Health

"The tribunal last night told Dutch authorities to force-feed Mr Seselj if there was a risk of him dying. "There is a prevailing interest in continuing with the trial of the accused in order to serve the ends of justice," it said in a statement. "The trial ... should not be undermined by the accused's manipulative behaviour." Mr Seselj, who surrendered to The Hague tribunal more than three years ago, has consistently sought to use the court as a stage to belittle and mock the institution. He went on hunger strike last month to demand unlimited conjugal visits and the opening of frozen bank accounts in the US, he insisted on defending himself at the trial and has hurled abuse at anyone who contradicts him."

"The UN war crimes tribunal in The Hague last night ordered the force-feeding of a Serbian warlord and senior politician who has been on hunger strike in custody for almost a month. The decision, the first such order since the court was set up more than a decade ago to deal with war crimes in the former Yugoslavia, came after a medical examination of Vojislav Seselj concluded that he might be a fortnight away from dying."

"Last night's statement from the tribunal was the first time it had resorted to such orders. It appears anxious to avoid creating another Serbian "martyr" after Milosevic died in its custody this year. Another Serbian warlord, Milan Babic, the former Croatian Serb leader, committed suicide while in custody. The tribunal said it had issued an "urgent order to the Dutch authorities" to ensure Mr Seselj did not die as a result of his hunger strike, now in its 27th day. While stating that any force-feeding deemed necessary for lifesaving purposes should not contradict "compelling internationally accepted standards of medical ethics or binding rules of international law", the judges at the tribunal also noted that the body of law laid down by the European court of human rights did not view force-feeding as "torture, inhuman or degrading treatment if there is a medical necessity to do so ... and if the manner in which the detainee is force-fed is not inhuman or degrading"."

"To our knowledge, this study is the first to explore nursing assistants’ experiences of administering manual restraint for CNF of patients with AN, and makes a substantial contribution to the limited literature on this practice. The findings highlight that the use of manual restraint for CNF of young persons with AN is a highly physically and emotionally distressing practice for nursing assistants. It is therefore important that sufficient supervision, support and training is made available to staff working in these settings."

"After being force-fed as a child, M'haimid now won't touch milk or millet, staples that were pumped into her every two hours, even when she kept vomiting. While she talks proudly about the 22 lbs. she has lost in the past month, she knows that at 264 lbs., she cannot rest. "My husband tells me not to tire myself out with this weight loss. These Mauritanian men, they still love fat women. But my health is more important," she says. Mariam Aicha, a former mayor of Nouakchott, recalls a doctor addressing delegates at a recent conference on health. "He said that, from his professional point of view, it was the thinner the better, but then admitted that as a man, he liked something to hold on to," she says."

"The participants in this study were recruited from a single inpatient eating disorder service in the UK, meaning that their experiences are likely to have been specific to this service. Caution is thus needed when transferring the findings of this study to other inpatient eating disorder settings. Further research exploring the phenomenon of CNF under manual restraint within different inpatient eating disorder services would be valuable in clarifying the extent to which the experience described in this study is common. The first author [MK] had lived experience of administering manual restraint for CNF of patients with AN, and conducted all interviews and performed data analysis. Although he maintained a descriptive phenomenological stance throughout, kept a reflexive diary, and made revisions to the analysis following discussions with [JM] and [NS] who both had no lived experience of manual restraint, his lived experience is likely to have had some influence on the analysis. However, we employed member checking to improve credibility, and all our participants expressed that the analysis had accurately captured their experiences. Notwithstanding, it may be beneficial for future research exploring staff’s experiences of CNF under manual restraint to be conducted by researchers who do not have lived experience of this practice, in order to reduce potential bias. The participants in this study were nursing assistants and thus were not registered nurses. Consideration thus needs to be taken into account of how this participant group may differ to registered nurses, for example, in their training, experience, duties and levels of responsibility. Although the majority of our participants were educated to degree or masters level in related subjects such as Psychology and Biology, and were supervised by registered mental health nurses (so it is likely that they possessed adequate clinical knowledge and skills), the aforementioned points still need to be taken into consideration when transferring the findings of this study to other inpatient eating disorder settings. Participants all volunteered to participate in this study. Therefore, they were self-selected. Consequently, the participants may have potentially represented those who were more vocal or those with more negative or positive experiences. This needs to be taken into consideration when interpreting the findings of this study."

"Becoming desensitised and sensitized Despite the physical and emotional challenges that encapsulated participants’ experiences of administering manual restraint for CNF of young persons with AN, and unlike the “Importance of coping” theme which described participants’ conscious attempts to cope with the procedure, five of the eight nursing assistants reported becoming emotionally desensitised to the practice over time. This was an adaptation predominately reported by male nursing assistants through descriptions such as “getting used to it”, becoming “desensitised” and becoming “immune”: We’re kind of immune to the screams, the noises, the fighting, the everything so it’s much easier nowadays, if it’s done properly and you’re not being hurt, it’s easy to go through a restraint without feeling very guilty that you’re doing anything wrong. (Participant 2) For some nursing assistants, this familiarity to the practice of applying manual restraint for CNF appeared to be facilitated by a change in their attitudes towards the practice over time. This attitude change appeared to involve the acceptance of CNF under restraint as something that was necessary, either as part of their job role or for the young person’s own safety: Now it’s just what needs to be done, it’s what needs to be done because the patient is not taking the responsibility of feeding themselves so we have to take on that responsibility. (Participant 4) In contrast to becoming desensitised, two nursing assistants reported that they had become emotionally sensitised to the manual restraint procedure. Participating in the restraint had become more emotionally challenging for these participants over time due to the therapeutic relationship they had built with the young person over time: The first restraints were a lot easier because I didn’t have a connection with the patients, whereas the later on it’s got, the more connection I have with the patients, the more worried I am, and the more emotionally demanding it is. (Participant 5)"

"While the courts can authorize interventions requested by the government such as force-feeding, immigrant detainees have limited power to appeal to courts about the conditions of their detention. As with the Guantánamo detainees, migrants are risking starvation, but not because they want to die. As Amrit Singh, the uncle of two men being force-fed, stated, “They want to know why they are still in the jail and want to get their rights and wake up the government immigration system.” Hunger striking offers one of few ways they can protest their prolonged confinement in pursuit of this goal."

