ORIGINAL STUDY
Court-Approved Electroconvulsive Therapy in Patients Unable to Provide Their Own Consent A Case Series
Folabo Y. Dare, DO and Keith G. Rasmussen, MD
Abstract: For patients who lack capacity to consent to electroconvulsive therapy (ECT) for various reasons (intellectual disability, severe mental illness, dementia, etc), court approval must be obtained to proceed with the treatments. We reviewed our experiences on a busy tertiary center ECT service in which we have treated 24 patients in recent years under the auspices of court approval for consent. We found that these patients generally tolerated the treatments well and had noticeable improvement in their symptoms as well as overall better quality of life. In particular, although the patients were unable to provide their own consent for ECT, they were amenable to receive the treatments and did not seem resistant or hostile to the treatment process. We conclude that, in patients unable to provide their own consent, court-approved ECT is well tolerated. Key Words: electroconvulsive therapy, consent, forensic psychiatry (J ECT 2015;31: 147–149)
necessarily mean that they have the capacity to do so, although the default position in most cases is that patients have capacity. Some patients who lack capacity probably would be willing to sign a consent form if placed in their hands, although they would not properly comprehend what they are signing. Thus, an astute ECT clinician should be vigilant for severely impaired patients who must nonetheless have substituted consent, although they seem willing to proceed with ECT. It may seem authoritarian to proceed with legal maneuvers to provide ECT and that patients thus treated may respond negatively or disagreeably in such matters. In this report, we will describe patients we have treated on our ECT service with court-approved ECT. We aimed to show that this process is well tolerated and efficacious for these patients.
METHODS
I
t is axiomatic that some type of formal consent be undertaken before electroconvulsive therapy (ECT) treatments are administered.1 The usual informed consent process for ECT requires certain cognitive abilities on the part of the patient to participate fully, such as information-processing skills, memory, and ability to comprehend the nature of their mental illness. Some prospective ECT patients lack these capacities for various reasons, such as intellectual disability, lack of insight into their condition, dementia, or severe formal thought disorder. To proceed with ECT in this patient population, court approval must be obtained in accordance with local statutes. Please note that, in this communication, we are using the expression court approval rather than court order because it has been our experience in our locale that judges may choose not to order ECT directly but rather to authorize a third party (usually the patient's legally appointed guardian) to provide consent. Thus, the term court approval is more broadly apropos. Statutes differ by state and nationality, but the following overarching criteria must be met in order for the court to grant permission to proceed with ECT without the recipient's consent: (1) less intrusive methods have been tried and found to be ineffective, (2) there is clear and convincing evidence that treatment of the recipient's mental illness using ECT is necessary and reasonable, (3) the recipient does not have the capacity to give or withhold consent to the use of ECT to treat his or her mental illness, and (4) the benefits from the administration of ECT outweigh the risks associated with the treatment. Patient refusal to sign the consent document does not constitute ipso facto need to go to court for approval. Similarly, patient willingness to sign consent also does not
From the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN. Received for publication June 25, 2014; accepted August 28, 2014. Reprints: Keith G. Rasmussen, MD, Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e‐mail: rasmussen. [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2014 by Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000189
This is a retrospective chart review using electronic medical record data. An electronic search of institutional clinical databases (Mayo Clinic Life Sciences System) was conducted to identify patients who were administered ECT under court approval in our practice. We scrutinized their medical records and collected the following data: age of initiation of ECT, sex, diagnosis, reason for court order, living situation, number of ECT treatments, method of delivery, interval between treatments, duration of treatment, and treatment tolerance. All patients thus treated during approximately the period from 2004 to 2014 were included. Not included in this report are patients who were treated emergently without their consent or with substituted consent obtained without court approval (but in accordance with Minnesota statutes providing for acute treatment in some circumstances with substituted consent).
