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

Transcription

1 South Staffordshire and Shropshire Healthcare NHS Foundation Trust ECT Care Pathway (prescriber to complete except where otherwise stated) 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. Page 1 of 51 of ECT Pathway 15/03/2017

2 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 2 of 51 of ECT Pathway 15/03/2017

3 2. Patient Information(prescriber to complete) Patient s Name Patient No: Ward Gender Male Female Consultant of Birth (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 3 of 51 of ECT Pathway 15/03/2017

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5 Surname Forename 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 Surname Print Name Forename P Number 4.Consent Form (Consultant or team doctor to complete) Page 5 of 51 of ECT Pathway 15/03/2017

6 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 I confirm that the patient s presentation concurs with the findings of any previous capacity assessment including those patients who have received a formal second opinion under the relevant Mental Health Act before each treament Signed: Name: (PRINT) Job Title: Contact details (if patient wishes to discuss options later) (via secretary) 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) Page 6 of 51 of ECT Pathway 15/03/2017

7 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 7 of 51 of ECT Pathway 15/03/2017

8 Surname Forename 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 8 of 51 of ECT Pathway 15/03/2017

9 Surname Forename P Number Confirmation of Consent To be completed by an Administrator 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 9 of 51 of ECT Pathway 15/03/2017

10 Surname Forename P Number Confirmation of Consent To be completed by an Administrator 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: Signed: Name: (PRINT) MHA status Job Title: Page 10 of 51 of ECT Pathway 15/03/2017

11 Surname Forename P Number 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 11 of 51 of ECT Pathway 15/03/2017

12 Surname Forename 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 12 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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 Prescription ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comment s e.g. re Dose prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) First Prescription Baseline CGI Score (refer to page 23) Bilateral Page 13 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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) ECT Prescription Comments e.g. re Dose prescripti on Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) CGI Score (refer to page 23) Bilateral Page 14 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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) CGI Score (refer to page 23) Bilateral Page 15 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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) CGI Score (refer to page 23) Bilateral Page 16 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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) CGI Score (refer to page 23) Bilateral Page 17 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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) CGI Score (refer to page 23) Bilateral Page 18 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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 prescripti on Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) CGI Score (refer to page 23) Bilateral Page 19 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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 prescripti on Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) CGI Score (refer to page 23) Bilateral Page 20 of 51 of ECT Pathway 15/03/2017

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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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) Comment s e.g. re Dose ECT Prescription prescription Written Signature of Name (Print) of Grade of (must be Consultant, Associate Specialist, ST4 and above) CGI Score (refer to page 23) Bilateral Page 21 of 51 of ECT Pathway 15/03/2017

22 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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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 Prescription ECT Session Number Type of ECT bilateral / Unilateral. Where appropriate Check Patient s preference (Consent form) Comments e.g. re Dose prescription Written Signature of Name of (Print) Grade of (must be Consultant, Associate Specialist, ST4 and above) CGI Score (refer to page 23) Bilateral Page 22 of 51 of ECT Pathway 15/03/2017

23 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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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) CGI Score (refer to page 23) Bilateral Page 23 of 51 of ECT Pathway 15/03/2017

24 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 Form T4 - certificate of consent to treatment [ECT] completed) (MHA 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) CGI Score (refer to page 23_ Bilateral Page 24 of 51 of ECT Pathway 15/03/2017

25 CLINICAL GLOBAL IMPRESSION SCALE (for ECT) Patient Details: Prescribing Consultant: Severity of illness: Considering your total clinical experience with this particular population, how mentally ill is the patient at this time (Doctor/nurse to score this before the patient leave the ward on treatment day 0 = Not assessed 4 = Moderately ill 1 = Normal, not at all ill 5 = Markedly ill 2 = Borderline mentally ill 6 = Severely ill 3 = Mildly ill 7 = Among the most extremely ill patients Pre session1= baseline score Pre Session 1 Pre Session 2 Pre Session 3 Pre Session 4 Pre Session 5 Pre Session 6 Pre Session 7 Pre Session 8 Pre Session 9 Pre Session 10 Pre Session 11 Pre Session 12 After Treatment Initiation: Rate total improvement whether or not, in your judgment, it is due entirely to ECT treatment. Compared to his/her condition at start of ECT, how much has he/she changed? 0 = Not assessed 4 = No change 1 = Very much improved 5 = Minimally worse 2 = Much improved 6 = Much worse 3 = Minimally improved 7 = Very much worse Pre Session 2 Pre Session 3 Pre Session 4 Pre Session 5 Pre Session 6 Pre Session 7 Pre Session 8 Pre Session 9 Pre Session 10 Pre Session 11 Pre Session 12 /patient s nurse to ensure that this scoring is completed regularly. First scoring MUST be done prior to start of ECT. Ward staff to ensure that scoring is complete BEFORE patient leaves for ECT. Page 25 of 51 of ECT Pathway 15/03/2017