"Physical injury. All nursing assistants reported sustaining frequent physical injuries as a result of applying manual restraint for CNF. Injuries typically ranged from back pains to bruises and were reportedly sustained by the physical aggression of young persons or through the execution of the manual restraint itself: When the patient was moving, as we were restraining her, I got thrown at a door handle and that caused quite big bruising on my back. (Participant 8) Some nursing assistants reported only becoming aware of a sustained injury after they had returned home from their shift: Sometimes it happens with bruises, like you go home, you haven’t realised how you might have sustained this bruise and then you realise . . . or you might feel back pains which you don’t really realise when you’re in the restraint. (Participant 6) In addition to back pains and bruises, two participants reported that they had either obtained, or had witnessed their colleagues obtain more severe physical injuries during manual restraints such as dislocated shoulders, head injuries and being kicked in the groin. In all reported instances this was due to the physical aggression of a young person: For some reason, one of the legs had not been held tightly, and she kicked the nurse who fell over and landed down. That was very scary because the staff banged her head and she got unconscious . . . they had to call an ambulance. (Participant 2)"

"Eventually eight of the women received sentences of imprisonment varying from one month to fourteen days, whilst Charlotte Marsh was sent to prison for three months' hard labour, and Mrs. Leigh for four. We knew that Mrs. Leigh and her comrades in the Birmingham Prison would carry out the hunger strike, and, on the following Friday, September 24th, reports appeared in the Press that the Government had resorted to the horrible expedient of feeding them by force by means of a tube passed into the stomach. Filled with concern the committee of the Women's Social and Political Union at once applied both to the prison and to the Home Office to know if this were true but all information was refused. The W. S. P. U. now made inquiries as to the probable results of this treatment, and were informed that it was liable to cause laceration of the throat and grave and permanent injury to the digestive functions, and that, especially if the patient should resist, as the tube was being inserted or withdrawn there was serious danger of its going astray and penetrating the lungs or some other vital part. The whole operation, together with all the attendant circumstances, could not fail to put a most excessive strain upon the heart and the entire nervous system, and, if there were any heart weakness, death might ensue at any moment. In the Lancet for September 28th, 1872, a case was reported of a man under sentence of death, who had been forcibly fed by means of the stomach pump, that is to say by means of an india-rubber tube passed through the mouth into the stomach, the method used in the case of the Suffragettes. The man had died. In the same issue of the Lancet, appeared the opinion upon this question of several prominent medical men. Dr. Anderson Moxey, M.D,, M.R.C.P., had said: " If anyone were to ask me to name the worst possible treatment for suicidal starvation I should say unhesitatingly, forcible feeding by means of the stomach pump." Dr. Tennant stated that this method of feeding produced " an incentive to resistance," and that the exhaustion thereby introduced was sometimes so great as to cause death by syncope. Dr. Russell had met with a case in which death had occurred immediately after the placing of the tube " before it could be withdrawn, much less used " ; and Dr. Conolly was " appalled by the dangers resulting from the forcible administration of food by the mouth." Amongst the various important medical experts consulted by The Women's Social and Political Union was Dr. Forbes Winslow, whose wide experience in cases of insanity could not be questioned. When asked professionally to give his views on the subject he said: So far as the stomach pump is concerned it is an instrument I have long ago discontinued using, even in the most serious cases of melancholia, where the victim, perhaps from some religious delusion, refuses all nourishment. It possibly may be regarde by some as the most simple means of administering food, but this I challenge by saying at once that it is the most complicated and the most dangerous. . . . I have known some of the most serious injuries inflicted by the persistent use of the stomach pump. I have known a case in which the tongue has been partly bitten off where it had been twisted behind the feeding tube. He added that forcible feeding was especially dangerous in cases of heart and lung weakness or of rupture or hernia, and that the result of persistent use would be to seriously injure the constitution, to lacerate the parts surrounding the mouth, to break and ruin the teeth."

"Pressure and responsibility. Six of the eight nursing assistants voiced feeling pressured and responsible for their colleagues and themselves while applying manual restraint for CNF. These participants appeared to attribute these feelings to their manual restraint performance, which could have a direct impact on their colleagues’ ability to effectively restrain, and the overall success of the nasogastric feeding procedure: You know in every restraint that if you lose your grip and they get a hand through or a leg through, the whole thing’s going to go wrong, so you feel responsible . . . If you lose their hand, they’ll grab the tube out and then the whole process has to start again . . . you feel the responsibility from all the other staff as well. (Participant 7) Failure to execute or maintain restraint positions could result in feelings of frustration and failure, and this was explicitly expressed in four nursing assistants’ interviews. It appeared that these participants placed a great deal of pressure and responsibility on themselves to execute their designated manual restraint positions."

"When the House of Commons met on Monday we learnt that our fears were only too well founded for Mr. Keir Hardie drew from Mr. Masterman who spoke on the Home Secretary’s behalf, the admission that the Suffragettes in Wison Green Gaol were being forcibly fed by means of a tube which pas passed through the mouth and into the stomach and through which the food was pumped. The unprecedented and outrageous nature of the assault was glossed over by the use of the term, “Hospital treatment,” in connection with it. Mr. Masterman admitted, however, that there were no regulations which authorized the proceeding, but he stated that it was resorted to in the case of men and women prisoners who were “weak minded” or “contumacious”. Mr. Hardie’s indignant protest and reminder that the last man prisoner to whom such treatment had been meted out had died under it, were met with shouts of laughter by the supporters of the Government. Horrified by their heartless and unseemly levity in the face of so serious a question, he at once addressed a statement to the Press in which he declared that he " could not have believed that a body of gentlemen could have found reason for mirth and applause " in a scene which had " no parallel in the recent history of our country." As far as he could learn, no power to feed by force had been given to prison authorities, save in the case of persons certified to be insane. He concluded by warning the public of the danger that one of the prisoners would succumb to the so-called "hospital treatment," and by appealing to the people of these islands to speak out ere our annals had been stained by such a tragedy. Others hastened to second this protest. Mr. C. Mansell-MouUin, M.D., F.R.C.S., wrote to The Times, as a hospital surgeon of thirty years' standing, to indignantly repudiate Mr. Masterman's use of the term " hospital treatment," declaring that it was a " foul libel " for that " violence and brutality have no place in hospitals as Mr. Masterman ought to know." Dr. Forbes Ross of Harley Street wrote to the Press saying: As a medical man, without any particular feeling for the cause of the Suffragettes, I consider that forcible feeding by the methods employed is an act of brutality beyond common endurance, and I am astounded that it is possible for Members of Parliament, with mothers, wives and sisters of their own, to allow it. A memorial signed by ii6 doctors, headed by Sir Victor Horsley, F.R.C.S., W. Hugh Fenton, M.D. M.A., C. Mansell-MouUin, M.D., F.R.C.S., Forbes Winslow, M.D., and Alexander Haig, M.D., F.R.C.P., was organised by Dr. Flora Murray and addressed to Mr. Asquith, protesting against the artificial feeding of the Suffragette prisoners, on the ground that it was attended by the gravest risks and was both unwise and inhuman. To this memorial many of the doctors added descriptive notes of their own. Mr. W. A. Davidson, M.D., F.R.C.S., wrote: " A most cruel and brutal procedure. Were the tubes clean? Were they new? If not they have probably been used for people suffering from some disease. The inside of the tube cannot well be cleaned; very often the trouble is not taken to clean them." In spite of every form of discouragement and ridicule, Mr. Keir Hardie continued constantly to raise the question of forcible feeding in the House of Commons only to be met by evasive, and sometimes grossly, inaccurate replies from the Home Office. Mr. Gladstone tried to shelter himself behind the officials who were his subordinates, and to place the responsibility on the medical officers. For this he was strongly condemned by the British Medical Journal which characterised his conduct as contemptible.*"