RESULTS Data on the patient sample are presented in Table 1. There are 24 participants. Fifteen (62.5%) were female, and the average age was 60.9 (range, 21–87) years. The average number of ECT treatments was 159.1 (range, 4–602). The most common delivery mode was bitemporal (3588); the next most common delivery mode was right unilateral (140) and 90 were bifrontal. The average duration of treatment was 66.4 (range,
Court-Approved Electroconvulsive Therapy in Patients Unable to Provide Their Own Consent A Case Series
Folabo Y. Dare, DO and Keith G. Rasmussen, MD
Abstract: For patients who lack capacity to consent to electroconvulsive therapy (ECT) for various reasons (intellectual disability, severe mental illness, dementia, etc), court approval must be obtained to proceed with the treatments. We reviewed our experiences on a busy tertiary center ECT service in which we have treated 24 patients in recent years under the auspices of court approval for consent. We found that these patients generally tolerated the treatments well and had noticeable improvement in their symptoms as well as overall better quality of life. In particular, although the patients were unable to provide their own consent for ECT, they were amenable to receive the treatments and did not seem resistant or hostile to the treatment process. We conclude that, in patients unable to provide their own consent, court-approved ECT is well tolerated. Key Words: electroconvulsive therapy, consent, forensic psychiatry (J ECT 2015;31: 147–149)
necessarily mean that they have the capacity to do so, although the default position in most cases is that patients have capacity. Some patients who lack capacity probably would be willing to sign a consent form if placed in their hands, although they would not properly comprehend what they are signing. Thus, an astute ECT clinician should be vigilant for severely impaired patients who must nonetheless have substituted consent, although they seem willing to proceed with ECT. It may seem authoritarian to proceed with legal maneuvers to provide ECT and that patients thus treated may respond negatively or disagreeably in such matters. In this report, we will describe patients we have treated on our ECT service with court-approved ECT. We aimed to show that this process is well tolerated and efficacious for these patients.
METHODS
I
t is axiomatic that some type of formal consent be undertaken before electroconvulsive therapy (ECT) treatments are administered.1 The usual informed consent process for ECT requires certain cognitive abilities on the part of the patient to participate fully, such as information-processing skills, memory, and ability to comprehend the nature of their mental illness. Some prospective ECT patients lack these capacities for various reasons, such as intellectual disability, lack of insight into their condition, dementia, or severe formal thought disorder. To proceed with ECT in this patient population, court approval must be obtained in accordance with local statutes. Please note that, in this communication, we are using the expression court approval rather than court order because it has been our experience in our locale that judges may choose not to order ECT directly but rather to authorize a third party (usually the patient's legally appointed guardian) to provide consent. Thus, the term court approval is more broadly apropos. Statutes differ by state and nationality, but the following overarching criteria must be met in order for the court to grant permission to proceed with ECT without the recipient's consent: (1) less intrusive methods have been tried and found to be ineffective, (2) there is clear and convincing evidence that treatment of the recipient's mental illness using ECT is necessary and reasonable, (3) the recipient does not have the capacity to give or withhold consent to the use of ECT to treat his or her mental illness, and (4) the benefits from the administration of ECT outweigh the risks associated with the treatment. Patient refusal to sign the consent document does not constitute ipso facto need to go to court for approval. Similarly, patient willingness to sign consent also does not
From the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN. Received for publication June 25, 2014; accepted August 28, 2014. Reprints: Keith G. Rasmussen, MD, Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (e‐mail: rasmussen. [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2014 by Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000189
This is a retrospective chart review using electronic medical record data. An electronic search of institutional clinical databases (Mayo Clinic Life Sciences System) was conducted to identify patients who were administered ECT under court approval in our practice. We scrutinized their medical records and collected the following data: age of initiation of ECT, sex, diagnosis, reason for court order, living situation, number of ECT treatments, method of delivery, interval between treatments, duration of treatment, and treatment tolerance. All patients thus treated during approximately the period from 2004 to 2014 were included. Not included in this report are patients who were treated emergently without their consent or with substituted consent obtained without court approval (but in accordance with Minnesota statutes providing for acute treatment in some circumstances with substituted consent).
RESULTS Data on the patient sample are presented in Table 1. There are 24 participants. Fifteen (62.5%) were female, and the average age was 60.9 (range, 21–87) years. The average number of ECT treatments was 159.1 (range, 4–602). The most common delivery mode was bitemporal (3588); the next most common delivery mode was right unilateral (140) and 90 were bifrontal. The average duration of treatment was 66.4 (range,
