Download PATIENT`S NAME: ______ DATE: ____________ TIME: ____

PATIENT’S NAME: _______________________________________________ DATE: ___________________ TIME: ___________
(Important: Do not sign this Consent without reading and understanding its contents. Mark out and initial any Procedure
and/or section of this form for which consent is not granted.)
1.
I hereby authorize and consent to the proposed procedures and/or treatments as described herein to be performed at Trinity Hospital of
Augusta, Augusta, Georgia by Dr. ______________________________________ or anyone designated by him/her if substitution
becomes necessary (collectively, the “responsible physician”). I acknowledge and understand by executing this form I have been
informed of the items set forth herein and other matters relative to my health care.
2.
My condition/diagnosis:___________________________________________________________________________
3.
The procedures/treatments to be performed: Electroconvulsive Therapy (ECT)
4.
The following has been explained to me in general terms and I understand that:
5.

Electroconvulsive Therapy (ECT) is a method for treating certain psychiatric conditions by stimulating the brain electrically in
order to produce a controlled seizure that has therapeutic effect.

The number of treatments are to be _________________ over a _________________ week period.

The purpose of the procedure is to treat the illness and bring about a return improvement to mental health. This treatment consists
of passing a controlled electric current between two electrodes applied to the patient's head. In most instances, the patient may be
given medication prior to treatment to reduce tension and to produce muscular relaxation. The patient will not feel the electrical
stimulus. When the electric current is administered, you will be unconscious and have minor muscular contractions, which usually
last from 15 to 180 seconds. In the majority of patients, the muscular contraction lasts 30-90 seconds. Your consciousness and
confusion should clear within 15 to 60 minutes. You may experience headache and nausea. This explanation represents a fair
description of the proposed treatments.

I understand during electroconvulsive therapy my heart rate and rhythm will be monitored by an electrocardiogram (EKG) and my
brain waves will be monitored by an electroencephalograph (EEG) for safety and therapeutic reasons. I understand I may receive
more than one convulsive electrical stimulus during the procedure. My psychiatrist will use his judgment to determine the amount
of stimulus that I will receive.
Risk of this Procedure:
 Like other medical and surgical procedures, ECT does involve some risk. Some side effects you may experience are headaches,
muscle soreness, or nausea. You may be confused just after awakening from ECT and this generally clears as the day progresses.
Generally there is amnesia for events that occur in close proximity (1-2 weeks before and sometimes after) to a course of ECT
depending on the number of ECT given. The day of treatment occasionally remains clouded. During the treatment period, memory
for recent events will likely be impaired. This could include current events, telephone numbers, dates and addresses and the like.
In most cases, memory difficulty goes away within a few days or weeks after completing the series of treatments.

Medical complications due to ECT are rare but are increased in persons with underlying medical illness. These can include heart
rate and heart rhythm irregularities, increased blood pressure, heart attack, and stroke. There is a remote risk of death due to
medical complications. Despite the frequent use of ECT on patients’ with significant physical medical conditions and in the
elderly, the rates of mortality associated with ECT appear to have decreased in recent years. The mortality attributed to ECT is
estimated to be the same as associated in minor surgery, roughly 1 per 10,000.
6.
Alternatives to ECT include medication, psychotherapy, or a combination of the two. However, on occasion ECT proves to be the only
effective mode of therapy.
7.
Benefits/Results of Treatment:
 Although most patients experience significant improvement after a course of ECT, no specific treatment results can be promised.
As with all medical treatments, some patients recover quickly, some slowly, and some will have little improvement at all. Even if
the recovery occurs, relapse or reoccurrence of the symptoms is possible hence, it is important that you continue to have follow up
with a physician. Medications or maintenance ECT are frequently prescribed to prevent relapse .
8.
The responsible physician, any physician selected by the responsible physician and other medical personnel participating in my care will
rely on my documented medical history, as well as other information obtained from me, my family or others having knowledge about
me, in determining whether to perform or recommend the procedures/treatments; therefore, I agree to provide accurate and complete
information about my medical history and conditions.
Trinity Hospital of Augusta
Informed Consent
for Electroconvulsive Therapy
Patient Label
Front
9.
The responsible physician, any physician selected by the responsible physician and other medical personnel participating in my care will
rely on my documented medical history, as well as other information obtained from me, my family or others having knowledge about
me, in determining whether to perform or recommend the procedures/treatments; therefore, I agree to provide accurate and complete
information about my medical history and conditions.
10. I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN
MADE TO ME concerning the outcome and/or result of any surgical or diagnostic procedure consented to herein.
11. I understand that during the course of the procedure described above it may be necessary or appropriate to perform additional
procedures, which are unforeseen, or not known to be needed at the time this consent is given. I consent to and authorize the persons
described herein to make the decisions concerning such procedure and also consent to and authorize the performance of such additional
procedures, as they deem necessary or appropriate.
12. I also consent to diagnostic studies, tests, anesthesia, x-ray examinations, and other treatment or course of treatment relating to the
diagnosis or procedures described herein.
13. This authorization includes consent of the administration of muscle relaxants, sedatives, anesthetics, and other drugs and medications in
connection with the treatments.
14.
I acknowledge that I have had all the opportunity to discuss the benefits/risks and alternatives to ECT and anesthesia that I desire.
15.
I understand that some or all of the health care professional performing services in this hospital are independent contractors and are
not hospital agents or employees. Independent contractors are responsible for their own actions and the hospital shall not be liable
for the acts or omissions of any such independent contractors.
I HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS CONCERNING THE PROCEDURES DESCRIBED
HEREIN AND THE QUESTIONS I HAVE ASKED HAVE BEEN ANSWERED OR EXPLAINED IN A SATISFACTORY
MANNER.
I hereby affirm that I am signing this consent in the following capacity:
_____ An adult consenting for himself or herself
_____ An agent acting pursuant to a durable power of attorney for health care
_____ A parent consenting for his or her minor child
_____ A married person consenting for his or her spouse
_____ A minor married person consenting for himself or herself
_____ A guardian consenting for his or her ward
_____ A person temporarily standing in loco parentis, whether or formally serving or not, consenting for the minor under his or
her care
_____ A minor 18 years of age or under consenting for himself or herself, when no other person to consent is available
_____ A female regardless of age or marital status, consenting for herself in connection with pregnancy or childbirth
_____ An adult, in the absence of a parent, consenting for his or her minor brother or sister
_____ A grandparent, in the absence of a parent, consenting for his or her minor grandchild
_____ The patient if a minor suffering from venereal disease or a drug abuse problem
If the patient is an adult not competent to make responsible decisions regarding his/her medical treatment and no health care agent,
spouse or legal guardian is available to give substituted consent, then:
_____ An adult child for his/her parent
_____ A parent for his/her adult child
_____ An adult for his brother or sister
_____ A grandparent for his/her adult grandchild
BY SIGNING BELOW, I ACKNOWLEDGE I HAVE READ THIS FORM OR HAD IT READ OR EXPLAINED TO ME AND I
UNDERSTAND THIS FORM AND I VOLUNTARILY CONSENT TO ALLOW THE PROCEDURES/TREATMENTS
DESCRIBED HEREIN TO BE PERFORMED AS HEREIN PROVIDED.
Witness: _______________________________
Patient: ____________________________________________
Signature of patient or other person authorized to sign
Date: __________________________________
Time ____________________
Physician Signature _________________________________________
Trinity Hospital of Augusta
Informed Consent
for Electroconvulsive Therapy
Date: _________________
Patient Label
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Time: ___________________