"Hunger striking and force feeding were acts committed by, and on, individuals in their own cells. Whether force fed by a cup, tube through the nostril (the most common method) or tube down the throat into the stomach (the most painful), the individual suffragette struggled on her own and often feared damage to the mind or body. Kitty Marion’s screaming in prison greatly upset the other women, but she found it was the only way she could fight against the torture of forcible feeding and remain sane. Rachel Peace, an embroideress, who had already experienced several nervous breakdowns, was not so fortunate. During a period of prolonged hunger striking and forcible feeding three times a day she feared, “I should go mad ... Old distressing symptoms have re-appeared. I have frightful dreams and am struggling with mad people half the night”. Her fears became true when she “lost her reason in prison” and spent the rest of her life in and out of asylums, with Lady Constance Lytton, an upper-middle-class WSPU worker, maintaining her. The forcible feeding of the disabled May Billinghurst in Holloway in January 1913 brought a particular wave of revulsion since she was “small, frail, and ha[d] been a cripple all her life”. Paralysed as a child and confined to a tricycle for mobility, she told how the three doctors and five wardresses who held her down: “forced a tube up my nostril; it was frightful agony, as my nostril is small. I coughed it up so that it didn’t go down my throat. They then were going to try the other nostril, which, I believe is a little deformed. They forced my mouth open with an iron instrument, and poured some food into my mouth. They pinched my nose and throat to make me swallow”. After 10 days of “almost incredible suffering”, when she was fed three times every 24 hours, she was released “a physical wreck”. Margaret Thompson, in prison in 1912, had a facial disability, resulting from a car accident; after examining her face to see if it was “fit” for forcible feeding, the doctor decided she should be fed by the cup rather than the tube. Miss McCrae, in prison at the same time, thought she too should take food through the cup, on account of her deafness, although she feared the other women would scorn her for doing so. For women with disabilities such as those mentioned here, imprisonment and forcible feeding were particular acts of courage."

"Importance of Coping Seven of the eight nursing assistants valued coping, and this was evidenced by the strategies they consciously employed which helped them cope with applying manual restraint for CNF. Coping strategies were typically utilised during and after manual restraint use. Two subthemes are reported."

"In 2013, a widespread hunger strike again swept through Guantánamo – 106 of 166 prisoners participated. Forty-one detainees met the requirements for being force-fed: skipping nine consecutive meals or their BMI dropping below 85 percent of their intake weight. One participant, Samir Naji al Hasan Moqbel, a Yemini citizen detained for 11 years, told The New York Times, “I had never experienced such pain” as from the feedings."

"For many of these women, the worst feature of prison life was the ‘public’ violation of their bodies when being forcibly fed. Helen Gordon Liddle hated the lack of privacy when enduring the pain of forced feeding. Nell Hall spoke of the “frightful indignity” of it all. For Sylvia Pankhurst, the sense of degradation endured was worse than the pain of sore and bleeding gums, with bits of loose jagged flesh, the agony of coughing up the tube three or four times before it was successfully inserted, the bruising of her shoulders and the aching of her back. Sometimes, when the struggle was over, or even in the heat of it, she felt as though she was broken up into many different selves, of which one, aloof and calm, surveyed all the misery, and one, ruthless and unswerving, forced the weak, shrinking body to its ordeal. Although the word ‘rape’ is not used in the personal accounts of force fed victims, the instrumental invasion of the body, accompanied by overpowering physical force, great suffering and humiliation was akin to it, especially so for women fed through the rectum or vagina. 'Janet Arthur’, later identified as Fanny Parker, in Perth prison in 1914, was one such victim: Thursday morning, 16th July ... the three wardresses appeared again. One of them said that if I did not resist, she would send the others away and do what she had come to do as gently and as decently as possible. I consented. This was another attempt to feed me by the rectum, and was done in a cruel way, causing me great pain. She returned some time later and said she had ‘something else’ to do. I took it to be another attempt to feed me in the same way, but it proved to be a grosser and more indecent outrage, which could have been done for no other purpose than torture. It was followed by soreness, which lasted for several days. When released, a medical examination revealed swelling and rawness in the genital region. The knowledge that new tubes were not always available and that used tubes may have been previously inflicted on diseased persons and the mentally ill or be dirty inside the tube, issues that had been openly discussed in Votes for Women, undoubtedly added to the feelings of abuse, dirtiness and indecency that the women felt."

"Patient aggression. All nursing assistants frequently reported being subjected to physical and/or verbal aggression by some young persons during manual restraint use. It appeared from their accounts that these young persons were using whatever means they could, to prevent or stop the restraint, in order to stop or avoid nasogastric feeding. Commonly cited verbal aggression included swearing and shouting. Commonly cited physical aggression included spitting, kicking, scratching, biting, punching and head-butting. Some participants reported being subjected to such physical aggression even when nasogastric feeding had been completed: We were starting to leave the restraint . . . I was doing the lower part of the legs and I was kind of tilted over and she actually head-butted me on the head . . . the feed’s finished but she still lashes out at staff. (Participant 4) Being on the receiving end of physical aggression elicited reciprocal urges of aggression for two nursing assistants. These urges were cited in the context of self-defence and the participants in question were clear that they did not reciprocate aggression in any form: One of the patients was trying to dig her nails in my skin and rip whatever I was wearing to protect my arms. . . I hate these moments particularly because I feel I want to hurt the child . . . at that moment you want to hurt them in order to protect yourself. (Participant 1)"

"Guantánamo hunger strikers filed lawsuits against the U.S. government for force-feeding prisoners and using the restraint chair. Several judges ruled that force-feedings are legal. In one case, a judge wrote that it did not constitute a violation of the Eighth Amendment against cruel and unusual punishment. Rather, she wrote that administrators “are acting out of a need to preserve the life of the Petitioners rather than letting them die.” This contradicts what many experts the medical and human rights professionals have said about force-feeding. The World Medical Association, an international medical ethics organization, asserted that force-feeding is “unjustifiable.” Organizations ranging from the ACLU to Human Rights Watch condemn the practice as “inherently cruel, inhuman, and degrading.”"

"In reply to the protests of medical men and the memorial from doctors, which had been addressed to him, Mr. Gladstone succeeded in drawing a statement from Sir Richard Douglas Powell, the President of the Royal College of Physicians, who said that he thought the memorial exaggerated, though he admitted that forcible feeding was not " wholly free from possibilities of accident with those who resist." He added that, in dissenting from the view expressed by the memorialists, he was assuming that the feeding of the prison patients was " entirely carried out by skilled nursing attendants under careful medical observation and control." We, of course, know that this was not the case. A large number of doctors, including Dr. R. G. Layton, physician to the Walsall hospital, replied to Sir Douglas Powell by again recapitulating the dangers of forcible feeding. But indeed the opinions of medical men were unnecessary to those who afterwards came in contact with the women who had been forcibly fed. Their exhausted condition was a form of evidence that no argument could upset. It is important to note also that during the year 1910 two ordinary criminals, a man. and a woman, were subjected to forcible feeding. The man died during the first operation; the woman committed suicide after the second."

