farnham road hospital ect clinic electro …

ECT Operational Policy Reviewed January 2014

Next Review January 2016

FARNHAM ROAD HOSPITAL ECT CLINIC

ELECTRO-CONVULSIVE THERAPY

OPERATIONAL POLICY

INTENT This policy aims to give guidance on the legislation, clinical assessment, and procedures

to be followed when giving electro-convulsive therapy within Surrey and Borders

Partnership NHS Foundation Trust.

These guidelines have been written in conjunction with the guidance of The Royal College of Psychiatrists ECT Hand Book (2012, third edition,CR176), and National Institute of Clinical Excellence TA 59 & CG90, ECTAS standards (Tenth Edition 2012), MCA (2005) Code of Practice (2007) and MHA Code of Practice (2008) Dr Philip Hall Consultant Psychiatrist ECT Lead Consultant Review date: January 2014



Policy and Procedure

Electro-Convulsive Therapy Operational Policy

Contents:

1 Introduction

2 General considerations

3 Referral process

4 Mental Health Act 1983 (MHA83)

5 The Mental Capacity Act 2005

6 Physical assessment

7 Cognitive assessment

8 Ward nurses responsibility

9 ECT nursing staff responsibilities

10 Responsibilities of doctors prior to administering ECT

11 ECT administration

12 Prescription of ECT

13 Prescription of medication for patients who will be receiving ECT

14 Anaesthesia for ECT

15 Recovery from anaesthesia

16 Outpatient ECT

17 Monitoring physical state during ECT

18 Application of ECT

19 Appendices**

** List of Appendices overleaf



Appendices:

No Title

1 Patient consent form

2 Outpatient Protocol

3 Outpatient ECT consent form

4 Outpatient ECT patient details

5 Outpatient Discharge form

6 ECT information leaflet

7 CQC ECT Leaflet

8 Confirmation or withdrawal of consent

9 Certificate of Incapacity

10 ECT Assessment form

11 Pre-anaesthetic checklist

12 Staff attendance checklist

13 Equipment checklist

14 Mini Mental State Examination

15 ECT anaesthetic record

16 ECT Treatment record

17 Record of recovery

18 Referring team guidelines

19 Stimulus dosing protocol

20 Referring team monitoring form

21 Clinical Global Impression Scale - Severity

22 Clinical Global Impression Scale - Improvement

23 Protocol for Maintenance ECT

24 Reception checklist

25 Pre-treatment checklist



Farnham Road Hospital ECT Clinic ELECTRO-CONVULSIVE THERAPY OPERATIONAL POLICY

1. Introduction

This operational policy describes the procedures for the giving of Electro-convulsive Therapy (ECT) at Farnham Road Hospital. Farnham Road Hospital ECT Department is currently the sole provider of ECT within Surrey. The clinic serves all the SABP inpatient and community services as well as a number of private providers. The service is led by a Consultant Psychiatrist and Senior nurse based at Farnham Road Hospital (FRH). The clinic currently manages approximately 500 patient-treatment episodes per year. Treatment is carried out on Tuesday and Friday mornings. Emergency ECT is available in the department other days, if the services to support this can be obtained. ECT can only be prescribed by:

A Consultant Psychiatrist

An Approved Clinician within the meaning of Mental Health Act 1983 or

A Second Opinion Doctor (SOAD) approved by Care Quality Commission.

A qualified senior nurse with appropriate competencies based at Farnham Road Hospital manages the ECT Department. ECT can only be given by medical staff, who have completed the appropriate professional training under the supervision of the lead ECT Consultant Psychiatrist at Farnham Road Hospital, Surrey and Borders Partnership NHS FoundationTrust. All medical staff and nurses working in the ECT department of Surrey and Borders Partnership NHS Foundation Trust must comply with, and have achieved, the standards of resuscitation training. They should have attended basic life support and defibrillation training specific to the ECT clinic in the clinic area, provided by the Trust every six months. 2. General considerations

2.1 It is recommended (NICE TA 59 / ICG 90) that electroconvulsive therapy (ECT) is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with: • Severe depressive illness • Catatonia • A prolonged or severe manic episode. Where ECT is prescribed outside the NICE guidelines, then this should be clearly documented and discussed with the ECT Lead consultant (this includes Maintenance ECT)



2.2 The decision as to whether ECT is clinically indicated should be based on a documented assessment of the risks and potential benefits to the individual, including: the risks associated with the anaesthetic; current co-morbidities; anticipated adverse events, particularly cognitive impairment; and the risks of not having treatment.

2.3 The risks associated with ECT may be enhanced during pregnancy, in older people, and in children and young people, and therefore clinicians should exercise particular caution when considering ECT treatment in these groups.

2.4 When the recommendations detailed above have been considered and applied, ECT is a safe and effective treatment. The patient must be well prepared and ECT given to a high standard. This policy is designed to inform the referring, and ECT teams of their responsibilities in ensuring safe and effective ECT.

2.5 The amended Mental Health Act (2007) introduces a new Section 58A which applies to ECT and to the medication administered as part of ECT. It applies to detained patients, (including patients subject to a community treatment order) and to all patients under 18 (whether or not they are detained). Relevant details are included in the policy.

2.6 This policy details minimum standards that are necessary for the application of ECT. If these minimum standards are not met, then ECT cannot be given. 3. Referral Process

3.1 The names of the patients requiring treatment will be given to the Senior ECT Nurse with as much advance notice as possible. Treatment can be given in urgent cases with 24 hours notification.

3.2 When outpatient ECT is being requested the prescribing medical officer will inform the senior ECT nurse of this request. Outpatient Protocol should be adhered to (Appendix 2).

3.3 It is the referring clinicians’ responsibility to ensure valid consent is obtained, to assess capacity, and where appropriate implement the MHA (as described below)

3.4 It is the referring teams’ responsibility to ensure the ECT Team receive the referral by contacting telephone number: 07990 775648

3.5 It is the referring clinicians’ responsibility to ensure that all pre-treatment examination & investigations have been carried out, and all the necessary paperwork has been completed



4. Mental Health Act 1983 (MHA’83)

4.1 Section 58A Electro-convulsive therapy is the section of the MHA’83 which applies when ECT is used as a form of medical treatment for mental disorder. A detained patient who has capacity to consent may not be given treatment under section 58A unless the Approved Clinician or a Second Opinion Appointed Doctor (SOAD) has certified that the patient has the capacity to consent, and has done so. A detained patient who has capacity and does not want to have ECT cannot be forced to have it unless in an urgent case requiring urgent treatment as described in Section 4.7. Urgent treatment under Section 62 can continue only for as long as it remains immediately necessary. 4.2 No patient aged under 18 years of age can be given treatment under section 58A unless a SOAD has certified that the treatment is appropriate. If a competent child refuses ECT, they cannot be made to have it, even though they are detained under a Section. 4.3 There is no initial three-month period during which a certificate is not needed (even for the medication administered as part of the ECT). 4.4 As mentioned above, the patient should be asked to sign the consent form prior to each ECT course, and provide further consent prior to each treatment. A patient can withdraw their consent at any time. A detained patient with capacity cannot be given ECT without their consent.

4.5 A detained patient who lacks the capacity to consent may not be given treatment under Section 58A unless the SOAD certifies that the patient lacks capacity to consent and that:- • the treatment is appropriate • no valid and applicable advance decision has been made by the patient under the Mental Capacity Act 2005 (MCA) refusing treatment; • no suitably authorised attorney or deputy objects to the treatment on the patients behalf; and • The treatment would not conflict with a decision by the Court of Protection which prevents the treatment being given. 4.6 Prior to a detained patient (not Supervised Community Treatment) being given ECT statutory paperwork needs to be completed. A form T4 Certificate of Consent to Treatment (patients at least 18 years old) or T5 Certificate of Consent to treatment and Second Opinion (patients under 18) or T6 Certificate of Second Opinion (patients who are not capable of understanding the nature, purpose and likely effects of the treatment must be completed by the Approved Clinician or the SOAD. A record of the conversation with the patient, and their capacity must be recorded in the patient’s records by the Approved Clinician or the SOAD. The original Form T4, T5, or Form T6 will be filed in the Mental Health Act Office with the patient’s detention papers. A copy of the form will be placed in the patient’s notes and attached to their prescription chart.



Form T4 Section 58A(3) Certificate of consent to treatment (Patients at least 18years old) – Completed by the Approved Clinician in charge of the treatment (or a SOAD) certifying that the patient has attained the age of 18 and is capable of understanding the nature, purpose and likely effects of the treatment and has consented to the treatment. Form T5 Section 58A(4) Certificate of consent to treatment and second opinion (Patients under 18) - Completed by a SOAD certifying that the patient has not yet attained the age of 18 and is capable of understanding the nature, purpose and likely effects of the treatment and has consented to that treatment and it is appropriate for the treatment to be given. Form T6 Section 58A(5) Certificate of second opinion (patients who are not capable of understanding the nature, purpose and likely effects of the treatment) – Completed by a SOAD who has consulted with a nurse and another person professionally concerned with the patient certifying that the patient is not capable of understanding the nature, purpose and likely effects of the treatment and that the treatment is appropriate and that the treatment does not conflict with any decision of an attorney, deputy, any decision of the Court of Protection or any advance decision to refuse treatment that is valid and applicable. Form CTO11 Section 64C(4) Certificate of appropriateness of treatment to be given to community patient (Part 4A certificate) – Completed by a SOAD who has consulted with two persons professionally concerned with the medical treatment of the patient certifying that the treatment is appropriate whilst the patient is not recalled to hospital subject to specified conditions. The form may also certify that treatment may be given following recall to hospital.

4.7 Section 62 Urgent Treatment Urgent Treatment under Section 62 can be given only if the treatment in question is immediately necessary to:- � save the patient’s life; � Prevent a serious deterioration of the patient’s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed. These are strict tests. It is not enough for there to be an urgent need for treatment or for clinicians involved to believe the treatment is necessary or beneficial. Urgent treatment under Section 62 can continue only for as long as it remains immediately necessary. The Mental Health Act Code of Practice Chapter 24 Treatments subject to special rules and procedure provides additional information.



