Under what circumstances can a Uk hospital give ECT without the patient's consent?

May 6, 2009 11:13 AM

Depression that doesn't respond to drugs - what are the guidelines on ECT for unwilling hospital patients?

My mother was hospitalised a week ago for depression. It's not the first time - in fact she's been in 4 times before over the last 30 years. Every time before she continued to go downhill for weeks or months after admission while the doctors messed around with courses of antidepressants, none of which have worked. Then as a last resort each time they administered ECT, which did work. My sister and I were expecting the same to happen this time so we were surprised, but pleased, to turn up at the hospital 2 days after she went in and find out that she was not there because she had agreed to ECT, but she was back half an hour later - she refused at the last minute. A couple of days later, exactly the same thing happened. My mother is not very lucid these days and says she wants to be sectioned so they will force her to take the treatment (that happened before after one of her suicide attempts). Well, she says that some of the time. At other times she is sure the treatment will kill her. Will they be able to section her while she is still talking in sentences that mostly make sense? Or must they wait until she becomes totally unresponsive (which has been the case another time)? We were supposed to be able to see her consultant yesterday but he cancelled the meeting, and I am very worried (though I should be used to all this since it's been going on since I was a small child). She won't be able to kill herself inside the hospital, surely? Her plans at the moment include starving herself to death and smashing her head against a wall - I think the nurses would notice in either case.
Any responses from people familiar with the UK mental health system gratefully received.

posted by tulipwool to health & fitness (17 comments total)

I won't even attempt to recapitulate Wikipedia on the subject of involuntary ECT and will note that "informed consent" requires that the patient be mentally competent.

It is not clear what you want to have happen, but I'll assume the "involuntary" is the part that you are concerned about. I would look to an attorney to see if you can obtain medical guardianship of your mother which would afford you the consent you desire.
posted by fydfyd at 11:48 AM on May 6

I'm in the US, and I'm not sure the ways in which psych care in the US differ from the UK.

However, the hospital is the safest place for her to be. It isn't foolproof, but both of her stated plans would draw attention from the nurses. Make sure you are communicating those statements to the nurses so they know to be on the look out.

Is the consultant her psychiatrist? Sometimes you have to be a little pushy as a family member to get what you need from physicians. Does the hospital have a patient/family advocate or a social worker? One of these people should be able to answer some of your questions about involuntary treatment, or know where to find out. They may also be able to help you sit down with the consultant.
posted by jeoc at 11:57 AM on May 6

Thanks. I didn't realise I had left my wishes so unclear. To straighten things out - I think the only treatment that can help my mother is ECT. If she can't bring herself to consent, I want the hospital to be able to force her into it, because the life she is enduring at the moment isn't worth living. But I am not a doctor of any kind. I don't want to force the hospital to give her ECT against their professional opinion. I just want to know how much worse she has to get before they will be able to treat her against her will if they think it is her only hope. I think they have no other useful treatments to give, but I don't know for sure because they cancelled a meeting where I would have asked them.
posted by tulipwool at 11:57 AM on May 6

If she can't bring herself to consent, I want the hospital to be able to force her into it

I do not think that is possible if your mother is able to express a lucid refusal.

Your mother sounds like she has something else in addition to depression going on, though, if she has a delusion that ECT will kill her. Are her doctors addressing that? If she's refusing a treatment because of delusions, that's a different kettle of fish (in the US at least).
posted by Sidhedevil at 12:21 PM on May 6

Involuntary treatment for competent adults is pretty much a no-no. It would be a violation of their civil rights.

In general, what would be needed would be for a court to declare the adult to not be competent, and to appoint a legal guardian. The guardian could then give consent for the treatment.

But without that legal cover, I don't think that hospitals will force treatment onto an unwilling patient, no matter how sick that patient is.

ECT is not a benign treatment. It causes permanent, cumulative, brain damage. Which means there are legitimate reasons why a patient would refuse it, reasons a doctor pretty much would have to respect.
posted by Chocolate Pickle at 1:36 PM on May 6

In the US you could attempt to get legal (or medical) guardianship of your mother, and then you would essentially be responsible for making the decisions for her care. You could make such an argument with the help of a lawyer who would argue that your mother is incompetent to make her own decisions. I have no idea what the criteria for that are in the UK, but I bet they're there.
posted by OmieWise at 1:51 PM on May 6

I'm a bit confused - how did she wind up in hospital to begin with? Is this a psychiatric hospital she's been admitted to? By whom? Is her regular doctor involved with her care?

