Electroconvulsive Therapy and Ethical/Legal Issues

What is Electroconvulsive Therapy (ECT)?

The induction of a grand mal (generalized) seizure through the application of electrical current to the brain via electrodes

ECT Mechanism of Action

Many parts of the central nervous system are affected

Hormones, neuropeptides, neurotrophic factors, and nearly every neurotransmitter

What hormones are effected in ECT?

Serotonin

Norepinephrine

Dopamine

Movements are minimal during ECT because of the administration of a ___________________________ prior to the treatment

muscle relaxant

ECT schedule

Treatments administered every other day—3 times per week

Most require 6-12 treatments; some require up to 20

Indications for ECT (3)

Major Depression

Mania

Schizophrenia

ECT for Major Depression

Considered only after a trial of therapy with antidepressant medication has proved ineffective

May be considered the treatment of choice when the need for tx response is urgent (extremely suicidal or refusing food and nutritionally compromised)

ECT for Mania

Only used when a patient has failed to respond to medication (As effective as lithium)

Treatment of bipolar disorders with mixed states.

Effective on clients who are refractory to antimanic drug therapy

Should NOT be used while a pt is receiving lithium (Lowers seizure threshold and prolongs seizures)

Why should ECT not be used if patient is on lithium?

Lowers the seizure threshold and may cause prolonged seizures when combined with lithium

ECT for Schizophrenia

Can induce a remission in some clients who present with acute schizophrenia

Does not appear to be of value to individuals with chronic schizophrenic illness.

Considerations for ECT (4)

Used for those who cannot take medication (Pregnant/elderly)

Never in children

Patient with heart conditions must precede with caution

Do not use with ICP patient

Side Effects of ECT

Temporary memory loss and confusion

Death is very rare but usually r/t cardio complications

Nursing Assessment prior to ECT

Must receive a thorough physical exam

Skeletal history and X-ray assessment should also be considered

Assess mood, level of anxiety, thought and communication patterns, and vital signs

Informed consent

What are the most important assessments prior to ECT?

Cardiovascular and pulmonary status

Laboratory blood and urine studies

What to do as a nurse 1 hour before ECT?

Take and recording vitals

Have client void and remove dentures, eyeglasses or contact lenses, jewelry, and hairpins

Following institutional requirements, client changes clothing

What medication is given prior to ECT by the nurse and why?

Atropine or glycopyrrolate IM

Decrease secretions to prevent aspiration

What medication is given prior to ECT by the Anesthesiologist and why?

Propofol or methohexital; short-acting sedative

Succinylcholine; Muscle relaxant is given IV

Why is Succinylcholine given prior to ECT?

Prevents severe muscle contractions during the seizure, thereby reducing the possibility of fractured or dislocated bones

When are where should a BP cuff be placed in ECT?

Placed on the lower leg and inflated above systolic pressure prior to the injection of the succinylcholine

Patients post-ECT

Anesthesiologist continues to oxygenate the pt with pure oxygen until spontaneous respirations return

Most clients awaken within 10 or 15 minutes of the treatment and are confused and disoriented

Some clients will sleep for 1 to 2 hours following the treatment.

Ethical and Legal Issues

• Autonomy: Respecting a patient’s right to make their own healthcare decisions.

• Beneficence: Acting in the patient’s best interest to promote good.

• Justice: Providing fair and equal treatment to all patients.

• Nonmaleficence: Avoiding actions that cause harm.

• Fidelity: Keeping promises and being faithful to professional responsibilities.

• Veracity: Telling the truth to patients.

Self-Determinism Fundamentals

Empowerment or having free will to make moral judgments (Personal autonomy)

Patient Self-Determination Act

Mandates that everyone has the right to make decisions regarding medical care

Information about advance care documents

Advance care directives in mental health

Living will

Durable power of attorney

Psychiatric advance directives

Living Will

A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes

Durable Power of Attorney

Allows an agent or representative of the patient to act on behalf of the patient

Difficulty of informed consent in mental health treatment

Competency is necessary to give consent but decision-making ability is often compromised in mental illness

Exceptions to confidentiality and right to privacy (HIPPA)

A duty to warn about harm to another

Suspected child or elder abuse

Privacy Rights

Have the right to confidentiality and the right to privacy

Exception: A DUTY TO WARN (suspected child or elder abuse)

Criteria for Admission to Inpatient Mental Health Facility

Danger to self or others

Least restrictive environment

Can benefit from hospitalization

Types of admissions to mental health facilities in Kentucky

Voluntary

Involuntary (72 hour, MWI, mental illness)

Involuntary Admission Types (3)

72-hour hold

Mental Health Inquest Warrant (MIW): Someone requests someone to go and a warrant is approved

KRS 504.020/Denovo: Forced treatment

Restraints are never to be used as ____________________________________ (2)

Punishment

Convenience of staff

Restraints/Seclusion should be used for the _______________________ , and only if less restrictive measures failed

shortest duration necessary

Restraints can be ______ or ________

physical ; chemical

To use restraints/seclusions one must have_______

a provider’s order

Least Restrictive Measures

Verbal De-escalation

Redirection

PRN Medication

"Cool off time"

Providing a calm quite environment

Time limits for seclusion/restraints: Age 18 and older

4 hours then reassess

Time limits for seclusion/restraints: Age 9-17

2 hours then reassess

Time limits for seclusion/restraints: Age 8 and younger

1 hour then reassess

If seclusion/restraint continues provider must _____________________ and rewrite the order every _________ hours

reassess the patient, 24

Nurses Role in Restraints (5)

Assessing patient behavior, safety, and physical needs

Offering food and fluids

Toileting

Monitoring VS and pain

Documentation

Documentation of restraints

Every 15-30 minutes

Time tx began, current mood, time released

Tips to avoid lawsuits in nursing (5)

Effective communication

Accurate and complete documentation in the medical record

Complying with the standards of care

Knowing the client

Practice within the nurse's level of competence and scope of practice

Types of lawsuits that occur in psychiatric nursing

Breach of confidentiality

Invasion of Privacy

Assault

Battery

False Imprisonment