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NURSE GUIDANCE FOR ECT, APRIL 2005 There are four components of nursing care in ECT: (1) providing emotional and educational support to the patient and family/carer; (2) assessing the pre-treatment plan and the patient’s behaviour, memory, and functional ability prior to ECT; (3) preparing and monitoring the patient during the actual procedure; and (4) recovering patient, observing and interpreting patient responses to ECT with recommendations for changes in the treatment plan as appropriate. These elements of nursing care should be reflected in the nursing care plan for patients receiving ECT. PROVIDING EDUCATIONAL AND EMOTIONAL SUPPORT Nursing care starts as soon as the patient and family / carer are offered ECT as a possible treatment option. At first, a vital role of the nurse will be to give the patient and family / carer an opportunity to express their feelings, including any myths or misconceptions about ECT. Patients may describe fear of pain, dying from electrocution, suffering permanent memory loss, or experiencing impaired intellectual functioning. As the patient expresses these fears and concerns, the nurse can clarify misconceptions and emphasise the therapeutic value of the procedure. These first interactions allow for the building of trust and rapport necessary to maintain a therapeutic nurse-patient relationship. Supporting the patient and family / carer in their need to discuss, question, and explore their feelings and concerns about ECT should be an essential part of nursing care before, during and after treatment. Continuing on from this initial meeting the nurse can begin “ECT teaching”. Depending on the patient’s presenting mental state, this should allow for the patient’s anxiety, readiness to learn, and ability to comprehend. (1). Where ever possible, family / carer teaching should take place at the same time as patient teaching, and the amount of information given should be individualised for each patient and family / carer. The nurse should review the information the patient and family / carer have received from the doctor regarding the procedure, and try to answer any questions the patient and family / carer might have about this information. During this assessment process, the nurse should also try to find out what specific patient behaviours the family / carer associates with the patient’s illness, and ascertain whether the patient or a family member has had ECT in the past. Any information about the family’s previous experience with ECT 1 will help the nurse identify familial beliefs about the patient’s illness, the ECT treatment, and the expected prognosis. Patient and family / carer should also be asked what other exposure they may have had to ECT, such as through friends who have received it, or by reading about it, or by seeing it portrayed in a film such as One flew over the cuckoos nest. Open – ended questions can give the nurse the opportunity to identify and correct misinformation and deal with specific concerns the patient or family / carer may have about the procedure. E.g. What concerns do you have about receiving the anaesthetic? How do you think you will feel after the first treatment? What do you know about ECT? These nursing actions may then promote the family’s ability to provide support to the patient during the treatment and so further allay the patient’s anxiety. (1) An information booklet and video presentation may be used to supplement teaching the patient and family / carer about ECT. A tour of the treatment suite itself may help familiarise the patient with the area, procedure, and equipment. (2) Encouraging the patient to talk with another patient who has benefited from ECT may be an additional source of information. (3) The nurse should facilitate flexibility in family / carer visiting arrangements, particularly during the patient’s first few treatments, allowing for family visitation before and after ECT if the patient and family / carer desire. This allays the family’s anxieties and concerns about the patient’s treatment, while encouraging the family / carer to provide support for the patient. The nurse should also encourage the family / carer to visit the patient frequently throughout the course of treatment. The nurse should ascertain the changes family members observe in the patient and answer questions that arise. In some instances the patient may request that a member of their family or carer be present in the treatment room whilst they receive ECT. They should discuss this with their doctor. The appointed family member / carer should be assessed and prepared , using such resources as a training video which shows someone having ECT. The multi disciplinary team must be informed of the pending presence of the family member / carer in the treatment room. 2 INFORMED CONSENT FOR ECT In November 2001 the DOH published the Good practice in consent implementation guide : consent to examination or treatment.(4) Before beginning ECT, an informed consent should be signed by the patient. In England and Wales, if the patient does not have the capacity to consent, a form for section 58 of the Mental Health Act must be completed by a second opinion approved doctor, or in an emergency and with a view to a section 58 being arranged a form for a section 62 of the Mental Health Act can be completed by the Responsible Medical Officer. (5) The patient should be provided with Mental Health Act leaflet 3 in these cases. The consent acknowledges the patient’s rights to obtain or refuse treatment. The consent form must comply with the recent Department of Health guidelines on consent documentation. (4) Even though it is the doctor’s ultimate responsibility to provide an explanation of the procedure when obtaining consent, the nurse plays an integral role in the consent process. (6) Informed consent is a dynamic process that is not completed with the signing of a formal document, but it implies a process that continues throughout the course of treatment. It suggests a number of nursing activities. (7) It is helpful if a nurse is present at the time when the information for consent is presented to the patient. The most appropriate nurse is one who has established a trusting and therapeutic relationship with