"As described below, the U.S. military has admitted to force-feeding prisoners at Guantánamo who are participating in hunger strikes. Although the ICRC stated that the indefinite detention and current conditions at Guantánamo are “tantamount to torture,” it is difficult to assess the ethical obligations of military medical personnel at Guantánamo without further information about the treatment of detainees and the psychological impact of their indefinite detention. The prisoners’ families, moreover, have little or no knowledge of whether their sons or husbands are participating in a strike. And if their relatives are participating in a protest, military medical personnel have not informed the families of their relatives’ health status or their wishes concerning nourishment. This failure contradicts the policy of the WMA that a “doctor has a responsibility to inform the family of the patient that the patient has embarked on a hunger strike, unless this is specifically prohibited by the patient.”"

"Three themes were extracted from the analysis: An unpleasant practice, Importance of coping, and Becoming desensitised and sensitised. It is important to consider these themes in relation to the 5-36 month difference within the experience level of nursing assistants."

"The first coordinated large-scale mass protest at Guantánamo began on February 27, 2002 when prisoners initiated a rolling hunger strike. This hunger strike appears to have started when an MP removed a homemade turban from a prisoner during his prayer. As the hunger strike expanded to a peak of 194 participants over a two-month period, it became a protest of the prisoners’ indefinite detention without any legal process and their harsh living conditions. A spokesman for the Guantánamo Joint Task Force, Marine Captain Alan Crouch, acknowledged in a February 28, 2002 official statement that 159 prisoners refused lunch and 109 refused dinner on February 27, 2002. On February 28th, 107 refused breakfast and 194 did not eat dinner. At the beginning of the hunger strike, the military attempted to minimize the seriousness of the protest. In a prepared statement, a Joint Task Force public affairs officer, Marine Major Steve Cox, stated that “[b]y no means is this an organized, concerted effort by the camp’s detainee population, but merely a demonstration of some of the detainees’ displeasure over the uncertainty of their future.” Several days into the hunger strike, Brig. Gen. John W. Rosa, Jr., Deputy Director for Operations, Joint Chiefs of Staff, stated that the detention center commander and the chaplain “have been out and around with and speaking to the detainees. The tensions have eased in their opinion.” But by mid-March, three detainees who had refused food and water for approximately fourteen days were forcibly given intravenous fluids. By this time, military officials were acknowledging that the prisoners were protesting “the fact that they don’t know what is happening to them” and that the hunger strike participants’ primary concern was “their murky future.” In early May, only two prisoners continued to participate in this hunger strike. Both men had been striking since March 1, 2002 to protest their indefinite detention. The military returned one man to Camp Delta on May 2, 2002 after force-feeding him, ending his 63-day hunger strike. The other final participant was forcibly fed through a tube inserted in his nose on May 10, 2002 after 71 days of fasting."

"In recent years, two hunger strikes by prisoners received extensive international attention, in part because a number of prisoners died during the protests: the 1981 hunger strike by Irish prisoners in Maze prison during which ten prisoners died, and the hunger strike by Turkish political prisoners in the summer of 1996 during which at least twelve prisoners died and numerous others suffered neurological and psychiatric problems. When the ICRC visited Maze prison in Ulster, the ICRC team members became very concerned despite the fact that, unlike at Guantánamo, medical personnel were authorized to see the hunger strikers and permitted to maintain close communication with the prisoners’ families: “‘[O]utside intervention’ was totally unacceptable in the (northern) Irish hunger strikes of 1980 and 1981. Although the ICRC sent a team with a medical doctor to see the fasting prisoners (as was widely reported in the press at the time), the hunger strikers in this case refused to accept any outside medical mediation. As soon became clear, the hunger strikes in Ulster were deadly serious, with a total of ten prisoners dying over several months. The prison doctors respected the expressed will of the hunger strikers, and force-feeding was not envisaged at any time. (This position based on respect for a patient’s integrity and his right to refuse treatment, was the exact opposite of the attitude held earlier in the century, when political hunger strikers were force-fed by court order in 1909). In the Irish strike, the prisoners’ families were very much involved and communicated with the prison doctors. In a few cases, it was the families of prisoners who asked doctors to intervene at an advanced stage to save their sons’ lives, a request that was complied with. The bottom line in the doctors’ position was that a prisoner’s express will (not to be nourished) would be respected as long as he was fit to decide, but that families could obtain medical assistance for their fasting relatives if [the prisoners] were no longer in a position to express refusal. (This sometimes led to bitter arguments, with some hunger strikers telling their families they would never forgive them if they broke the strike by asking for medical assistance on their behalf. Most families, in fact, supported their sons or husbands on the strike.)"

"An Unpleasant Practice Administering manual restraint for CNF of young persons with AN was an unpleasant practice for all nursing assistants, and this was evidenced by the numerous reported adverse physical, psychological and interpersonal outcomes. Some felt that they did not receive enough support from the eating disorder organisation in managing these outcomes. Six subthemes are reported. Emotional distress. Despite recognising the necessity of CNF under manual restraint for young persons with AN who were refusing all foods and/or fluids, seven of the eight nursing assistants described the emotional distress they experienced as a result of administering manual restraint. Some described the practice as “traumatising” both for themselves and the young person; this was predominately attributed to the coercive nature of the practice and the young person’s distressing response to it, which typically included active resistance, aggression, screaming, coughing, complaints of discomfort, and occasional nasal bleeding from nasogastric tube insertion: It’s scary, it’s emotionally draining for both the patient and staff . . . there’s blood coming out [from the young person’s nose], the child is screaming down the place, so as much as you’re supporting the child, it becomes very difficult because it seems like you’re either attacking or physically punishing somebody. (Participant 2) Seven nursing assistants reported experiencing a range of unpleasant emotions as a result of applying manual restraint for CNF. Anxiety, guilt and anger were commonly cited emotions. Participants felt anger, often, in response to being hurt by the young person during restraint, and the young person’s lack of cooperation. Anxiety and guilt were commonly attributed to the unpredictability and coerciveness of manual restraint respectively: Before I go into a restraint, my heart starts pumping a bit more . . . I feel very anxious because we don’t know what could happen. (Participant 4)"

"The ICRC’s observation of the Irish prisoners’ protest also emphasizes the ethical issues for medical providers raised by hunger strikes in prison facilities, particularly concerning the issue of force-feeding such prisoners. As is widely known, the World Medical Association (WMA) Declaration of Tokyo of 1975 prohibits a medical doctor’s participation in torture, whether actively, passively, or through the use of medical knowledge. Article 5 of the Tokyo Declaration also stipulates that prisoners on hunger strikes shall not be force-fed. According to Dr. André Wynen, former and Honorary Secretary-General and founding member of the WMA, Article 5 of the Tokyo Declaration relates to the declaration’s prohibition on medical providers’ involvement intorture. “If a prisoner undergoing torture decided to protest against his plight by going on a hunger strike, a doctor should not be obliged to administer nourishment against the prisoner’s will and thereby effectively revive him for more torture.” The WMA supplemented Article 5 of the Tokyo Declaration with the 1991 Declaration of Malta. The Malta Declaration also prohibits force-feeding, but stipulates that doctors should ultimately act for the benefit of their patients when the prisoner’s detention does not raise concerns about physician involvement in torture and the hunger striker is no longer capable of sound judgment because of the effects of long-term fasting."

