role but olanzapine may offer value.² Treatment focusses on restoring sufficient calories, nutritional balance and appropriate eating patterns but even for moderate to severe AN, this should be outpatient-based.² Given the chronicity of the disorder, individually tailored treatment is needed with psychological interventions running alongside nutritional and weight monitoring. For BN, cognitive behaviour treatment produces remission in up to 40% and fluoxetine is approved in the United Kingdom with topiramate also prescribed (outside of pregnancy).²

The role of physicians and acute medical wards

Physicians have an important but limited role in the management of EDs. When an ED is recognised, monitoring for complications such as electrolyte disturbances and dehydration should be initiated. Longer-term complications such as gastric motility issues and osteoporosis also need to be routinely assessed for. Most management will occur within primary care or intensive outpatient programmes.² If concerns are raised regarding the rapidity of weight loss, hypoglycaemia, dehydration or electrolyte abnormalities then management may need to be escalated to an inpatient unit. Guidelines recommend specialist eating disorder units, but in New Zealand patients are frequently defaulted to acute general medical wards regardless of bed shortages or ED resources.¹⁰

The key role for the hospital physician is in the avoidance, assessment and management of refeeding syndrome (RS) and its complications. RS is a constellation of metabolic and electrolyte abnormalities that occur as a result of the reintroduction of calories after a prolonged period of decreased intake.¹¹ Phosphate depletion in these settings—alongside potassium and magnesium decreases—can cause respiratory depression and decreased cardiac contractility. The disturbance can precipitate arrythmias; hence the role for physicians in assessment, electrolyte repletion and monitoring, i.e., medical stabilisation.

Guidelines recommend checking potassium, magnesium and phosphate before initiation of feeding then regular monitoring of patients at risk until stabilised (not requiring electrolyte supplementation for 2 days).¹¹

Multiple studies have shown the degree of malnutrition to be the most important predictive factor in the development of RS.¹² However, a recent Australian study showed that no patient—even when severely malnourished—developed clinical manifestations (symptoms or organ dysfunction) of RS when it occurred.¹² Canadian research from a specialist ED unit utilising rapid refeeding for weight gain had no full cases of RS, severe hypophosphataemia or death over 4 years and no need for medical ward transfer for RS (n=103).¹³ Hence, although monitoring is important, it is possible that treating teams are being overly cautious in admitting those deemed to be at risk.

The use of telemetry monitoring for AN complicated by syncope, severe sinus bradycardia, junctional rhythm or marked prolongation of the QT interval is recommended, but evidence for malignant arrhythmias as a cause of sudden death in EDs is limited, cardiac death is rare and most cardiac manifestations are mild and reversible.^14,15 Cardiac instability acutely is dependent on electrolyte depletion and hence if these are replete and the ECG stable then there is no indication for ongoing cardiac monitoring. Nutrition, weight and electrolyte monitoring can occur in the community alongside the psychological treatment integral to recovery. None of the eight international guidelines informing best practice for the management of EDs (available in English) mandate prolonged telemetry or prolonged inpatient care on a medical ward for cardiac monitoring.^16–23 Postural hypotension is common with low body mass, exists in numerous other clinical situations and is not an indication alone for acute medical admission.

Hence there is no need for a hospital physician outside of acute stabilisation. Weight and electrolyte monitoring alongside feeding do not require a medical ward.

Current practice breaches standards and violates patient rights

Despite the emphasis on specialist units, ED specialists, psychologists and psychiatrists, people with EDs in New Zealand are routinely admitted to acute medical wards for prolonged periods that well exceed that required for medical stabilisation. For example, in Wellington Regional Hospital the mean length of stay (LOS) is 19.11 days. At Hutt Hospital the mean LOS is 29.8 days. This is over double the mean LOS of a unit in Australia set up to provide specialist care.²⁴

Neither the Wellington nor Hutt hospitals employ an ED specialist. Wellington consult liaison psychiatry teams are expected to provide the care required yet their own referrals have doubled over the last decade without a commensurate increase in resources. This means that general physicians are frequently left to “lead” the care of a complex psychiatric condition outside their scope of practice with no training or resources. Healthcare assistants, rather than psychiatric nurses, are also used to provide day to day nursing care and meal monitoring. Although there have been increases in resources for the community EDs service in Wellington, they do not take patients under the Mental Health (Compulsory Assessment and Treatment) Act 1992  for weight restoration.

