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State of New York, Office of Mental Health E.C.T. CONSENT FORM Patient's name: "C " #: Facility: Pilgrim Psychiatric Center Date of Birth: Ward/Unit: CONSENT FOR ELECTRO CONVULSIVE THERAPY (E.C.T.) GENERAL INFORMATION: E.C.T., is a method for treating certain mental or emotional conditions by stimulating the brain electrically in order to produce a convulsive seizure. The procedure is carried out at Pilgrim Psychiatric Center by the E.C.T. team, consisting of doctors and nurses. DESCRIPTION OF THE PROCEDURE: While you are lying on a stretcher, a needle is placed in a vein and an anesthetic medication is injected. After you are asleep, a muscle-relaxing medication is then given through the same needle, and you are given pure oxygen through a mask. When your muscles are relaxed, an electrical stimulus is briefly applied to your scalp in order to stimulate the brain into a period of intense, rhythmical, electrical activity (seizure.) This seizure lasts a minute or two and may occasionally but not usually be accompanied by mild contractions of the muscles. When the seizure is over, you will be taken to a recovery area and observed by trained staff until you awaken, usually in about 20 minutes. E.C.T. will be given every other day for about 6 to 20 treatments, although more than 20 treatments may be required to reach maximum improvement. Thereafter, some patients require continuation/maintenance treatments usually no more than once a week. RISKS OF THE TREATMENT: E.C.T. is among the safest of medical treatments given under general anesthesia. The risk of death or serious injury with E.C.T. is about 1 in 50,000 treatments, much smaller than that reported for childbirth. The extremely rare deaths that do occur are usually due to cardiovascular complications. There is a small risk of a blood clot in the vein as a result of the I.V. insertion. SIDE EFFECTS AND COMPLICATIONS: You may experience some confusion just after you awake from E.C.T. and this generally clears up within an hour or so. Memory for recent events may be disturbed, dates, names of friends, public events, addresses and telephone numbers may be forgotten. In most cases this memory difficulty goes away within a few days or weeks, although sometime you may continue to experience memory problems for several months. Certain treatment techniques can be used to prevent or minimize the occurrence of such memory problems (for example, unilateral E.C.T. or brief pulse E.C.T.), and your doctor will discuss these options with you. No long-term effects of E.C.T. have been found on intellectual ability (IQ) or memory capacity 45 621 B UPC (Rev. 2/00) Side 2 E.C.T. CONSENT FORM (Cont.) Patient's name: State of New York, Office of Mental Health RESULTS OF TREATMENT: Although many patients experience significant improvement after a course of E.C.T., no specific treatment results can be promised to you. As with all medical treatments, some patients will recover quickly, some slowly, and a few might not recover at all. Even when recovery is complete, a relapse is still possible. Medication therapy is often prescribed after a course of E.C.T. in order to prevent such relapses. AVAILABILITY OF ALTERNATIVE TREATMENTS: Medications or other therapies may be available to treat your particular condition, and it is possible that some of them might work as well, or better than, E.C.T. The advantages and disadvantages of medication therapy will be discussed with you by your doctor. RIGHT TO WITHDRAW CONSENT: Even though you voluntarily sign an agreement to receive E.C.T., you may withdraw your consent at any time, even during the process of the procedure. Withdrawal of consent for E.C.T. does not in any way prejudice your continued treatment with the best alternative methods available. 1,________, have read the above description of the E.C.T. treatment that has been recommended to me, and it has also been explained to me by _________, who has answered any questions I had. I agree to have the treatments, and understand that Dr._______ will be in charge of administering the treatments. Signature of Patient Signature of Witness This procedure was discussed with family/significant other. [ ] Yes Date Date [ ] No Progress note documenting patient/family received this information was written on _______________ Signature & name of the psychiatrist explaining the procedure Date 46 621 C LIPC (2/00)) Side 1 |
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