Appendices.

Appendix One.

Salford Health Authority Mental Health Unit - E.C.T. Guidelines for the preparation and care of patients undergoing E.C.T.

1)Prior to the prescription and commencement of E.C.T. the following must be undertaken as indicated:

a)HB-all patients

sickle cell test if indicated

U & Es-if on lithium / diuretics / I.V.I.s

Urine-routine urinalysis including glucose

E.C.G.-men over 40 years of age-women over 45 years of age

-also any patient who is hypertensive or has a history of heart disease

C.X.R.-only if chest symptoms or previous history of respiratory disease.

b)A full physical examination must be undertaken unless one has been recorded in the preceding 4 weeks.

1. Signed consent form pinned to front cover of notes and current medication sheets must accompany patient.
2. Identity bracelets must be worn.
3. Nurses who do escort duty to E.C.T. must know patient.
4. Wards sending more than 3 patients are required to send a minimum of 2 staff.

If these guidelines are not adhered to, E.C.T. will not be given.

January 1990.

Mental Health Services of Salford N.H.S. Trust - E.C.T. Guidelines.

1) PRIOR TO COMMENCING E.C.T.:

1. A full physical examination must be undertaken, and the findings recorded on the E.C.T. chart.
2. The following investigations must be performed, as appropriate, and the results clearly visible in the patient's notes.

FBC: All patients

Sickle Test: If indicated on the basis of ethnic origin

U & EIf on diuretics, Lithium, I.V.I.s, Potassium supplements

Glucose: All diabetics

Urinalysis: All patients

E.C.G.: All patients over 45 years of age; Any patient who is hypertensive, diabetic or has a history of heart disease

C.X.R.: Only if history of respiratory disease, or on-going chest symptoms

1. A signed consent form, or up-to-date Section form, should be in the front of the patient's notes.
2. The current medication sheet must accompany the patient.
3. Identity bracelets should be worn by all patients.
4. Nurses escorting patients to E.C.T. should ideally know them, or at the very least, have been given some background information about the patient's condition or any recent changes in condition, treatment, or pre-medication that is relevant to the anaesthetic and E.C.T.
5. Wards sending more than 3 patients are required to send a minimum of 2 staff.

Current anaesthetic recommendations stress the importance of adequate supervision of any patient having any anaesthetic on a day-case basis, however minor the procedure.

Those patients who DO NOT LIVE ALONE require a responsible adult to accompany them home, after lunch, and subsequently take responsibility for them at home.

Those patients WHO DO LIVE ALONE should be kept in hospital overnight following treatment.

Patients transferred between Hope and Prestwich for E.C.T. must be accompanied by at least one qualified member of staff.

In the interest of patient safety, if these guidelines are not adhered to, then E.C.T. will not be given. November 1996.

Salford Royal Hospitals N.H.S. Trust.

Criteria for Day Surgery.

Guidelines for Referral of Patients Requiring General or Regional Anaesthesia.

NON-MEDICAL FACTORS.

1. Distance between Hospital and home no more than 60 minutes travelling time.
2. Access to transportation. Public transport should not be used.
3. Patients should have telephone communication with the Hospital.
4. No patient should be alone at night after the operation.

MEDICAL FACTORS.

1. Age. No patient over 75 years.
2. Length of operation. Surgical procedures should be capable of completion within 90 minutes of start of general anaesthetic, but this is not a hard and fast rule.
3. Physical status. All patients should be A.S.A. Grades I or II - rarely III.

A.S.A. I-A normal healthy patient.

A.S.A. II-A patient with mild to moderate systemic disease caused by the condition to be treated surgically or by any other disease.

A.S.A. III-Severe systemic disease or disturbance from any cause.

Patients with Grade III who might be considered suitable for day surgery anaesthesia are those with chronic arthritic disease or chronic haemolytic disease.

Occasionally some apparently Grade I patients are not suitable - e.g. those with:

1. Sickle cell disease.
2. Malignant hyperpyrexia.
3. Porphyria.

MORE DETAILED CONTRA-INDICATIONS TO DAY SURGERY ANAESTHESIA. CARDIOVASCULAR DISEASE.

1. Myocardial infarction within the preceding six months.
2. Hypertension. B.P. above 175/100 mm Hg.
   Resting pulse rates below 50/mm and above 100/mm require further investigation.
3. Cerebro-vascular insufficiency.
4. Cardiac failure.
5. Heart block other than type I.