26 Surname Forename 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. Pre ECT Patient Score 3 mths post 6 mths post Maximum Points 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 5 Spell the word WORLD backwards (DLROW) 4. Recall Repeat the three words I asked you to say earlier 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 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 the 3 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 26 of 51 of ECT Pathway 15/03/2017

27 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 27 of 51 of ECT Pathway 15/03/2017

28 Surname Forename P Number 11. Nursing Checklist for ECT Patient Ward Nurse ECT Nurse To re-check and attend to items 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) 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 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? *Dentures removed documented 17. and properly stored? *Hearing aid / spectacles removed 18. documented and properly stored? Initials (Ward Nurse) Initials (ECT Nurse) Page 28 of 51 of ECT Pathway 15/03/2017

29 Surname Forename P Number 12. Anaesthetic Administration Record by Anaesthetist Please ensure Section 6 has been completed of Treatment Session Number Anaesthetic Drug and Dosage Used Muscle Relaxant Other O² Levels Comments / Complications Change of ASA Signature of Anaesthetist Page 29 of 51 of ECT Pathway 15/03/2017

30 13. Treatment Administration by ECT Doctor Key to Visible Fit Intensity : 0 = No Fit 1 = V. Well Mod Fit 2 = Well Mod Fit 3 = Brisk Fit 4 Very Brisk Fit MHA Status At prescription Consent/capac ity status (Yes/No) Session / treatment number Dose Setting Electrode placement Bilat / Uni Impedence Visible fit Durati on Visible fit Intensity see above Visible fit bilateral / unilateral EEG fit Duration Anticonvulsants Prescribed and Dosage Comment /Complica tions Signature Bilat Bilat Bilat Bilat Bilat Bilat Bilat Bilat Bilat Bilat Bilat Bilat Page 30 of 51 of ECT Pathway 15/03/2017

31 Surname Forename P Number 14. Recovery Nursing Observation Record Where changes to baseline observations have been observed please inform medical team for further advice. and Start Time Checked with anaesthetist re any problems T BP P SaO 2 Resp Rec Time Rec BP Comments Signature Page 31 of 51 of ECT Pathway 15/03/2017

32 To be performed approximately 3 hours after treatment Post Treatment Observations Surname Forename P Number 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 Respiration 1 hour post treatment Respiration 3 hour post treatment 1.1 Do you know where you are? Do you know what has happened so far Ask today? 1.3 Do you know what time of day it is? 1.4 What is today s date? Can they walk in a straight line or are 2.1 they tending to veer off to one side? 2. Watch for 3. Assess 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? 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? Page 32 of 51 of ECT Pathway 15/03/2017

33 To be performed approximately 3 hours after treatment Post Treatment Observations 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 Respiration 1 hour post treatment Respiration 3 hour post treatment 1. Ask 2. Watch for 3. Assess 1.1 Do you know where you are? 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 Are they being clumsy, not noticing 2.3 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? Page 33 of 51 of ECT Pathway 15/03/2017

34 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 Surname Forename P Number Assess 4.1 What is your home address? 4.2 What school did you go to? What year did you get married? 4.3 (or the date of some major personal event if not married) How old is your son/daughter? (or 4.4 the age of some loved still living person if no living offspring) What are the names of your 4.5 neighbours? Has the person manipulated the cutlery in the usual way, using 5.1 both knife and fork and positioning them normally on either side of the plate? Has the person been able to 5.2 locate all items on the table easily? Has the person seemed to be 5.3 aware of people sitting to their left and right equally? Has the person left food on just 5.4 one side of the plate? Have they been able to manoeuvre their way around the 5.5 ward and/or bedroom easily or have they seemed clumsy? Has the person returned to a 6.1 normal level of wakefulness? Page 34 of 51 of ECT Pathway 15/03/2017

35 Post treatment observation Surname Forename P Number 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 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 35 of 51 of ECT Pathway 15/03/2017

36 Surname Forename P Number 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, in accordance with DVLA guidance, operate machinery, drink alcohol or sign legal documents for the whole duration of your ECT treatment and 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) Page 36 of 51 of ECT Pathway 15/03/2017

