South Staffordshire and Shropshire Healthcare NHS Foundation Trust ECT Care Pathway (prescriber to complete except where otherwise

Transcription

1 South Staffordshire and Shropshire Healthcare NHS Foundation Trust ECT Care Pathway (prescriber to complete except where otherwise Patient Name of Birth Patient Number Consultant Pathway Commenced. P..... /... /... Instructions Regarding the Use of the ECT Pathway The ECT pathway is designed to guide clinicians through the process based on best practice. This pathway reflects ECTAS standards, NICE Guidance and the Mental Health Act. All sections should be completed. It should be read in conjunction with the trust ECT policy. The pathway will begin on decision to prescribe ECT and finish six months after the course of ECT finishes. The audit tool should completed at the end of the course The pathway forms part of the patient s record and should be contained within the patient s case notes. 1. Instructions to ECT s Regarding Medication The current drugs card should accompany the patient to the ECT Department for all treatment Please refer to the Royal College of Psychiatrist s ECT Handbook 2 nd edition (available in full text at RCPsych website) for information regarding the impact of medications e.g. Anticonvulsants, Benzodiazepines, SSRI s and Lithium on ECT / seizure threshold and duration The Royal College recommends that the patient s existing drug regime is assessed prior to the course and that a consistent prescription regime is followed on treatment days where possible (ECTAS ) Non-psychiatric medication should be given routinely with a sip of water up to an hour before ECT (Omit hypoglycaemic agents in diabetics until after treatment) Page 9 of 65

2 2. Patient Information(prescriber to complete) Patient s Name Patient No: Gender Male Female of Birth Ward Consultant (Please print) Ethnicity (Please circle) A White or white British B White Irish C Any other White background CM White Traveller CN White Gypsy D Mixed White and Black Caribbean E Mixed White and Black African F Mixed White and Asian G Any other mixed background H Asian or Asian British Indian J Asian or Asian British Pakistani K Asian or Asian British Bangladeshi L Any other Asian background M Black or Black British Caribbean N Black or Black British African P Any other Black background R Chinese S Any other ethnic group Diagnosis ICD-10 Code:. Patient Status In-patient Out-patient Please clearly state the indication for ECT: NB : ECT will not be administered unless the indication is clearly stated Previous courses of ECT (give dates, indications, location and outcome for each course) s Indication Location Outcome NICE Indications: - Please tick which of the following conditions apply to your patient: (There should be at least one tick in both sections) Severe depressive disorder Yes No Severe or prolonged manic episode Yes No Catatonia Yes No and Where an adequate trial of other treatment options proven ineffective Yes No And / or the condition is potentially life threatening Yes No Page 10 of 65

3 Surname Forename ECT Policy/C/YEL/cm/10/v3.0 P Number 3. ECT prescribed outside NICE Guidance ( to complete) (NB If the treatment is within NICE guidance and patient consenting 2 nd opinion is not required please continue with pathway) When prescribing outside of NICE guidance for informal / consenting patients please obtain a second opinion from a consultant colleague / SOAD Consultant s opinion: Indication for Treatment outside guidance Justification / evidence base What would happen if ECT is not given? Signature of Consultant Print Name 2 nd Opinion: (Trust Guidance should be followed) Confirmation Signature of Doctor Designation Print Name Page 11 of 65

4 Surname Forename ECT Policy/C/YEL/cm/10/v3.0 P Number 4.Consent Form (Consultant or team doctor to complete) Procedure to be administered: A course of bilateral / unilateral electroconvulsive therapy up to a maximum of 12 treatments (Delete as applicable) I have explained the procedure to the patient. In particular, I have explained: The intended benefits: Improvement of depression Other (please specify).. Serious / frequently occurring risks: Memory loss (possibly permanent) Post treatment confusion and transient side-effects: Headache & Muscle aches Nausea Muzzy-headedness Fatigue I confirm that I have explained to the patient the nature, purpose, likely effects and adverse effects of this treatment and possible alternatives, including no treatment, and that the patient has been provided with the royal college of Psychiatrists ECT information sheet. I confirm that in my opinion the benefits of ECT outweigh the risks (Bi / Uni Lateral explained). I confirm I have explained that this procedure will involve: General Anaesthesia & Muscle Relaxation Signed: : Name: (PRINT) Job Title: Contact details (if patient wishes to discuss options later) (via secretary) 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 she / he can understand Signed: : Name: (PRINT) Statement of advocate or carer (where appropriate) (please circle) I have interpreted the information above to the patient to the best of my ability and in a way in which I believe she / he can understand Signed: : Name: (PRINT) Designation Advocate / Carer Page 12 of 65