RESPIRATORY DISEASE.

1. Severe bronchitis and emphysema.
2. Severe asthma.
3. Severe bronchiectasis.
4. Acute respiratory infections.

MUSCULO-SKELETAL CONDITIONS.

1. Conditions causing reduction in vital capacity, e.g. kyphoscoliosis.
2. Conditions making endotracheal intubation difficult, e.g.:

1. ankylosis of temporal mandibular joints.
2. Congenital defects of head, neck and jaws.
3. Ankylosing spondylitis.

NERVOUS SYSTEM.

1. Motor neurone disease.
2. Muscular dystrophies and myotonic disorders.
3. Severe epilepsy.

HAEMATOLOGY.

1. 1. Coagulation defects.
2. Severe haemolytic anaemias.
3. Anti-coagulant therapy.

ENDOCRINE.

1. Unstable diabetics on insulin or oral hypoglycaemic agents.
2. Obesity, i.e. greater that 20% above ideal weight for age and sex.

PREGNANCY.

Appendix Two.

Salford Health Authority Mental Health Unit.

Procedure Guidance Notes on the Mental Health Act 1983. Subject: Consent to Treatment.

Code:PGN CONS
Date Published:December 1992.
Review Date:December 1994.

This guidance has been prepared as reference information for staff within the Mental Health Unit.

Introduction.

1. Detailed information has been prepared on this subject in the "Quality statements, guidelines and procedure folder" under "Consent to treatment [Mental Health Act 1983]".

2. To aid staff identify the correct procedure, flow charts and appropriate forms have been attached: -

Consent to treatment after the first 3 months - flow chart attached - Appendix 1.

Consent to treatment at review of treatment - flow chart attached - Appendix 2.

Certificate of consent to treatment - Form 38 [when patient consents].

Certificate of second opinion - Form 39 [when patient does not consent].

Annex AMHAC 1 form

[completed by R.M.O., when appropriate, on renewal of section and forwarded to Mental Health Act Commission].

Section 62 - urgent treatment

[when patient urgently requires medication or E.C.T.].

Mental Health Services of Salford. An N.H.S. Trust.

Procedure.
Subject:Consent to Treatment.
Code:PGN.CONS
Date Published:March 1995.
Review Date:October 1999.

This guidance has been prepared as reference information for staff within the Mental Health Unit.

Introduction.

1. Detailed information has been prepared on this subject in the "Quality Statements, Guidelines and Procedure Folder" under "Consent to treatment (Mental Health Act 1983)".

2. To aid staff identify the correct procedure, flow charts and appropriate forms have been attached: -

Consent to treatment after the first 3 months - flow chart attached - Appendix 1.

Consent to treatment at review of treatment - flow chart attached - Appendix 2.

Certificate of consent to treatment - Form 38 [when patient consents].

Certificate of second opinion - Form 39 [when patient does not consent].

Annex AMHAC 1 form (completed by R.M.O., when appropriate, on renewal of section and forwarded to Mental Health Act Commission).

Section 62 - urgent treatment (when patient urgently requires medication or E.C.T.).

Appendix Three.

PRESTWICH / HOPE HOSPITAL, MANCHESTER.

E.C.T. Consent (Patient).

I ........................................................................... hereby consent to undergo the administration of E.C.T., the nature and effect of which have been explained to me by Dr. .......................................................................

I also consent to the administration of an anaesthetic for this purpose.
No assurance has been given to me that the treatment will be administered by any particular practitioner.

(Date) ...................................(Signed) ..........................................................
(Patient)
____________________________
I confirm that I have explained to the patient the nature and effect of this treatment.

(Date) ...................................(Signed) ..........................................................
(Medical Officer)

Date
Treatment No and Type
Brietal Sodium
Atropine
Anectine
Comments include duration of fit, Cuff method if used, etc.
Initials of both doctors

........................................... HOSPITAL UNIT No. ___________________

FULL NAME (BLOCK LETTERS)
Mr. / Mrs. / Miss
____________________________

WARD OR ADDRESS

_____________________________________________________
(A)ESSENTIAL FACTS:-
(1)DATE OF BIRTH:...................................................