"U.S. Immigration and Customs Enforcement, or ICE, is force-feeding nine detainees who are on a hunger strike at a detention center in El Paso, Texas. The protesters are mostly from India and are being held in ICE custody while their asylum or immigration cases are processed. Since the beginning of the year, they have been protesting their detainment and mistreatment by guards who they allege have threatened them with deportation and withheld information about their cases, according to the detainees’ lawyers. In mid-January, a federal court ordered ICE to force-feed the strikers. An ICE official stated: “For their health and safety, ICE closely monitors the food and water intake of those detainees identified as being on a hunger strike.” ICE policy states that the agency authorizes “involuntary medical treatment” if a detainee’s health is threatened by hunger striking. Force-feeding involves tying a detainee to a bed, inserting a feeding tube down the nose and esophagus and pumping liquid nutrition into the stomach. ICE detainees have reported rectal bleeding and vomiting as a consequence of being force-fed."

"Physical exhaustion. All nursing assistants described the physical exhaustion they felt in relation to applying manual restraint for CNF, especially in circumstance where the young person was highly resistive. There were multiple manual restraints to perform per shift, and reports of sweating during restraints were not uncommon. At times, the manual restraint continued even after nasogastric feeding had been completed because the young person was either trying to self-harm or purge the liquid supplement they had just been given. This made the whole restraint even more tiring for participants: Once you’ve been in a restraint in a feed you just want to be done with it because it’s a physical thing, your body’s tired, you’re hot and sweaty, you’re covered in their sweat as well . . . and if someone continues it by trying to purge, it’s more tiring than anything else. (Participant 5) Despite the physical exhaustiveness of using manual restraint, all nursing assistants also reported that the restraint of some young persons involved minimal physical exertion because of their increased compliance and preference to be fed under restraint: I was restraining her arm and one of her legs, and it wasn’t very intense. The patient was going through this process for a very long time, so she was at that stage where she wanted this holding let’s say, but she wasn’t aggressive or very resistive. (Participant 1) Once you’ve been in a restraint in a feed you just want to be done with it because it’s a physical thing, your body’s tired, you’re hot and sweaty, you’re covered in their sweat as well . . . and if someone continues it by trying to purge, it’s more tiring than anything else. (Participant 5)"

"From 1905 until the outbreak of the First World War in August 1914 about 1000 women were sent to prison because of their suffrage activities, most of these being members of the WSPU... While these prison ‘experiences’ have not been ignored by historians, they have been discussed as a part of a broader account of the suffrage movement rather than focused upon in depth as a subject worthy of investigation. Furthermore, a dominant narrative of these experiences has emerged which [asserts] that the women themselves were to blame for their often harsh prison experiences, including the pain of hungerstriking and forcible feeding...."

"Detaching the self. Five of the eight nursing assistants reported actively detaching themselves from the process when they were administering manual restraint for CNF. This was predominately described by female nursing assistants and was evidenced through the use of terms such as “zoning out”, “shutting off” and “taking my mind off”. Detaching the self appeared to be a conscious response used by participants to cope with the adverse psychological outcomes of manual restraint use: I sort of try to stay focused on what I’m doing during the whole process but sort of try to take my mind out of this as well so that I can cope with it because it’s a very stressful procedure so I’m trying to think of something more calming. (Participant 1) I get to a point when I just shut off and then I’m just staring into nowhere and just trying to remain in the restraint position because it’s just too much to take in. (Participant 8) For one nursing assistant, detaching the self was a “necessary” coping strategy that guarded against the adverse psychological outcomes that could result from paying attention to the young person’s distress during restraint. Failing to “zone out”, in this participants view, was self-destructive: It becomes quite emotionally damaging to pay attention too much to what the patients are screaming and shouting about in the feed so I prefer to kind of zone out, it’s my coping mechanism . . . it’s necessary to zone out and I kick myself if I don’t do it because it’s just self-destructive not to. (Participant 5)"

"Hunger strikes have plagued Guantánamo since it opened in 2002. In one of the largest hunger strikes to occur in a U.S. detention facility, about 500 detainees stopped eating under the slogan “starvation until death” in late June 2005. They began this strike to protest the conditions of their confinement, including alleged beatings, abuse of their religious freedom by mishandling the Koran and indefinite detention without trial. In response, military doctors authorized “involuntary intravenous hydration and/or enteral tube feeding” – in other words, IV treatment and force-feeding. Prisoners found ways to get around the feedings, like making themselves vomit or siphoning out their stomachs by sucking on the external end of the feeding tube. The strike overwhelmed camp commanders. In December 2005, they called in help from the Federal Bureau of Prisons, which had previously authorized force-feeding. The consultants observed as strikers were force-fed twice a day and recommended using the emergency restraint chair, a “padded cell on wheels.” That requires strapping detainees down onto the chair, making it easier for guards to insert and remove a feeding tube. Detainees referred to it as the “execution chair.” This had the desired effect on the prisoners: Only a handful continued the hunger strike and it was over by February 2006. The camp ordered 20 more chairs."

"Big has long been considered beautiful in Mauritania. But now, a generation of women are abandoning an ancient practice to fatten up – and some are even redefining beauty to put their health first. It's not a lifetime spent scoffing junk food and slurping fizzy drinks that's to blame for obesity here; rather, a tradition as old as the desert: gavage. On the tree-lined boulevards of Paris, the French word describes the process of fattening up geese to produce foie gras. On the sand-blanketed streets of Mauritania's capital, Nouakchott, it describes the process of forcibly funneling sweetened milk and millet porridge down the throats of young girls. In this vast nomadic nation, thin women are an admission of poverty. Voluptuous wives and daughters, by contrast, are displays of a man's wealth, and that's where force-feeding comes in. After campaigns at the national and community level, the brutal practice is on the way out. The latest government survey, in 2001, estimated that about 10 percent of women ages 15-19 were force-fed as young girls, down from 35 percent among 45 to 54-year-olds. But that older generation of women is now battling a variety of illnesses as well as child-bearing complications, doctors and midwives say. "Even getting out of bed is difficult for some of them, never mind working," says Mariame Baba Sy, the head of a government commission on women's issues."

