These guidance notes are intended to provide information on care pathway for ECT. Section Content Page No

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1 Electro-Convulsive Therapy - Practice Guidance Note ECT Guidance Pack for Integrated Care Pathway V03 V03 issued Issue 1 Apr 16 Planned review April 2019 ECT-PGN-02 Author/Designation Responsible Officer / Designation Sharron Robinson Medical Director These guidance notes are intended to provide information on care pathway for ECT Section Content Page No Procedures for ECT Pre and Post treatment Anaesthetic guidelines Procedure for Nurse Escorting ECT patient Consent to Treatment Guidance for clinicians 8 3 Medication during and after course of ECT 10 4 Procedure for the administration of morning medication prior to ECT 12 5 Procedures for use of ECT in vulnerable groups 13 6 Procedure for Continuation ECT 16 7 Procedure for Maintenance ECT 16 8 Procedure for the discontinuation of ECT 18 9 Procedure for Out-patient ECT Procedure for Out of Hours ECT and Bank holiday arrangements Recommendations regarding laterality of ECT Privacy and Dignity Reference List 23 ECT-PGN-02 - ECT Guidance Pack Guidance V03 - Issue 1 Issued Apr 16

2 Leaflets, Forms and Care Plans listed separately for easy printing Document No: Description Issue Issue Date Review Date Appendix 1 MC1 Form Record of a decision about the best interests of a person who lacks capacity 1 Apr 16 Apr 19 Appendix 2 LEAFLET Understanding NICE Guidance on use of ECT 1 Apr 16 Apr 19 Appendix 3 LEAFLETS ECT for patients detained in hospital Linked to PI Website 1 Apr 16 Apr 19 Appendix 4 RCPsych-Depression, ECT and fitness to drive 1 Apr 16 Apr 19 Appendix 5 Procedure for prescribing outside of NICE Guidance 1 Apr 16 Apr 19 Appendix 6 Certification of all detained/sct patients flow chart 1 Apr 16 Apr 19 ECT-PGN-02 - ECT Guidance Pack Guidance V03 - Issue 1 Issued Apr 16

3 1 Procedures for ECT Pre and Post treatment - Anaesthetic guidelines Patients presenting for ECT will require multiple aneasthetics over a short period of time. These anaesthetic guidelines are advisory and are to aid consistent and safe anaesthetic practice as well as comply with ECTAS standards 1.1 Co-existing physical illness Wherever possible the patient should be optimally physically fit before anesthesia and ECT is given Every attempt should have been made to correct any dehydration and maintain an adequate fluid intake prior to an anesthesia Prior to Electroconvulsive Therapy (ECT) the patient should be assessed and prepared both mentally and physically to ensure every action is taken to maintain their comfort, safety and dignity. 1.2 Pre treatment A statement regarding the patient s capacity must be recorded and any Advance Statements taken into consideration. If the patient is assessed as lacking capacity and has no family/carer to consult, an independent mental capacity Advocate must be involved The prescribing doctor must consent the patient as per Trust policy NTW(C)05 - Consent to Examination or Treatment Policy (available on Trust s intranet site, including relevant forms) The patient should be given copies of the following leaflets by the prescribing doctor: o The Use Of Electroconvulsive Therapy, o Understanding NICE Guidance Information For Service Users, Their Advocates And Carers, And The Public (available by contacting the NHS Response Line , quoting ref. NO207), o The Trust s Electroconvulsive Therapy Patient Information Leaflet 1

4 And, if applicable, o The patient information leaflet Electroconvulsive Therapy for Patients Detained in Hospital (available via the Mental Health Act section of the Intranet see links below). The patient should be given the opportunity to discuss above mentioned leaflets with the doctor Newcastle and North Tyneside Northgate St. Georges Park South Tyneside Sunderland and Gateshead leaflet If ECT is being prescribed outside of National Institute for Health and Clinical Excellence (NICE) guidelines, refer to Trust policy NTW(C)51 - ECT policy Procedure for prescribing outside of NICE guidance 1.3 For patients on a Section of the Mental Health Act (MHA), relevant forms must be completed The ECT prescription form must be completed in its entirety by the prescribing doctor (no more than two ECT treatments to be prescribed at one time) Check that the patient s ethnicity is recorded 1.4 Routine Pre-ECT investigations Full physical examination, including cardiovascular, respiratory and neurological systems must be completed, noting any current physical or mental conditions. See Trust policy, NTW(C)29 - Standard for Physical Assessment and Examination see link below:- 2

