- Laws of Fiji

Last Updated: 1 December 2016

[MH 10,250] Form 1 INFORMED CONSENT FOR ADMINISTRATION OF ELECTRO CONVULSIVE THERAPY (ECT) BY PERSON SUBJECT TO PROCEDURE(Section 73)

(Order 10)

PART A: INFORMED CONSENT FOR ADMINISTRATION OF ECT BY PERSON SUBJECT TO PROCEDURE

Name______________________________	NHN______________________________
Address______________________________	Ward______________________________

Part 1 — Information To Consider Before Signing
The treatment is recommended where the alternative forms of treatment have either not had the desired result or would work too slowly to be effective in a particular case.

The procedure and Technique of ECT
(a)	You will be given a brief general anaesthetic. This involves giving a drug to relax the muscles. The anaesthetist will generally give the anaesthetic by means of intravenous injection.
(b)	While you are anaesthetised, another medical practitioner will use medical apparatus designed to pass a modified electrical current for a few seconds through your brain, with the intention of affecting those parts concerned with emotion and thought.
(c)	While the current is passing, the anaesthetic will prevent you from feeling anything and also your body from moving more than slightly.
(d)	Treatment may be given 2 or 3 times a week.
(e)	A course of treatment will generally involve up to 12 treatments but, on some occasions, more treatments will be required. Any queries you have in relation to the number of treatments you may need can be raised with your doctor.

Possible outcome of ECT
Benefits depend upon the symptoms of the conditions for which treatment is given. Relief may be obtained from symptoms of depression, agitation and insomnia.

Other alternative treatments that is possible.
Other treatments may also be suitable for your condition. Any queries you have in relation to these can be discussed with your doctor. A written explanation of the alternative treatments available in relation to your condition is attached.

Possible complications of ECT:
Some patients notice a difficulty with their memory for recent events which almost invariably clears up within a month of receiving the last treatment. Some patients experience a headache or a brief period of confusion, or both, on awakening after the anaesthetic. Otherwise, because the treatment and anaesthetic are very brief and present no significant stresses to the body, serious complications are uncommon. All general anaesthetics carry some risk.

Consent for treatment:
This treatment cannot be carried out without your consent (see Part 2 below), unless you are an involuntary patient at the mental health facility. If you are an involuntary patient, the treatment can only be carried out without your consent after a full hearing before the Mental Health Review Board.
Before giving this consent you may ask your doctor any questions relating to the techniques or procedures to be followed. You may also withdraw your consent and discontinue this treatment AT ANY TIME.

Legal advice:
You also have the right to get legal advice and medical advice before you give your consent.

PART 2		(left thumb print)
CONSENT TO ELECTRO CONVULSIVE THERAPY
(VOLUNTARY PATIENTS)
I,____________________________________(patient’s name)
consent to being treated with a course of electro convulsive therapy.


I ACKNOWLEDGE that I have read/have had read to me Part 1 of this form, and that I understand the information it contains.
I UNDERSTAND that I am free at any time to change my mind and withdraw from the course of treatment if I so desire.
I fully understand part 1 as explained to me in (English / iTaukei / Hindi or___________) by approved medical staff.

Signature________________________________ Date____/______/_________


	PART 3
	CONSENT TO ELECTRO CONVULSIVE THERAPY (INVOLUNTARY PATIENTS)

	I,__________________________________consent to being	(left thumb print)
	treated with electro convulsive therapy.




	I ACKNOWLEDGE that I have read/have had read to me Part 1 of this form, and that I understand the information it contains.

	I UNDERSTAND that I am free at any time to change my mind and withdraw from the course of treatment if I so desire.

	I fully understood part 1 as explained to me in (English / iTaukei / Hindi or________________) by approved medical staff.

	I UNDERSTAND that my consent will be reviewed by the Mental Health Review Board.

	Signature:_______________________________Date____/________/___________


	PART 4
	CERTIFICATION OF WITNESS

	I certify that all matters dealt with in this Form have been orally explained to the person in respect
	of whom treatment is proposed and have been so explained in a language with which that person is familiar.

	Signature of witness:___________________________________ Date____/____/_______

	Name of witness_____________________________________________

PART B: DISCLOSURE OF FINANCIAL RELATIONSHIP
Item A
To be completed by the person proposing the administration of the treatment.
	□	I declare that there is no financial relationship between me and the mental health facility or
		institution in which it is proposed to administer the treatment.
OR
	□	I declare that the following (attached) is a full disclosure of the financial relationship between
		me and the mental health facility or institution in which it is proposed to administer the
		treatment.

Signature:_____________________________________________
Name:_______________________________________________

Item B
To be completed by the medical practitioner who proposes to administer the treatment (unless that
medical practitioner is also the person who completed Item A, in which case this item need not be
completed).
	□	I declare that there is no financial relationship between me and the mental health facility or
		institution in which it is proposed to administer the treatment.
OR
	□	I declare that the following (attached) is a full disclosure of the financial relationship between
		me and the mental health facility or institution in which it is proposed to administer the
		treatment.

Signature:_____________________________________________
Name:________________________________________________