"The literature has highlighted the numerous adverse physical and psychological staff outcomes as a result of manual restraint use. Staff have reported experiencing physical exhaustion, physical pain and injury, and numerous unpleasant emotions (e.g., anxiety, fear, anger) as a result of administering manual restraint (Bigwood & Crowe, 2008; Bonner et al., 2002; Chapman et al., 2016; Sequeira & Halstead, 2004; Wilson et al., 2017). Manual restraint has also been linked to staff feelings of internal conflict, as staff may perceive the act of manually restraining patients as incongruent with their therapeutic role (Bigwood & Crowe, 2008; Chapman et al., 2016; Sequeira & Halstead, 2004; Wilson et al., 2017). Although manual restraint is commonly administered within inpatient mental health settings (Stewart et al., 2009; Wilson et al., 2017), the literature has also illustrated its use within the emergency department, LD services, and paediatric general hospital and residential childcare settings (Chapman et al., 2016; Fish & Culshaw, 2005; Lombart et al., 2019; Steckley & Kendrick, 2008; Svendsen et al., 2017). The manual restraint of young persons raises ethical and moral issues for staff, and this has been evidenced by the distress and internal conflict staff may experience when manually restraining young persons (Lombart et al., 2019; Steckley & Kendrick, 2008; Svendsen et al., 2017). For instance, staff have reported feeling guilty when restraining children for medical procedures, with some describing how “difficult and demanding” the process can be (Lombart et al., 2019; Svendsen et al., 2017). Presently, little research has been conducted on the use of manual restraint within child and adolescent settings. However, even less research has been conducted on the use of manual restraint for CNF of patients with AN within inpatient eating disorder settings."

"Trans-pyloric feeding All infants with a trans-pyloric feeding tube require a gastric tube in place for aspiration, potentially drainage and possible medication administration (consult the Pharmacist or Neonatologist involved). Trans-pyloric tubes may be on free drainage but are not used for regular aspiration. Indications *Infants who are not tolerating gastric feeds. *Duodenal atresia - post-operatively *Infants who are at great risk for aspiration, e.g. gastro-oesophageal reflux receiving CPAP. Risk is minimised because the end of the tube is beyond the pyloric sphincter. Complications *Aspiration *Difficulty with tube placement *Perforation of the gut *Malabsorption Considerations *Trans-pyloric feeding may induce symptoms of malabsorption because the stomach is not able to aid in digestion e.g. frequent bowel motion, slow weight gain, necrotising enterocolitis. *Consider where medication is absorbed prior to administration (i.e. stomach or small intestines)"

"Follow the steps below to ensure the safety of the infant is maintained. *That the correct hourly rate on the continuous feed pump is maintained *The total volume infused is accurate. *Two nurses check and sign on the balance sheet each time rate is changed and at the change of shift. *The tubing is changed every 24 hours and labelled clearly with date, time and EBM/NIF. *Ensures that the trans-pyloric tube is not aspirated unless on Doctor's/NS-ANP's orders. *Gastric tube is aspirated 6 hourly and documented. *Administer medication as prescribed by disconnecting at the junction of the trans-pyloric tube and the pump tubing or as per medical staff/NS-ANP instruction (be aware of where of where medication is absorbed) *Only use four hours worth of milk at a time (unless otherwise specified on the bottle label)"

"AN is an eating disorder characterised by an extremely low body weight, a severe restriction of food, a strong desire to be thin, and an intense fear of gaining weight (National Institute of Mental Health, 2018). Under relevant mental health legislation, patients with AN can be administered CNF in extreme cases when they are presenting with very low body weight, and refusing to eat and/or drink (Fuller et al., 2019; Royal College of Psychiatrists, 2014). In the rare case when a patient is resistant to nasogastric feeding, staff members may administer manual restraint to ensure the safety of themselves and the patient during feeding (Fuller et al., 2019, 2020; Neiderman et al., 2001). Within the UK, manual restraint in this context may be used in the absence of other restrictive practices (e.g., seclusion), and may involve holding the patient’s arms, legs and head in a safe position, in order to allow for the safe passing of a nasogastric tube and subsequent feeding (Fuller et al., 2019; Neiderman et al., 2001). Feeding in the context of active resistance is a rare event and raises ethical, legal and clinical issues for all those involved (National Collaborating Centre for Mental Health, 2004). Despite the wealth of research that exists on the treatment of AN, we could only locate one published qualitative study that explored the experience of CNF in the context of AN, including the experience of CNF under manual restraint (Neiderman et al., 2001). In this qualitative survey study exploring children and adolescent patients’, and their parents’ experiences of nasogastric feeding, the authors summarised patients’ nasogastric feeding experiences into two main categories: “I regretted it at the time but think that it was necessary” and “I hated it then and hate it now”. This study however did not focus specifically on the practice of CNF under manual restraint, and did not use in-depth qualitative data collection methods such as individual interviews (the authors used qualitative questionnaires). Studies specifically exploring the experience of CNF under manual restraint from either the patient or staff member’s perspective using in-depth data collection methods, could provide valuable insight into this under-researched practice."

"Trans-pyloric tube placement Follow the steps below for placement of trans-pyloric tube. 1. A weighted tube is required for trans-pyloric placement (white Vygon paediatric duodenal tube with weighted tip, 6 Fr or Corpak Jejunal weighted tube). These do not harden over time and may be left in situ for several weeks. 2. Length for tube insertion is measured from as per gastric placement with a further length from the xiphoid to the left or right costal margin. 3. The tube is allowed to cool in the refrigerator for an hour; this reduces the chance of it coiling during insertion. 4. Swaddle infant to provide comfort 5. With the infant lying supine at a 15o-40o angle, insert the tube to the stomach as normal. 6. Check stomach positioning by aspirating and testing on a pH strip (reading of 5 or less) 7. Place the infant into a right lateral position 8. Advance the tube 1 cm at a time while instilling up to 2-3 ml of air and auscultate the abdomen 9. Transpyloric placement is characterised by high pitch crackles and the inability to withdraw air ('snap test') 10. Insert further length (as measured) to ensure distal duodenal or proximal jejunal placement. 11. Give a 3 ml feed and remove stylet (if present with brand). 12. The infant should then be placed right side down for 1-1.5 hours 13. Confirmation of placement will then be made by a radiograph. 14. Secure tubing to infant's cheek in same manner as gastric tubes 15. Insertion should be documented in the infant's caremap (equipment section) and in the clinical notes"

"If an infant is expected to require long term gastric feeding the parents need to be taught care and insertion techniques prior to discharge. See Parent information. 1. Prior to tube insertion the tube must be lubricated with water. 2. Measure length of tube as for short term gastric tubes. 3. Ensure that the cap is on the medication port of the Corpak long term feeding tube. 4. Insert long term feeding tube as for short term tubes. 5. Remove stylet once inserted. 6. Establish gastric placement by aspirating stomach contents and testing on pH strips. A reading of 5 or less should be apparent when touched with stomach fluid. 7. If unable to aspirate fluid then push 1-2 ml of air with a 50 ml syringe. Listen with a stethoscope on the baby's stomach. You should hear a 'whoosh' of air. 8. Secure tube to face with duoderm base and hypafix on top. 9. Flush tube with 3 ml of water using 50 ml syringe. 10. Rinse stylet with warm soapy water and save for future use."