(2)LEGAL STATUS.....................
IF SECTION HAS FORM 38 BEEN COMPLETED. YES/NO
HAS FORM 39 BEEN COMPLETED. YES/NO

(3)ANY ALLERGIES, OR PREVIOUS DRUG/ECT ADVERSE REACTIONS (SPECIFY)
.........................................................................................................

(4)PRIMARY DIAGNOSIS.......................................................
SECONDARY DIAGNOSIS .......................................................

(B)ESSENTIAL PHYSICAL FACTS:-
(1)IS PATIENT RIGHT OR LEFT HANDED .....................................
IS PATIENT RIGHT OR LEFT FOOTED ......................................

IS IT ESSENTIAL FOR PATIENT TO HAVE BILATERAL ECT?.......
(NEW POLICY: UNILATERAL UNLESS REQUESTED OTHERWISE).

(2)CVS:BP
OTHER ABNORMALITIES.............................................
RS:STATE ABNORMALITIES.............................................
SPINE: STATE ABNORMALITIES.............................................

(3)WEIGHT (in Kg)...............................................
RECENT HAEMOGLOBIN LEVEL ..............................................
RECENT ELECTROLITE LEVELS (if abnormal) ..........................

(4)E.C.G. RESULT ..............................................................................

(5)CURRENT MEDICATION (DAY PATIENT. OUTPATIENT ONLY).
.........................................................................................................
.........................................................................................................

SIGNATURE ...........................................DATE ............................................

Appendix Four.

Salford Health Authority Mental Health Unit.
Procedure Guidance Notes on the Mental Health Act 1983.
Subject:Electro Convulsive Therapy
Code:PGN ECT
Date Published:December 1992.
Review Date:December 1994.

This guidance has been prepared as reference information for staff within the Mental Health Unit.

Informal Patients

1. Informal patients who consent to E.C.T. sign the local consent to Electrotherapy / Anaesthetic form.

Detained Patients

2. If the patient is Compulsorily detained (other than a short term detention, i.e. Sections 4, 5(2), 5(4), 136) under the Mental Health Act 1983, a current copy of one of the following forms must be present and should be seen by the Doctor before E.C.T. commences.

FORM 38-Consent to treatment

FORM 39-Certificate of Second Opinion

Section 62-Urgent Treatment.

3. Consent to treatment regulations do not apply to short-term sections and such patients should be treated as for informal patients, i.e. can only have E.C.T. if valid consent is given and they sign the appropriate form as above (1).

4. Flow chart attached - Appendix 1.

Mental Health Services of Salford. An N.H.S. Trust.

Procedure.

Subject:Electro Convulsive Therapy (E.C.T.)
Code:PGN.ECT
Date Published:July 1996.
Review Date:July 2000.
guidance has been prepared as reference information for staff within the Mental Health Unit.
Informal Patients

1. Informal patients who consent to E.C.T. sign the local consent to Electrotherapy / Anaesthetic form.

Detained Patients

2. If the patient is compulsorily detained (other than a short term detention, i.e. Sections 4, 5(2), 5(4), 136) under the Mental Health Act 1983, a current copy of one of the following forms must be present and should be seen by the Doctor before E.C.T. commences.

FORM 38-Consent to treatment

FORM 39-Certificate of Second Opinion

Section 62-Urgent Treatment.

3. Consent to treatment regulations do not apply to short-term sections and such patients should be treated as for informal patients, i.e. can only have E.C.T. if valid consent is given and they sign the appropriate form as above (1).

4. Flow chart attached - Appendix 1.

Appendix Five.

Mental Health Services of Salford - Quality Statement.

Subject:Consent to Treatment (Mental Health Act 1983)
Code:CTT.QST
Date Published:February 1994
Review Date:February 1999
Which deals with consent to treatment. The majority of the information arises directly from the M.H.A. Code of Practice.

1. Part IV of the Act provides specific statutory authority for forms of medical treatment for mental disorder to be given to most patients liable to be detained without their consent in certain circumstances and with certain safeguards. It also provides specific safeguards. Patients liable to be detained are those who are detained or have been granted leave of absence (Section 17). It also provides specific safeguards to all patients when treatments are proposed that give rise to special concern.