Each Section 62 must state clearly the dates ECT is to be given and should cover no more than two treatments. Successive Section 62 can be used if there is a delay in securing a SOAD opinion providing the clinical situation continues to warrant it. 4.8 Section 17A Supervised Community Treatment (SCT) Part 4A of the Act sets out different rules for treatment of SCT patients who have not been recalled to hospital by the responsible clinician. This includes SCT patients who are in hospital without having been recalled (e.g. if they have been admitted to hospital voluntarily). Whether or not Part 4A patients consent to treatment or ECT it can only be given if approved by a SOAD on a Part 4A certificate. The MHA refers to this as the “certificate requirement”. Broadly speaking, the certificate requirement applies to any treatment for which a certificate would be necessary under Section 58 or 58A of the Act were the patient detained instead. In general SCT patients recalled to hospital are subject to sections 58 and58A in the same way as other detained patients. An exception to this is where the Part 4A certificate already explicitly authorises for the administration of ECT on recall to hospital. ECT Treatment that is already being given on the basis of a Part 4A certificate may be continued, even though it is not authorised for administration on recall, if, the approved clinician in charge of the treatment considers that discontinuing it would cause serious suffering. But it may only be continued pending compliance with section 58A, in other words while steps are taken to obtain a new certificate. Responsible clinicians should ensure that arrangements are made to obtain a new SOAD certificate under section 58A if one is needed, as soon as they revoke a CTO. Emergency treatment under section 64G - In an emergency, treatment can be given to Part 4A patients who lack capacity (and who have not been recalled to hospital) by anyone, whether or not they are acting under the direction of an Approved Clinician. ECT (or medication administered as part of ECT) can only be given if it is immediately necessary to: • save the patient’s life; • prevent a serious deterioration of the patient’s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed 5. The Mental Capacity Act 2005

5.1 The Mental Capacity Act 2005 (MCA) Code of Practice, Chapter 13, provides additional guidance relating to the relationship between the Mental Capacity Act and the Mental Health Act 1983. Passively compliant informal patients may be given ECT under the MCA, however prior to giving ECT the MCA advises that professionals may need to think about using the MHA to detain and treat somebody who lacks capacity to consent to treatment (rather than use the MCA), if:



• it is not possible to give the person the care or treatment they need without doing something that might deprive them of their liberty • the person needs treatment that cannot be given under the MCA (for example, because the person has made a valid and applicable advance decision to refuse an essential part of treatment). Advance Decisions made under the Mental Capacity Act 2005 to refuse ECT cannot be overridden even if the patient is detained under the MHA’83.

• the person may need to be restrained in a way that is not allowed under the MCA. 5.2 Section 5 of the MCA provides legal protection for people who care for or treat someone who lacks capacity. But they must follow the act’s principles and may only take action that is in the person’s best interests. This applies to care or treatment for physical and mental conditions. But section 5 does have its limits. For example, somebody using restraint only has protection if the restraint is: • necessary to protect the person who lacks capacity from harm, and • in proportion to the likelihood and seriousness of that harm. There is no protection under section 5 if ECT is given that goes against a valid and applicable decision to refuse treatment.

Consideration should be given as to whether a second opinion for a consultant colleague should also be sought.

Once this has been done the doctor should clearly document that the patient is incapacitated yet compliant and arrangements be made with the ECT service to administer one treatment.

The patient should be reassessed following each treatment with respect to both capacity and compliance.

It is advised that when the decision to proceed with ECT is made, a Certificate of Incapacity form (Appendix 9) is completed. At subsequent assessment, if it is found the patient remains incapacitated and compliant this will be clearly documented in his case notes if further treatment is deemed necessary. If the patient indicates lack of compliance in any way, then consideration to using the MHA will need to be given. If the patient develops capacity to consent, a compliant patient completes a normal consent form when they have been properly informed about the treatment to allow treatment to proceed.



PRE-ANAESTHETIC PHYSICAL ASSESSMENT

6. Physical assessment 6.1 Patients should be fit to receive an anaesthetic and ECT. Any conditions likely to increase the risks of the procedure should be fully assessed and treated beforehand and discussed with the anaesthetist. 6.2 Patients should have a documented recent medical history, physical examination and investigations, including ECG, prior to starting a course of ECT. All Patients should have an up to date set of relevant blood tests (FBC / U&Es as a minimum) with results available to the treating team. A chest x-ray should be performed if there are respiratory signs or symptoms. Patients of Afro-Caribbean, African, or Middle Eastern origin should have a sickle cell test. A Venous thromboembolism risk assessment should be carried out where appropriate. The required investigations are indicated in the ECT documentation to be completed by the referring psychiatrist. 6.3 New patients may need to be seen by or discussed with the anaesthetist as soon as possible before ECT is due to commence. If the patient has significant cardiovascular or respiratory disease, or other physical conditions that raise concerns, the anaesthetist may require additional investigations and therefore needs to be contacted at the earliest opportunity after the decision to give ECT has been made. Otherwise all new patients will be assessed by a consultant anaesthetist on the day of their first treatment. 6.4 If ECT is indicated for a physically ill patient and the anaesthetic may be contraindicated, the prescribing doctor may need to discuss this with the anaesthetist concerned. In certain cases, ECT may be given on the main hospital site where more resuscitation facilities are available. 6.5 Absolute contraindications to general anaesthesia for ECT: • Increased intracranial pressure • Untreated heart failure • Untreated respiratory failure • Untreated metabolic disorders Relative contraindications for general anaesthesia for ECT: • Myocardial infarction within three months • Significant cardiovascular or respiratory disease • Pregnancy • Morbid obesity • Symptomatic hiatus hernia • Recent fractures or severe osteoporosis • Previous anaesthetic problems • BP over 170/100



6.6 On the day of treatment the ward/referring team should record blood pressure, pulse and temperature, and any changes in drug treatment. The ECT team require this information as changes in drug treatment may affect both physical response to ECT and interfere with seizure threshold. 7. Monitoring before, during and post ECT

7.1 It is the referring clinicians responsibility to ensure that the patients cognitive function in measured and documented prior, during and post ECT (ECTAS 2012). This is a mandatory College requirement.

7.2 as there is no specific tool identified for this purpose the MMSE (Appendix 14) will be used as a minimum. The MMSE score should be documented prior to the course of ECT starting, and within 2 weeks of the completion of the course of ECT, and after a further 1-2 months. 7.3 on a weekly basis the referring team should ensure that the patient’s memory and orientation is tested and documented. The patient’s subjective experience of both cognitive and non-cognitive side effects should be documented on a weekly basis. 7.4 the patients clinical status/symptomatic response should be assessed and recorded at baseline, and between each treatment session and following the course of ECT using the Clinical Global Impression –Severity (CGI-S) scale. The referring team will be responsible for the baseline and post completion CGI-S. The referring team is also required to record the CGI-Improvement score prior to each treatment. ** the referring team must ensure that the “Referring Team Monitoring form” (Appendix 20) is completed and returned to the ECT department after a course of ECT finished** A separate “Guidelines for the Referring Team” is Appendix 18

8. Ward nurses responsibilities

When ECT is prescribed as a treatment for inpatients residing on the wards the ward nurse in charge will inform the ECT Department giving the names of the patients and the prescribing medical officer. This information will be forwarded to the Senior Nurse in charge of the ECT Department. Patients should not eat or drink for at least six hours before the time of the ECT treatment, e.g. preferably nil by mouth from midnight. Patient’s medications prior to ECT should be in accordance with Guidelines as outlined in ‘Section 13’ of this document.



A competent nurse known to each patient, preferably the patient’s Named Nurse or Co-worker should accompany the patient throughout the various stages of treatment. The role of this nurse is to act as the patient’s advocate, offering support and reassurance and relaying the patient’s anxieties to the core ECT nursing team or medical staff as appropriate. The accompanying nurse may also be required to assist more experienced members of nursing staff (for example, in supporting limbs during the seizure). There must be at least one accompanying nurse for every 2-3 patients.

The patient’s named nurse, prior to leaving the ward should complete a pre-ECT checklist as far as possible.

9. ECT Nursing staff responsibilities

The ECT nurse in charge will ensure that an accurate record of clinic staff attendance is kept (Appendix 12). The composition of the core team of dedicated and experienced nurses who work regularly in the clinic assumes that one patient will be undergoing treatment and two patients will be in various stages of recovery at any one time. To ensure safe level of staffing at all times within the department, the senior nurse will review the staffing levels prior to a clinic. The core team for Farnham Road Hospital requires a minimum of three trained nurses, (at least two of whom will be RMN) and supporting Health Care Assistants (HCA). One qualified nurse will take responsibility for the preparation area and the treatment area. One qualified nurse will take responsibility for operating the Thymatron (ECT) machine in administering the treatment. One qualified nurse will take responsibility for the management of patients’ recovery area. One HCA will take responsibility for the pre-treatment waiting room area. One HCA will assist in the preparation area and in recovering trolleys from the recovery area back to the preparation area. One HCA will take responsibility for the post recovery sitting area. An Operating Department Practitioner (ODP), in accordance with the guidelines laid down by the Association of Anaesthetists of Great Britain and Ireland (2002) will be present throughout treatment to assist the anaesthetist during the treatment and in the event of any medical emergency. There is a telephone system within the department, which ensures that practitioners can communicate with each other between all rooms/areas. Patients’ case notes (where appropriate) and medication charts must be in the department before their treatment can commence. The Patient Reception Checklist (Appendix 24) the Pre-Anaesthetic Checklist (Appendix 11) and the Pre-ECT checklist (Appendix 25) must be completed before treatment begins.



The identity band, fastened securely to the wrist will bear the patient’s name, RiO number and hospital ward/department. Jewellery such as hairgrips, chains, bracelets, watches etc. are kept safely in a container on the ECT trolley shelf. Dentures likewise are kept in a container on the ECT trolley shelf. All other personal items i.e. footwear, coats, jackets, spectacles, prostheses are likewise kept safely on the patient’s ECT trolley shelf. Smoking is discouraged before treatment and the anaesthetist is informed if this has occurred. The patient is offered the opportunity to empty their bladder before treatment.

The designated senior nurse will monitor these arrangements to ensure that they are being adhered to and take corrective action as necessary. 10. Responsibilities of doctors prior to administering ECT The doctor will ensure that both patient and a doctor from the Responsible Medical Team prescribing ECT have signed the ‘ECT Consent form’ (Appendix 1). The doctor will ensure that the Mental Health Act consent to treatment regulations for detained patients have been adhered to. 11. ECT Administration

Preparation of the treatment area ECT trolleys should be checked as safe and ready to use and appropriately prepared with trolley linen and pillow. An adequate supply of required anaesthetic agents and drugs should be available and accessible. The ODP should ensure that all safety and treatment equipment in the treatment area is in working order and switched on, and that a full spare oxygen cylinder is available. The qualified nurses should ensure that monitoring and safety equipment in the preparation area and the recovery area is in working order and that two spare oxygen cylinders are available.

The nurse should ensure that there is an adequate supply of recording paper to record EEG and ECG tracings and an accessible spare roll of recording paper. There should be an adequate supply of electrolyte solution, gel or paste. A doctor trained in administering ECT and anaesthetist must be present before treatment commences. All staff in the clinic and from referring wards/departments will be acutely aware of patients’ prospective needs in relation to alleviating their fears and apprehensions at this time. Individual patient care planning in respect to giving persons undergoing ECT their needed support and reassurance will be adhered to. This agreed approach prevents individual patients being subjected to misunderstanding or contradictory information. The ECT department will always be fully prepared before patient’s arrival.



A patient will be taken into the treatment area only when the treatment procedure is ready to commence. The department is designed to secure privacy for patients throughout all stages of their treatment. The doctor administering ECT will ensure that an accurate record of treatment is made (Appendix 16) and in the case notes, including:

Presence, nature and duration of seizure activity

Record of anaesthesia (Appendix 15)

Comments on recovery period

EEG record print out of seizure shall be filed in the patient’s case notes.

