Once a decision to shift gears is made (if it is agreed that such a shift makes sense), a variety of things may happen. Even though all such patients are extremely medically fragile, not all patients will immediately decline. What sort of supportive care should be offered to this group? What might be offered in the way of stabilization care and/or care focused on quality of life issues?

And what about those whose health does precipitously decline? Should palliative end-of-life care be offered to the patient? Certainly such patients can suffer in their final days or hours as they die from the complications of their starvation. Traditionally end-of-life palliative care has been reserved for patients with a terminal medical illness or (in some cases) patients with a severe (but not necessarily terminal) illness who have decided to forgo further treatment for it. But might there be a role for such care for anorexia patients?

An additional issue that arises here is about continuity of care, and in particular continuity of caregivers. Many patients develop close ties to their therapists and wish to continue to see them even when they refuse hospitalization. In the past this has (at least in some places) been discouraged, the thought being that only patients actively seeking curative treatment and aiming to gain weight should be able to continue in therapy. Refusing to continue therapy for non-compliant patients has traditionally been seen as a way of communicating both the seriousness of the situation as well as the therapist’s unwillingness to be complicit in the patient’s self-destructive behavior. However, in a context where a shift in plan reflects the recognition that further curative treatment will not be helpful, the patient is not “non-compliant” and the traditional rationale no longer makes sense. So, if a patient still feels the need for on-going counseling and very much wants the same therapist should that be allowed, if the therapist is willing? What might need to occur for therapists to feel comfortable with such scenarios? Or is that unrealistic (might it be too much to ask of therapists that they watch their patients die)? What needs to happen so that, as much as possible, the patient doesn’t feel punished or abandoned?