Despite the lack of medical input required, psychiatric services do not take over care when patients are stable—the expectation is that patients remain on medical wards. This practice creates false expectations in those with EDs and their families that they require inpatient medical care when they only need feeding. The psychiatric care including intensive psychological support needed for treatment and remission is not available on medical wards.²⁵ This creates challenges for physicians who retain duty of care over a condition that is primarily psychiatric. It also presents challenges for nursing staff who are not trained in EDs and are unable to provide the psychological input required, potentially leading to moral distress. The close observation required for EDs in terms of ensuring caloric input is also a time-consuming task for busy medical nursing staff.

Current practice not only breaches the guidelines for specialist care but also compromises patient rights. The Code of Health and Disability Services Consumers’ Rights (the Code)²⁶ establishes the rights of consumers and the obligations of providers. Right four states that consumers have the right “to services of an appropriate standard”. This includes the right to “reasonable skill” in the delivery of care and the right to a service that complies with “professional” standards.

Admitting ED patients to medical wards breaches these standards. Physicians and medical nurses are not trained in ED management, nor do they have psychiatric training and hence standards outlined by professional bodies cannot be followed. Access to psychologists is poor and sometimes absent altogether.²⁵ General medicine is also the admitting service for infectious disease and hence has a high prevalence of transmissible infection. Prolonged inpatient admissions to medical wards puts ED patients at risk of nosocomial infection as New Zealand hospitals lack the basic design requirements to apply appropriate preventive measures.²⁷

Admitting people with EDs to medical wards also impacts the care of other patients. Although people with EDs do not usually have behavioural disturbances that directly compromise the care of others, their admissions still have an impact on the rights of medical patients.^27,28 When psychiatric admissions utilise medical wards—or fail to be discharged when stable—they occupy beds required for medical patients. New Zealand hospitals do not have the bed numbers to meet medical need, and many patients wait for long periods in the emergency department—often in corridors. In Wellington, “bed block” was so extreme in 2024 that a corridor outside the waiting room was blocked off and used as a temporary ward. Older adults—those most likely to be admitted to acute medical wards—are particularly vulnerable to the complications of long waits including higher in-hospital mortality, falls and bed sores.²⁹

When medical patients are waiting in emergency department corridors for beds their rights to privacy and dignity are also compromised. People with EDs are often admitted to the limited number of single rooms despite these being required for infectious disease, delirium, dementia and terminal care.²⁷ ED patients’ right to privacy appears to be prioritised over the clinical needs and rights of medical patients who are less able to manage their own privacy and dignity due to physical, cognitive and sensory impairments.^27,28

It is an exercise in double book-keeping to admit psychiatry patients to medical beds because of the mental health crisis and lack of ED beds. Doing so ignores the paucity of medical beds and the harm that occurs with bed block, delays in medical care and the poor access to single rooms.

Risks to physicians

Admitting people with EDs to medical wards not only breaches patient rights, it also exposes physicians to sanctions and complaints from patients and their families. Doctors practicing outside their scope are subject to professional censure under the Health Practitioners Competency Assurance Act 2003 but all complaints—even when not escalated—take a toll on doctors. Admitting people with EDs for weight gain (i.e., not just medical stabilisation) in addition to their own medical workloads also contributes to stress and burnout for physicians who are already responsible for the largest admitting units in New Zealand hospitals.

Although demand outstrips supply in all public specialities, general physicians are the only specialists expected to repeatedly manage the workload of another service in addition to their own. It should be noted that when surgical lists are unable to be managed in the public system they are outsourced to private providers at significant cost to the tax payer—a practice that has been flagged to increase.³⁰ For mental health, despite the well-documented shortages, the expectation appears to be to continue to default complex and severe conditions to general medicine despite longstanding concerns regarding resources, standards of care and patient rights.^25,31

Summary and recommendations

Expecting acute general medicine wards to manage EDs breaches the right to an appropriate standard of care for people with EDs, compromises the rights of medical patients waiting for inpatient beds and places physicians at medico-legal risk. Given the prevalence of EDs, the paucity of medical beds and the increasing medical needs of an ageing population the practice is untenable.

People with EDs need access to timely specialist care with a high level of psychological support and appropriate psychiatric supervision. This may occur in an inpatient, outpatient or community setting depending on the needs of the individual. The role of a medical ward and physicians is to provide acute stabilisation in severe cases, not to provide prolonged admissions for weight gain.

We recommend all general medicine teams request their LOS data on EDs and insist that hospitals stop using medical wards for the long-term management of a complex psychiatric condition.  Funders need to recognise that all patients—not just those awaiting surgeries—need access to timely and appropriate care.