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.au (Affix identification label here) URN: Electroconvulsive Therapy Family name: , no part of this work may be (ECT) Consent Given name(s): 1968 Adult (18 years and over) Address: Facility: ......................................................................................................... Date of birth: Sex: M F I Copyright Act The State of Queensland (Queensland Health) 2022A. Does the patient have capacity? E. Risks specific to the patient in not having © o request permission email: ip_officer@health.qld.gov electroconvulsive therapy (ECT) T Yes è GO TO ii No è GO TO i (Doctor/clinician to document specific risks in not having i. A health practitioner must, to the greatest extent possible, electroconvulsive therapy [ECT]): follow an Advance Health Directive (AHD) if it is consistent Except as permitted under the reproduced communicated or adapted without permission from Queensland Healthwith appropriate and safe clinical practice. a) Does the patient have a valid, applicable AHD? Yes No è GO TO iii b) If yes, has the AHD been sighted and a copy is in the medical record? Yes è GO TO ii No (doctor/clinician will need to sight AHD prior to ECT administration) ii. Is the patient currently subject to a Treatment Authority, Forensic Order or Treatment Support Order? Yes è GO TO iii No è GO T O section B if the patient has capacity, otherwise proceed with AHD iii. A doctor must apply to the Mental Health Review Tribunal F. Alternative treatment options (MHRT) for ECT if the patient either: (Doctor/clinician to document alternative treatment not • does not have capacity to consent to ECT; or included in the patient information sheet): THIS BINDING MARGIN • has capacity to consent to ECT (including via an AHD) but is subject to a Treatment Authority, Forensic Order ELECTROCONVULSIVE or Treatment Support Order. Has the MHRT approved the treatment? WRITE IN Yes è Proceed with treatment as per MHR T approval No (ECT cannot be administered) B. Is an interpreter required? DO NOT If yes, the interpreter has: provided a sight translation of the informed consent form in person translated the informed consent form over the telephone Name of interpreter: G. Information for the doctor/clinician The information in this consent form is not intended to be Interpreter code: Language: a substitute for direct communication between the doctor/ THERAPY clinician and the patient. C. Patient requests the following procedure(s) I have explained to the patient the contents of this form and am of the opinion that the information has been understood Electroconvulsive therapy (ECT) and the patient has the capacity to give informed consent to Acute course Continuation Maintenance the proposed treatment, including as detailed in section 233 (ECT) CONSENT v8.00Clinical content review: 2021Clinical check: 07/2022Published: 07/2022D. Risks specific to the patient in having of the Mental Health Act 2016. electroconvulsive therapy (ECT) I understand that I must review the consent for an acute course or continuation of ECT after 12 treatments or 3 (Doctor/clinician to document additional risks not included in months, or a maintenance treatment after 12 treatments or the patient information sheet): 6 months, whichever occurs sooner. Name of doctor/clinician: SW9312 Designation: Signature: Date: Page 1 of 6 .au (Affix identification label here) URN: Electroconvulsive Therapy Family name: (ECT) Consent Given name(s): , no part of this work may be Adult (18 years and over) Address: 1968 Date of birth: Sex: M F I Copyright Act H. Patient consent The State of Queensland (Queensland Health) 2022 I acknowledge that the doctor/clinician has explained: © o request permission email: ip_officer@health.qld.gov T • the “Electroconvulsive therapy (ECT)” patient information sheet • the medical condition and proposed treatment, including the possibility of additional treatment Except as permitted under the • the specific risks and benefits of the procedure reproduced communicated or adapted without permission from Queensland Health • the prognosis, and risks of not having the procedure • alternative treatment options • that there is no guarantee the procedure will improve the medical condition • that if a life-threatening event occurs during the procedure, I will be treated based on documented discussions (e.g. AHD or ARP [Acute Resuscitation Plan]) • that a doctor/clinician other than the consultant/specialist may assist with/conduct the clinically appropriate treatment; this may include a doctor/clinician undergoing further training under supervision • that if the doctor/clinician wishes to record video, audio or images during the procedure where the recording is not required as part of the treatment (e.g. for training or research purposes), I will be asked to sign a separate consent form. If I choose not to consent, it will not adversely affect my access, outcome or rights to medical treatment in any way. I give my consent freely and voluntarily. THIS BINDING MARGIN I was able to ask questions and raise concerns with the doctor/clinician. I understand I have the right to change my mind regarding consent at any time, including after signing this form (this WRITE IN should be in consultation with the doctor/clinician). I have received the following consent and patient DO NOT information sheet(s): “Electroconvulsive therapy (ECT)” “General anaesthetic” On the basis of the above statements, I consent to having electroconvulsive therapy (ECT). Name of patient: Signature: Date: Page 2 of 6 .au Electroconvulsive therapy (ECT) Adult (18 years and over) | Informed consent: patient information , no part of this work may be 1968 A copy of this form should be given to the patient to read carefully and allow time to ask any questions about the procedure. The consent form and patient information sheet should be Copyright Act included in the patient’s medical record. The State of Queensland (Queensland Health) 2022 © o request permission email: ip_officer@health.qld.gov T 1. What is electroconvulsive therapy (ECT) and how will it help me/the patient? Except as permitted under the reproduced communicated or adapted without permission from Queensland HealthElectroconvulsive therapy (ECT) has been used across the world as an effective treatment for some severe mental illnesses for many years. The value of this