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The treatment of severe and enduring eating disorders remains a challenging and controversial topic. Clinicians often feel limited in options, next steps, and ways to support clients with varied levels of motivation and resources. This presentation gives alternative routes for treatment and recovery that may be more sustainable for some. We will discuss moving away from traditional models that have proven to be limited and creative strategies with what to do next. We will look at models of harm reduction, palliative care, and hospice in treatment of this sensitive and vulnerable population. We will redefine goal setting with this population including a goal of partial recovery or living as 'stable enough.' Alternative forms of treatment will be addressed including the role of ketamine, TMS, and EMDR with this population. Ethical dilemmas will be addressed including the decision making process, individual professional ethics, and practical strategies for ethical challenges. This will cover last resort options such as involuntary care and guardianship and when these are appropriate. Case studies will be reviewed and include complex dynamics. Cases presented will include co-occurring sensory and body image concerns, diagnoses of PTSD and Dissociative Identity Disorder, and onset during early developmental years.