5 ECT can usually be given safely with patients with cardiac pacemakers. A pacemaker check should be performed prior to referral for treatment. Any patient with a more complex device such as an implanted defibrillator should be discussed with their cardiologist prior to starting treatment. Any history of allergies must be checked and recorded. This must include egg intolerance/allergy, as one of the commonly used IV anaesthetic drugs, Propofol, is formulated in egg protein and could result in a serious systemic allergic reaction in patients with an egg allergy Full blood count, serum urea and electrolytes for all patients. Liver function test for patients with cachexia, a history of alcoholism, drug abuse or recent overdose ECG to be completed as appropriate (discuss with anaesthetist) Chest X-ray completed if clinically indicated (discuss with anaesthetist) Sickle cell test to be taken for all Afro Caribbean, Middle Eastern, Asian and Eastern Mediterranean patients, unless previously investigated/known Hepatitis B status for patients known to abuse intravenous drugs Oral examination to be completed The patient should meet ECT staff, when possible, prior to their first treatment and a visit to the department should be offered. This could be used as an opportunity to discuss any anxieties the patient may have Any records of previous ECT treatments must be available for viewing by staff at the ECT clinic The patient s clinical status should be clearly documented prior to a course of ECT A baseline recognised depression rating scale should be carried out prior to treatment, wherever possible, repeated at appropriate intervals during the course of treatment and at the end of treatment, to measure response Cognitive testing, using a validated tool (e.g. MMSE or 3MS available on RIO) should be completed prior to and at regular intervals during the course of treatment Ward staff to assess patient for any requirement for supportive observation prior to treatment to ensure nil by mouth from midnight Patient to be booked for treatment by ward staff/doctor/secretary at least on the day prior to treatment (each subsequent treatment requires booking in) 3

6 The patient should receive a maximum of 2 treatments a week, (except in an emergency) 1.5 Morning of Treatment Ward staff (or in the case of out-patients, ECT staff if not accompanied by CPN) to complete the ward section of the nursing checklist for ECT patients and the ECT documentation checklist Suitable escort to be identified by the nurse in charge of the ward/team Wherever possible, patients should be discouraged from smoking on the morning of treatment Blood sugar levels to be assessed immediately before each treatment if patient is diabetic All patients should be escorted to the department with all (including previous) ECT documentation, notes and drug prescription(s) being available for scrutiny by the ECT team Fasting guidelines for Adults and young people receiving ECT After induction of anaesthesia there is a risk of aspiration of gastric contents as protective reflexes are lost (gag and cough). Aspiration of gastric contents can lead to chemical pneumonia which is associated with a significant morbidity and mortality To avoid aspiration of gastric contents, patients should not eat or drink for a period of time prior to receiving an anaesthesia induction agent associated with ECT If necessary patients should be observed prior to ECT to ensure this is adhered to. Patients should be risk assessed if non adherence to these guidelines is suspected These guidelines follow AAGBI recommendations which are based on the American Society of Anaesthesiologists (ASA) guidelines. There is little evidence as to the effects solid food ingested before an anaesthetic but the fasting time for clear fluids is evidence based These guidelines are based on Newcastle upon Tyne Hospitals NHS Foundation Trust Preoperative Guidelines for Adults and children by Dr. V. Addison. They have been agreed by visiting Anaesthetists at the three ECT locations within NTW, and are subject to triennial review 4

7 6 hours for solid food, carbonated drinks, milk 3 hours for carbonated rich drinks used for enhanced recovery programme (e.g. Polycal liquid) 2 hours for clear non-particulate and non-carbonated fluids. Tea/coffee with a small amount of milk Note: There is no need to cancel if the patient has been chewing gum or sucking boiled sweets immediately prior to ECT. It is an anaesthetic decision as to whether a patient is adequately fasted. Oral premedication can be taken with up to 75ml of water 1 hour before anaesthesia Particularly vulnerable groups e.g. the elderly, sick patients and breast feeding mothers may require IV fluids prior to ECT. The need for this should be assessed by the referring team on each relevant occasion prior to ECT taking place References: 1. Pre-operative and patient Preparation: The Role of the Anaesthetist 2 AAGBI (2010) Appendix 1 ECT staff to check all documentation, complete nursing checklist for ECT patients, the ECT documentation checklist (ensuring patient has been nil by mouth) and complete the first part of the post-ect checklist Anaesthetist to be informed of any abnormalities Patient should be encouraged to empty bladder Patient to be given morning medication with a sip of water at least two hours prior to treatment (check with doctor/anaesthetist regarding which, if any, medication to be omitted) 1.6 Post-Treatment In the case of an outpatient, or an inpatient leaving ward (even briefly) on the day of treatment (for whatever reason) the Post Anaesthetic Information For Patients Receiving ECT is to be discussed with the patient, their responsible adult, signed and filed/scanned into patient records (copy given to patient) The patient s clinical status and symptomatic response must be assessed and recorded between each treatment session (ECT Accreditation Service (ECTAS) standard M7.11 Type 1) 5