treatment is known internationally and the method has been improved in recent years to get better results and fewer side effects. Modern ECT is safe for most people (exceptions are now rare) and for some conditions, ECT is the best and safest treatment option. ECT will not be given to anybody deemed unfit for treatment and your physical health such as a cardiac condition will be assessed as a part of this. ECT is not painful. ECT is good for major depression, mania and some forms of schizophrenia. In depression, it is particularly good for those people who are very depressed and those who may be suicidal. It is used in the treatment of depression when antidepressants have not worked. It is also used for patients who have bad side effects with antidepressants or whose medical condition means they can’t take antidepressants safely. THIS BINDING MARGINYour doctor/clinician will discuss with you why ECT is the best treatment for you and what other relevant treatment options are available. ECT can help you by treating your condition which may also help you in the lifting of WRITE IN depression and better thinking ability. Duration of treatment DO NOT Acute course or continuation of ECT treatment sessions, usually given 1 to 3 times per week. This consent is current for up to 3 months or 12 treatments, whichever is sooner. After that time the doctor/clinician will review my consent with me if further treatment is to be given. When significant changes occur in treatment, consent must be sought again and a new form signed. Maintenance (preventative treatment given at intervals between weekly and monthly) course of ECT treatment sessions for up to 12 treatments or 6 months, whichever is sooner. After that time the doctor/clinician will review my consent with me if further treatment is to be given. When significant changes occur in treatment, consent must be sought again and a new form signed. Preparing for the treatment Before your treatment, you will need to have some tests including an ECG, chest x-rays, a physical examination, and a blood test(s). Your doctor/clinician will explain these tests and when to have them. • You must fast (eat no food or drink any fluid or water) for several hours before the ECT treatment to ensure your stomach is empty • If you do eat or drink anything within the fasting period, you must tell the nursing or medical staff and your treatment may be reassessed or rescheduled Electroconvulsive therapy (ECT) patient information SW9312 v8.00 Clinical content review: 2021 Clinical check: 07/2022 Published: 07/2022 Page 3 of 6 • You MUST tell the doctor/clinician if there is During the treatment, the anaesthetist will any chance you may be pregnant. continue to give you oxygen via a mask and Your doctor/clinician may have to change the monitor your heart rate and oxygen level. medication you were taking before ECT, as You will be asleep during all of this treatment, some medications can affect how well the which means that you will not feel or ECT works. remember any of the actual treatment. On the morning of the treatment day, some Within a few minutes, the anaesthetic medication will still be given but with a tiny medication will have worn off and you will sip of water. wake up. During this time, you will be moved During the procedure to the recovery room where you will be monitored until you are awake enough to You will be brought into the treatment area return to your ward (or wait to be taken home and asked to lie down on a trolley. Staff will if you are having day procedure ECT). attach some medical equipment to you: • a blood pressure cuff on your arm 2. What are the risks? • a small device over a finger to check pulse and oxygen levels in your blood Modern ECT and general anaesthetic • small stick-on electrodes are placed on treatment is usually completed in a short your forehead and behind your ears to period of time and serious complications are record the brain’s electrical activity during uncommon. the treatment There are risks and complications with this • extra equipment may be used if there are procedure. There may also be risks specific extra risk factors that are known from your to each person’s individual condition and medical history, examination or tests circumstances. Please discuss these with the • a facemask is placed over your nose and doctor/clinician and ensure they are written mouth to give you oxygen; this is to prepare on the consent form before you sign it. Risks your body and brain for the extra activity include but are not limited to the following: that will happen briefly with the treatment. You will have a short general anaesthetic so Common risks and complications you will be asleep and not feel or remember • immediately after ECT most people have the treatment. The anaesthetic medication a short period of confusion and do not will be injected into a vein, to make it work remember the actual treatment quickly. • short-term memory may be affected • existing memory problems, caused by your A special anaesthetic doctor (anaesthetist) illness, may also get worse will give the anaesthetic. You will also be • memories of events from your past are given a muscle relaxant to keep any muscle less likely to be affected than short-term reaction to the ECT at a safe level. memories A doctor/clinician who has specialised • although specific memories may not return, training in ECT gives the treatment in a overall memory will usually get better in the special ECT treatment area. The doctor/ weeks to months after treatment clinician puts the treating electrodes to your • anaesthetic side effects, such as headache, scalp and passes a measured amount of nausea, vomiting; if these occur, tell the electricity to a part of the brain to cause a staff looking after you, who will be able to seizure (fit). The seizure will last about give you some medication to help 1 minute. This should not be confused with • muscle soreness due to either the muscle the electrical stimulation which is brief and relaxants or the muscle activity caused by lasts only for a few seconds. the seizure • a temporary rise in blood pressure and heart rate followed by a slowing of the heart rate. Electroconvulsive therapy (ECT) patient information SW9312 v8.00 Clinical content review: 2021 Clinical check: 07/2022 Published: 07/2022 Page 4 of 6
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