"Follow the steps below for commencing feeds via a long term tube. 1. Warm milk in a bottle and bowl of warm water as usual. 2. If the infant is in a cot pick them up for feeds and utilise a pacifier for non-nutritive sucking if appropriate 3. Connect a 50 ml syringe to the long term feeding tube and pour feed into syringe. 4. Adjust the flow of the feed by raising or lowering the height of the syringe. 5. When finished flush the tube with 3 ml of sterile water via 50 ml syringe. 6. Close tube. Note: USE ONLY A 50 ML SYRINGE TO ADMINISTER ANY MILK OR MEDICATION. The higher pressure of the smaller syringes has potential to perforate the tube."

"Within the UK, it is common for graduates of non-nursing degrees (e.g., psychology) who are wishing to pursue a career in mental health (e.g., clinical psychology) to first start out working as healthcare and nursing assistants in mental health settings to gain relevant clinical experience."

"Follow the steps to measure the correct length of tube required and ensure the baby's comfort. 1.Measure the distance from either the nostril or the mouth (depending on insertion site) to the earlobe then to the half way point between the xiphisternum and the umbilicus. 2.Swaddle infant to provide comfort, offer dummy if infant normally has one. 3. Gently check nostrils for patency if inserting nasogastrically. 4. Select the appropriate size gastric tube; size 6 French for the majority of infants, alternatively size 8 French for large infants or those requiring gut drainage. 5. Gently insert the tube in a smooth swift motion, advancing slightly down and towards the ear on that side, to the desired length. Do not force the tube -if resistance is felt or the tube comes back via the mouth or other nostril then the procedure should be stopped to allow the child to recover prior to any further attempts. If a tube is unable to be inserted in after two attempts, a senior nurse colleague may have one further attempt. If still unsuccessful, discontinue procedure, notify medical staff and document same in clinical record."

"Early histories of the suffrage movement present a more sympathetic picture of prison life than many subsequent accounts. Metcalfe, for example, writing in 1917, speaks of the “scenes of horror which had taken place in Holloway and other prisons ... in the unavailing effort to govern women against their consent”. However, it is the history written by the constitutional suffragist, Ray Strachey, a member of the NUWSS and hostile to the WSPU, that became the influential text. Strachey blames the WSPU women themselves for the treatment they received... Unwilling to acknowledge the hunger strike as a political tool, Strachey comments how the suffragettes, once in prison, ceased to be militant and created a number of protests including the refusal to eat food. “Forcible feeding was tried in vain”, she continues; “the prisoners struggled so violently against it that the process became actually dangerous, and the prison officials were obliged to let them starve till they came to the edge of physical collapse, and then to let them go”. In spite of the severe pain and damage to health which the process involved, “scores of suffragettes adopted it ... The officials tried everything they could think of in vain ...”. This picture of irrational women, deliberately seeking their own torture was eagerly seized upon by male historians who sought to ridicule the WSPU and its politics. George Dangerfield’s The Strange Death of Liberal England, first published in 1935, discusses the suffragette movement as... a form of “pre-war lesbianism” of “daring ladies”... Dangerfield too presents the suffragettes as fanatical women who chose the hardships of prison life in a sado-masochistic way ... “How can one avoid the thought”, he questions, “that they sought these sufferings with an enraptured, a positively unhealthy pleasure?” If the victim does not resist, “forcible feeding is no more than extremely unpleasant. But the suffragettes were determined to resist”. In view of the fact that Dangerfield’s account contained no footnotes whatsoever to primary sources to support his claims, it is incredulous that his analysis was received so enthusiastically and became so influential. The Times and Tribune, for example, hailed it as “brilliant”... Thus the scene of the drama is set and the props are changed only with slight variations. Roger Fulford in 1957... mocked their prison experiences, claiming that solitary confinement in prison was “not always unwelcome to adults”. Furthermore, although “forcible feeding is a disgusting topic ... it was not dangerous ... [It] is of course a familiar form of treatment in lunatic asylums”. While Andrew Rosen is much more sympathetic to the women prisoners, he too, in a matter of fact way speaks of how forcible feeding involved mouths being prised open, lacerations, phlegm, vomiting, pain in various organs, loss of weight “and so on”..."

"Manual restraint is a form of physical restraint practice, used particularly within inpatient mental health settings, whereby one or more persons restrict the movement of another by manually holding them (Stewart et al., 2009; Stubbs & Paterson, 2011). This differs from mechanical physical restraint which refers to the use of devices (e.g., belts or cuffs) to restrict movement (Care Quality Commission, 2018). Manual restraint is commonly used in conjunction with seclusion and chemical restraint to prevent harm to patients and staff, or to administer medications and other treatments (Chapman et al., 2016; Hawkins et al., 2005; Ryan & Bowers, 2006). For instance, the literature has highlighted the use of manual restraint in response to patient self-harming, aggressive and attempted absconding behaviours (Bowers et al., 2015), and patient medication refusal (Owiti & Bowers, 2011). Concerns have been raised about manual restraint use (Mind, 2013), and internationalguidelines and programmes advocating for its reduction have emerged (e.g., Department of Health, 2014; Mental Health Commission, 2014; O’Hagan et al., 2008; Royal Australian and New Zealand College of Psychiatrists, 2016). Within England alone, over 50,000 incidents of manual restraint were recorded between the years of 2016 and 2017 in National Health Service funded secondary mental health, learning disability (LD) and autism services (Collinson, 2017), demonstrating the commonality of manual restraint practice. This study explores nursing assistants’ experiences of administering manual restraint for compulsory nasogastric feeding (CNF) of young persons with anorexia nervosa (AN)."

"Follow the steps below to ensure correct tube placement, and the ongoing safety of the baby is maintained whilst receiving tube feeds. 1.On inserting a new tube verify placement by aspirating gastric contents and test with the pH indicator strips. Correct position is confirmed when the pH reading is less than or equal to 5. Presence of aspirate alone does not guarantee correct placement Note: Some medications, frequent feeds and continuous feeding may alter the pH and/or the colour of the aspirate e.g. acid inhibiting medications. If pH is >5 or there is difficulty in obtaining aspirate, follow the NPSA Decision tree for nasogastric tube placement checks in Children and Infants. The ‘whoosh’ test (injecting air down the tube and listening) is no longer considered safe practice and should not be used to confirm correct tube placement. 2. Record citing of tube, including internal length and pH in the child’s care map and observation chart. 3. Ensure tube remains in correct position by visually checking the tube position, and checking the aspirate with pH strips prior to each bolus feed or administration of any oral medications. This should be recorded in the feeding section of the observation charts. Note: The tube does not need to be fully aspirated prior to each feed, only enough to pH test, or if there is significant abdominal distention from air which needs aspirating. Infants on continuous feeds should have the position of the tube visualised every hour with routine observations, and pH tested every 4 hours with bottle/syringe changes. 4. Secure the tube using duoderm and hypafix tape placed either on the cheek or chin, and ensure this is firmly attached to the tube. 5. Continually assess feeding tolerance. Observe for vomiting, painful and firm abdominal distension, abdominal discolouration, abnormal bowel sounds, blood in stools, haemorrhagic or heavily bile stained (spinach or avocado) gastric aspirate during pH check. Seek medical review if there is any suspicion of feed intolerance. 6. If findings are not reassuring on medical review then feeds should be withheld. Start gastric decompression, consider further investigation and management for suspected NEC, discuss a feeding plan at the next ward round. 7. Ensure infants who are NBM have their gastric tubes on free drainage with the free end of the tube draining into a specimen pot. Do not attach the syringe connected to the gastric tube to the lid of the incubator. For infants on respiratory support, consider aspirating air from the stomach before each feed. 8. Tubes should be routinely replaced every 2 weeks. Note: if the gastric tube is not to be removed this should be recorded clearly on the observation chart and in the clinical notes (e.g. post TOF repair – see surgical guideline)"