8 The treatment outcome must be monitored and recorded at least weekly between treatment sessions and the treatment appropriately adjusted in light of this (ECTAS standard 7.10 Type 1) The patient s orientation and memory should be reassessed after the first treatment, and again at intervals throughout the treatment course The patient should have a clinical interview recorded at the end of the course of treatment to establish any cognitive side effects Non-cognitive side effects should be assessed and recorded between treatment sessions The patient s subjective experience of treatment side effects and objective cognitive side effects should be recorded between treatment sessions (e.g. using a memory log) The ECT team must be informed when the course of treatment ends Guidelines for the care of patients following ECT ECT is administered under a brief general anaesthetic. The anaesthetic drugs used may vary, but are chosen because of their short duration of action, and would be expected to be metabolized, and therefore not exerting any lasting effects, within hours. Patients can show marked variation in their response to anaesthetic agents however, and many psychiatric patients are taking a number of other agents which may potentially alter their response to anaesthetic drugs Patients may appear to have recovered from a general anaesthetic, i.e. can talk, walk about, eat etc., while still being uncoordinated. They may not be aware that their judgement of distances for instance is impaired. For this reason patients who have had a general anaesthetic should be supervised for 24 hours. In-patients should not be allowed to leave the ward unsupervised, or to use kettles or cookers to prepare drinks or food Because of the variation in the speed with which the body eliminates anaesthetic drugs caution should be exercised in the use of other sedative medication within 24 hours of a general anaesthetic as interaction of the different drugs may result in excessive cardio respiratory depression. 1.7 Follow up The treatment outcome should be adequately monitored and recorded after the treatment course The patient s cognitive side effects/memory are assessed using the MMSE and subjective questioning in a clinical interview 3 or 4 working days after the end of the treatment course and at 1 or 2 months follow up. This is the referring Teams responsibility. 6

9 1.8 Procedure for escorting ECT Patients ECTAS Standard 3.28 (Type 1): Inpatients are escorted from the waiting room through ECT and recovery and back to the ward. The escort should be a registered nurse, ODA or doctor. N.B. If the escort is delegated to an unqualified member of staff/care Assistant, then it is the nurse who will be accountable for the consequences of that delegation. The Royal College of Psychiatrists (RCP) recommends that: The escorting nurse should always be a trained nurse - without exception (RCP ECT Handbook 2005) Each patient should be individually escorted Staffing levels should be managed in advance to facilitate this Students should never be sole escort of a patient The escort should: Have up-to-date training in basic life support and be competent in its practice Attend a training session for nurse escorts in ECT (see local provider) A good knowledge of the ECT process, especially the possible side effects (both common and rare) and the nursing actions required in the event of their occurrence Familiarity with the clinic environment, especially the location of emergency equipment (in the use of which the nurse should be trained and competent) The escort should know the patient they are escorting, including awareness of their legal status, consent and any possible medical complications They should ensure the safekeeping of any patient valuables and prostheses (prostheses should not be removed until arrival at the ECT clinic) The escort is responsible for handing over any information/concerns raised by the ECT team to the nurse in charge of the ward and ensuring that the post-ect checklist is continued if this has been identified as necessary by the recovery nurse/anaesthetist The escort should remain with the patient throughout the entire ECT process (preparation, treatment and recovery), providing support, reassurance and orientation until recovery is complete and escort the patient back to the ward (or in the case of an outpatient handing over responsibility to the appropriate relative/carer) 7

10 2 Consent to Treatment Guidance for Clinicians Ref: NTW(C)05 - Consent to Examination or Treatment Policy see clinical policy website link below for latest version Clinicians are also referred to Section 1.4 of the NICE guidance on ECT. It is the responsibility of the patient s consultant to ensure that ECT is administered legally. A statement of capacity should be recorded in the patient s care record Where a patient has capacity, then valid consent must be obtained to administer ECT In order to obtain valid consent the following must take place:- i ii iii iv A discussion should take place between the clinician and patient (and carer/advocate if appropriate) as to the nature and purpose of ECT and the risks and benefits of ECT in general and for the patient specifically. This must be recorded. More than one discussion may be needed to help the patient fully understand all aspects of the treatment and potential side effects Appropriate written information must be given to the patient. This should include the Trust and NICE information leaflets on ECT. This will usually be the responsibility of the person taking consent. A patient information DVD is also available upon request from the ECT department The discussion will usually take place at least 24 hours before the first treatment session in order to enable the patient sufficient time to consider their decision. In the case of emergency treatment, this period may be less than 24 hours The patient will be offered the opportunity to meet ECT nursing staff and visit the ECT Suite. In most cases this will occur prior to giving consent to ECT and as part of the process of providing information and opportunity for discussion about the treatment 8

