Medical 
                      Emergencies in 
                      Eating Disorders: 
                      Guidance on Recognition 
                                                                                                                                                
                      and Management
                       
                      (Replacing MARSIPAN and Junior MARSIPAN)  
                      May 2022 
                       
          COLLEGE REPORT CR233                                                                                                                                                                                    
                                                                                                                                                                                                     
                                               CR233: Medical Emergencies in Eating Disorders: Guidance on Recognition and Management │ 1 
                                
                                                                                      
                                                                                                                                                                                                     
                      Endorsement statement 
                       
                      The Royal College of Psychiatrists’ Medical Emergencies in Eating Disorders: Guidance 
                      on Recognition and Management has been endorsed by the Council of the Academy 
                      of Medical Royal Colleges, which represents all the Medical Royal Colleges and 
                      Faculties in the UK.  
                      In endorsing the document, the Council recognised the importance of the guidance 
                      across health care settings and the need for clinicians in all specialties to understand 
                      how to recognise and manage medical emergencies in eating disorders.  
                      The Academy welcomes the guidance and encourages it use throughout the NHS. 
                       
                      Alastair Henderson   
                      Chief Executive 
                      10 Dallington Street 
                      London, EC1V 0DB 
                      T+ 020 7490 6810 
                      alastair.henderson@aomrc.org.uk  
                      www.aomrc.org.uk  
                       
                       
                       
                       
                      This report was developed with support and advice from an independent expert 
                      reference group established by the Royal College of Psychiatrists 
                       
                      © 2022 The Royal College of Psychiatrists 
                      College Reports and position statements constitute College policy and have been sanctioned by 
                      the College via the Registrar. 
                      The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in 
                      Scotland (SC038369).                                                                        
                                                                                                                                                                                                     
                                               CR233: Medical Emergencies in Eating Disorders: Guidance on Recognition and Management │ 2 
                                
                                                                                      
                                                                                                                                                                                                     
                      Contents 
                      List of tables, figures and boxes ................................................................................................. 6 
                      List of contributors .......................................................................................................................... 7 
                       
                      Forewords ........................................................................................................................................... 11 
                      Executive summary and recommendations ..................................................................... 13 
                           Recommendations................................................................................................................................................ 15 
                       
                      1. Introduction .................................................................................................................................. 18 
                           a. History of the project ....................................................................................................................................... 19 
                           b. What has happened since? ........................................................................................................................ 19 
                      2. Risk assessment: evaluating the impending risk to life due to the patient’s 
                      illness .................................................................................................................................................. 27 
                           a. Introduction ......................................................................................................................................................... 28 
                           b. An all-age risk assessment framework for assessing impending risk to life .............. 30 
                           c. Differential diagnosis ..................................................................................................................................... 35 
                           d. Assessing different domains of acute risk ........................................................................................ 36 
                      3. Location of care and transfer between services ......................................................... 59 
                           a. Where should treatment take place? ................................................................................................. 60 
                           b. Quality of inpatient care .............................................................................................................................. 62 
                           c. Transfer between services .......................................................................................................................... 63 
                      4. Safe refeeding of malnourished patients with restrictive eating disorders ... 68 
                           a. Introduction ......................................................................................................................................................... 69 
                           b. Refeeding and ‘underfeeding’ syndromes: recognition, avoidance and  
                           management ........................................................................................................................................................... 74 
                           c. Guidance for refeeding ................................................................................................................................. 77 
                      5. Nasogastric and other routes of feeding........................................................................ 86 
                           a. Introduction ......................................................................................................................................................... 87 
                           b. When to consider NGT feeding ............................................................................................................... 88 
                           c. Monitoring ............................................................................................................................................................ 88 
                           d. NGT feeding under restraint ..................................................................................................................... 90 
                           e. NGT feeding and veganism ....................................................................................................................... 90 
                           f. Use of nasal bridles in NGT feeding ........................................................................................................ 91 
                           g. Nasojejunal and other feeding routes ................................................................................................. 91
                                                                                                                                                                                                     
                           h. NGT feeding in psychiatric settings ..................................................................................................... 92 
                      6. Management of behavioural manifestations of eating disorders on  
                      medical or paediatric wards  .................................................................................................... 93 
                           a. Introduction ......................................................................................................................................................... 94 
                           b. Avoiding weight increase/restoration................................................................................................. 95 
                                                                                                                                                                                                     
                                               CR233: Medical Emergencies in Eating Disorders: Guidance on Recognition and Management │ 3 
                                
                                                                                      
                                                                                                                                                                                                     
                           c. Self-harm and suicidal thoughts ............................................................................................................ 97 
                           d. Comorbid psychiatric conditions ........................................................................................................... 97 
                           e. When the patient is driven to aggressive or other disturbed behaviour ..................... 98 
                           f. Approaches to treatment of behavioural manifestations of eating disorders ........... 98 
                      7. Helping parents, relatives and carers .............................................................................102 
                           a. The family’s role in treatment of the eating disorder .............................................................. 103 
                           b. How the family or carers may respond to the eating disorder ......................................... 104 
                           c. Communication and confidentiality issues ................................................................................... 105 
                           d. A collaborative approach .......................................................................................................................... 106 
                           e. Issues affecting mainly children and adolescents .................................................................... 107 
                           f. Issues affecting mainly adult patients ............................................................................................... 108 
                           g. Dos and don’ts for carers, relatives and friends of people with eating disorders . 109 
                      8. Compulsory admission and treatment........................................................................... 112 
                           a. Introduction ......................................................................................................................................................... 113 
                           b. Use of mental health legislation in emergency departments and  
                           medical/paediatric settings ........................................................................................................................... 118 
                           c. Mental health law ............................................................................................................................................ 118 
                           d. Holding powers ................................................................................................................................................ 119 
                           e. Common law ..................................................................................................................................................... 120 
                           f. The Mental Capacity Act ............................................................................................................................. 120 
                           g. Organisational issues ................................................................................................................................... 120 
                           h. Compulsory admission and treatment for under-18s ............................................................... 121 
                      9. Eating disorders and type 1 diabetes mellitus ............................................................ 125 
                           a. Definitions and clinical features ............................................................................................................ 126 
                           b. Recommended healthcare team ........................................................................................................ 126 
                           c. Assessment and treatment ...................................................................................................................... 127 
                      10. Policies and protocols .......................................................................................................... 128 
                           a. General principles .......................................................................................................................................... 129 
                           b. Suggested areas to be covered by an oversight group within a protocol for  
                           managing severe eating disorders .......................................................................................................... 130 
                           c. Responsibilities of different local health care providers ........................................................ 134 
                           d. Training and continuing professional development ............................................................... 134 
                           e. Appropriate care settings and other considerations ................................................................ 135 
                      11. Challenges for commissioners and managers .......................................................... 136 
                           a. Overview ............................................................................................................................................................... 137 
                           b. Responsibilities of those commissioning care ............................................................................. 141 
                           c. Areas with limited local eating disorders provision. ................................................................. 143 
                      12. Recommendations for audit and research ................................................................ 147 
                           a. National Confidential Enquiry into deaths from eating disorders .................................. 148 
                           b. The impact of guidelines on treatment of eating disorders ............................................... 148 
                           c. Studies of capacity in eating disorders other than anorexia nervosa ........................... 148 
                           d. Risk factors and feeding rates in refeeding .................................................................................. 148 
                                                                                                                                                                                                     
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