3.10 Risks and Side Effects of E.C.T.

3.10.1 Risk assessment for E.C.T.

The Project Team was told by consultants in the Trust:

On a patient's first referral, an anaesthetist makes an assessment, including investigations. E.C.T. is only allowed if the anaesthetist is satisfied it is safe to do so. The final decision on whether a patient can be given E.C.T. is that of the anaesthetist, who takes into account the consultant's view.

Older people are at a higher risk, especially if they have heart disease. If a patient's physical health is borderline, the anaesthetist will check with the consultant psychiatrist about the decision to give E.C.T. (although this does not happen often). Problems with heart conditions, falls and strokes (even in older people) are few.

There is no evidence that E.C.T. has ever been given in a coronary care unit or intensive care unit in Salford 79.

3.10.2 Side Effects of E.C.T.

The Project Team was told by consultants that in the Trust, there was currently no mechanism in place for monitoring the side effects of E.C.T., including memory loss. Dr. Moss felt that differences were individual to patients. This should be an important area for further research to be undertaken.

3.10.3 Anaesthesia.

The anaesthetists used by the Mental Health Services of Salford N.H.S. Trust are employed by the Salford Royal Hospitals N.H.S. Trust. The service involves four E.C.T. consultant anaesthetist sessions. During the period of the project, the source funding for these was an unresolved issue, with sessions being cancelled and discharges being delayed. A service level agreement was drafted to improve the situation, although this had extra funding implications.

The Project Team was told by consultants that:

No day case surgery in undertaken on patients over 75 years in the Salford
Royal Hospitals N.H.S. Trust, but E.C.T. is undertaken on patients older
than this in the Mental Health Trust. Greater monitoring of E.C.T. patients
may be required.

Repeated anaesthesia has no cumulative effect, as only has a short-term effect. Repeated anaesthesia does, however, increase the level of risk.

3.10.4 E.C.T. and Death.

The Project Team was told by consultants that death and serious injury due to E.C.T. are very rare. There had been no instances in the Trust in at least the previous 18 months. In the past there had been two or three deaths, but these were of people who would probably have died any way.

3.11 Consent to Treatment.

3.11.1 Rules and Guidance.

The local guidance on consent within the Mental Health Services of Salford N.H.S. Trust in force at the time of the Project was:

Procedure: Consent to Treatment (March 1995) - review date October 1999: see Appendix Two; and

Quality Statement: Consent to Treatment (Mental Health Act 1983) (February 1994) - review date February 1999: see Appendix Four.

It was not until the Project Team specifically asked about these documents that they referred to by the Trust. While the procedure and quality statement had been updated (albeit significantly later than the review dates set on the original versions), the lack of reference to them in any of the discussions or correspondence with the Trust raises a question about staff awareness and implementation of them.

On the question of consent, the Mental Health Act 1983 and the Mental Health Act Code of Practice provides the essential framework. Many statements from these are reproduced in the Trust's procedure guidance and quality statement.

If a patient is able and willing to give consent to E.C.T. and anaesthesia, they are then asked to sign a standard N.H.S. consent form, which is countersigned by the R.M.O. The Trust actually provided the C.H.C. with a consent form specific for E.C.T. [Appendix Three]. This identifies that the E.C.T. treatment has been explained. The form should be checked by the medical staff giving the E.C.T. and anaesthetic and by the nursing staff. Treatment should not be given without a valid consent form being provided.

The treatment course is reviewed weekly by the R.M.O. and the multi-disciplinary team. Competence to give or refuse consent is not formally assessed prior to each individual session. Consent is, however, reaffirmed by the patient at each treatment by his/her confirmation to the named nurse or nurse in charge prior to each treatment that they will be attending for that treatment and not by mere assent or being there.

While some patients' capacity to consent may vary over time, their right to refuse treatment should always be observed. Any attempts at persuasion should involve only discussion and reason without undue pressure. If a patient does refuse E.C.T., alternative treatments should be continued, along with an explanation of the associated benefits and risks.

If a patient refuses to give consent or their consent is clinically judged to be not valid, the R.M.O. has to make a clinical judgement as to whether to carry on with the treatment under the Mental Health Act, in line with the Code of Practice. In the case of patients who are given E.C.T. without their consent, the authority of a Second Opinion Appointed Doctor (S.O.A.D.) from the Mental Health Act Commission to do this must be recorded on a Form 39. This should accompany the patient. Without it, the patient should not be given any treatment. E.C.T. staff also have a responsibility to check the number of treatments the patient is given against the specified number authorised by the S.O.A.D.

During Mental Health Act training, staff are taught about the withdrawal of consent. This can be done not only by a patients saying that they do not want the treatment, but also by action, such as refusing to get on a trolley or not putting their arm out for the anaesthetic. To give treatment in these circumstances (unless the Mental Health Act is fulfilled) would be illegal.