11 v vi vii viii ix The discussion will, if possible, take place between the consultant and the patient (and carer/advocate). At times when the consultant is absent the discussion and obtaining consent may be carried out by a junior doctor with the clinical team. The decision to proceed to ECT should be that of a consultant (or delegate). A consultant will remain responsible for ensuring that valid consent has been given and that the junior doctor obtaining consent has been assessed as competent to carry this out The patient must be reminded that they may withdraw consent at any time. This must be recorded ECT clinic staff will confirm consent prior to each treatment Consent Form 1b will be completed see link below for consent Form 1b In the event that a patient is detained under the Mental Health Act but has capacity and consents to ECT, then the consultant will complete a Form T4 in addition to Consent Form 1b (See most recent version of document under NTW(C)05 Consent to Examination and/or Treatment Policy which sits within link below) Patients Lacking Capacity In the event that a patient lacks capacity, it should be clearly established if the patient is compliant with treatment. Provided this is the case, current interpretation of the law suggests that ECT may be given without consent under the Mental Capacity Act (MCA) in the best interests of the patient In these circumstances:- Lack of capacity should initially be determined and recorded by a consultant using the MC1 form; See most recent version of document under Trust policy NTW(C)34 - Mental Capacity Act Appendix 1 which sits within Clinical Policy website link below Consideration must be given to any advance directives made by the patient If the patient does not have any family or carer to consult, an Independent Mental Capacity Advocate (IMCA) must be appointed 9

12 The treatment should be discussed (if appropriate) with the carer/imca of the patient and this discussion and their views recorded. Reasons why this discussion could not take place should also be recorded A second opinion from a consultant should be obtained confirming the need to ECT treatment in preference to alternative treatments and recorded Consent Form 4 (See most recent version of document under Trust policy NTW(C)05 Consent to Examination and/or Treatment, which sits within Clinical Policy website link below Capacity should be re-assessed and recorded prior to each treatment session. If possible, this should be carried out by the consultant or a delegated colleague. If this is not possible it is essential that the junior doctor assessing capacity has been assessed as competent to carry out such an assessment. This remains the responsibility of the supervising consultant As soon as capacity is regained the process of obtaining valid consent (as above) should proceed. If the patient consents then Consent Form 1b - should be completed and staff will confirm consent at each subsequent treatment. If the patient refuses consent to ECT or if consent is uncertain or variable, then alternative treatment options should be discussed. If the consultant retains the view that ECT is the most appropriate treatment, consideration may be given to whether to detain the patient under the Mental Health Act and obtain a second opinion from the Mental Health Act Commission. If treatment is agreed, a Form T6 will be completed specifying the number of further treatments a patient may be given If there are concerns about the capacity of a patient the ECT consultant will suspend treatment pending reassessment of capacity by the clinical team. It is essential that there is good up-to-date communication between the ECT and clinical teams to prevent misunderstandings about current status of capacity and consent 3 Medication During and After a Course of ECT 3.1 Many psychotropic drugs may have significant effects on seizure threshold and the seizure duration, e.g.: (a) There are drugs which may increase the seizure threshold making it harder to induce an adequate fit: Benzodiazepine Anticonvulsants Tricyclic Antidepressants 10

13 (b) Antipsychotics (but note that Clozapine in higher doses/plasma concentrations can lower threshold) There are also drugs which may lower the seizure threshold: Caffeine Theophylline Stimulants Muscle Relaxant Hyperventilation SSRI Lithium 3.2 Seizure threshold is invariably measured at the first treatment indicating the correct current stimulus to be used for treatment. Thus there is no need to adjust the electrical doses in patients taking the above medication. 3.3 However, if the patient is not showing satisfactory response to ECT it may be prudent to check the medication and take the following steps: (a) Patient taking benzodiazepine drugs: Wherever possible, the concomitant prescription of benzodiazepines should be avoided during the course of ECT For a hypnotic drug, use a non-benzodiazepine drug If patient has been taking benzodiazepines for a long time, it may be better to continue it during ECT, perhaps in reduced doses (b) Patient taking antidepressant drugs: Antidepressant drugs should not be abruptly discontinued before ECT especially ones with a short half life or SSRI do not discontinue MAOI before ECT. Discuss with the anaesthetist For a patient taking SSRI, consider starting with a low electrical dose (e.g mc) at the first treatment (c) Lithium Co-administration of lithium reduces the seizure threshold Co-administration of lithium is not a contraindication. Giving low electrical does (25-50 m.c) at the first treatment may be considered 11