The anaesthetist administering anaesthesia will ensure that an accurate Record of Anaesthesia is made (Appendix 15).

The qualified nurse responsible for the recovery area will ensure that an accurate record of recovery is made (Appendix 17).

The patient is kept in the recovery area until they are fully recovered and able to walk to the post treatment sitting area. The ECT nurse in charge will ensure that post ECT observation (Appendix 17) is completed for all patients before they leave the department.

12. Prescription of ECT

12.1 ECT documentation should be completed accurately and in full. Any omissions may mean that ECT cannot be given unless rectified by the referring team. 12.2 ECT should be prescribed by the RC or nominated medical deputy. It is good practice to discuss the likely length of treatment with the patient in advance. If more than twelve treatments are indicated, it is good practice to obtain a local second opinion. Bilateral or unilateral ECT should be specified on the prescription. Most ECT is prescribed bilaterally, which is thought to be more effective than unilateral treatment. However unilateral ECT is prescribed, particularly when there is cognitive impairment related to ECT. If unilateral ECT is prescribed, then the cerebral dominance of the patient must be tested and recorded. 95% of people are right handed with left cerebral dominance 60% of left handed people have left cerebral dominance, 20% right and 20% mixed dominance. Patients should be asked to demonstrate common tasks to determine handedness and cerebral dominance, e.g. writing, using scissors and brushing teeth. If laterality is uncertain, then unilateral ECT can be given to the right cerebral hemisphere and changed to the left if marked post-ECT confusion occurs.

12. Prescription of medication for patients who will be receiving ECT

13.1 Many drugs used in psychiatric practice affect the seizure threshold and this should be taken into consideration when patients are due to start a course of ECT. Of particular note are anticonvulsants, barbiturates and benzodiazepines, which raise the seizure threshold, requiring more energy to be delivered during ECT and increasing the potential for side effects and treatment failure. If possible, alternative drugs should be sought .



13.2 Caution should be taken when withdrawing long-standing benzodiazepines, anticonvulsants and barbiturates as this lowers the seizure threshold. 13.3 Long acting benzodiazepines such as diazepam should ideally be discontinued several days before ECT. However if the prescription is long-term and essential, then the dose should be reduced as far as possible prior to ECT and the use of a higher stimulus considered. Lorazepam should be omitted on the day before ECT if possible. 13.4 Zopiclone, and short acting benzodiazepine hypnotics, should also be withdrawn if possible.

13.5 When anticonvulsants are being used as a treatment for epilepsy their effect is to normalise the seizure threshold so this treatment should continue unchanged during the course of ECT. If essential for mood stabilisation, maintain the patient on minimum effective dose.

Concomitant lithium preparations and ECT can increase the likelihood of delirium or confusion, though the combination is generally well tolerated. It is recommended to start with a low stimulus and to monitor very closely. 13.6 Clozapine should be withheld for 24 hours before ECT 13.7 Moclobemide should be suspended for 24 hours pre-ECT. 13.8 Oral anti-diabetic medication and insulin should be given after ECT when the patient is ready to eat. 13.9 It is the referring psychiatrist’s responsibility to assess and adjust the patient’s medication prior to ECT. 13.10 all cardiac medications, including Beta-Blockers, as well as bronchodilators and anti-reflux medications should be given on the morning of treatment, up to 2 hours prior to the patient attending the ECT clinic with a small quantity of water. 14. Anaesthesia for ECT

14.1 A Consultant Anaesthetist provides general anaesthesia. A nominated Consultant Anaesthetist will act in an advisory capacity on matters of policy, training and resuscitation. 14.2 Anaesthesia for the procedure will be accompanied by muscle relaxation to modify convulsions. The anaesthetist should be satisfied that the patient has been adequately prepared to minimise any risks, or ECT may not be given. 14.3 The patient should be anaesthetised on a tipping trolley.



14.4 Anaesthetic agents: There are two induction agents for ECT; Propofol, and Sodium Thiopentone. Propofol is currently the induction agent of choice for the clinic. It is a short acting, well-tolerated agent which attenuates the hypertensive response to ECT. It can reduce seizure length and the Committee on the Safety of Medicines have advised special caution in day-case surgery because of concerns over anaphylaxis and delayed recovery. It can also be associated with bradycardia and hypotension in some cases. Local experience suggests that while Propofol is a good agent for most patients, for a minority it significantly raises seizure thresholds making it difficult to induce seizures without using high doses of ECT. Switching these patients to Thiopentone has helped produce more satisfactory seizures and has not noticeably delayed recovery time. Thiopentone is used as the second line anaesthetic agent, when patients have short seizures with Propofol, possibly the result of the anticonvulsant effects of the anaesthetic. If brief or abortive seizures occur with Propofol, despite increased dose of ECT and other attempts to lower the seizure threshold, then either reduced doses of Propofol should be considered or a change of anaesthetic agent to Thiopentone. Suxamethonium is used to induce paralysis. It is important in patients with slow circulation times to wait for thorough depolarisation and termination of fasciculation before ECT is given. Fasciculation may be confused with seizure activity. The patient should be well ventilated with oxygen. Hypoxia increases the seizure threshold in addition to being a significant risk itself. A mouth gag should be used for all patients with teeth. After ECT has been given and the patient is physically stable, they should be turned to the recovery position and ventilated until normal respiration resumes, then transferred to the recovery area. 15. Recovery from anaesthesia

15.1 Following direction from the Anaesthetist, a trained recovery nurse will escort the patient to the recovery room and will monitor recovery. This nurse will not leave the patient until full protective reflexes and consciousness have returned. Oxygen saturation, respiration, pulse rate, blood pressure and cognitive state should be monitored and recorded. Any deviation from expected recovery should be communicated to the anaesthetist. Observations should be recorded as set out in the nursing checklist which is in the ECT record pack.

15.2 When patients have been accompanied to ECT by a qualified nurse from the ward/community known to them, this nurse will take part in the recovery process, with supervision from the recovery nurse. In certain circumstances it may be more appropriate for another member of staff to be present e.g. an experienced healthcare assistant who has a good relationship with an anxious patient. Unconscious patients should be attended by a trained recovery nurse at all times.



16. Outpatient ECT 16.1 Outpatients receive a general anaesthetic and should be treated as day cases. The following are the standard instructions for adult day-case surgery patients, following a general anaesthetic:- The anaesthetic drugs that have been administered may remain in the body for at least 24 hours, which may temporarily impair co-ordination and cognition.

16.2 Patients should be advised that they should: • Ensure that a responsible adult can collect them from the ward. • Have a responsible adult stay with them for at least 24 hours. • Drink plenty of fluids and eat a light diet if they can • When rising to a sitting or standing position, they should do so slowly to avoid dizziness. • Lie quietly if they feel sick and take clear liquids only.

• Take things easy the day after their ECT treatment. 16.3 Patients should be advised that they should not: • Drive a car or any other vehicle during or following their course of ECT until the prescribing doctor says they are fit to do so (they should note that their insurance may be invalid if they do so). This does not apply to patients receiving maintenance ECT who should not drive on or the day following ECT. There are special regulations for drivers of public service and heavy goods vehicles. For further details please refer to the DVLA guidance. • Operate machinery or appliances such as cookers and kettles for 24 hours. • Make important decisions or sign important documents for 24 hours. • Drink alcohol. • Lock themselves in any room inside their house in case the person looking after them is needed to help.

16.4 Patients should be escorted to and from their treatment by a member of staff from the inpatient unit; a community team member or other responsible adult. The patient should be fully recovered before returning home. Patients should be supervised by a responsible adult for the night following ECT. 16.5 It is the responsibility of the prescribing consultant to ensure that the above information is given to the patient and that the care coordinator/lead professional produces an appropriate care plan for ECT. The care coordinator/lead professional is also responsible for ensuring that completed documentation and notes accompany the patient on the day of ECT.

17. Monitoring physical state during ECT 17.1 Patient monitoring equipment should include use of a pulse oximeter. An ECG monitor and capnograph monitor are available in the ECT suite.



18. Application of ECT 18.1 ECT machine: The machine currently used is a Thymatron System IV machine. Two of these machines are available. 18.2 A junior doctor or SAS grade psychiatrist who has received appropriate training can administer ECT.

18.3 Stimulus dosing: The primary consideration with stimulus dosing is to produce an adequate ictal response whilst minimising cognitive side effects and maximising the rate of clinical response. The rate of clinical improvement during the course of ECT can be enhanced if the stimulus is moderately above the seizure threshold (moderately suprathreshold). Seizure threshold is the minimum “dose” of electricity required to induce generalised cerebral seizure activity. Seizure threshold varies markedly between patients dependent on many factors, some of which are listed below. Factors affecting seizure threshold RAISE: Age Anticonvulsants concurrently or recently discontinued Baldness Barbiturates concurrently or recently discontinued Benzodiazepines concurrently or recently discontinued Bilateral electrode placement Bones (thick), e.g. Paget’s disease Dehydration ECT increasing number of treatments ECT previous course within last month Poor electrical contact with scalp Oxygen saturation of blood (low) Propofol (and other anaesthetic agents) Male Sex LOWER : Antidepressant and antipsychotic drugs Caffeine Carbon dioxide saturation of blood (low) Hyperventilation 18.4 The optimal dose for ECT should be moderate supra-threshold. This should be one and half to two times the seizure threshold for bilateral and at least four times for unilateral ECT for the treatment to be effective. Generally, this is confirmed by a generalised seizure of adequate length and a good clinical response. Grossly supra-threshold dosing exposes the patient to the risk of cognitive side effects. Therefore, there is a therapeutic window with a lower limit to the dose of stimuli below which ECT is less effective and an upper limit



over which, whilst clinically effective, the patient may have unacceptable side–effects. The therapeutic window can be established empirically by dose titration. 18.5 Placement of Electrodes: Placement of electrodes should be based on an appraisal of the advantages and disadvantages for each patient. 18.6 Bilateral ECT: Electrode placement is at a point about 4cm perpendicular to mid-way between the external angle of the eye and external auditory meatus bilaterally. 18.7 Unilateral ECT: On the non-dominant side one electrode is placed at the point of 4cm perpendicular to mid-way between the external angle of the eye and external auditory meatus and the other electrode on the mid-line on the occipito-parietal junction. 18.8 Refer to the protocol for giving ECT available in ECT department



19.0 Appendices:

No Title

1 Patient consent form

2 Outpatient Protocol

3 Outpatient ECT consent form

4 Outpatient ECT patient details

5 Outpatient Discharge form

6 ECT information leaflet

7 CQC ECT Leaflet

8 Confirmation or withdrawal of consent

9 Certificate of Incapacity

10 ECT Assessment form

11 Pre-anaesthetic checklist

12 Staff attendance checklist

13 Equipment checklist

14 Mini Mental State Examination

15 ECT anaesthetic record

16 ECT Treatment record

17 Record of recovery

18 Referring team guidelines

19 Stimulus dosing protocol

20 Referring team monitoring form

21 Clinical Global Impression Scale - Severity

22 Clinical Global Impression Scale - Improvement

23 Protocol for maintenance ECT

24 Reception checklist

25 Pre-treatment checklist

26 Referring Team Documentation Checklist



Appendix 1

Page 1 of 3

ECT Consent to Treatment Patient’s details (or pre-printed label) Patient’s surname/family name:……………………………………………………………………

Patient’s first names:………………………………………………………………………………...