5 Surname Forename ECT Policy/C/YEL/cm/10/v3.0 P Number Statement of patient Patient s Name NHS or P Number Please read this form carefully. You should already have your own copy of the information booklet that describes the intended benefits and frequently occurring risks of ECT. 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 and 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. I understand that any procedure in addition to those described on this form will be carried out only if it is necessary to save my life or to prevent serious harm to my health. I have been told about additional procedures that may become necessary during my treatment. I have listed below any procedures that I do not wish to be carried out without further discussion. Procedures that I do not wish to be carried out without further discussion: Patient s Signature: : Name: (PRINT) A witness should sign below if the patient is unable to sign but has indicated his or her consent: Witness Signature: : Name: (PRINT) Important Notes: (tick if applicable) See also advance directive / living will (e.g. Jehovah s Witness form) Page 13 of 65

6 Surname Forename P Number Confirmation of Consent To be completed by a health professional each time the patient attends for the procedure, ensuring the patient has signed the form in advance of treatment - any changes to MHA / consent status should be documented. On behalf of the team treating the patient, I have confirmed with the patient that she / he has no further questions and wishes the procedure to go ahead. I have explained that the patient may withdraw consent at any time of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) of Procedure: Signed: Name: (PRINT) MHA status : Job Title: MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: Page 14 of 65

7 Surname Forename P Number Confirmation of Consent To be completed by a health professional each time the patient attends for the procedure, ensuring the patient has signed the form in advance of treatment - any changes to MHA / consent status should be documented. On behalf of the team treating the patient, I have confirmed with the patient that she / he has no further questions and wishes the procedure to go ahead. I have explained that the patient may withdraw consent at any time of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: Signed: Name: (PRINT) MHA status : Job Title: of Procedure: MHA status Signed: : Name: (PRINT) Job Title: Surname Forename P Number Page 15 of 65

8 5. Physical Status (To be completed by a doctor from the prescribing team) A Full Physical needs to be completed within seven days of commencing ECT Please check patient records for date of last full physical Relevant Physical Illness / Condition of last full physical (within last 7 days) Yes No Yes No MI Adrenal disease Angina Asthma / bronchitis Cardiac failure CVA Hypertension Epilepsy Ischemic Heart Disease Hiatus hernia Anaemia Hepatitis B/Jaundice/Liver disease Thyroid disease Sickle cell trait / disease Diabetes Pregnancy Details: Dental problems e.g. crowns, dentures, loose teeth Communication problems e.g. deafness Other factors that increase the risk of treatment? Details: Details: Details: Alcohol intake Details: Is patient a smoker Details (no. per day): Bleeding/bruising easily Details: Other relevant medical history and diagnoses and previous drug side effects (including serious illness) Known Allergies (including plasters) Please clarify with G.P. before prescribing ECT Details of previous operation record and any problems with anaesthesia Page 16 of 65

9 Surname Forename ECT Policy/C/YEL/cm/10/v3.0 P Number Please record any clinically indicated or important pre ECT physical investigations (please refer to ECT policy available on website) Test Comments / Results Full Blood Count (all patients) U&E and LFTs (all patients) Urine for blood, protein, sugar (all patients) Pulse rate and rhythm (all patients) Blood Pressure (all patients) Weight (all patients) Chest X-Ray (where clinically indicated. If in doubt discuss with anaesthetist) ECG (male smokers over 45 yrs of age and anyone else over 50) Other Signature and name of team doctor completing this section : 6. Pre ECT Anaesthetic Assessment Please specify ASA (American Society of Anaesthetist) Grade: I II III IV V Definitions: I Fit and Well II Minor medical problem(s) not effecting lifestyle (no impairment of motor activity e.g. can walk as far as desired) III Significant medical problem(s) affecting lifestyle (e.g. impairs motor activity) IV Serious medical problem(s) with constant threat to life V Moribund; surgery etc. Comments: Signature and Name of Anaesthetist confirming that the patient is fit for ECT treatment : Page 17 of 65