14 (d) Antipsychotic Drugs All antipsychotic drugs, including clozapine, can be safely administered with ECT Withhold clozapine for 12 hours before ECT. The next dose can be given at the usual time and at the usual dose There may be synergistic effect between ECT and antipsychotic drugs in treatment resistant schizophrenia. No such synergistic effect in depressive illness (e) Antiepileptic Drugs If use to treat epilepsy, the prescription of these drugs should be continued. If used as a mood stabliser, continue prescribing it during the course of ECT & if seizure indication becomes problematic try reducing the daily dose before ECT as for benzodiazepines. 4 Procedure for the administration of morning medication prior to ECT 4.1 Introduction Patients should receive the following medications before ECT. Medication Exclusion Antihypertensives Diuretics Antianginals Antiarrhythmics Lidocaine (lignocaine) Digoxin Glaucoma eyedrops Antiulcer agents Bronchodilators Theophyline 12

15 4.1.2 Actions Patients should receive their routine antihypertensive and antianginal medication with a small sip of water about two hours before ECT Transdermal nitrates should be in place at least 30 minutes before treatment. For patients with diabetes, adjustments in the dosage of insulin and oral hypoglycaemics may be required on the morning of ECT because of the overnight fast. Holding the morning insulin dose until after the patient has had breakfast in the usual approach. In severe diabetic patients with a propensity towards ketoacidosis consultation with an endocrinologist may be helpful Anti-gastric reflux agents and anti-ulcer agents should be taken at least 2 hours before ECT with a sip of water Most other medications can be held until 1-2 hours following each ECT, unless the medication is clearly physiologically protective for the patient during treatment 5 Procedures for Use of ECT in Vulnerable Groups 5.1 The Elderly Not contraindicated by age alone Response compares favourably with younger patients Need for careful physical assessment, with particular regard for risk of cardiovascular disease Particular care with concomitant medication Seizure threshold may be relatively high in some elderly patients Special precautions may be required to guard against memory impairment or confusion (e.g. use of unilateral treatment, reduced treatment frequency) (Ref: Susan Barlow - Chapter 8 - RCP The ECT Handbook 2005) 13

16 5.2 Young People (patients under 18 years of age) ECT should be used with caution in young people due to lack of evidence from Randomised Control Trials (RCTs) First line use should be very rare No lower age limit within provisions of MHA Seizure threshold decreases the younger the patient stimuli as low as 25mc may be required ECT session should be arranged so that treatment is given separately from adult patients (e.g. young patient placed at beginning or end of list) Clinicians are advised to stop all non-essential medication used by the patient at the time of the course of treatment, due to reports of increased length of seizures and post-ect convulsions Although the Mental Health Act does not prevent a person with parental responsibility from consenting to ECT on behalf of a child who lacks competence, or young person who lacks capacity, to consent and who is neither detained under the Act nor a patient subject to a CTO, careful consideration should be given as to whether to rely on parental consent. This is because although there is no case law at present directly on this point, given the nature and invasiveness of ECT, it may lie outside the types of decision that parents can make on behalf of their child. The factors to consider whether it is possible to rely on parental consent are set out in paragraph 19.41of the act. In cases where the Act is not applicable, court authorisation should be sought. Although the application to the court should be made before a SOAD is asked to approve the treatment the views of a SOAD should be sought before making the application as the court is likely to wish to consider a SOAD s opinion before determining whether to authorise ECT. In practice, the issues the court is likely to address will mirror those that the SOAD is required to consider. A Second Opinion Appointed Doctor (SOAD) visit will be necessary to consider ECT treatment, regardless of the patient s capacity or consent status, and treatment can only be given if certified by the SOAD on Form T5 or T6. In an emergency and where the patient is detained under or subject to a section of the MHA to which part 4 applies ECT may be given under section 62 prior to the SOAD s visit (Ref: Heinrich C Lamprecht, I Nicol Ferrier Alan G Swann - Chapter 2 RCP The ECT Handbook 2005) 14