"Commencing continuous Gastric or Trans-pyloric feeding Continuous feeding should only be instituted once the infant has reached volumes of at least 7 ml/hr, or on discussion with Neonatologist. This restriction is to avoid the need to purge the tubing every 4 hr with the change of bottle that would be required for lower rates (due to safe hang times). Follow the steps below for commencing continuous Gastric or Jejunal feeding: 1. Draw up prescribed volume of milk. 2. Label with type of milk, date and time. 3. Ensure the correct procedure for setting up the continuous feed pump is observed. 4. Check that the tube is in the correct position and the tape is secure (observe hourly). 5. Commence continuous feed 6. Aspirate gastric tube at least once per shift to confirm placement and determine residual volume"

"Eating disorder services that provide CNF under manual restraint as an intervention need to ensure that their frontline nursing staff have access to sufficient support, supervision and training at a minimum, given the adverse physical and psychological staff outcomes that may result from this practice. Such eating disorder services also need to have policies in place that ensure that manual restraints for CNF procedures are spread out fairly amongst staff, especially in services in which this intervention is frequently used."

"Talking with others. Six of the eight nursing assistants reported seeking out conversations with their colleagues and young persons who were further in their recovery, after they had been involved in a manual restraint for CNF. For some participants, this appeared to be a method of cheering up through humour: Sometimes you just need to get away and be lifted up by someone else. If you can bounce off of a staff member it’s pretty good...or go to some of the hyper kids, the kids that at the moment are really doing well, and if they’re all having banter with each other, you can sort of get brought into it and sometimes you just forget what’s just happened in the restraint. (Participant 5) For other participants conversing with their colleagues was a method of “venting out” after a particularly challenging restraint which had elicited feelings of frustration: You can vent out amongst each other as the people that have done the restraint. (Participant 3) Four nursing assistants reported seeking out trusted staff members to confide in. For the majority of these participants this was a method of expressing their feelings, especially in circumstances where they had partaken in a restraint that had upset them: . . . and then I spoke to a member of staff that I trusted in that situation and it turned out that the same thing had happened to her so it was nice to have that understanding, it made me feel much less alone. (Participant 7)"

"Thor involved a prison physician petitioning the court to allow him to force-feed a quadriplegic patient who had decided to die. Id. The court considered four state interests: preserving life; preventing suicide; maintaining the integrity of the medical profession; and protecting innocent third parties. Id., at 737, 21 Cal.Rptr.2d 357, 855 P.2d 375. Finally, the court considered how this would affect orderly administration of the prison system. Id., at 744, 21 Cal.Rptr.2d 357, 855 P.2d 375. In considering the first four factors, the court, noted that this patient was quadriplegic and serving a life sentence; the patient's decision to refuse medical treatment was an informed decision, and there were no other persons involved in this decision. Id., at 743-44, 21 Cal.Rptr.2d 357, 855 P.2d 375. Finally, the state had presented no evidence on the effect this would have on administration of the prison system. Id., at 745, 21 Cal.Rptr.2d 357, 855 P.2d 375. The third case prohibiting state interference with a prisoner's hunger strike is from Florida. The inmate went on a hunger strike to protest his transfer to a different prison and to protest the lodging of complaints against a prison chaplain. Singletary v. Costello, 665 So.2d 1099, 1101 (Fla.App.1996). The court first recognized a strong interest in the inmate's rights to privacy and to refuse medical treatment. Id., at 1104. The court then weighed the state's interests in preserving life, preventing suicide, protecting third parties, maintaining the ethics of the medical profession, and maintaining order in the prison. Id., at 1105. On the facts of the case, the court stated that "although the state interest in the preservation of life is powerful, in and of itself, it will not foreclose a competent person from declining life-sustaining medical treatment.... This is because the life that the state is seeking to protect is the life of the same person who has competently decided to [forgo] the medical intervention." (Citation omitted.) Id., at 1109. The court found it important, also, that the prisoner had expressly stated that he did not want to die, meaning that the state's interest in preventing suicide was not implicated. Id. Finally, no evidence was offered on the other factors; therefore, the court denied the state's petition."

"Nasogastric/Orogastric Tube Placement Indications: * Pre-term: immature suck swallow reflex * Neurological disease: impaired sucking reflex * Respiratory support: increased tachypnea with risk of aspiration * Gastric decompression * NEC * Abdominal surgery"

"Participants were recruited from a private 25-bed locked inpatient specialist child and adolescent eating disorder service in the UK which provides inpatient treatment to young persons aged 9-18 years with eating disorders. In addition to providing multidisciplinary input from a number of professionals including psychiatrists, paediatricians, psychologists, family therapists and dieticians, the eating disorder service, under the powers of the Mental Health Act 1983 (Department of Health, 2015), and occasionally parental consent, also provides CNF under manual restraint as an intervention to young persons with AN presenting with ongoing food and/or fluid refusal and subsequent non-compliance with nasogastric feeding. A standard CNF intervention under manual restraint within the eating disorder service could typically last between 10 and 30 minutes, and involve up to five nursing assistants restraining the young person in the seated position, and up to two registered mental health nurses inserting the nasogastric tube, checking the tube’s placement, and delivering subsequent dietary nutrition through the tube via syringe. As reported by participants, up to 12 CNF interventions under manual restraint could occur per shift within the eating disorder service. This was owing to the fact that some young persons had care plans in place for pre-planned CNF interventions under manual restraint to be implemented multiple times per day (e.g., at specific times during the mornings, afternoons and evenings) due to their global and ongoing refusal of all foods and fluids, and their non-compliance with nasogastric feeding. Chemical restraint was not routinely used within the eating disorder service, and there was a service policy in place for CNF interventions under manual restraint to be aborted and reattempted at a later time in circumstances where it was not possible to safely administer nasogastric feeding within 30 minutes of manual restraint holds being applied."

"Nasogastric tubes should be used preferentially except under conditions below where orogastric tubes may need to be placed: *Nasal prong CPAP *Choanal atresia *Respiratory distress respirations >60bpm grunting recession *Babies with an oxygen requirement *Nasal trauma *Cranio-facial anomalies"