10 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 18 of 65

11 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 19 of 65

12 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 20 of 65

13 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 21 of 65

14 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 22 of 65

15 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 23 of 65

16 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 24 of 65

17 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 25 of 65

18 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 26 of 65

19 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 27 of 65

20 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 28 of 65

21 7. ECT Prescription ( to complete all sections) Not more than two ECT s to be prescribed at one time. to review weekly at least. Prescription valid for two weeks. If unilateral ECT is prescribed, right unilateral will be given if not otherwise specified. should refer to the Royal College ECT Handbook Second Edition for advice on laterality Patient Name: P number: of Medical Review: Response to treatment in this course thus far: (please circle) N/A Too early to say Responding adequately Inadequate response Increase Dose Side Effects to treatment in this course thus far: (please circle) N/A Headaches Aches Fatigue Anxiety Confusion Memory Loss Legal / Consent Status The patient is: (please tick one box and circle relevant MH section) Over 18, Informal, Capicitous and Consenting (consent form for ECT completed) Over 18, Informal, Incapacitous, Not objecting, No advance refusal or objection from LPA, C of P / deputy and family / advocate consulted (treatment prescribed in best interests under mental capacity act ) Over 18, Detained (section 2,3,36,37,38,45A, 47 or 48), Capacitous & Consenting (MHA Form T4 - certificate of consent to treatment [ECT] completed) Over 18, Detained (Section 2,3 36,37, 38,45A, 47 or 48), Capacitous but Refusing Emergencies only (Section 62 Form conditions a or b completed) Over 18, Detained (Section 2,3, 36,37, 38,45A, 47 or 48), Incapacitous & no advance refusal or objection from LPA, C of P / deputy (MHA Form T6 Certificate of second opinion or in emergency Section 62 Form conditions a or b completed) Over18, Detained - Section 2,3, 36,37, 38,45A or 48, Incapacitous but either advance refusal or objection of LPA, C of P / deputy (Section 62 Form conditions a or b completed) Other scenarios eg under 18s / CTOs etc please specify..and seek advice from MHA dept & ECT dept ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose ECT Prescription prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) Bilateral Page 29 of 65

22 Surname Forename ECT Policy/C/YEL/cm/10/v3.0 P Number This section should be completed by a doctor from the prescribing team. Cognitive Functioning must be completed before ECT treatment commences and at 3 and 6 months post completion of course of ECT 9. Cognitive Functioning 1. Orientation What is today s day / date / month / year / season? Where are we? Town / city / county / country / building / floor? 2. Registration Name 3 common objects e.g. apple, chair, ball Ask the patient to repeat all three Repeat until all three are remembered. Number of trials needed: 3. Attention and Calculation Start from 100 and keep subtracting 7 Stop after 5 answers: (93, 86, 79, 72, 65) OR Spell the word WORLD backwards (DLROW) 4. Recall Repeat the three words I asked you to say earlier. 5. Language Naming: Show a watch and pencil and ask the patient to name them. Repeating: Repeat the following no ifs, ands, or buts. Reading: Show the sentence overleaf (Close Your Eyes) Read the sentence and do what it says Pre ECT Patient Score 3 mths 6 mths post post Maximum Points Write: a short sentence on your own. 1 Three stage command: Take a piece of paper in your right hand, fold it in half and place it on 3 the floor 6. Construction Copy this diagram (see next page) 1 Total MMS Score: Is there evidence of autobiographical memory loss? If yes give details in medical notes 8. Other ongoing subjective side effects. If yes give details in medical notes 9. Symptomatic Response e.g. good / poor etc Signed Name Page 30 of 65

23 Surname Forename P Number 9a Cognitive Functioning This section provides a baseline to the nursing assessment post ECT and should be completed as soon as possible before the commencement of ECT by the ward nursing team Baseline Question Comments/Response Can the patient walk in a straight line or are they tending to veer off to one side? Do they seem to be fully aware of their surroundings on both sides of them? Are they being clumsy, not noticing things to one side or bumping into things, perhaps missing the chair slightly when they sit? Has the patient complained of nausea? Has the patient complained of headaches? Has the patient complained of any aches or pains? Is the patient agitated? The name of the school the patient went to: What year did the patient get married? (or the date of some major personal event if not married): The ages of the patients children (or the age of some loved still living person if no living offspring): What are the names of your neighbours/or close friend? Has the person manipulated the cutlery in the usual way, using both knife and fork and positioning them normally on either side of the plate? Has the person been able to locate all items on the table easily? Has the person seemed to be aware of people sitting to their left and right equally? Has the person left food on just one side of the plate? Have they been able to manoeuvre their way around the ward and/or bedroom easily or have they seemed clumsy? Completed by Page 31 of 65

