Refusals of treatment in adolescents and young adults

Case

Kristin is a 17-year-old admitted through the emergency department of a children’s hospital, where she presented with severe dehydration and abdominal pain. Her mother accompanied her to the hospital, and her father soon joined them. Kristin has a history of multiple hospital admissions for episodes of severe weight loss and dehydration. She was assigned to the general adolescent medicine service, and diagnosed with acute inflammation of the pancreas and gallbladder secondary to the diagnosis of anorexia nervosa. When asked about her daughter’s medical history, Kristin’s mother denied her daughter had an eating disorder. Her father explained that Kristin had always been a very driven gymnast. With a height of 5′6″ (168 cm), Kristin’s weight upon admission was 79 pounds (36 kg). Over the next week, as members of the adolescent team tried to engage Kristin directly in a discussion of her health and a treatment plan, Kristin, despite being alert and intelligent, grew agitated and angry in response to any mention of an eating disorder or anorexia, even threatening to “fire” certain providers who upset her. Kristin’s mother largely stood by and asked team members not to upset her daughter. While Kristin had initially allowed nasojejunal feeds and line placement for intravenous (IV) fluids, she later questioned the nurse suspiciously when she hung a new IV bag, asking, “How many calories are in that stuff?” She demanded that the line be removed. The nurse managed to persuade Kristin that the only way she would get better was through IV rehydration and nutrition. The patient acquiesced and did not attempt to remove the line.