37 Surname Forename P Number... 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 37 of 51 of ECT Pathway 15/03/2017

38 Surname Forename P Number 16c. ECT Out Patient s Treatment Instructions This fact sheet provides additional information for patients receiving ECT as an outpatient. 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. You will be accompanied home following each ECT treatment 7. You should NOT DRIVE a motor vehicle; operate machinery or SIGN ANY IMPORTANT DOCUMENTS for the whole duration of the course of ECT treatment. You should seek the advice of your Consultant, Clinical Team or GP regarding the appropriateness of resuming these actions. 8. You will have appropriate direct supervision by a responsible adult for 24 hours following each ECT 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 38 of 51 of ECT Pathway 15/03/2017

39 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 39 of 51 of ECT Pathway 15/03/2017

40 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: 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 Met Not Met Not Met Page 40 of 51 of ECT Pathway 15/03/2017

41 Surname Forename P Number The following are recorded between treatment sessions: 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 Met Not Met 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 Met Not Met Only complete questions 31 to 41 for informal patients For patients that consented to ECT: 31. There is a signed consent form Met Not Met 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 Met Not Met 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 Not Met Page 41 of 51 of ECT Pathway 15/03/2017

42 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 42 of 51 of ECT Pathway 15/03/2017

43 ELECTROCONVULSIVE THERAPY (ECT) Q. What is ECT? 1: How ECT is given ECT (Electroconvulsive Therapy) is a treatment used in psychiatry for severe mental illness/distress. It was originally developed in the 1930s and was used very widely during the 1950s and 1960s for a variety of conditions. Since then its use has declined. Page 43 of 51 of ECT Pathway 15/03/2017

44 ECT has changed a lot in recent years and modern ECT is undertaken only occasionally in severe illnesses. Usually the person having it will be in hospital, though many units can now offer ECT as a day case treatment. ECT remains a controversial treatment, which some people have very strong feelings about. There are those who claim it can be a life-saving procedure while others feel it should be banned. Q. How is ECT given? ECT is a way of causing someone to have a seizure, and it is this seizure that is needed for the treatment to work. The seizure is made to happen by passing an electrical current across the person's brain in a carefully controlled way from a special ECT machine. The current can be given to the whole brain (bilateral ECT) or just one side (unilateral ECT). The seizure itself is very similar to the seizures that occur in people with certain types of epilepsy, but it is caused on purpose in very controlled circumstances. ECT does not cause epilepsy. Just like in a surgical operation, the person will have an anaesthetic before the treatment and will also receive a muscle relaxant so the physical effects of the seizure are as small as possible. By finding the right dose of electricity, the ECT team will try to cause a seizure between 10 and 50 seconds long. A senior anaesthetist gives the anaesthetic and the person will have heart, blood pressure, breathing, oxygen levels, etc monitored while they are asleep. Many units also monitor the brain waves during the seizure using an electroencephalograph (EEG) machine. The person is unconscious for around 5 minutes, though they take longer to fully recovery from the anaesthetic. Most units give ECT twice a week. Q. Where is ECT given? ECT should always be given in a special ECT suite. This suite should have separate places for people to wait, have their treatment, wake up fully from the anaesthetic and then recover properly before leaving the suite. There should also be enough properly Page 44 of 51 of ECT Pathway 15/03/2017