17 5.3 ECT and Pregnancy ECT in the second and third trimesters, particularly, may present more technical difficulties for the anaesthetist as the risk of inhalation of the stomach contents increases. There should be a case-by-case consideration of intubation. The patient s obstetrician and the anaesthetist should be involved before decision is made to proceed with treatment. Routine foetal heart monitoring should be carried out before and after each individual treatment beyond the first trimester (obstetric consultation may suggest earlier monitoring in high-risk pregnancies). (Ref: Heinrick C Lamprecht, I Nicol Ferrier, Alan G Swann Chapter 2 RCP The ECT Handbook 2005) 5.4 People with a Learning Disability Relative to the use of psychotropic medication, the use of ECT for patients who have both a Learning disability and a psychiatric disorder remains uncommon. There have been numerous case reports of ECT being used effectively in the treatment of patients suffering from affective disorders but there have been no properly randomised clinical trials of the use of ECT in this group There are no absolute contraindications to the use of ECT in people with a Learning disability. Indications for ECT are the same as for the general population Mild learning disability alone is not a barrier to informed consent provided that sufficient time is taken to present information in a manner that the patient can understand The Mental Capacity Assessment and Best Interest forms should be used for more severely disabled people who assent to treatment Because of the atypical presentations of psychiatric illness in this group of patients, treatment is best reserved for patients whose illness has proved refractory to medication or in whom the side effects are intolerable or where the clinical condition of the sufferer has severely deteriorated Because of the relatively large number of patients in this group who are taking anticonvulsant medication, particular care needs to be taken over stimulus dose titration. 15

18 6 Procedure for Continuation ECT Continuation ECT refers to use in preventing early relapse of an index episode of illness, e.g. treatments in excess of the initial course (usually 12 treatments) consented to or specified on the MHA T6. An example would be the case of a patient only showing a good response at session 8. Discontinuing treatment at session 12 could result in the patient being inadequately treated. Limited use of continuation ECT is acceptable under NICE guidance for a short period following the initial control of severe symptoms (refer to NICE guidance and draft Trust Consensus Statement). The RC and clinical team should discuss the reasons for continuing the course of ECT beyond the number of treatments originally specified with the patient and carer(s) and record this in the medical notes. Alternative treatment options should be discussed and recorded. The risks and benefits of continuation ECT should be discussed and recorded. A statement of capacity should be recorded. A new consent form stipulating a maximum number of ECT treatment sessions up to 12 will be completed. Physical examination and further investigations will be carried out if clinically indicated. Clinical progress, cognitive functioning and side effects will be monitored as in the initial course of treatment. (Ref: Richard Barnes Chapter 9, RCP The ECT Handbook 2 nd Edition 2005) 7 Procedure for Maintenance ECT Maintenance ECT refers to use in preventing further episodes or recurrence of illness, e.g. ECT administered at intervals usually between one week and three months NICE guidance states that ECT should not be used for maintenance therapy as there is no conclusive evidence to support its effectiveness and lack of information on whether the adverse effects (e.g. on cognitive function), may be cumulative with repeated administration 16

19 However, it is recognised that certain patients respond only to ECT and in these cases, maintenance ECT may be the treatment of choice Case reports suggest that prolonged courses of ECT can be effective and do not have any progressive adverse effects on cognition The Royal College of Psychiatrists advises that maintenance ECT is permissible under some circumstances e.g. where a patient s illness has proved resistant to treatment and where past response to ECT has been positive The RC should discuss the reasons for proposing maintenance ECT and possible alternative treatments with the patient and carer and do this in the current case notes A second opinion may be sought from the Regional Affective Disorders Unit at the RVI and documented The decision to recommend maintenance ECT should be discussed with the ECT Consultant The risks and benefits of maintenance ECT should be discussed and recorded A statement of capacity should be recorded prior to commencement A consent form stipulating the number of treatments should be completed. The maximum number of treatments should be 12 or the maximum time before renewal of consent 6 months whichever is the sooner Patients should undergo the usual clinical procedure for a standard course of ECT including physical examination, haematological investigations etc Consent should be renewed after 12 treatments of 6 months whichever is the sooner. At this time, risks and benefits of treatment should be discussed with the patient (and carer/advocate if appropriate) and recorded. A further second opinion should also be sought at this time Clinical progress, cognitive functioning and side effects should all be assessed and recorded by the clinical team at regular intervals Maintenance ECT should be discontinued at the earliest opportunity when the patient has recovered sufficient stability to be managed without maintenance ECT, or when the side-effect burden of ECT outweighs the benefits 17