Date of birth:…………………………………………………………………………………………

Responsible health professional:………………………………………………………………….

Job title:………………………………………………………………………………………………

Patient’s RiO/NHS number (or other identifier):…………………………………………………

Male Female

Ethnicity:………………………………………………………………………………………………

Legal Status:………………………………………………………………………………………….

If Informal: (Please tick as appropriate) T4 T6 S62

Special requirements:……………………………………………………………………………….

(e.g. other language/communication methods)

To be retained in patient’s records



Page 2 of 3 Name of proposed procedure or course of treatment

Electroconvulsive therapy: Unilateral Bilateral Either (Please tick laterality) Diagnosis:……………………………………………………………………………………………. NICE Indication: YES / NO

If NO Patient informed ECT Team informed Statement of health professional (To be filled in by health professional with appropriate knowledge of proposed procedure, as specified in

consent policy)

I have explained the procedure to the patient. In particular, I have explained:

The intended benefits and the use of bilateral or unilateral treatment

Serious or frequently occurring risks, including dental risks

What the procedure involves, the benefits and likely risks of any alternative treatments (including no treatment) and discussed any particular concerns of the patient

Which medication to take and not to take on the morning of ECT

I have also explained any procedures which may become necessary during the procedure

NO YES (Please specify below)

................................................................................................................................................................

This procedure will involve:

General anaesthesia Local anaesthesia Sedation

The following information has been provided:

Understanding Electrocovulsive Therapy (ECT):

An Information Guide

CQC ECT Leaflet (if detained)

Other forms of information:…………………………………………………………………………

I confirm patient has capacity to consent - Is able to understand relevant information

- Is able to retain the relevant information

- Is able to weigh up the relevant information

Signed:……………………………………..Job Title:………………………………………………

Name(print):…………………………………………Contact details:……………………………

Statement of interpreter (where appropriate) I have interpreted the information above to the patient to the best of my ability and in a way in which I believe they can understand. Signed:…………………………………………Name (print):…………………………………

Copy accepted by patient: Yes No



Page 3 of 3 Statement of patient Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy of page 2 which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask – we are here to help you. You have the right to change your mind at any time, including after you have signed this form. I agree to the procedure or course of treatment described on this form. I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience. I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure, unless the urgency of my situation prevents this. (This only applies to patients having general or regional anaesthesia.) I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health. I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion. …………………………………………………………………..…………………………………….. Patient’s consent

Total number of treatments consented to:

Patient’s signature:………………………………………………Date:………………………….. Name (print):……………………………………………………………………………………….. A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people/children may also like a parent to sign here (see notes).

Signed:…………………………………………………………….Date:………………………….

Name (print):………………………………………………………………………………………..



Appendix 2

Farnham Road Hospital ECT Clinic

Outpatient Protocol 1. Introduction This protocol should be read in conjunction with the Trust ECT policy. Outpatient ECT is where an individual attends for treatment from their home and will be directly discharged back home to the ongoing care of a responsible adult without the interim involvement of an inpatient ward or day hospital. Factors to consider before referring patients for outpatient ECT: - Suicide risk. - Physical fitness to undergo and recover from a general anaesthetic. - Ability to retain information about their treatment and fulfil the safety requirements pre- and post-treatment. - Social support network, i.e. a responsible adult who can remain with them post-treatment, transport to and from sessions. - Input of care professionals, i.e. CMHT. - Compliance with the treatment plan, i.e. agreed attendance at the ECT clinic and medical reviews. If there are any concerns over any of the above, these should be rectified prior to ECT treatment or consideration given to admitting the patients overnight on the day of the ECT treatment or a brief admission to hospital for the duration of the ECT treatment course. 2. Responsibilities of the referring team

The patient should be referred to the ECT nurse as soon as outpatient ECT is being considered (at least 72 hours before the first treatment).

The patients should be prepared for ECT in exactly the same way as an inpatient.

The patient should be met at or escorted to the ECT clinic by a qualified member of staff organised by the referring team, or accompanied to the clinic by a responsible adult.

That the patient’s notes and ECT paperwork are brought to the clinic on or before the day of treatment.

The ECT nurse will complete the pre-ECT checklist and observations.

The referring team must remain in regular contact with the ECT nurse during the duration of the ECT treatment course.

The outpatient information form attached must be completed and a copy given to the patient and/or carer to retain for future reference in addition to the Trust ECT Patient Information Leaflet.



Appendix 3

Page 1 of 2

Outpatient ECT consent

On the day you received electro-convulsive therapy you were given a general anaesthetic; therefore you should not do any of the following for at least the next 24 hours:

Drive any type of vehicle

Operate any machinery or electrical appliances

Consume alcohol

Sign any legal documents or make any important decisions for 24 hours You should have another responsible adult to remain with you for the first 24 hours after treatment. If you suffer any serious side effects, then contact your own general practitioner in the first instance and pass on the information on this sheet. If you have any concerns relating to your treatment or develop a cold or physical illness, then contact the ward that organised your ECT treatment. The information will be passed on to your hospital doctor. The evening before your next treatment, please remember not to eat any food after midnight, and take the tablets or medicines only as agreed with your hospital doctor.

Patient’s signature:……………………………………………….Date…………………………… Name (PRINT)……………………………………………………………………………………… Guidance to health professional (to be read in conjunction with consent policy)

What a consent form is for This form documents the patient’s agreement to go ahead with the investigation or treatment you have proposed. It is not a legal waiver – if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as an aide-memoire to health professional and patients, by providing a checklist of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way, however, should the written information provided for the patient be regarded as a substitute for face-to-face discussions with the patient.

The law on consent See the Department of Health’s Reference guide to consent for examination or treatment for a comprehensive summary of the law on consent (also available at www.doh.gov.uk/consent).

http://www.doh.gov.uk/consent



Page 2 of 2

Who can give consent Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and intelligence to enable him or her to understand fully what is proposed”, then he or she will be competent to give consent for himself or herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is not able to give consent for himself or herself, someone with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where the child is able to give consent for himself or herself, you should always involve those with parental responsibility in the child’s care, unless the child specifically asks you not to do so. If a patient is mentally competent to give consent but is physically unable to sign a form, you should complete this form as usual and ask an independent witness to confirm that the patient has given consent orally or non-verbally.

When NOT to use this form If the patient is 18 or over and is not legally competent to give consent, you should use form 4 (form for adults who are unable to consent to investigation or treatment) instead of this form. A patient will not be legally competent to give consent if:

they are unable to comprehend and retain information material to the decision and/or

they are unable to weigh and use this information in coming to a decision. You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so. Relatives cannot be asked to sign this form on behalf of an adult who is not legally competent to consent for himself or herself.

Information Information about what the treatment will involve, it’s benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about ‘significant risks which would affect the judgement of a reasonable patient’. ‘Significant’ has not been legally defined, but the GMC requires doctors to tell patients about ‘serious or frequently occurring’ risks. In addition if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on page 2 of the form or in the patient’s notes.



Appendix 4

Out-patient ECT information

Patient’s Name:…………………………………………………………………………………….

Date of birth:…………………………………………………………………………………………

RiO Number:……………………………………………………………………………………

Hospital:…………………………………………Ward/Clinic:……………………………………

Consultant:……………………………………………………………………………………………

Key Worker…………………………….Team doctor:……………………………………………..

ECT Department contact telephone number:…………………………………………………...

Next of Kin:………………………………………………………………………………………….

Before Electro-Convulsive Therapy which involves a general anaesthetic you must not eat or drink from midnight on the night before your treatment. You will also adhere to advice from the psychiatrist regarding what medications you can take on the evening and night before your treatment and on the morning of your treatment. When you attend for treatment you will always inform the ECT clinic staff of which medications you have taken the evening and night before clinic attendance and which you have taken that morning. It is very important that you inform clinic staff on the morning of attendance if and when you have mistakenly taken food and/or drink in the previous six hours. After your treatment for at least the next 24 hours you should not do any of the following:

Drive any type of vehicle

Operate machinery or electrical appliances

Consume alcohol

Sign any legal documents or make any important decisions for 24 hours You should have another responsible adult to remain with you for the first 24 hours after treatment. If you suffer any serious side effects, the contact your own general practitioner in the first instance and pass on the information on this sheet. If you have any concerns relating to your treatment or develop a cold or physical illness, then contact the department that organised your ECT treatment. The information will be passed on to your hospital doctor. Doctor:…………………………………………………………………………………………..….

Patient signature:………………………………………………………Date:……………………

A copy of this form is given to patient



Appendix 5 Page 1 of 2

Outpatient Discharge Form

1. If you are receiving ECT as an outpatient your doctor will have explained the procedure to you to ensure that you meet the requirements needed so that you have safe and effective ECT treatments. 2. You and your carer will both need to sign the form below each time you attend for a treatment to confirm that you have read and understood the following information. 3. During ECT you will receive a general anaesthetic and therefore the the following standard precautions apply: You must: • Be in the company of a responsible adult for 24 hours following the treatment. • Be accompanied home • Not leave the hospital if you are feeling unsteady or confused. • Not operate machinery or appliances for 24 hours. • Take DVLA advice on driving following an episode of mental illness. (Your psychiatrist should inform you of this). • Not be left in sole charge of young children until the following morning. • Not sign any legal document or make important decisions for 24 hours. • Not consume alcohol for 24 hours. Once you have returned home if you begin to feel unwell please contact: ……………………………………………………………………………………………………… If you are unable to attend for an ECT treatment please contact:…………………………… Treatment 1 I confirm that I have read and understood the following guidelines Signed: Patient……………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 2 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 3 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 4 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer…………………………………………………………………………………………………



Page 2 of 2

Treatment 5 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 6 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 7 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 8 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 9 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 10 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 11 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer………………………………………………………………………………………………… Treatment 12 I confirm that I have read and understood the following guidelines Signed: Patient………………………………………………………………………………………………… Carer……………………………………………




Information on ECT

This leaflet is for anyone who wants to know more about ECT (Electro-convulsive therapy). It discusses how it works, why it is used, its effects and side-effects, and alternative treatments.

ECT remains a controversial treatment and some of the conflicting views about it are described. If your questions are not answered in this leaflet, there are some sources of further information at the end of the leaflet.

Where there are areas of uncertainty, we have listed other sources of information that you can use. Important concerns are the effectiveness and side-effects of ECT and how it compares with other treatments. At the time of writing, these references are available free and in full on the Internet.

What is ECT? ECT is a treatment for a small number of severe mental illnesses. It was originally developed in the 1930s and was used widely during the 1950s and 1960s for a variety of conditions. It is now clear that ECT should only be used in a smaller number of more serious conditions.

