Electroconvulsive Therapy (ECT) Consent Form: Acute Phase

My doctor, _____________________________________, has recommended that I receive treatment with electroconvulsive therapy (ECT). This treatment, including the risks and benefits that I may experience, has been fully described to me. I give my consent to be treated with ECT.

Whether ECT or an alternative treatment, like medication or psychotherapy, is most appropriate for me depends on my prior experience with these treatments, the features of my illness, and other considerations. Why ECT has been recommended for me has been explained.

ECT involves a series of treatments that may be given on an inpatient or outpatient basis. To receive each treatment I will come to a specially equipped area in this facility. The treatments are usually given in the morning. Because the treatments involve general anesthesia, I will have had nothing to eat or drink for several hours before each treatment. Before the treatment, a small needle will be placed in my vein so that I can be given medications. An anesthetic medication will be injected that will quickly put me to sleep. I will then be given another medication that will relax my muscles. Because I will be asleep, I will not experience pain or discomfort or remember the procedure. Other medications may also be given depending on my needs.

To prepare for the treatment, monitoring sensors will be placed on my head and body. Blood pressure cuffs will be placed on an arm and leg. This monitoring involves no pain or discomfort. After I am asleep, a carefully controlled amount of electricity will be passed between two electrodes that have been placed on my head.

I may receive bilateral ECT or unilateral ECT. In bilateral ECT, one electrode is placed on the left side of the head, the other on the right side. In unilateral ECT, both electrodes are placed on the same side of the head, usually the right side. Right unilateral ECT (electrodes on the right side) is likely to produce less memory difficulty than bilateral ECT. However, for some patients bilateral ECT may be a more effective treatment. My doctor will carefully consider the choice of unilateral or bilateral ECT.

The electrical current produces a seizure in the brain. The amount of electricity used to produce the seizure will be adjusted to my individual needs, based on the judgment of the ECT physician. The medication used to relax my muscles will greatly soften the contractions in my body that would ordinarily accompany the seizure. I will be given oxygen to breathe. The seizure will last for approximately 1 minute. During the procedure, my heart, blood pressure, and brain waves will be monitored. Within a few minutes, the anesthetic medications will wear off and I will awaken. I will then be observed until it is time to leave the ECT area.

The number of treatments that I will receive cannot be known ahead of time. A typical course of ECT is 6 to 12 treatments, but some patients may need fewer and some may need more. Treatments are usually given three times a week, but the frequency of treatment may also vary depending on my needs. If I need more than ________ treatments, my written consent will be reobtained.

ECT is expected to improve my illness. However, I understand that I may recover completely, partially, or not at all. After ECT, my symptoms may return. How long I will remain well cannot be known ahead of time. To make the return of symptoms less likely after ECT, I will need additional treatment with medication, psychotherapy, and/or ECT. The treatment I will receive to prevent the return of symptoms will be discussed with me.

Like other medical treatments, ECT has risks and side effects. To reduce the risk of complications, I will receive a medical evaluation before starting ECT. The medications I have been taking may be adjusted. However, in spite of precautions, it is possible that I will experience a medical complication. As with any procedure using general anesthesia, there is a remote possibility of death from ECT. The risk of death from ECT is very low, about 1 in 10,000 patients. This rate may be higher in patients with severe medical conditions.

ECT very rarely results in serious medical complications, such as heart attack, stroke, respiratory difficulty, or continuous seizure. More often, ECT results in irregularities in heart rate and rhythm. These irregularities are usually mild and short lasting but in rare instances can be life threatening. With modem ECT technique, dental complications are infrequent and bone fractures or dislocations are very rare.

If serious side effects occur, I understand that medical care and treatment will be instituted immediately and that facilities to handle emergencies are available. I understand, however, that neither the institution nor the treating physicians are required to provide long-term medical treatment. I shall be responsible for the cost of such treatment whether personally or through medical insurance or other medical coverage. I understand that no compensation will be paid for lost wages or other consequential damages.

The minor side effects that are frequent include headache, muscle soreness, and nausea. These side effects usually respond to simple treatment.

When I awaken after each treatment, I may be confused. This confusion usually goes away within 1 hour. During the treatment course I may have new difficulties in attention and concentration and other aspects of thinking. These problems rapidly go away after completion of ECT.

I understand that memory loss is a common side effect of ECT. The memory loss with ECT has a characteristic pattern, including problems remembering past events and new information. The degree of memory problems is often related to the number and type of treatments given. A smaller number of treatments is likely to produce less memory difficulty than a larger number. Shortly following a treatment, the problems with memory are greatest. As time from treatment increases, memory improves.

I may experience difficulties remembering events that happened before and while I received ECT. The spottiness in my memory for past events may extend back to several months before I received ECT, and, less commonly, for longer periods of time, sometimes several years or more. Although many of these memories should return during the first few months following my ECT course, I may be left with some permanent gaps in memory.

For a short period following ECT, I may also experience difficulty in remembering new information. This difficulty in forming new memories should be temporary and typically disappears within several weeks following the ECT course.

The majority of patients state that the benefits of ECT outweigh the problems with memory. Furthermore, most patients report that their memory is actually improved after ECT. Nonetheless, a minority of patients report problems in memory that remain for months or even years. The reasons for these reported long-lasting impairments are not fully understood. As with any medical treatment, people who receive ECT differ considerably in the extent to which they experience side effects.

Because of the possible problems with confusion and memory, I should not make any important personal or business decisions during or immediately after the ECT course. During and shortly after the ECT course, and until discussed with my doctor, I should refrain from driving, transacting business, or other activities for which memory difficulties may be troublesome.

The conduct of ECT at this facility is under the direction of Dr. ______________________. I may contact him/her at _______________________ if I have further questions.

I am free to ask my doctor or members of the ECT treatment team questions about ECT at this time or at any time during or following the ECT course. My decision to agree to ECT is being made voluntarily, and I may withdraw my consent for further treatment at any time.

I have been given a copy of this consent form to keep.