2. Its provisions can be summarised as follows:

a)Treatments requiring the Patient's Consent and a Second Opinion (Section 57) Psycho-surgery and the surgical implantation of hormones for the suppression of male sexual drive (exceptionally these safeguards apply to all patients).

b)Treatments requiring the Patient's Consent or a Second Opinion (Section 58) The administration of medicine beyond three months, and treatment by E.C.T. at any time. These safeguards apply to all patients liable to be detained except those detained under S4, S5 (2) or (4), S35, S135, S136 and S37 (4); also patients conditionally discharged under S42 (2) and S73 and S74. All these patients can only be treated under common law.

c)Treatments that do not require the Patient's Consent (Section 63) All medical treatments for mental disorder given by or under the direction of the patient's responsible medical officer and which are not referred to in Section 57 or 58 (this provision applies to the same patients as S58).

d)Urgent Treatment (Section 62) In certain circumstances the provisions of Section 57 and 58 do not apply where urgent treatment is required.

3. Detained status itself does not imply inability to give consent. For all treatments proposed for a detained patient and which may be lawfully given under the Act, it is necessary first to seek the patient's agreement. It is the personal responsibility of the patient's R.M.O. to ensure that the patient's valid consent has been sought and the interview at which such consent was sought should be properly recorded.

Validity of Consent.

4. The responsible medical officer must determine whether the patient is willing to take the medication and whether his consent is valid, i.e. whether he is "capable of understanding the nature, purpose and likely effects of the treatment."

5. If the patients consents validly, the responsible medical officer records this on form 38.

6. If he refuses, or there is doubt about the validity of his/her consent, then a second opinion must be obtained from a doctor appointed for that purpose by the Mental Health Act Commission.

7. Electro Convulsive Therapy always requires either the patient's consent or a second opinion, even where the treatment is given in the first 12 weeks of detention.

Renewal of Consent.

8. The patient's consent, certified on form 38, does not expire. No formal renewals or review are required, but the patient's consent should be reviewed from time to time. Good practice would be for form 38 to be completed at the renewal of each section.

9. The patient is free to withdraw his consent at any time.

10. In the case of patients subject to a form 39, formal reviews of treatment are required. These are recorded on the Mental Health Act Commission's form "Review of Treatment", (Section 61 Mental Health Act).

11. For unrestricted patients, these reviews should occur at each section renewal.

12. For restricted patients, they should occur at the end of the first six months of the order if the treatment under the form 39 began before that time, and then on each occasion when a statutory report to the Secretary of Statefalls due.

Treatments Requiring Consent or a Second Opinion (Section 58).

13. Treatments requiring patient's informed consent or a second opinion currently specified by the Act are E.C.T. treatment and drug treatment of more than three months duration. This applies to patients detained under Sections 2 and 3 and by Court Treatment Orders.

14. Where the patient consents, the responsible medical officer or a medical practitioner appointed by the Commission (Second Opinion Appointed Doctor) will certify that informed consent has been given (form 38).

15. Where the patient does not consent, a second opinion appointed doctor will be requested by the responsible medical officer via Medical Records. On arrival the S.O.A.D. will consult with the R.M.O. and two persons professionally concerned with the patient, one a nurse and the other neither a doctor or a nurse and complete form 38 (if the patient now consents) or a form 39.

16. Once signed, forms 38 and 39 are lodged with other papers relating to the patient's compulsory detention, in the Medical Records Office. Two photocopies must be made, one to be kept with the patient's prescription sheet and the other to be retained with the photocopied section papers.

Medication Before Three Months.

17. This period starts on the occasion when medication for mental disorder was first administered by any means. The patient's responsible medical officer must ensure that the patient's valid consent is sought prior to the administration of any medication. If such consent is not forthcoming or is withdrawn during this period, the responsible medical officer must consider if he wishes to proceed in the absence of consent, consider alternative treatments or give no further treatment.

Medication After Three Months (Section 58).

18. At the end of the three month period referred to above, the patient's responsible medical officer should personally seek the patient's consent to continuing medication and such consent should be sought for any subsequent administration of medication. If the patient consents the responsible medical officer must certify accordingly (form 38). The responsible medical officer should indicate on the certificate the drugs proposed, by the classes described in the British National Formulary (indicating the dosages if they are above the B.N.F. advisory maximum limits) and the method of their administration. If the patient's consent is not forthcoming the responsible medical officer must comply with the safeguard requirements of Section 58 (although for urgent treatment Section 62 may apply).