ECT consists of passing an electrical current through the brain to produce an epileptic fit – hence the name, electro-convulsive. On the face of it, this sounds bizarre. Why should anyone ever have thought that this was a sensible way to treat a mental disorder? The idea developed from the observation that, in the days before there was any kind of effective medication, some people with depression or schizophrenia, and who also had epilepsy, seemed to feel better after having a fit. Research suggests that the effect is due to the fit rather than the electrical current.

Q How often is it used?

It is now used less often. Between 1985 and 2002 its use in England more than halved, possibly because of better psychological and drug treatments for depression.

Q How does ECT work?

No-one is certain how ECT works, and there are a number of theories.

It can change patterns of blood flow through the brain. It can change the metabolism of areas of the brain which may be affected by depression. Many doctors believe that severe depression is caused by problems with certain brain chemicals. It is thought that ECT causes the release of these chemicals and, probably more importantly, makes the chemicals more likely to work and so help recovery. Recent research has suggested that ECT can stimulate the growth of new cells and nerve pathways in certain areas of the brain



Page 2 of 11

Q Does ECT really work?

It has been suggested that ECT works not because of the fit, but because of all the other things – like the extra attention and support and the anaesthetic – that happen to someone having it.

Several studies have compared standard ECT with "sham" or placebo ECT. In placebo ECT, the patient has exactly the same things done to them – including going to the ECT rooms and having the anaesthetic and muscle relaxant – but no electrical current is passed and there is no fit. In these studies, those patients who had standard ECT were much more likely to recover, and did so more quickly than those who had the placebo treatment. Those who didn't have adequate fits did less well than those who did.

Interestingly, a number of the patients having "sham" treatment recovered too, even though they were very unwell; it's clear that the extra support does have a benefit as might be expected. However, ECT has been shown to have an extra effect in severe depression – it seems, in the short term, to be more helpful than medication.

Pros & Cons of ECT

Q Who is ECT likely to help? The National Institute of Health and Clinical Excellence (NICE) have looked in detail at the use of ECT and have said that it should be used only in depression, resistant mania or catatonia. They say ECT should be considered for acute treatment of severe depression that is life-threatening and when a rapid response is required, or when other treatments have failed. It should not be used routinely in moderate depression, but should be considered for people with moderate depression if their depression has not responded to multiple drug treatments and psychological treatment.

Q Who is ECT unlikely to help?

ECT is unlikely to help those with mild to moderate depression or most other psychiatric conditions. It has no role in the general treatment of schizophrenia.

Q Why is it given when there are other treatments available?

ECT has been shown to be the most effective treatment for severe depression. It would normally be offered if:

several different medications have been tried but have not helped the side-effects of antidepressants are too severe you have found ECT helpful in the past your life is in danger because you are not eating or drinking enough you are seriously considering suicide.



Page 3 of 11

Q What are the side effects of ECT? ECT is a major procedure involving, over a few weeks, several epileptic seizures and several anaesthetics. It is used for people with severe illness who are very unwell and whose life may be in danger. As with any treatment, ECT can cause a number of side-effects. Some of these are mild and some are more severe.

Short-term

Many people complain of a headache immediately after ECT and of aching in their muscles. They may feel muzzy-headed and generally out of sorts, or even a bit sick. Some become distressed after the treatment and may be tearful or frightened during recovery. For most people, however, these effects settle within a few hours, particularly with help and support from nursing staff, simple pain killers and some light refreshment.

There may be some temporary loss of memory for the time immediately before and after the ECT.

Older people may be quite confused for two or three hours after a treatment. This can be reduced by changing the way the ECT is given (such as passing the current over only one side of the brain rather than across the whole brain).

There is a small physical risk from having a general anaesthetic – death or serious injury occurs in about 1 in 80,000 treatments, around the same level of risk in dental anaesthesia. However, as ECT is given in a course of treatments, the risk per course of treatment will be around 1 in 10 000.

Long-term

The greater concern is that of the long-term side effects, particularly memory problems. Surveys conducted by doctors and clinical staff usually find a low level of severe side-effects, maybe around 1 in 10. Service user-led surveys have found much more, maybe in half of those having ECT. Some surveys conducted by those strongly against ECT say there are severe side-effects in everyone.

Some difficulties with memory are probably present in everyone receiving ECT. Most people find these memories return when the course of ECT has finished and a few weeks have passed. However, some people do complain that their memory has been permanently affected, that their memories never come back. It is not clear how much of this is due to the ECT and how much is due to the depressive illness or other factors.

Some people have complained of more distressing experiences, such as feeling that their personalities have changed, that they have lost skills or that they are no longer the person they were before ECT. They say that they have never got over the experience and feel permanently harmed.



Page 4 of 11 What seems to be generally agreed is that the more ECT someone is given, the more it is likely to affect their memory.

Q What if ECT is not given? You may take longer to recover. If you are very depressed and are not eating or drinking enough, you may become physically ill or die. There is an increased risk of suicide if your depression is severe and has not been helped by other treatments.

Q What are the alternatives? If someone with severe depression declines ECT, there are a number of possibilities. The medication may be changed, new medication added or intensive psychotherapy offered, although this should already have been tried. Given time, some episodes of severe depression will get better on their own, although being severely depressed carries a significant risk of suicide. Deciding to have (or not to have) ECT

Q Giving consent to having ECT Like any significant treatments in medicine or surgery, you will be asked to give consent, or permission for the ECT to be done. The ECT treatment, the reasons for doing it and the possible benefits and side-effects should be explained in a way that you can understand. If you decide to go ahead, you then sign a consent form. It is a record that ECT has been explained to you, that you understand what is going to happen, and that you give your consent to it. However, you can withdraw your consent at any point, even before the first treatment.

Q What if I really don’t want ECT? If you have very strong feelings about ECT, you should make them known to the doctors and nurses caring for you, but also friends, family or an advocate who can speak for you. Doctors must consider these views when they think about what to do. If you have made it very clear that you do not wish to have ECT, then you should not receive it. You could write an 'advance decision to refuse ECT' to make clear how you want to be treated if you become unwell again. Alternatively you could appoint someone to be your Health and Welfare Attorney to make decisions on your behalf when you are not able to decide for yourself..



Page 5 of 11

Q Can ECT be given to me without my permission? Most ECT treatments are given to people who have agreed to it. This means that they have had:a full discussion of what ECT involves, why it is being considered in their case, the advantages and disadvantages, a discussion of side-effects. You cannot be given ECT against your wishes, even if you are sectioned under the Mental Health Act. It is the responsibility of the doctors and nurses involved to make sure that this discussion has been had – and to document it. Sometimes, however, people become so unwell that they are unable to take on board all of the issues – perhaps because they are severely withdrawn or have ideas about themselves that stop them fully understanding their position (e.g. they believe their illness is a punishment they deserve). In these circumstances, it may be impossible for them to give proper agreement or consent. When this happens, it is still possible to give ECT. The legal provisions for this differ from country to country, even within the United Kingdom. In England and Wales, ECT can be given under the Mental Health Act which requires the agreement of two doctors and another professional who is usually a social worker. There must then be a second opinion from an independent specialist who is not directly involved in their care. The clinical team should also speak to family and other carers, to consider their views and any views the patient may have expressed before. Sometimes - if a person doesn't have the capacity to give an informed consent - the team may decide the ECT can be given under the Mental Capacity Act. This is unusual, as in most cases, the Mental Health Act provides the most appropriate protection for a patient's rights. The Mental Capacity Act can only be used if the patient lacks capacity and a "decision maker" (usually the consultant in charge of their care) decides that ECT is in the patient's "best interests". It is expected the decision maker will consult with other people to try to find out what the person's views would have been. This would usually include family members and other people close to them. The decision maker should also make "all reasonable attempts" to help the patient to regain capacity to consent (if this is possible). An independent specialist is not needed, though the clinical team may request a second opinion from another consultant. Whether ECT is given under the Mental Health Act or the Mental Capacity Act, regular assessments of the patient's ability to understand their treatment must be made. Once they are able to give consent, the treatment can only continue if they do consent and must stop if they refuse.

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/beingsectionedengland.aspx

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/beingsectionedengland.aspx

http://www.dh.gov.uk/health/2011/07/mental-health-act/

http://www.legislation.gov.uk/ukpga/2005/9/contents



Page 6 of 11

In Scotland, the principles above are the same, although the laws involved are the Mental Health (Care and Treatment) (Scotland) Act 2003 and the Adults With Capacity Act (Scotland) 2000. How is ECT given? ECT is generally used to treat severe illnesses, so the person having it will often be in hospital. If you do not need to be an in-patient, it should be possible for you to attend as a day patient to have ECT. You may need to check if this is available to you from your local service. The seizure is made to happen by passing an electrical current across the person’s brain in a carefully controlled way from a special ECT machine. An anaesthetic and muscle relaxant are given so that:

the patient is not conscious when the ECT is given;

the muscle spasms that would normally be part of a fit – and which could produce serious injuries - are reduced to small, rhythmic movements in the arms, legs and body.

By adjusting the dose of electricity, the ECT team will try to produce a seizure lasting between 20 and 50 seconds.

Q Is there any preparation? In the days before a course of ECT is started, your doctor will arrange for you to have some tests to make sure it is safe for you to have a general anaesthetic. These may include:

a chest X-ray

a tracing of your heart working (ECG)

blood tests

You will be asked not to have anything to eat or drink for 6 hours before the ECT. This is so that that the anaesthetic can be given safely.

Q Where is ECT done? ECT should always be done in a special set of rooms that are not used for any other purpose, usually called the “ECT suite”. There should be separate rooms for people to wait, have their treatment, wake up fully from the anaesthetic and then recover properly before leaving. There should be enough qualified staff to look after the person all the time they are there so that any confusion or distress can be helped.

http://www.legislation.gov.uk/asp/2003/13/contents

http://www.legislation.gov.uk/asp/2003/13/contents

http://www.scotland.gov.uk/Publications/2008/03/25120154/1

http://www.scotland.gov.uk/Publications/2008/03/25120154/1



Page 7 of 11

Q What happens during ECT? You should arrive at the ECT suite with an experienced nurse who you know and who is able to explain what is happening. Many ECT suites are happy for family members to be there, so you may wish to check with your local team that this is possible, if it is reassuring for you. You should be met by a member of the ECT staff who will do routine physical checks if they have not already been done. The staff member will check that you are still willing to have ECT and if you have any further questions. When you are ready you will be accompanied into the treatment area and be helped onto a trolley. The ECT team will connect monitoring equipment to check your heart rate, blood pressure, oxygen levels, ECG and EEG during the fit. A needle will then be put into your hand, through which the anaesthetist will give the anaesthetic drug and, once you are asleep, a muscle relaxant. While you are going off to sleep, the anaesthetist will also give you oxygen to breathe. Once you are asleep and fully relaxed a doctor will give the ECT treatment; your fit will last between around 20 to 50 seconds. The muscle relaxant wears off quickly (within a couple of minutes) and, as soon as the anaesthetist is happy that you are waking up, you will be taken through to the recovery area where an experienced nurse will monitor you until you are fully awake. When you wake up, you will be in the recovery room with a nurse. He or she will take your blood pressure and ask you simple questions to check on how awake you are. There will be a small monitor on your finger to measure the oxygen in your blood and you may wake up with an oxygen mask. You will probably take a while to wake up and may not know quite where you are at first. You may feel a bit sick. After half an hour or so, these effects should have worn off. Most ECT units have a second area for light refreshments. You will be free to leave the suite when the staff are happy that your physical state is stable and you feel ready to do so. The whole process usually takes around half an hour.