45 qualified staff to look after the person all the time they are there so any distress is kept to a minimum. Q. What happens during ECT? From the point of view of the person having ECT, they should arrive at the ECT suite with an experienced nurse who they know and who is able to explain what is happening to them. Many ECT suites are happy for family members to be there. When the person arrives in the suite they should be met by a member of the ECT staff, who will do routine physical checks if these have not already been done. The staff member will also check that the person is still happy to have ECT and there will be someone else to answer any particular questions. When the person is ready they will be accompanied into the treatment area and be helped onto a trolley. The anaesthetist and anaesthetic assistant will connect monitoring equipment to check their heart rate, blood pressure, oxygen levels, etc. They may also be connected to an EEG machine, to check the brain waves (a way of measuring normal brain activity). A needle will then be put into a small vein, probably on the back of their hand, though which the anaesthetist will give the anaesthetic drug and, once they are asleep, a muscle relaxant. While the person is going off to sleep the anaesthetist will also give them oxygen to breathe. Once the person is asleep and fully relaxed a doctor will give the treatment. The muscle relaxant wears off quickly (within a couple of minutes) and as soon as the anaesthetist is happy that the person is waking up, they will move through to the recovery area, where an experienced nurse will monitor them until fully awake. Most ECT suites have a second area for light refreshments. The person will leave the suite when they feel ready and when everyone is happy they are OK. The whole process usually takes around half an hour. Q. What about bilateral and unilateral ECT? In bilateral ECT, the electrical current is passed across the whole brain; in unilateral ECT, it is just passed across one side. Both of them cause a seizure in the whole of the brain. Although there is a lot of research being done, it's still not clear which type of ECT is "best". Bilateral ECT seems to work more quickly and effectively and it's probably the most widely used in Britain; however, bilateral ECT seems to cause more side effects. Unilateral ECT has fewer side effects, but may not be as effective; unilateral ECT is also more difficult to do properly. Sometimes ECT clinics will start a course of treatment with bilateral ECT and switch to unilateral if the patient experiences side effects. Alternatively they may start with unilateral and switch to bilateral if recovery isn't happening. The choice of bilateral or unilateral ECT will depend on the needs and wishes of the patient, the opinion of their doctor and the skills of the ECT team. Q. How many times is ECT given? Most units give ECT twice per week, often on a Monday and Thursday, or Tuesday and Friday. It is impossible to predict how many treatments someone will need, however, in general it will take 2 or 3 treatments before any response is seen and people start to Page 45 of 51 of ECT Pathway 15/03/2017

46 improve after 4 to 5 treatments. Some people having ECT report others tell them they are looking better before they feel so themselves. On average, a course will usually last for 6 to 8 treatments though some times as many as 12 may be needed. If someone has shown no response at all after 12 treatments it is unlikely that ECT is going to help. A doctor should see the person after each treatment and their consultant see them after every two. ECT should be stopped as soon as the person has made a recovery or at any time if they withdraw their consent. Q. What happens after ECT? Even when someone finds it effective, ECT is only a part of the treatment. It can help to ease problems so that the sufferer is able to look at why they became unwell. Hopefully they can then take steps to continue their recovery and perhaps find ways to make sure the situation doesn't happen again. Psychotherapy and counselling might help and many sufferers also find their own ways to help themselves. Medication is usually needed to help to maintain the benefits. Certainly people who have ECT and then do not have other forms of help are at very high risk of quickly becoming unwell again. Q. What if I really don't want ECT? If you have very strong feelings about ECT you should make them known to relevant people, who would include the doctors and nurses caring for you, but also friends, family or other advocates who can speak for you. Doctors must consider these views when they think about what to do. If you have made it very clear that you do not wish to have ECT then you should not receive it. Q. How do I know if ECT is carried out properly locally? The Royal College of Psychiatrists has set up the ECT Accreditation Service (ECTAS) to provide an independent assessment of the quality of ECT services. ECTAS sets very high standards for how ECT is given, and visits all the ECT suites signed up to it. The visiting team involves psychiatrists, anaesthetists, nurses and lay people. It publishes the results of its findings and also provides a forum for sharing best clinical practice. Membership of ECTAS is not currently compulsory but your ECT suite will be able to tell you if they have signed up to ECTAS, what their most recent report was and who to speak to if you are concerned that your local suite has not been assessed. Q. Who might benefit from ECT? 2: The Pros and Cons of ECT Recently, the National Institute of Clinical Excellence (NICE) have looked in detail at the use of ECT and have agreed it is an effective treatment for severe depression, severe mania and catatonia. In general ECT is mostly used for severe depression, though some research suggests it may be helpful in Parkinson's disease and possibly other neurological conditions. Page 46 of 51 of ECT Pathway 15/03/2017