She needs two doctors and another interested party - another doctor, a social worker, or a close concerned relative. If she's talking about suicide or self harm, particularly with her history, then yes, she can be sectioned. The ECT is something they can do to her while she's sectioned, if they think it's the best treatment option for her. They can't do things that cause irreparable physical damage (like lobotomies or implants), but I do know that my MIL was given ECT to snap her out of catatonic states of depression when she was sectioned. This was before the 1983 Act, though, so it might be worthwhile running the options past her consultants.

It might well be worthwhile to get involved as the third party if she needs sectioning. It might give you a bit more leverage if you decided for whatever reason that she needed to be released from the hospital, as you'd be more credible to the PCT as an involved and informed party.

If you don't want to be the third party, for whatever reason, Mind has terrific mental health advocates. They work with the person concerned to express what their needs and wants are, and are pretty damned fearless in fighting for what the person they support actually wants (filtered through their actual needs). Sometimes it's too close for families, and they need a sympathetic and clued in third party to help out. I really can't say enough good things about the work advocates do.

I'm not a psychiatrist, but I've been through this with my mother-in-law, and have supported my husband and his father through a few episodes. All my best wishes to you, your sister and your mother in this dark time. It will get better - have faith! :)
posted by Grrlscout at 2:12 PM on May 6

Chocolate Pickle said: ECT is not a benign treatment. It causes permanent, cumulative, brain damage.
erm, only in some patients, some of the time. Most cognitive side effects are gone after 3 months.
And it's the fastest, most effecient treatment out there.
(Major) Depression, however, causes brain damage. And is probably the closest thing on earth to living hell.
I'd say speak to the doctors know and let them where you stand. It may not be enough to make them force ECT on your mother, but at least here in Denmark, the opinion and experiences of the relatives can sometimes influence the decision to use forced treatment.

Best wishes
posted by Thug at 2:39 PM on May 6

Grrlscout - thank you for your answer. I was hoping to hear from someone who'd been involved here, rather than in America, though I am also grateful to the Americans who have responded. I don't want to ignore your questions.
Yes, it's a psychiatric hospital. The process of her illness has been much the same as the other times - first to the GP, who said confidently that a few weeks of antidepressants would sort everything out. Back again 2 weeks later, clearly more depressed, more anxious, having dropped her hobbies and social activities because she couldn't cope. GP ups the drugs, says come back in 2 weeks. In this interval Mum can't stand to be alone, has panic attacks and insomnia, starts telling people she won't kill herself (no one had asked the question). Next GP appointment - different drugs. 'In another 2 weeks, when I see you again, you'll be so much better!' says the GP. Hollow laughs from the family (not in front of Mum, obviously) who have been here so often before. Mum now gets worse on a daily basis. Shaking, confusion, more panic attacks, repeats everything she says over and over and over again, demands to see GP who now gets an inkling that the drugs don't work and contacts the hospital, who send someone to see her at home and say she doesn't need to come in because she has a supportive family. But we have families of our own and being with her is very, very draining. She demands attention every moment and will not talk about anything but her own state of mind. When she starts saying she will kill herself, we ask the crisis team from the hospital to come out and see her, they tell her she needs to be admitted, and eventually she agrees.
(Last time - about 4 and a half years ago - she just got quieter instead of talking about suicide, and we left her in her house alone, and my sister woke at dawn to find Mum standing over her bed dripping blood, having made the 15-minute walk to her house after cutting her wrists and taking a lot of pills. So we took the suicide talk seriously.)

I'm sorry this is so long (though I've left some stuff out). When you asked how she wound up in hospital I thought ' the usual way, of course' and only then realised that I was assuming all depressed people go through all the same stages.

I was hoping that incessant talk of suicide might be a good enough reason for a section, but was afraid she might have to actually attempt it and fail before they would do anything. Even if they legally can section her, though, that doesn't mean they definitely will. We have been trying not to bother the staff (and feeling rather guilty that they are looking after her and not us, even though they have a better chance of keeping her alive than we have) but we're going to have to start badgering them, I suppose, because they never tell us anything. Thanks again.
posted by tulipwool at 3:28 PM on May 6

Involuntary treatment for competent adults is pretty much a no-no. It would be a violation of their civil rights.