Q. What are bilateral and unilateral ECT? In bilateral ECT, the electrical current is passed across the whole brain; in unilateral ECT, it is just passed across one side. Both of them cause a seizure in the whole of the brain.



Page 8 of 11

Bilateral ECT seems to work more quickly and effectively and it's probably the most widely used in Britain; however, there has been concern that it may cause more side-effects. Unilateral ECT is now used less. It had been thought to cause less memory loss, but recent research has shown that it is necessary to use much larger doses of electricity to make unilateral ECT as effective as bilateral ECT. If the dose of electricity is increased to make it equally effective, the risks of memory loss are as great as with bilateral ECT. Sometimes ECT clinics will start a course of treatment with bilateral ECT and switch to unilateral if the patient experiences side-effects. Alternatively, they may start with unilateral and switch to bilateral if the person isn't getting better. You may wish to speak to the doctor who is suggesting ECT for you to decide whether unilateral or bilateral ECT is best for you.

Q How often and many times is ECT given? Most units give ECT twice per week, often on a Monday and Thursday, or Tuesday and Friday. It is impossible to predict how many treatments someone will need. However, in general, it will take 2 or 3 treatments before you see any difference, and 4 to 5 treatments for noticeable improvement.

A course will on average be 6 to 8 treatments, although as many as 12 may be needed, particularly if you have been depressed for a long time. If after 12 treatments you feel no better, it is unlikely that ECT is going to help and the course would usually stop. A member of the mental health team should see you after each treatment to see how your are responding to treatment and check that you are not experiencing any serious side-effects. Your consultant should see you after every two. ECT should be stopped as soon as you have made a recovery, or if you say you don't want to have it any more.

Q What happens after a course of ECT? Even when someone finds it effective, ECT is only a part of recovering from depression. Like antidepressants, it can help to ease problems so you are able to look at why you became unwell. Hopefully you can then take steps to continue your recovery and perhaps find ways to make sure the situation doesn’t happen again. Psychotherapy and counselling can help and many people find their own ways to help themselves. Certainly people who have ECT, and then do not have other forms of help, are likely to quickly become unwell again.

http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/antidepressants.aspx

http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/psychotherapies.aspx



Page 9 of 11

The ECT Controversy There are many areas in which people disagree over ECT, including whether it should even be done at all. People tend to have very strong feelings about ECT, often based on their own experiences. The main areas of disagreement are over whether it works, how it works and what the side-effects are.

Q Why is ECT still being given? ECT is now used much less and is mostly a treatment for severe depression. This is almost certainly because modern treatments for depression, like psychotherapy (talking treatments), antidepressants and other psychological and social supports are much more effective than they were in the past. Even so, depression can for some people still be very severe and life-threatening, with extreme withdrawal and reluctance, or inability to eat, drink or communicate properly. Occasionally people may also develop strange ideas (delusions) about themselves or others. If other treatments have not have worked, it may be worth considering ECT.

Q What do patients think of ECT? In 2003 researchers analysed all the work which had been done on patients' experiences of ECT. They found that the proportion of people who had had ECT and found it helpful ranged from 30% to 80%. The researchers commented that studies reporting lower satisfaction tended to have been conducted by patients and those reporting higher satisfaction were carried out by doctors. Between 30% and 50% of patients complained of difficulties with memory after ECT.

Q What do those in favour of ECT say? Many doctors and nurses will say that they have seen ECT relieve very severe depressive illnesses when other treatments have failed. Bearing in mind that 15% of people with severe depression will kill themselves, they feel that ECT has saved patients' lives, and therefore the overall benefits are greater than the risks. Some people who have had ECT will agree and may even ask for it if they find themselves becoming depressed again.

Q What do those against ECT say? There are many different views and many different reasons why people object to ECT. Some say that ECT is an inhumane and degrading treatment, which belongs to the past. They say that the side-effects are severe and that psychiatrists have either accidentally or deliberately ignored how severe they can be. They say that ECT permanently damages both the brain and the mind, and if it does work at all, does so in a way that is ultimately harmful for the patient. Many would want to see it banned.



Page 10 of 11

Q What happens in other countries? At the moment, ECT is part of standard psychiatric practice in Britain and the majority of countries worldwide. Some countries (and some states in America also) have restricted its use more than in the UK, though only a small number have prohibited its use.

Q How do I know if ECT is done properly locally? The Royal College of Psychiatrists has set up the ECT Accreditation Service (ECTAS) to provide an independent assessment of the quality of ECT services. ECTAS sets very high standards for ECT, and visits all the ECT units who have registered with it. The visiting team involves psychiatrists, anaesthetists, and nurses. It publishes the results of its findings and also provides a forum for sharing best clinical practice. Membership of ECTAS is not compulsory, but every ECT unit should be able to tell you: if they have signed up to ECTAS; the result of their most recent report; who to speak to if you are concerned that your local unit has not been assessed. A list of accredited site is available on the Royal College of Psychiatrists' website.

Q Where can I get more information? Hospital Many ECT suites provide their own information packs and they should be able to give written information to patients or their family/carers before a course starts. The information in these packs is often strongly in favour of ECT. The Internet has many sites discussing ECT that are produced by professionals, organisations, people who have had ECT, or others with particular opinions. There are more negative than positive websites. Further Information National Institute for Health and Clinical Excellence (NICE) Electroconvulsive therapy (ECT): the clinical effectiveness and cost effectiveness of electroconvulsive therapy (ECT) for depressive illness, schizophrenia, catatonia and mania. (TA59 2003) Depression: the treatment and management of depression in adults (CG 90 2009) Scottish ECT Accreditation Network (SEAN): A site designed to complement the work of SEAN, by enabling communication of the latest information on ECT in Scotland. Electroconvulsive Therapy Accreditation Services (ECTAS): Launched in May 2003, ECTAS aims to assure and improve the quality of the administration of ECT; awards an accreditation rating to clinics that meet essential standard.

http://www.rcpsych.ac.uk/quality/qualityandaccreditation/ectclinics/ectas/ectasresourcelibrary.aspx


http://www.nice.org.uk/TA059



http://www.nice.org.uk/cg90

http://www.isdscotland.org/Health-Topics/Quality-Improvement/Scottish-ECT-Accreditation-Network/




Page 11 of 11

References Ebmeier, K. et al (2006) Recent development and current controversies in depression. Lancet, 367,153-167 Eranti,S. V. & McLoughlin, D.M (2003) Electroconvulsive therapy - state of the art. the British Journal of Psychiatry 182: 8-9 Rose, D., Fleischmann, P., Wykes, T., Leese, M. & Bindman, J. (2003) Patients' perspectives on electroconvulsive therapy: systematic review BMJ 2003;326;1363-1368 Scott A.I.F. (2004) The ECT Handbook (Second edition): The Third Report of the Royal College of Psychiatrists’ Special Committee on ECT. Royal College of Psychiatrists: London UK ECT Review Group. (2003 ) Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 361: 799-808 Department of Health Statistical survey (2007) Electro Convulsive Therapy: Survey covering the period from January 2002 to March 2002, England. DH: London This leaflet was produced by the Royal College of Psychiatrists' Public Education Editorial Board. Original author: Dr Richard Barnes. With input from the Royal College of Psychiatrists' Special Committee on ECT and related treatments. This leaflet reflects the best available evidence available at the time of writing.

http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/StatisticalWorkAreas/Statisticalhealthcare/DH_4000216

http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/StatisticalWorkAreas/Statisticalhealthcare/DH_4000216




Electro-convulsive therapy (ECT)

Your rights about consent to treatment This booklet is for anyone detained in hospital or on a community treatment order under

the Mental Health Act 1983.

August 2012

Large print



Page 2 of 6

About this booklet

If you are detained (‘sectioned’) in hospital or are receiving treatment as part of a community treatment order (CTO) under the Mental Health Act and you are recalled to hospital, your doctor may advise that you need electro-convulsive therapy (ECT).

This booklet explains your rights in relation to ECT.

About us We are the Care Quality Commission, the independent regulator of health and adult social care in England. We protect the interests of people whose rights are restricted under the Mental Health Act. We make sure that mental health law is used correctly and that patients are cared for properly while they are detained in hospital or are on a community treatment order.



Page 3 of 6

ECT and your rights

The letters ECT are short for ‘electro-convulsive therapy’. ECT is a treatment used for a small number of mental disorders.

If your doctor thinks it will help you to have ECT, he or she will explain what it is and why they think you should have it.

Before your doctor can give you ECT, they must ask if you agree to receive it.

If you are well enough to decide for yourself, you will only be given ECT if you agree to it, or if it is an emergency. You don't have to agree to ECT if you don't want it. If you agree at first, you can change your mind later.

If you say that you don't want to be given ECT at any future date, this is called an ‘advance decision to refuse treatment’. Although the Mental Health Act allows doctors to give ECT in an emergency to a person who has made an advance decision to refuse it, this would only happen in exceptional cases. If you don't want to be given ECT – even if it might save your life – you must make your ‘advance decision’ in writing and sign it yourself, and also ask a witness to sign it.

A Mental Health Advocate (see page 6) or a member of staff should be able to help you if you want more information about advance decisions or if you want to make an advance decision.

If you are too ill to give your consent and you have not made an advance decision to refuse ECT, your doctor must tell us if they think that you need to receive it.

We will arrange for an independent doctor called a Second Opinion Appointed Doctor (or SOAD) to visit you.

Your doctor can only give you ECT if the Second Opinion Appointed Doctor agrees that you need it. If they don't agree, your doctor cannot give you ECT.

If you are under 18 years of age, you may only be given ECT if a Second Opinion Appointed Doctor agrees that you should receive it. This applies even if you have already given your consent.



Page 4 of 6

What to expect from the Second Opinion Appointed Doctor (SOAD)

If you need to be examined by a Second Opinion Appointed Doctor, they will do the following:

check that you are being lawfully detained and cared for;

meet with you to discuss the treatment and hear your views. Normally this will be in private unless you want someone else there as well. If you need an interpreter or signer, the hospital will provide one;

speak to your doctor and two other professionals who have been involved in your care and treatment;

decide whether ECT is appropriate for you and will help you recover.

If the Second Opinion Appointed Doctor agrees that you should have ECT, they must fill in a certificate confirming this and stating the number of treatments they think you should

have. They must send a copy of the certificate to us. Your own doctor will tell you what the Second Opinion Appointed Doctor decides. The Second Opinion Appointed Doctor is independent of the hospital, and the decision he or she makes is a personal clinical decision. You cannot appeal to us if you disagree with

the decision.