47 Q. Who would not benefit from ECT? ECT is unlikely to help those with mild depression or most other psychiatric conditions including personality disorders. NICE have specifically stated that it has no role in the general treatment of schizophrenia. Q. What are the side effects of ECT? This is one of the areas of greatest disagreement. ECT is a major procedure where, over a few weeks, someone has several seizures and several anaesthetics. It is used for people with severe illness/distress who are very unwell, sometimes life-threateningly. As may then be expected, ECT can cause a number of side effects, some mild and some more severe. There are a number of less severe side effects that relate to each individual treatment. Many people complain of a headache immediately after ECT and of a general aching in their muscles. They may feel muzzy-headed and generally out of sorts, or even nauseous. Some are quite distressed after the treatment and may be tearful or frightened during recovery. For most people, however, these effects settle within a few hours, particularly with the help of paracetamol, some light refreshment and a supportive environment The greater concern is for the long-term side effects, like irreversible memory loss or personality change. Surveys conducted by scientists and members of the medical profession usually find a low level of severe side effects, maybe around 1 in 10. Those conducted by user groups have found much more, maybe half of those having them. Some surveys conducted by those strongly against ECT say there are severe side effects in everyone. Clearly, no one is certain. Older people may be quite confused after a treatment and this can persist for two or three hours. It is possible to change the way the ECT is done (such as using unilateral ECT) to reduce this. Many people complain of problems with memory indeed some difficulties with memory are probably present in everyone with severe depression receiving ECT. This is usually a loss of memory for the treatment itself and maybe an hour or two before and after. Some people some would say many also have problems with memory for past events, even very significant ones such as the birth of a child. Most people find these memories return when the course of ECT has finished and a few weeks have passed. There are people who complain their memory has been permanently affected and the memories never come back. It is not clear how much of this is due to the ECT and how much is due to the depressive illness, or other factors such as how the person feels about the treatment they have had, or even how they feel about themselves. There are people who complain of even more distressing experiences, such as feeling their personalities have changed, they have lost skills or they are no longer the person they were before ECT. They say that they have never got over the experience and feel permanently harmed. Page 47 of 51 of ECT Pathway 15/03/2017

48 Q. What may happen if ECT is not given? ECT is never the only alternative, although the doctor prescribing it may feel it represents the best chance of recovery. If someone with severe depression declines ECT there are a number of possibilities. The medication may be changed or new drugs added. A referral for counselling or psychotherapy may be appropriate. Alternatively, the doctors and nurses may look at ways of helping the person change aspects of their life that are causing the depression. Usually, a combination of all 3 of these will be used. Q. Does ECT really work? It has been suggested that ECT works not because of the fit, but because of all the other things like the extra attention and support and the anaesthetic that happen to someone having it. There have been several research studies comparing standard ECT with "sham" ECT. In "sham" ECT, the patient has exactly the same things done to them including going to the suite and the anaesthetic and muscle relaxant but no electrical current is passed and there is no fit. In these studies, those patients who had standard ECT were much more likely to recover and did so much quicker than those who had "sham" treatment. Also those who didn't have adequate fits did less well than those who did. Interestingly, a number of the patients having "sham" treatment recovered too, even though they were very unwell; it's clear that the extra support has an important role too. However, when prescribed to the right people, ECT has been shown to be the most effective treatment for severe depression. Q. How does ECT work? No one is certain how ECT works. There is a lot of evidence that ECT causes changes in the way the brain works, but there is disagreement about the exact effects that lead to improvement. Those who support ECT say that in very severe types of depression certain parts of the brain are not working normally, because of changes in the brain chemicals that allow nerves to "talk" to each other. ECT alters the way these chemicals are acting in the brain and so help a recovery. People against ECT say it works by 'concussing' and damaging the brain, or even that it has no effect at all other than to make patients say they feel better in order to avoid having it. Q. How is ECT controversial? 3: Controversies in ECT There are many areas of disagreement about ECT, including whether it should even be used at all. The main areas of disagreement are over whether it works, how it works and what the side effects are. Some of the arguments about this are covered in "The Pros and Cons of ECT". Page 48 of 51 of ECT Pathway 15/03/2017