20 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 (Ref: Richard Barnes Chapter 9, RCP the ECT Handbook 2 nd edition 2005) 8 Procedure for the Discontinuation of ECT 8.1 Overview The prescribing and discontinuation of ECT are the decisions of the patient s Consultant/RC. However, the decision to discontinue ECT may also take place in the context of discussions with the ECT Consultant and/or Anaesthetist in the light of adverse reactions to ECT such as cognitive problems or anaesthetic problems Discontinuation may also take place because of poor efficacy or, most importantly, because the patient has withdrawn consent The clinical status of a patient should always be assessed between each ECT session and treatment should be stopped when a response has been achieved A patient should not receive more treatments than is required to achieve an adequate response, even if more have been prescribed, hence the patient must be reviewed after each treatment during the treatment course. 8.2 Recommendations (from ECT Handbook, 2005) A set course of treatments should not be prescribed the need for further treatments should be assessed after each individual treatment Bilateral ECT If no clinical improvement at all is seen after 6 properly given bilateral treatments, then the course should be abandoned It may be worth continuing up to 12 bilateral treatments before abandoning ECT in patients who have shown definite but slight or temporary improvement with early treatments Unilateral ECT For patients who do not respond to unilateral ECT, consideration should be given to switching to bilateral treatment. It will be necessary to reiterate seizure threshold in this case. 18

21 9 Procedure for Out-patient ECT 9.1 The Procedure aims to provide a safe, high quality service for patients receiving ECT on an out-patient basis. 9.2 Actions The prescribing doctor must consider the following: Past and present medical conditions, (e.g. cardiac/chest problems, previous anaesthetic complications). Please refer to guidelines for anaesthesia A previous course of ECT and any side effects or complications Patient s domestic situation (e.g. who they live with and if support from a responsible adult is available at home for a continuous 24 hours post treatment and between treatments). If domestic situation cannot accommodate this, consideration can be given to alternatives, i.e. overnight stay in a hostel with appropriate staffing or admission for night post treatment Patient s reliability in remaining nil by mouth pre-ect, and in taking medication as prescribed and directed (e.g. if on cardiac, diabetic therapy or benzodiazepines) History of ongoing suicidal ideation; to be aware that suicide risk may increase in early stages of treatment when volition may improve The prescribing doctor should contact the ECT Department to discuss the patient and book in the treatment session The prescribing doctor must ensure all necessary investigations have been carried out (adhere to the procedure for the preparation of patients for ECT ) The prescribing doctor must ensure that all documentation is completed and signed as appropriate, e.g. consent form, prescription form The prescribing doctor must give patient and carers written information (Trust s ECT information leaflet and NICE patient information booklet) and provide an opportunity to view the ECT patient information video (if available) The patient and carer should be offered a visit to the Department and to meet with a nurse from ECT to discuss any further concerns or queries they may have The patient and carer must be informed of the necessity to remain nil by mouth from midnight on the day of treatment. 19

22 9.2.8 The patient and carer must be informed of any medication that they may need to take on the morning of treatment. (To be encouraged to take 2 hours before treatment with a sip of water if appropriate.) The prescribing doctor should ask both patient and carer to read and sign a copy of the disclaimer form to confirm that they are aware of all the important information. A copy of the disclaimer form to be given to the patient The patient s medical notes and ECT documentation should be forwarded to the Department prior to treatment The Crisis Team may be requested to provide support If treatment is to proceed, a letter informing the patient s GP should be sent out. A letter should also be sent at the end of treatment detailing the patient s response The patient will be advised of an appointment time to attend the Department. They should be escorted by community staff, if possible, and it will be their responsibility to complete Part 1 of the nursing checklist for ECT patients and the ECT documentation checklist. They should remain with the patient throughout treatment and recovery On the morning of treatment the ECT staff will complete the checklists and will obtain the patient s signature on the acknowledgement of receipt of information for patients receiving ECT treatment guidelines form The patient should remain in the ECT Department post treatment until fully recovered, awake and orientated to time, place and person. Their initial signs must be within normal baseline range, and they are tolerating diet and fluids The ECT doctor and anaesthetist must establish whether the patient is mentally and physically fit to leave and record this on the post ECT checklist If the doctor feels that the patient is not medically fit to leave, but they insist on going home, the implications of this course of action should be fully discussed with the patient and accompanying responsible adult and the patient s decision should be recorded in their progress notes The patient should be reviewed between each treatment (the minimum standard is between every 2 treatments), including assessment of cognitive functioning (MMSE recommended by the RCP). All significant changes should be conveyed to the ECT team Clients should be accompanied home by their community nurse, if possible, or a responsible adult. 20