Page 5 of 6

Very urgent situations

In some very urgent situations, the rules about consent to treatment do not apply. The Mental Health Act allows ECT to be given to a patient without their consent if the treatment is needed to:

save their life; or stop their condition from getting much worse.

Although the Mental Health Act allows ECT to be given in an emergency to a person who has made an advance decision to refuse it, this would only happen in exceptional cases.

Other sources of help

Independent Mental Health Advocates While you are detained under the Mental Health Act, you have a legal right to support from an Independent Mental Health Advocate.

Independent Mental Health Advocates can help you find out more about your rights and how to use them.

If you would like to talk to an Independent Mental Health Advocate, please speak to your treating team.

Making a complaint We have published the following booklets that explain what to do if you want to make a complaint about something that happened during your care and treatment under the Mental Health Act.

‘How we support the rights and interests of people who are detained in hospital’

‘How we support the rights and interests of people on community treatment orders (CTOs)’

If you would like a copy of the booklet that applies to you, ask the ward staff or community care staff or go to our website at www.cqc.org.uk.

http://www.cqc.org.uk/



Page 6 of 6

How to contact us If you would like to contact us, you (or a friend or relative on your behalf) can:

write to our office in Newcastle (the address is on the back page of this booklet); or

speak to someone in our office between 8.30am and 5.30pm from Monday to Friday by

phoning 03000 616161 (choose option 1). If the office is closed, leave a message on our telephone answering service. Please leave your name, address and phone number so that someone can contact you on the next working day.

Get in touch Write to us at: CQC Mental Health Act Citygate Gallowgate Newcastle upon Tyne NE1 4PA

Phone: 03000 616161 (choose option 1)

Email: [email protected]

Website: www.cqc.org.uk

If you would like this booklet in a different language or format (for example in large print or easy-read or on audio CD) please visit our website www.cqc.org.uk or contact us using the details above.

mailto:[email protected]

http://www.cqc.org.uk/



Appendix 8 Confirmation or withdrawal of consent

Patient Name:………………………………………………………………………………………

Date of Birth:…………………………………….RiO No:………………………………

Address:………………………………………………………………………………………………

To be completed by a health professional each time the patient attends for the procedure, if the patient has signed the form in advance. On behalf of the team treating the patient, I have confirmed with the patient that he/she has no further questions and wishes the procedure to go ahead. I have explained that the patient may withdraw consent at any time.

Treatment Consent Confirmed

No Date Comment Name Signature

1

2

3

4

5

6

7

8

9

10

11

12

Patient has withdrawn consent (ask patient to sign /date here). Signature………………………………. Print name:……………………………. Date……………………………….. Important notes: (Applicable / Not Applicable)

See also advance directive / living will (e.g. Jehovah’s Witness form)



Page 1 of 3

Appendix 9

Certificate of Incapacity For adults who are unable to give consent to investigation or treatment. All sections to be completed by the health professional proposing the procedure.

Patient’s details (or pre-printed label) Patient’s surname/family name:…………………………………………………………………… Patient’s first names:………………………………………………………………………………... Date of birth:………………………………………………………………………………………… Responsible health professional:…………………………………………………………………. Job title:……………………………………………………………………………………………… Patient’s RiO/NHS number (or other identifier):…………………………………………………

Male Female

Special requirements:………………………………………………………………………………. (e.g. other language/communication methods)

Signature of health professional proposing treatment The procedure, detailed overleaf, is, in my clinical judgement, in the best interests of the patient, who lacks capacity, to consent for himself or herself. Where possible and appropriate I have discussed the patient’s condition with those close to them and taken their knowledge of the patient’s views and beliefs into account in determining their best interests.

I have/have not sought a non-statutory second opinion (see below).

(delete as appropriate)

I confirm that I have read the legislation table and have taken into account of all the

Issues governing the administration of ECT as pertaining to the Mental Capacity Act 2005 and where relevant the Mental Health Act 1983. Where second opinion sought, the second opinion should sign below to confirm agreement:

Signature:…………………………………………………….Date:……………………………. Name (print):………………………………………Job title:……………………………………… Where patient is detained un the MHA 1983:

A Has a Second Opinion been requested from CQC? YES / NO B Is a T6 completed and attached ? YES / NO Date completed:…............ C Has a Section 62 Form been completed ? YES / NO



Page 2 of 3

(A) Name of proposed procedure or course of treatment

Electroconvulsive therapy: Unilateral Bilateral Either (Please tick laterality)

(B) Assessment of patient’s capacity I confirm that:

The patient is unable to comprehend and retain information material to the decision;

and/or

The patient is unable to use and weigh this information in the decision-making

process; or

The patient is unable to communicate their decision (whether by talking, using sign

language or any other means)

The patient is unconscious

Please provide details (excluding where patient unconscious): for example of how above judgements were reached; which colleagues consulted; what attempts were made to assist the patient make their own decision and why these were not successful. ………………………………………………………………………………………………………

(C) Number of treatments to be given under this authority

Where Section 58A (5) is applicable, the number of treatments will also be stated on the Form T6 (D) Assessment of patient’s best interests

To the best of my knowledge, the patient has not refused this procedure in a valid

advance directive.

Where possible and appropriate, I have consulted with colleagues and those close

to the patient, and I believe the procedure to be in the patient’s best interests because: ………………………………………………………………………………………………………… (where incapacity is likely to be temporary, for example if patient unconscious, or where patient has fluctuating capacity)

The treatment cannot wait until the patient recovers capacity because:

………………………………………………………………………………………………………… (E) Change in capacity status If the patient’s condition alters, during the treatment course, such that they are deemed to become capacitous, Consent Form (1) will need to be completed. Additionally, if Section 58A(3) applies, Form T4 will also need to be completed.



Page 3 of 3

(F) Involvement of the patient’s family and others close to the patient The final responsibility, for determining whether a procedure is in an incapacitated patient’s best interests, lies with the health professional performing the procedure. However, it is good practice to consult with those close to the patient (e.g. spouse/partner, family and friends, carer, supporter or advocate) unless you have good reason to believe that the patient would not have wished particular individuals to be consulted, or unless the urgency of their situation prevents this. ‘Best interests’ go far wider than ‘best medical interests’, and include factors such as the patient’s wishes and beliefs when competent, their current wishes, their general well-being and their spiritual and religious welfare. (To be signed by a person or persons close to the patient, if they wish.) In addition, where substitute decision-making is in place, i.e. an individual holding Lasting Power of Attorney (LPA) or Deputy appointed by the Court (CAD), then the healthcare professional must take account of their views as to this treatment and this should be recorded below. (See Legislation Table for full details.) i/We have been involved in a discussion with the relevant health professionals over the treatment of [insert patient’s name] I/We understand that the patient is unable to give their own consent, based on the criteria set out in this form. I/We also understand that treatment can lawfully be provided if it is in the patient’s best interests to receive it. Any other comments (including any concerns about decision): ………………………………………………………………………………………………………… Name:……………………………………Relationship to patient……………………………….. LPA (Yes/No)…………………………...CAD (Yes/No)…………………………………………. (Delete as appropriate) Address (if not the same as patient)……………………………………………………………… ………………………………………………………………………………………………………… Signature:………………………………………………………………..Date:…………………… If a person close to the patient was not available in person, has this matter been discussed in any other way (e.g. over the telephone?)

Yes No

Details:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………



Appendix 10

ECT Assessment Form

Patients Name: Date of Birth:

RiO Number: Legal Status:

Ward: Hospital:

Consultant: Completed by:

Investigations Date: Full blood count Urea and electrolytes Liver function tests Thyroid Function Test International normalised ratio (INR) Hepatitis B antigen status Blood sugar levels Electrocardiogram Chest X-ray Lung function tests Pregnancy test Sickle Cell test

Physical examination Date: * Blood pressure/Pulse * Weight in Kilogram * Cardiac failure * Severe valvular disease * Unstable dysrhythmia * Uncontrolled hypertension * Significant infection * Poor dentition * Dentures * Marked cachexia * Arthritis, particularly of the neck or jaw

Medical History: * Angina * Recent myocardial infarction * Cerebrovascular accident (CVA) * Diabetes * Hypertension * Hiatus hernia * Known drug allergies * Adverse reactions to previous anaesthetic

Current Medication: ……………………………………………. ……………………………………………. ……………………………………………. ……………………………………………. ……………………………………………. ……………………………………………. …………………………………………….



Appendix 11

PRE-ANAESTHETIC CHECKLIST

Ward: Consultant:

RiO No: Surname:

Weight: kg

BP Hb G/dl

First Names:

Electrolytes

CXR E.C.G. Date of Birth:

Patient Identification Label

Pre

ECT Notes

Previous YES/

Anaesthetics

Pre ECT Assessment by

Dr.

CVS R/S ASA 1 2 3 4 5

Angina Smoker

Scheduled/Emergency

Hiatus Hernia Cough

Out/Pt In/Pt

+

- Reflux Asthma

Handedness

Sputum

Epilepsy

Relevant Drugs

Allergies and Drug Sensitivities

FORM COMPLETED BY: NAME:_____________________ SIGNATURE:__________________DATE:__________ A New Pre-Anaesthetic checklist must be completed before every new course of ECT. (A course consists of six treatments).



Appendix 12

Staff Attendance Check List Checked by:

Date: Day:

Discipline

Charge Nurse

Psychiatrist

Anaesthetist

ODP

Waiting Room Nurse(s)

Preparation/Treatment/Recovery

Room Nurse(s)

Post Recovery Rest Room

Nurse (s)

Escort Duty Only Nurse(s)

No. of patients attended

No. of patients treated



Appendix 13

Equipment Check List

Date: Day:

Checked before Treatment: Checked after Treatment:

Room Equipment Before After

Treatment

Room

Anaesthetic Machine In order

Not

In order

Not

ECG/PULSE/SpO² Monitor In order

Not

In order

Not

Automatic Defibrillator In order

Not

In order

Not

Pulse Oximeter In order

Not

In order

Not

ECT Machine In order

Not

In order

Not

Suction In order

Not

In order

Not

Oxygen Cylinder In order

Not

In order

Not

Emergency Medication / Box In order

Not

In order

Not

Anaesthetic Medication In order

Not

In order

Not

Recovery

Room

Pulse Oximeter In order

Not

In order

Not

Suction In order

Not

In order

Not

Oxygen Cylinder In order

Not

In order

Not

Trolleys In order

Not

In order

Not

Action taken if the equipment is not in order: Sign: Date:



Appendix 14

MINI MENTAL STATE EXAMINATION Patient ………………………….. Examiner ……………… ….. … Date ……………….. maximum score score orientation 5 ( ) What is the ~ (year) (season) (date) (month) 5 ( ) Where are we ~ (country) (county) (town) (hospital) (floor) registration 3 ( ) Name 3 objects ~ 1 second to say each. Then ask patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat them until he/she learns all three. Count trial and record. Trials ………….. attention and calculation 5 ( ) Serial 7s. 1 point for each correct. Stop after 5 answers. Alternatively spell “world” backwards. recall 3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct. language 9 ( ) Name a pencil and watch (2 points). Repeat the following “no ifs and or buts”. (1 point). Follow a 3-stage command: “Take a paper in your right hand, fold it in half, and put it on the floor”. (3 points). Read and obey the following: Close your eyes (1 point) Write a sentence (1 point) Copy a design (1 point)