49 Q. Why is ECT still being given? ECT is used much less than in the past and is mostly now a treatment for severe depression. This is almost certainly because modern treatments for depression like anti-depressants, psychotherapy (talking treatments) and other psychological and social supports are much more effective than in the past. Even so depression can still be very severe indeed with extreme withdrawal and reluctance, or inability to eat, drink or communicate properly. Occasionally people may also develop strange ideas (delusions) about themselves or others. In these circumstances, where other treatments may not have worked, ECT may be considered a worthwhile alternative. The scientific evidence we have is that ECT is still the most powerful treatment for severe depression Some people who have had ECT before and found it helpful, request it if they become unwell again. Q. When is ECT given without consent? The majority of ECT treatments are given to people who have consented to it. This means that they have had a full discussion of what ECT involves, why it is being considered in their case and all the advantages and disadvantages, including a discussion of side effects. Sometimes, however, people become so unwell that they are unable to take onboard all of the issues perhaps because they are severely withdrawn or have ideas about themselves that stop them fully understanding their position (e.g. they believe what is happening to them is a punishment they deserve). In these circumstances it is impossible for them to give proper consent. When this happens, if the clinical team think that ECT would still help, it is possible to give ECT but only after the patient has first been assessed by their own GP and a social worker, and then has had a second opinion from an independent specialist. The clinical team should also speak to family and other advocates, to consider their views and any views the patient may have expressed before. This process almost always involves the use of the Mental Health Act, which means the patient, and their family, have a right of appeal against parts of their treatment. Giving ECT to someone who is actually refusing to have it, whilst possible in the above circumstances, is actually very rare. Some people who have had ECT complain that they were not properly informed of the risks and benefits, and say that they wouldn't have had ECT if they had known more. It is the responsibility of the team looking after the patient to be sure that they are fully informed about all the relevant things to do with ECT. Q. Why do people disagree so strongly? People tend to have very strong feelings about ECT, often based on their own experiences. Many doctors will say they have seen patients successfully treated with it and have found very severe depressive illnesses completely lifted. Some will even say that it has saved people's lives. People who have had ECT will also express these views. Some who have had ECT complain of severe side effects, or say it has been used inappropriately in their case, or not properly explained or even forced on them. Others Page 49 of 51 of ECT Pathway 15/03/2017

50 (including a variety of mental health professionals) feel there is something basically wrong, cruel or inhumane about ECT and these widely ranging views means that obtaining agreement is often difficult. Q. Isn't ECT banned? ECT has never been banned in Britain or in the USA. Some countries in Europe and the rest of the world (and some states in America also) have restricted its use. The reasons behind these restrictions are complicated. At the moment, ECT is part of standard psychiatric practice in Britain and the majority of countries worldwide. Q. What do the people in favour of ECT say? Those in favour of ECT say it is an effective treatment, particularly for severe depression, which works when other treatments have not. They believe it causes a clinical improvement, which may be very significant indeed, and they say it can be life saving. They feel it is an important option in psychiatric practice and the overall benefits are greater than the risks. There is much research being done to improve ECT practice and reduce its side-effects Q. What do the people against ECT say? There are many different views and many different reasons why people object to ECT and it is wrong to generalise. However, many say that ECT is an inhumane and degrading treatment, which belongs to the past. They say that the side effects are severe and that psychiatrists have either accidentally or deliberately ignored how severe they can be. They say that ECT permanently damages both the brain and the mind, and if it does work at all, does so in a way that is ultimately harmful for the patient. Most would see it banned. Q. Where can I get more information? Many ECT suites provide their own information packs and they should be able to give written information to patients or their family/carers before a course starts. If the suite has been approved by ECTAS, then they will have ensured the information is balanced. The Internet has many sites discussing ECT that are produced by professionals, organisations, people who have had ECT, or others with particular opinions. There are more negative than positive websites. You may wish to get information from several sources before making up your own mind. Since people often express their views on ECT very forcefully (either against or for) it can be hard to be sure what to believe. Most do agree, however, that people who are considering ECT and their families and others should try to understand as much as possible about it so they can make a decision that is right for them. Page 50 of 51 of ECT Pathway 15/03/2017

51 Further Information National Institute for Health and Clinical Excellence (NICE). Electroconvulsive therapy (ECT): the clinical effectiveness and cost effectiveness of electroconvulsive therapy (ECT) for depressive illness, schizophrenia, catatonia and mania. Scottish ECT Accreditation Network (SEAN). A site designed to complement the work of SEAN, by enabling communication of the latest information on ECT in Scotland. Electroconvulsive Therapy Accreditation Services (ECTAS). Launched in May 2003, ECTAS aims to assure and improve the quality of the administration of ECT; awards an accreditation rating to clinics that meet essential standard. This leaflet was produced by the Royal College of Psychiatrists' Public Education Editorial Board. Author: Dr Richard Barnes With input from the Royal College of Psychiatrists' Special Committee on ECT and related treatments. About our leaflets Readers comments Produced: January 2007 [2007] Royal College of Psychiatrists and the Mersey Care NHS Trust. This leaflet may be downloaded, printed out, photocopied and distributed free of charge as long as the Royal College of Psychiatrists is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from the Head of Publications. The College does not allow reposting of its leaflets on other sites, but allows them to be linked to directly. For a catalogue of public education materials or copies of our leaflets contact: Leaflets Department The Royal College of Psychiatrists 17 Belgrave Square London SW1X 8PG Charity registration number Page 51 of 51 of ECT Pathway 15/03/2017