Not true, however, the legal threshold permitting the administration of involuntarily mental health treatment is set incredibly high. Basically, if you were in the US, this could happen if your mother was involuntarily committed to a psychiatric facility that performs this treatment (in Philadelphia, UPenn does), and then her doctors (two are required) would have to go to mental health court and testify that she responds to no other treatment and without receiving the ECT she would not achieve baseline stability and would continue to be a danger to herself. Any involuntary treatment, including forced medication, requires two doctors to appear in this fashion as petitioners in mental health court. This very, very rarely happens, but I did actually have a client once that this happened to.
posted by The Straightener at 7:03 PM on May 6

Even if they legally can section her, though, that doesn't mean they definitely will.

And even if she's sectioned, does that mean they can force her to comply with specific treatments if she gives a lucid refusal? It wouldn't, as The Straightener points out, mean that if she was involuntarily committed in the US, and my understanding is that the UK is more vigilant about patients' rights than the US.

It seems to me like you have a bunch of questions that you need someone to answer:

1. Are you sectioning Mom?
2. If you do section Mom, will you have the authority to order ECT even if she gives a lucid refusal?
3. If not, does the fact that her refusal is based on an irrational fear that ECT "will kill her" mean it's delusional rather than lucid?
4. If she's in a state where she's delusional about the ability of treatments to help or harm her, are you doing anything to address that issue as well as the suicidal depression?

I'm so sorry for your mom and for your family. This must be horrible for you to deal with.
posted by Sidhedevil at 7:39 PM on May 6

Has your mother ever been diagnosed as bipolar? The sequence of events you describe with the anti depressants making her anxious and possibly delusional make me wonder if she's experiencing rapidly cycling mania/ depression.

Not a doctor but had a friend go through this for a few years. She was diagnosed as bipolar and put on a mood stabilizer and it was night and day.
posted by fshgrl at 12:01 AM on May 7

Tulipwool, this is AskMefi - it's where you're supposed to share the full story, so we can help! :)

I'm so sorry to hear that you all have been through this. I know what you mean about having it be incredibly draining to care for someone in that sort of fragile state. Walking on eggshells, sifting every word and mood to see if it means a turn for the better or worse - you are doing the right thing in insisting that she get the care she needs, and to not let the PCT push this back on you and your family. At least she is talking to you this time, telling you that she doesn't want things to get to where they were before. She's asking for help directly, instead of muddling through. Small comfort, perhaps, but it is a good sign all the same.

My MIL was first sectioned in 1969. and has been in and out of psych hospitals since (on about a 5-7 yr cycle). The process of diagnosis and treatment decision trees are so different today that I'm not sure anything I have to say might help you at all in that regard. She had several diagnoses before being diagnosed as being bipolar, though on the depressive side. For her, the struggle was to get a correct diagnosis - back in those days, they were probably a bit too quick to section.

It sounds like she needs to change surgeries! Does she see the same doctor on a consistent basis, or is she registered with a surgery that cycles doctors in and out? I'm trying to fathom why a doctor who'd seen her through the last episode you describe would think that the usual spectrum of NICE/NHS schedule of antidepressants would help someone who's shown the kinds of symptoms your mom has shown. At the very least, she needs a doctor who's more clued up on mental health issues than the one she currently has. Maybe you could talk to the doctor at the psych hospital to see if he could see her on an outpatient basis? My MIL goes to Fieldhead to see her psych doctor once a month, with the remainder of her care being administered by her GP and a district nurse. Once your mother has been stabilised (and perhaps had her diagnosis reevaluated), the same sort of care plan might work for her?

You already have at least two of the three necessary parties in place to section your mother - it sounds like it's down to the doctor at her psych hospital to section her. Frankly, given her history, I'm surprised they haven't done this already. Might they be hesitant because she is lucid enough to voice her concerns just now? Have you asked what the criteria are for sectioning within her particular PCT? They have guidelines given by the law and professional orgs, but each PCT can interpret them as they see fit.

If they do section her, and you're the third party, the doctors should keep you informed about her care (and consult you about any sort of major treatments or changes). You'd be her advocate, in essence. The problem is that once she is sectioned, it can be hard to argue that she's compos mentis when she's feeling better and wants to go home.