_______________ Total score Assess level of consciousness along a continuum Alert Drowsy Stupor Coma



Appendix 15

ECT Anaesthetic record

ANAESTHETIC (treatment number) Date:

Patient Name: Date of Birth:

ANAESTHETIST:

ODA:

TIME:

IV ACCESS:Cannula Site/Size:

PROPOFOL/ THIOPENTONE

SUX

BITE BLOCK

AIRWAY CONTROL

OXIMETER

CAPNOGRAPHY

INSPIRED OXYGEN %

TIME Comments

Blood pressure 200

190

180

170

160

150

140

130

120

110

Pulse º 100

90

80

70

60

50

40

Resps x 25

20

15

10

5

O2: L/min

SpO2

Signed: Print Name: Designation:



Appendix 16 ECT Treatment record

TREATMENT Number Date:

Patient Name: Date of Birth:

No: Treatment: Comments: Signed:

Setting%

Dose mC

Impedance

Seizure pattern & duration

EEG duration

Setting%

Dose mC

Impedance


EEG duration

Setting%

Dose mC

Impedance


EEG duration



Appendix 17 ECT Record of Recovery

RECOVERY(treatment number) Date:

Arrival Time:

Patients Name: Date of Birth:

TIME Comments:

Blood pressure 200

190

180

170

160

150

140

130

120

110

Pulse º 100

90

80

70

60

50

40

Resps x 25

20

15

10

5

O2: L/min

SpO2

Yes No

Patient’s airway: Open & breathing spontaneously

Responsive to speech and command

Sustained head lift for 5 seconds

Vital signs stable

Sp02 < > 96-100%

Cannula removed

Time patient left recovery

Comments

Recovery section completed by:

Print Name: Signed: Designation:

Fit for discharge: Yes □ No □

Time patient left ECT department:



Appendix 18

ECT: Referring Team Guidelines It is essential that the Referring Team be familiar with the latest ECT policy document and paperwork. The following is an additional guide to the referring team’s responsibilities, pre, during & post treatment. Pre-Treatment: 1. Ensure all relevant documents are completed by medical staff competent to do so. 2. The paperwork requires an indicator that the patient has the necessary capacity to give consent, or if incapacitous, that the certificate of incapacity is completed (in addition to any relevant MHA paperwork such as a S62 etc). 3. The capacity paperwork includes a statement on whether the indication for ECT is within the NICE guidelines. Remember that NICE does not approve Maintenance ECT (see separate protocol). Any indication outside NICE should be discussed with the patient and with the ECT Lead Consultant. 4. All relevant investigations are organised and results made available to the ECT team. The minimum for all is an up to date FBC, U&Es and an ECG. Investigations and physical examination should be documented in Appendix 10. 5. The referring team are required to make a formal assessment of severity of illness (CGI-S) and cognition (MMSE) before treatment is started. 6. Referrals should be made to the ECT Team at the earliest opportunity by contacting telephone number: 07990 775648 7. Appropriate arrangements will need to be made for the patient to be transported to and from the ECT clinic with an appropriate escort (please ensure awareness of outpatient protocol (Appendix 2) where relevant) 8. Laterality of the treatment to be given should be clearly stated. The majority of patients in the UK receive Bilateral ECT. There continues to be evidence that unilateral ECT has a lower efficacy than treatment given bilaterally, although response rates are improved by the use of Seizure Threshold Stimulus dosing protocol (Appendix 19) as used at Farnham Road. Unilateral ECT should be considered when there are pre-existing cognitive problems, where a patient has experienced significant cognitive issues during a previous course of ECT, or in response to patient choice.



During Treatment:

1 Whilst the consent document states a total number of treatments, the actual number given will need weekly review. The Treating Team should review ideally after each treatment, and certainly on a weekly basis, with a maximum of 2 treatments being prescribed before the next review. This includes patients receiving ECT on an outpatient basis. The ECT paperwork now includes a ‘Referring Team Monitoring form (Appendix 20), which should be used to document illness severity and cognitive function pre-treatment (CGI-S, MMSE), side effects and clinical improvement during treatment (CGI-I),as well as post treatment CGI-S and MMSE score. ECTAS also now require that recognised Depression rating scale is used; pre, during (weekly) and post-ECT.

1. The referring team are responsible of monitoring of and recording both cognitive and non-cognitive side effects. This should include documenting the patient’s subjective experiences.

2. A total number of treatments given will of course depend on the balance between response and tolerance. Some clinical response after 4 treatments is a good indicator of subsequent remission – but 40% of patients with no improvement after 6 treatments will go on to achieve a clinically important improvement. If is therefore important not to stop a course prematurely due to lack of response. Lack of clinically meaningful response by 12 treatments however indicates there is little prospect of improvement with further ECT.

Post Treatment:

1. It is now a requirement that a cognitive assessment is made immediately following the cessation of a course of ECT and one to two months later.

2. The referring team monitoring form (Appendix 20) should be completed and

returned to the ECT team at Farnham Road Hospital within a week of a patient finishing a course.

3. It should be remembered that, whilst ECT is highly effective at achieving a response, the relapse rates at 12 months are also very high unless appropriate medication is given post-ECT (anti-depressants, mood stabilisers), even when ECT is being given for a treatment-resistant depression.

4. ECTAS require monthly follow-up for three months after cessation of ECT.



Appendix 19

Stimulus Dosing Protocol

Adequate Seizure = Generalised Tonic / Clonic Visual > 5, EEG > 15

1st treatment session 1st Stimulation 10% (50mC) 2nd Stimulation 20% (100mC) Threshold established 3rd Stimulation 40% (200mC) 4th Stimulation 60% (300mC)

Subsequent treatment session

Threshold Bilateral Unilateral

10% 15% 40%

20% 30% 80%

30% 45% 120%

40% 60% 160%

If adequate seizure not seen, then re-stimulation should be given at a higher dose

If maximum dose unable to achieve adequate seizure, then contributing factors will need to be reviewed



Appendix 20

ECT referring Team Monitoring Form

Pre-Treatment: Diagnosis:

………………………………………………………………………………………………

MMSE:………………………………………………………………………………………………

CGI-S:…………………………………………………………………………………………………

Depressions Rating (e.g. HADS):………………………………………………………………….

Treatment Treatment

number CGI-I Cognitive SIEs

Non-Cognitive

Depression Rating

1

2

3

4

5

6

7

8

9

10

11

12

Post-Treatment (Within 7 days of last session)

MMSE:………………………………………………………………………………………………

CGI-S…………………………………………………………………………………………………

Depression Rating Scale:…………………………………………………………………………...

n.b. MMSE should be repeated 1-2 months post-ECT

Please return to ECT Department at Farnham Road Hospital after completion



Appendix 21

Clinic Global Impression Scale

CGI - Severity

- A global assessment of - Current symptoms - Behaviour - Impact on function

7 point scale based on previous 48 hours Score Remarks

1 Normal, not ill No psychopathology

2 Borderline ill Subtle/suspected pathology

3 Mildly ill Clear symptoms, minimal impact on functioning

4 Moderately ill Overt symptoms with moderate impact on functioning

5 Markedly ill Intrusive symptoms with distinct impact on functioning

6 Severely ill Disruptive pathology, marked impact of function/behaviour, requiring supervision

7 Extremely ill Pathology drastically interferes with many life functions



Appendix 22

Clinical Global Impression Scale

CGI- Improvement

- Evaluation considering improvement in symptoms and impact on behaviour/ function

7 Point scale rated against start of ECT

Score Remarks

1 Very much better Good level of functioning minimal symptoms, substantial change

2 Much improved Symptoms persist but improvement noted and increase in functioning

3 Minimally improved

Slightly better but little clinically meaningful reduction in symptoms

4 No change

5 Minimally worse Slightly worse, but may not be clinically meaningful

6 Much worse Significant increase in symptoms and functioning

7 Very much worse Severe exacerbation of symptoms and loss of functioning



Appendix 23 PROTOCOL FOR MAINTENANCE ECT

1. Overview

‘Maintenance ECT’ is defined as ECT delivered at intervals of usually between one week and three months that is designed to prevent relapse of illness. Maintenance ECT is not recommended under NICE guidelines but may be permissible in some circumstances.

2. Responsibilities (of referring team) If prescribing maintenance ECT the following protocol should be adhered to: - The RESPONSIBLE CLINICIAN should record in the patients notes the reasons for

proposing maintenance ECT as opposed to alternative treatments. - The decision should be discussed fully with the patient and their family or carers. - An informal second opinion should be sought if the patient is not detained under the

MHA. - The decision to recommend maintenance ECT should be discussed with the ECT

consultant. - The risks and benefits of maintenance ECT should be recorded in the patient’s notes. - A statement of capacity should be recorded prior to commencement. - A consent form stipulating the number of treatments should be completed. The

maximum being 12 or the maximum treatments needed over a six month period (whichever is the lower).

- Consent should be renewed after 12 treatments or six months – whichever is sooner.

A further statement of capacity and second opinion should also be sought at this time and recorded.

- Patients should undergo the usual clinical investigations before ECT commences. - Clinical progress, cognitive functioning and side-effects should all be assessed at

regular intervals. Maintenance ECT should be discontinued at the earliest opportunity when the patient has recovered sufficiently and is stable or when the side-effects of ECT outweigh the benefits. For patients detained under a section of the Mental Health Act, a formal second opinion is required and the Section 12 Doctor should be informed that the patient is being consented for maintenance ECT.



Appendix 24

Patient reception checklist

Please write YES, NO, or N/A (not applicable) Name:………………………….. .. Date of birth:……………….. RiOnumber:………………….. Ward/Hosp……………………………………… Responsible Clinician:……………………………….

1 2 3 4 5 6 7 8 9 10 11 12

Case notes available

Identity wrist band

Prescription chart available

Anaesthetic form available

ECG available

Appropriate x-rays available

Dentures removed

Prosthesis/contact lenses removed

Impeding jewellery removed

Signature

Date



Appendix 25

Pre ECT checklist

Name:………………………….. .. Date of birth:……………….. RiO number:………………….. Ward/Hosp……………………………………… RESPONSIBLE CLINICIAN:………………………….

1 2 3 4 5 6 7 8 9 10 11 12

Oral intake at

Passed urine at

Pulse

BP

Temperature

Signature

Date



Appendix 26

Referring Team ECT Documentation Checklist

Please ensure you have read the Referring Team Guidance (appendix 18) ALL patients:

1. Consent Form (app. 1)

2. Information Leaflet (app. 6)

3. Confirmation of consent (app.8)

4. ECT assessment form & pre-anaesthetic checklist (app. 10 & 11)

5. MMSE (app.14)

6. Referring Team Monitoring form (app.20) All outpatients: OP protocol/information/consent (app.2-5) All detained patients: CQC information leaflet (app.7) All incapacitious patients: Certificate of incapacity (app 9) – whether detained or informal

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