24 Surname Forename P Number 11. Nursing Checklist for ECT Patient Ward Nurse ECT Nurse To re-check and attend to items To complete items 1-13 by (yes), x (no), R (refused) or N/a (not applicable) Does patient have / wear :- please circle Dentures Yes or No Capped teeth Yes or No Hearing Aid Yes or No Spectacles Yes or No Contact lenses Yes or No 1. Patients identity confirmed 2. Correct case notes and prescription record 3. ECT record complete and in case notes 4. ECT nurse informed of any abnormalities a) Consent form complete OR 5. b) MHA documentation complete and in case notes 6. Consent reaffirmed by Patient (see Section 4) 7. Relevant investigation results in case notes (CXR, ECG, bloods) Session a) Blood pressure b) Pulse c) Temperature d) resps e) BM stix/blood glucose check immediately prior to each treatment for diabetics Has the patient passed urine (time)? When did patient last ear or drink (time)? 11. Has make up been removed? Hair shampooed night before and not wearing hair lacquer, gel etc? Jewellery and hairpins removed, documented and properly stored? *Anaesthetist informed of any abnormalities? *Artificial eyes / contact lenses removed documented and properly stored? *Electrode site prepared? 17. *Dentures removed documented and properly stored? 18. *Hearing aid / spectacles removed documented and properly stored? Initials (Ward Nurse) Page 32 of 65

25 Initials (ECT Nurse) Page 33 of 65

26 ECT Page 34 of 65

27 Page 35 of 65

28 and Start Time Surname Forename P Number 14. Recovery Nursing Observation Record Where changes to baseline observations have been observed please inform medical team for further advice. Checked with anaesthet ist re any problems T BP P SaO2 Resp Rec Time Rec BP Comments Signature Page 36 of 65

29 Surname Forename P Number ECT Poli 15. Ward Nursing Observation Checklist Post ECT Please indicate Correct / positive responses by patient with and incorrect / adverse / negative responses with Any negative / adverse responses should be discussed with Consultant prior to next ECT Treatment. Provide initials, tick and time in box Session Number Temperature 1 hour post treatment Temperature 3 hour post treatment Pulse Rate (bpm) 1 hour post treatment Pulse Rate (bpm) 3 hour post treatment Blood Pressure 1 hour post treatment Blood Pressure 3 hour post treatment Post Treatment Observations Respiration 1 hour post treatment Respiration 3 hour post treatment 1.1 Do you know where you are? 1. Ask 2. Watch for 3. Assess 1.2 Do you know what has happened so far today? 1.3 Do you know what time of day it is? 1.4 What is today s date? 2.1 Can they walk in a straight line or are they tending to veer off to one side? 2.2 Do they seem to be fully aware of their surroundings on both sides of them 2.3 Are they being clumsy, not noticing things to one side or bumping into things, perhaps missing the chair slightly when they sit? 3.1 Are you feeling sick? 3.2 Do you have a headache? 3.3 Do you have any aches or pains? 3.4 Is the patient agitated? 3.5 Does the patient seem fully alert? To be performed approximately 3 hours after treatment Page 37 of 65

30 Surname Forename P Number Session Number continued Temperature 1 hour post treatment Temperature 3 hour post treatment Pulse Rate (bpm) 1 hour post treatment Pulse Rate (bpm) 3 hour post treatment Blood Pressure 1 hour post treatment Blood Pressure 3 hour post treatment Post Treatment Observations Respiration 1 hour post treatment Respiration 3 hour post treatment 1.1 Do you know where you are? 1. Ask 2. Watch for 3. Assess 1.2 Do you know what has happened so far today? 1.3 Do you know what time of day it is? 1.4 What is today s date? 2.1 Can they walk in a straight line or are they tending to veer off to one side? 2.2 Do they seem to be fully aware of their surroundings on both sides of them 2.3 Are they being clumsy, not noticing things to one side or bumping into things, perhaps missing the chair slightly when they sit? 3.1 Are you feeling sick? 3.2 Do you have a headache? 3.3 Do you have any aches or pains? 3.4 Is the patient agitated? 3.5 Does the patient seem fully alert? To be performed approximately 3 hours after treatment Page 38 of 65