In addition to the Mind advocates I recommended before, NHS hospitals have PALS (Patient Advocates). Fieldhead has PALS, so I'm sure your mother's psych hospital has a programme as well. PALS mainly help families and patients navigate the NHS, but they also do quite a bit to help families and patients when they feel they aren't getting through to the medical staff. PALS actually do advocate - it isn't just a PR exercise. They might be able to help you and your mother, if you feel you aren't getting the best care (or best information flow) from her docs. It isn't an adversarial sort of setup, so you wouldn't have to worry about antagonising her doctors if you consulted a PAL. Just a thought.

I'm sending you my best and brightest wishes for a good outcome on this. If you'd like to memail me, feel free.
posted by Grrlscout at 12:45 AM on May 7

I've visited Mum today, but still don't know any more about the hospital's plan. I got a few seconds to ask a question of someone from the Community Mental Health Team while Mum was distracted. He said he doesn't know if they plan to section her, but we will find out at a meeting on Tuesday morning. Since last Tuesday's meeting never happened, I'm not that reassured.

Several people said that a section does not automatically give the hospital the right to administer ECT. Mum was sectioned last time, though, and her consent was unnecessary then - she got the treatment. They certainly didn't ask any family member's permission either (though if they had we would have given it eagerly). Thug - thanks for your view on ECT. I appreciate the view of the other commentators that the patient's wishes should be paramount. If there was nothing they could do for Mum, and she wanted to die, I would support her then. But we've seen ECT work before so I cannot support her decision to stay like this. She's worse than ever today.

Several people also suggested Mum might actually be bipolar. In all the decades this has been going on, the only diagnosis we have ever heard is depression, but I will raise the question on Tuesday if I get the chance. In the last couple of days they have changed her medication to Olanzapine. I looked it up and it is used in bipolar disorder and schizophrenia but also in treatment resistant depression, which is what Mum is supposed to have, so that doesn't settle anything. The delusions are not new. She has been convinced of a number of bizarre things over the years while in the throes of depression (or whatever it is she's got).

Grrlscout - she had the same GP for many years and through her first 4 hospitalisations but he retired a couple of years ago. One of the hospital crisis team did tell us that someone with such a huge case file shouldn't have been sent away with antidepressants on her first 3 visits with this attack, but we didn't know that at the time. We knew the drugs didn't ever work before but assumed they have to go through the motions anyway. The old GP would have done the same if he was still in practice I think - it's what he did last time (2004).

Thank you to all for your good wishes. It actually does help. I'm pregnant, which my husband and I are very happy about, but I think my hormones are making me more upset about all this. If I get any concrete news on Tuesday I'll update for the sake of anyone in a similar position who might find this thread in the future.
posted by tulipwool at 5:39 AM on May 7

It causes permanent, cumulative, brain damage.

Please ignore this ignorant editorializing that has nothing to do with the question you asked or the advice you're seeking.
posted by foxy_hedgehog at 8:15 AM on May 8

Well, the meeting did happen. It wasn't particularly informative. I did ask about her diagnosis and was told there has been no change - they still consider her depressed, not bipolar or anything else.

The consultant said he has a new drug to try! Wow, a new drug. Only had about 30 of those before! I am afraid I don't remember what it's called. In the very unlikely event of it actually helping I will return and add the name.

If the new drug fails (by which I mean when it fails) he will be likely to section her in order to give ECT. He won't do that before the next time we meet though, which is a week on Thursday. Another 10 days at least with her in this state.
She has a new delusion. Now she thinks she controls the weather. I didn't think she'd even read Rasselas.

Thanks, foxy_hedgehog. I know ECT doesn't always do damage. Even if brain damage was certain I'd prefer it to her going on like this.
posted by tulipwool at 6:19 AM on May 12

I hate it when an old thread doesn't have an end so will update - the news is good.

My mum was actually sectioned the day after my last post - the consultant changed his mind. She has had 3 ECT treatments and is much, much saner. Still very unhappy but now able to think straight. They have taken her off the section, and she may only need 1 more session of ECT, which she is now willing to undergo. She's still on diazepam (valium), 2 antidepressants and an anti-psychotic, but they are actually having an effect now. The hospital say if she doesn't have any setbacks, she may be able to come home in a week or two, with daily visits from the mental health team to start with. The speed of the improvement, after months of only getting worse despite bucketfuls of pills, is startling.

Thanks to all those who replied.
posted by tulipwool at 3:39 AM on June 10