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File: Ect Pdf 108644 | Psychiatry 01
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 ...

icon picture PDF Filetype PDF | Posted on 27 Sep 2022 | 3 years ago
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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
The words contained in this file might help you see if this file matches what you are looking for:

...Au affix identification label here urn electroconvulsive therapy family name no part of this work may be ect consent given s adult years and over address facility date birth sex m f i copyright act the state queensland health a does patient have capacity e risks specific to in not having o request permission email ip officer qld gov t yes go ii doctor clinician document practitioner must greatest extent possible follow an advance directive ahd if it is consistent except as permitted under reproduced communicated or adapted without from healthwith appropriate safe clinical practice valid applicable iii b has been sighted copy medical record will need sight prior administration currently subject treatment authority forensic order support section otherwise proceed with apply mental review tribunal alternative options mhrt for either included information sheet binding margin including via but approved write per mhr approval cannot administered interpreter required do provided translation i...

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