31 What is your home address? 4.2 What school did you go to? What year did you get married? (or the date of some major personal event if not married) How old is your son/daughter? (or the age of some loved still living person if no living offspring) What are the names of your neighbours? Has the person manipulated the cutlery in the usual way, using both knife and fork and positioning them normally on either side of the plate? Has the person been able to locate all items on the table easily? Has the person seemed to be aware of people sitting to their left and right equally? Has the person left food on just one side of the plate? Have they been able to manoeuvre their way around the ward and/or bedroom easily or have they seemed clumsy? Page 39 of Next Day following treatment 5. Sensory Awareness Ask the questions as above and also observe carefully the person s behaviour at table and while washing: 4. Autobiographical 6. Assess Surname Forename P Number 6.1 Has the person returned to a normal level of wakefulness?

32 Surname Forename P Number ECT 16a. Discharge Protocol for Day Patients In addition to any other matters of clinical judgement the following criteria should be satisfied for ECT Day Patients before they leave the hospital: Session Number Temperature 1 hour post treatment Temperature 3 hour post treatment Pulse Rate (bpm) 1 hour post treatment Pulse Rate (bpm) 3 hour post treatment Blood Pressure 1 hour post treatment Blood Pressure 3 hour post treatment Post treatment observation Respiration 1 hour post treatment Respiration 3 hour post treatment 1. The patient is alert and fully recovered 2. The patient s normal level of mobility has returned 3. The patient is able to tolerate diet and fluids 4. The patient is in the care of a responsible adult 5. The patient and carer have been given and understand the ECT Out Patients Treatment Instructions leaflet 6. The patient and carer have a contact number to call in case of any problems or concerns Nurse initials Page 40 of 65

33 16b. ECT Day Patient Advice Form Patient Name :. I confirm that I have been advised that as a day patient receiving ECT that I (16c pg 28 care pathway): Should not drive, operate machinery, drink alcohol or sign legal documents for at minimum of 24 hours following treatment and I will seek the advice of my Clinical Team regarding for further advice re this Should be accompanied home and have supervision by a responsible adult for 24 hours following treatment and I agree to follow / comply with this advice. Please bring this form to your next appointment. Session 1 Signed. (patient)... Name Signed... (responsible adult) Session 2 Signed. (patient)... Name Signed... (responsible adult) Session 3 Signed. (patient)... Name... Signed... (responsible adult)... Session 4 Signed. (patient)... Name Signed... (responsible adult) Session 5 Signed. (patient)... Name Signed... (responsible adult) Session 6 Signed. (patient)...

34 Surname Forename P Number ECT Policy/C/YEL/cm/10/v3.0 Name... Signed... (responsible adult)... Session 7 Signed. (patient)... Name Signed... (responsible adult) Session 8 Signed. (patient)... Name Signed... (responsible adult) Session 9 Signed. (patient)... Name Signed... (responsible adult) Session 10 Signed. (patient)... Name Signed... (responsible adult) Session 11 Signed. (patient)... Name Signed... (responsible adult) Session 12 Signed.. (patient)... Name Signed... (responsible adult) Page 42 of 65

35 Surname Forename P Number 16c. ECT - Out Patient s Treatment Instructions This fact sheet provides additional information for patients receiving ECT as an out-patient. It should be read along with the ECT INFORMATION LEAFLET You have been prescribed a course of ECT as an out-patient. This will take place twice a week on Tuesday and Friday mornings. Each time you will be given a short anaesthetic and it is important that you keep to the following instructions when you come for treatment: 1. DO NOT have anything to eat or drink after midnight on the day before your treatment 2. PLEASE ARRIVE ON Ward at hours on ECT mornings. 3. DO NOT take any tablets before you have ECT. It you are on regular tablets bring them with you, inform the nurse and take them after treatment when you have recovered. 4. Please DO NOT bring any jewellery or valuables into hospital with you. 5. Please ensure that there are NO GRIPS or METAL objects in your hair and DO NOT use hair lacquer. 6. It is best if a relative or friend can drive you to the hospital and take you home again. Unless you are told differently you should be ready to return home by hours or later if it is more convenient to you. 7. You should NOT DRIVE a motor vehicle, operate machinery or SIGN ANY IMPORTANT DOCUMENTS for a minimum of 24 hours after treatment. You should seek the advice of your Consultant, Clinical Team or GP regarding the appropriateness of resuming these actions. 9. You should remain under the supervision of a responsible adult for 24 hours after treatment. If you are worried about the treatment or if you have any queries please do not hesitate to contact staff on Ward, telephone. PLEASE BRING THIS SHEET WITH YOU WHEN YOU COME FOR TREATMENT Your next appointment date: Day Day Page 43 of 65

