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Failure to discontinue anticonvulsant before commencing ECT (00HDC07173)

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(00HDC07173, 12 March 2002)

Psychiatrist ~ Mental health clinic ~ Standard of care ~ ECT ~ Information about treatment ~ Medication review ~ Delay in treatment ~ Rights 4(1), 4(3), 4(5), 6(1)

A woman complained that her husband should not have received electroconvulsive therapy (ECT) on an outpatient basis, and that his treatment was overly protracted, some appointments were cancelled at short notice, and the Tegretol and lithium carbonate he was taking were not discontinued prior to treatment.  Furthermore, although the outpatient clinic agreed to hold an internal inquiry into why his drugs were not discontinued, it did not inform him whether this took place or, if so, of the outcome. This aspect of the complaint was not upheld, as the inquiry did not take place. Had it done so, under Right 6(1) the patient would have been entitled to know the results.

During the ECT treatment, the patient had to resign from his job, as he was suffering from extreme fatigue, was unable to make basic decisions, and required assistance with most aspects of daily living.  Following the treatment he suffered severe medium- and short-term memory problems, his ability to retain complex information was significantly reduced, his senses of smell and taste were reduced, he displayed increased irritability and angered rapidly, and he suffered expressive language dysfunction - symptoms indicative of acquired brain injury.

The purpose of ECT is to induce seizure activity in the brain; however, Tegretol is an anticonvulsant medication, which prevents seizure activity.  Six ECT treatments failed to elicit adequate seizures. It was held that the psychiatrist breached Right 4(1) by not reviewing the patient's current medication, and discontinuing the Tegretol and lithium prior to, or at an earlier point during, the course of ECT.  The psychiatrist's decision to continue lithium, which can increase confusion immediately after ECT, was a further oversight.

Following the initial six weeks of treatment there was an unacceptable delay in further treatment. The scheduling difficulties were frustrating for the patient, and unsatisfactory in terms of overall treatment. Such a course should not be commenced unless it is assured that it can be completed in a timely fashion, and the DHB was held to have breached Right 4(3).

In failing to have in place appropriate policies and procedures for the administration of ECT, the DHB also breached Rights 4(1) and 4(5).  No clinician was appointed as care co-ordinator with overall responsibility for the clinical surveillance of the patient's ECT, and co-ordination between the community and hospital providers - especially important in the case of an outpatient - was inadequate, and compromised the standard of care the patient received.

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