The Three Month Rule.

19. The three month period gives time for the doctor to create a treatmen programme suitable for the patient's need. Although the patient can be treated in the absence of consent during this period, no such treatment should be given in the absence of an attempt to obtain valid consent. The three month period is not affected by renewal of the detention order, withdrawal of consent, leave or change in or discontinuance of the treatment. A fresh period will only begin if there is a break in the patient's liability for detention.

20. If medication is likely to be continued beyond the three month period the need for consent or a second opinion should be foreseen in good time. The responsible medical officer should satisfy himself at all times that the consent remains valid.

Responsibility for Checking.

21. The Medical Records Department will remind the responsible medical officer to review consent when renewing sections and provide review of treatment forms at the appropriate times for patients subject to second opinions.

22. The responsible medical officer and medical staff will check the twelve week date on the prescription sheet and any existing forms 38 and 39.

Administering Drugs.

23. It is the responsibility of the doctor or nurse to check the prescription sheet and any attached documentation to ensure they have authority to administer the treatment.

Withdrawal of Consent.

24. The patient subject to the provisions of Part IV of the Act may withdraw consent at any time. Fresh consent or the implementing of Section 58 procedures is then required before further treatment can be carried out or re-instated. Where the patient withdraws consent he should receive a clear explanation (recorded in the patient's records) of:

• the likely consequences of not receiving the treatment.
• (where applicable) that a second medical opinion under Part IV of the Act may or will be sought in order to authorise treatment in the continuing absence of the patient's consent.
• (where applicable) the doctor's power to begin or continue treatment under Section 62 until a second medical opinion has been obtained.

Treatments Not Requiring Patient's Consent (Section 63).

25. Apart from treatment specifically mentioned in Sections 57 and 58, other forms of medical treatment for the mental disorder from which the patient is suffering (so long as they are given by or under the direction of the patient's responsible medical officer) may be given without the patient's consent being required (although it should always be sought). Section 63 covers a wide range of therapeutic activities involving a variety of professional staff and includes in particular psychological and social therapies. (See Section 145 of the Mental Health Act 1983 for a definition of medical treatment).

Urgent Treatment.

26. Any decision to treat a patients urgently under Section 62 is a responsibility of the patient's responsible medical officer who should bearin mind the following considerations:

1. Treatment can only be given where it is immediately necessary to achieve one of the objects set out in Section 62 and it is not possible to comply with the safeguards of Part 4 of the Act. It is insufficient for the proposed treatment to be simply "necessary" or "beneficial".
2. In certain circumstances "hazardous" or "irreversible" treatment cannot be administered under this section even if it is immediately necessary. The patient's responsible medical officer is responsible for deciding whether treatment falls into either of the categories, having regard to mainstream medical opinion.
3. Urgent treatment given under section 62 can only continue for as long as it is immediately necessary to achieve the statutory objective(s).
4. Before deciding to give treatment under Section 62 the patient's responsible medical officer should wherever possible discuss the proposed urgent treatment with others involved with the patient's care.

27. Treatment under Section 62 of the Mental Health Act 1983 can only be given under the direction of the patient's (responsible medical officer) consultant.

Special Forms.

28. Any treatment under Section 62 of the Mental Health Act 1983 is recorded on a special form which is available from the Medical Records Office.

29. The form is completed and signed by the patient's consultant and returned to the Medical Records Office.

Second Opinion.

30. Each treatment of E.C.T. or medication administered under Section 62 of the Mental Health Act 1983 must be recorded on a separate form.

31. If it is intended to continue the use of E.C.T. or medication a request for a second opinion doctor is made at the same time the first treatment is given.

Complying with Provisions of the Mental Health Act.

32. Any system for ensuring compliance with the Consent to TreatmentProvisions of the Mental Health Act must ensure that:

1. The date of the first dose of psychotropic medication is noted.
2. The question of consent is considered about ten weeks from that date.
3. Once a form 38 or form 39 has been completed all prescriptions fall within the plan of treatment described in it OR
4. If a prescription that is not covered by the existing form 38 or 39 is required then a new form 38 or 39 is prepared.
5. The review of treatment for patients subjected to form 39 are carried out.

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