23 10 Procedure for Out of Hours ECT 10.1 The services currently provide regular treatment twice weekly 9.00 am to noon except for Bank Holidays when the Monday sessions will be postponed until Tuesday morning Requests for Electro Convulsive Therapy outside of these days and times and within working hours (9.00 am to 5.00 pm) should follow the appropriate Procedure as follows: Such treatments must be negotiated in advance with the nurse in charge of the ECT department and, wherever possible, allowing 24 hours notice It is the responsibility of the ward/department/medic requesting treatment to contact the local anaesthetic department to arrange an anaesthetist and contact the theatre manager to arrange an anaesthetics nurse. Consideration may need to be given to the location of the treatment, as on some occasions it will be necessary to conduct out of hours ECT within an operating theatre list It is the responsibility of the ward/department referring doctor to arrange to have an appropriate doctor available to administer the treatment. This will usually be the on call doctor (the ECT team will establish if the on call doctor has undertaken ECT training and advise the referring doctor accordingly). Should there be a need; the referring doctor will liaise with the second on call or on call Consultant in order that the treatment can be administered Referrers should be aware that there is no formal system in place to provide an out of working hours on call system for nursing staff with the ECT department. Therefore, it may no be possible to provide a nurse from within the service out of hours. The ECT nursing team is committed to providing a safe and effective service, and has, on occasion, facilitated out of hours ECT in order to ensure that patients receive treatment. However, this is a voluntary arrangement and must be negotiated with the nursing team in advance 10.3 Bank Holiday arrangements Tranwell Unit, St. Georges Park and Hadrian clinic: Whenever ECT would fall on a Bank holiday Monday the session will be rearranged for the following day (Tuesday) 21

24 11 Recommendations Regarding Laterality of ECT 11.1 (ECT Handbook, Royal College of Psychiatrists, January 2004) 11.2 Unilateral electrode replacement is strongly recommended as the initial treatment in any prescription beyond the NICE guidance. It would, in any case, be good practice in the treatment of illnesses that are not life threatening or severe. At this point, neither unilateral nor bilateral electrode placement is a treatment of choice in all indications for ECT. The selection of electrode placement should, where possible, be part if the process of informed consent for ECT: Where the rate of clinical improvement and completeness of response have priority, bilateral placement is preferable Where minimising the cognitive adverse effects has priority, unilateral placement is preferable. This may be particularly relevant in neuropsychiatric conditions such as Parkinson s Disease 11.3 Bilateral electrode placement will also be preferred: Where the index episode of illness or any early episode of illness has not been treated successfully with unilateral ECT Where determining cerebral dominance is difficult in the treatment of mania, where the optimal technique for the use of unilateral ECT has not been established 11.4 Unilateral electrode placement will also be preferred: Where the rate of clinical improvement is not critical. Where there is a history of recovery with unilateral ECT 11.5 In patients who are right handed, unilateral ECT will be given as right unilateral ECT to the non-dominant hemisphere. In patients who are left handed bilateral electrode placement might be preferred. 12 Privacy and Dignity 12.1 Maintaining Privacy and Dignity is particularly important within ECT sessions, where patients are increasingly vulnerable when unconscious/semi conscious for some time due to receiving anaesthesia Privacy and Dignity principles as outlined in Essence of Care Standards should be adhered to by staff throughout the treatment process. 22

25 12.3 Care should be taken to ensure no inappropriate clinical discussions are overheard by patients in the immediate pre and post treatment phases (hearing is the first sense to cease upon administration of the anaesthesia and the first to be regained during recovery) The recovery areas should be constructed to protect Privacy and Dignity e.g. adequate screening if the area is multifunctional, screening in-between individual recovery bays. Background noise should be kept minimal. Patients should be appropriately and adequately covered at all times when on a trolley (patients are prone to lowering body temperature when receiving anaesthesia) and their individual interest safeguarded at all times. 13 Reference list The ECT Handbook 2 nd Edition The Third Report of the Royal College of Psychiatrists, Special Committee on ECT published 2005, edited by Allan I F Scott National Institute of Clinical Excellence Guidance on the use of Electro Convulsive Therapy Technology Appraisal 59 April 2003 Standards for Administration of ECT The ECT Accreditation Services (ECTAS) - Tenth edition December 2012 Management of depression in primary and secondary care clinical Guideline October 2009 NICE Depression Guidelines - ines&newsearch=true#/search/?reload 23