Judge rules anorexic Morris woman can't be force-fed

MORRISTOWN - A 29-year-old, severely-anorexic Morris County woman who has been a Greystone Park Psychiatric patient since 2014 cannot be artificially fed against her wishes, a Superior Court judge ruled Monday.

The 140-minute opinion delivered by Superior Court Judge Paul Armstrong in Morristown was shaped by established rights to self-determination and privacy, legislation passed since the 1990s, and multiple landmark rulings that include the case of Karen Ann Quinlan, whose parents Armstrong represented in the 1970s when Joseph and Julia Quinlan fought successfully to have their daughter, who was in a persistent vegetative state, removed from a ventilator.

Armstrong found that the woman identified as A.G. had expressed an unwavering wish to refuse force-feeding after a near-lifelong battle with anorexia nervosa. Armstrong said that the people around her -- her parents, treating psychiatrist and physicians, the bioethics committee of Morristown Medical Center, her guardian and lawyer - all concur that it's in A.G.'s best interests to be transferred to a palliative care unit at the hospital where she won't be force-fed as the state Department of Human Services - which operates Greystone - wanted.

"The lessons of the landmark cases of Karen Ann Quinlan, Clare Conroy, Nancy Ellen Jobes, Kathleen Farrell, Hilda Peter, and Nancy Cruzan are that patients, their families, physicians, and their institutions remain proper cooperators in making the evolving and necessary difficult decisions fronting modern medicine," Armstrong said.

"In a paradigm of this proper cooperative spirit there now appears before this court patient A.G., her mother and father, her treating psychiatrist and internist, the members of Morristown Medical Center bioethics committee, her legal guardian, her legal counsel, who, in one compassionate, solicitious, uniform voice, urged this court to authorize the transfer of patient A.G. to the palliative care unit of Morristown Medical Center in order that she may be treated with a comfort care plan to address her dire diagnosis," Armstrong said.

The state Department of Human Services wanted A.G. - who has weighed between 60 and 69 pounds in the past year - to be force-fed through a nasogastric tube and additionally helped through an experimental program of Ketamine use for her depression and increased time with family and her pets.

State Deputy Attorney General Gene Rosenblum had contended that A.G. was not mentally competent to decide whether she should be artificially fed.

Armstrong noted that A.G. expressed a refusal to be force-fed to family and physicians, in a document signed at Greystone, and clearly to him, when he and court-appointed attorney Edward G. D'Alessandro Jr. and others met with A.G. at Morristown Medical Center on Nov. 3.

Armstrong said that A.G. was oriented, responsive and understood the court case focusing on her. At Greystone, she had signed a Practitioner's Order for Life-Sustaining Treatment document that stated, in declining medical intervention, that she "wanted to live freely" without being bothered by anyone.

He also found that all the medical testimony he heard at a hearing on Nov. 4, along with scholarly treatises presented to him on treatment of anorexics, that A.G. has a "dire diagnosis and poor prognosis."

Armstrong said that during the interview with A.G. on Nov. 3, "Her testimony may be fairly summarized as an impassioned, deeply-held rejection" of daily force-feeding and further treatment for the disorder.

"A.G. expressed an unequivocal desire to accept palliative care as suggested by her treating physician and the bioethics committee at Morristown Medical Center. This decision was made by A.G. with a clear understanding that death was or could be the possible outcome," the judge said.

Armstrong referred liberally to the Karen Ann Quinlan case, in which the state Supreme Court in March 1976 ruled that Karen could be removed from a ventilator but addressed the issues of self-determination and how families are best situated to make medical decisions for incapacitated people. In A.G.'s case, her parents - who did not attend Monday's ruling but have been in close touch with the hospital - helped their daughter for more than 10 years by admitting her to facilities for eating disorders, attending therapy sessions with her, and managing her medications.

The judge also noted the important role of hospital bioethics committees, such as the one at Morristown Medical Center, whose goals are to foster resolutions to medical ethics issues so they don't wind up in court.

Dr. Jeanne Kerwin, manager of palliative care for Atlantic Health Systems, the parent company of Morristown Medical Center, had testified on Nov. 4 that the bioethics committee met, along with A.G.'s parents, to discuss her future. A.G.'s bleak long-term prognosis for overcoming anorexia was a key factor in the committee recommending palliative care instead of force-feeding for A.G., Kerwin had testified.

"It was the long-term prognosis. We thought the benefits did not outweigh the burdens," she had testified on Nov. 4.   Armstrong quoted Kerwin's testimony extensively in his decision.

A.G.'s treating psychiatrist at the hospital, Dr. Joshua Braun, supported his patient's decision to refuse nutrition. During his testimony earlier this month, he had expressed horror at how A.G. would have to be restrained because she had vowed to fight a nasogastric tube.

A.G., who suffers from depression and alcoholism along with anorexia, binge-purge type, has been a civilly-committed patient at Greystone since 2014. This past June, when her weight was around 60 pounds, state deputy attorneys general representing Greystone asked Superior Court to name a guardian for A.G. That pro bono guardian, Susan Joseph, then obtained a court order that A.G. be artificially fed at Morristown Medical Center.

The feeding tube brought A.G.'s weight up to 90 pounds but it also resulted in "re-feeding syndrome," which damaged her heart and it was removed. A.G. has been living at the hospital on diet soda and black coffee and occasional nibbles of food. In October, her guardian returned to court to ask that the feeding order be amended to allow A.G.'s transfer to palliative care. The state Department of Human Services opposed the move and Armstrong conducted a trial Nov. 4 and met with A.G. before making his decision.

Staff Writer Peggy Wright: 973-267-1142; pwright@GannettNJ.com.