36 17. Protocol on Maintenance / Continuation ECT 1. Maintenance ECT should only be prescribed by Consultants 2. Maintenance ECT should be re-prescribed every two treatments 3. It is recommended that at each review patients giving consent are reminded that they can withdraw that consent. 4. Typical continuation treatment in a frequently relapsing patient would be to reduce ECT to fortnightly for 3 months, then 3 weekly for 3 months, then monthly for 3 months then to stop and observe for signs of relapse. 5. It is recommended that the patient s memory and other cognitive functions are recorded monthly 4 and 5 are recommendations derived from Electroconvulsive Therapy a Good Practice Statement The Scottish Office 1997 Page 44 of 65

37 Surname Forename P Number 18. Audit Tool To be completed by the referring team after the course has finished Please record by ticking or crossing compliance for each section Please sign, print name and record designation together with any comments at the end of the tool then forward results to Clinical Audit Team, St Georges, Stafford The following have been recorded: Met Not Met 1. The patient s ethnicity 2. The patient s Mental Health Act status 3. A detailed medical history 4. A Mental State Examination 5. An assessment of cognitive functioning and memory 6. A full physical examination including the cardiovascular, respiratory and neurological systems 7. Existing drug regime 8. An assessment of orientation 9. A clear statement on why ECT has been prescribed 10. An indication that the prescription is within NICE guidelines, or the reason for any exception 11. Written evidence that the anaesthetic risk was assessed, e.g. the ASA grade of the patient is identified and assessment made on the basis of this 12. Current medication, drug allergies and any noted drug problems 13. Results from a recent blood test 14. There is written evidence that ECT was given two times a week at most For a typical treatment the following are recorded: 15. The name of the anaesthetic used 16. The dose of the anaesthetic used 17. The name of the muscle relaxant 18. The dose of the muscle relaxant 19. The current delivered 20. The quality and duration of seizure including whether it was bilateral or unilateral 21. Cardio respiratory changes 22. Post-procedural problems 23. Immediate side effects 24. An assessment of the patient s overall health, e.g. blood pressure, pulse, respiration Met Not Met Page 45 of 65

38 25. Clinical status / symptomatic response 26. Orientation 27. Non-cognitive side effects 28. The patient s cognitive functioning 29. Both the patient s subjective experience of treatment side effects and objective cognitive side effects At the end of a course of treatment: 30. The patient has a clinical interview to establish any autobiographical memory loss, and this is documented For patients that consented to ECT: 31. There is a signed consent form Met Met Met Not Met Not Met Only complete questions 31 to 41 for informal patients The consent form covers the following areas: 32. The maximum number of treatments in the course 33. If the course was for bilateral or unilateral treatment 34. Confirmation that the psychiatrist or nominated deputy has explained the procedure to the patient 35. Confirmation that the psychiatrist or nominated deputy has explained the intended benefits and risks of the procedure 36. Confirmation that the psychiatrist or nominated deputy has discussed with the patient alternative available treatments (including no treatment) 37. Confirmation that the psychiatrist or nominated deputy has discussed the benefits and side effects of alternative treatment 38. That written information had been provided to the patient 39. What procedures the treatment would involve e.g. anaesthesia and muscle relaxation 40. A statement from an interpreter where appropriate 41. A section specifying whether the patient continued to consent before each treatment Patients who were not able to give consent: 42. For patients detained under Mental Health Legislation, the relevant Mental Health Act documents were attached Met Met Not Met Not Met

39 Surname Forename P Number For Day Patients Before treatment commences, day patients and / or their carers sign a form which confirms: Met Not Met 43. They will be accompanied home 44. They will have appropriate supervision by a responsible adult for each night / or 24 hours after ECT treatment 45. They will not drive or operate machinery for a least the next 24 hours 46. They will not drink alcohol for a least the next 24 hours 47. They will not sign any legal documents for a least the next 24 hours 48. If you have any comments regarding any aspect of the audit, please use the box below: Name of Auditor (please print) Signature of Auditor Team Location of completion Forward Results to: Clinical Audit Team, St Georges Hospital, Stafford Page 47 of 65

40 ELECTROCONVULSIVE THERAPY (ECT) Page 48 of 65