the patient and who is best able to assess whether the patient comprehends the explanation. The presence of a nurse at this time may facilitate the patient’s confidence in asking questions, and the nurse may be able to simplify the language if necessary. The nurse can also ensure that the patient has been provided with a full explanation; understands the nature, purpose, and implications of the treatment, including the option to withdraw consent at any time; and has had all his or her questions answered before signing the consent form. After signing the informed consent, but prior to beginning treatment, the nurse should again thoroughly review this information. The nurse should discuss the treatment in an open and direct manner, so communicating that ECT is an accepted and beneficial form of treatment. (1) It is the responsibility of the psychiatrist to obtain the patient’s consent. Depressed patients frequently experience impaired concentration and so are less likely to comprehend and retain new information. For these patients, it is essential that the nurse repeat the information given by the psychiatrist at regular intervals, because new knowledge is seldom fully 3 absorbed after only one explanation. Throughout the patient’s treatment course, the nurse should reinforce what the patient already understands, (note, the level of understanding varies from patient to patient, and some patients may never understand the information given to them). Where applicable, the nurse should remind the patient of anything he or she has forgotten, and provide the patient with the opportunity to ask new questions. Written information also available in other languages should be provided to the patient and their family / carer. An interpreter should be arranged if required. The patient should be informed about how to obtain additional information and access to an independent advocate. (9) PRETREATMENT NURSING CARE The ECT treatment nurse should ensure that the treatment suite is properly prepared for the ECT procedure. The equipment needed to provide optimal ECT patient care, as recommended by the Royal College of Psychiatrists is stipulated in their ECTAS standards. (9) An adjustable height stretcher trolley should be available for the less ambulant patients. Other moving and handling aids should also be accessible. In order to provide best practice nursing care for the ECT patient, a pretreatment checklist should be completed as designated by local hospital policy. (8) Arrangements should be made for the safekeeping of the patient’s valuables. The ECT nurse should check that all relevant documentation has been completed. The nurse should explain the procedure to the patient again and ask whether they have any more questions or queries, providing reassurance. Because general anaesthesia is required for ECT, the patient should fast from food and fluids, ( as per local policy) before treatment to prevent possible aspiration. The exceptions could be the patients who are taking cardiac medications, anti hypertensive, or H2 blockers routinely. These medications should be administered before treatment as directed by the doctor, with a sip of water. Day patients should avoid a heavy meal the evening before the treatment. On the morning of treatment the patient should be asked to remove make up, nail varnish, body piercing etc. The nurse should ask the patient when he or she last ate and last drank. The patient’s hair should be clean and dry to allow for electrode contact. Hairpins, hairnets and other hair ornaments should also be removed for the same reason. (10) The patient should be encouraged to pass urine before the treatment to avoid incontinence during the procedure and to minimise the likelihood of bladder distension and damage during treatment. Prostheses, dentures, glasses, hearing aids, contact lenses, 4 should be removed at the latest possible moment, prior to the administration of the anaesthetic, to prevent problems of communication with the patient. The patient’s identity is checked and the patient wears an identity bracelet. (9) A protocol for day / out patients should be in place which covers their needs, inclusive of : preparing them for leaving hospital after treatment, and a written / verbal contract that they will not drive and have a responsible adult to care for them for 24 hours after treatment, arrangements for further appointments. The patient must be escorted to the ECT clinic waiting area, through ECT and recovery and back to the ward by a qualified nurse or equivalent. (9) In the case of in-patients, the ideal escort is the patient’s Named Nurse, while in the case of out-patients, the patient’s community nurse, keyworker, a member of the ECT team or out-patient department team should perform a similar function. The escort should be known to the patient and be aware of the patient’s legal and consent status and have an understanding of ECT. (9) To further minimise anxiety the escort nurse should consider the use of anxiety management techniques, ensuring as short a wait as possible in the treatment waiting room, offering reassurance and support. (12) The doctor may prescribe a pre-med as per local protocol. Special arrangements should be made when patients are given ECT in a clinic remote from a hospital base, i.e. the patient should have an individual trained nurse escort, and commuting patients should be treated at the beginning of the session to allow maximum time for recovery. (9) Regarding anaesthesia outside hospital, the view of the Association of Anaesthetists is that the standards of monitoring used during general anaesthesia should be exactly the same in all locations. (17) NURSING CARE DURING THE PROCEDURE Because there will be several people in the treatment room, including psychiatrists, the treatment nurse and the anaesthesia staff, the patient should be introduced to each member of the team and given a brief explanation of the member’s role in the ECT procedure. The patient should then be assisted on to a trolley and asked to remove his / her prostheses, dentures, glasses etc. Removing the patients shoes will allow for the clear observation of the patient’s extremities during the treatment. Once comfortably on the trolley, a member of the anaesthetic staff will insert a cannulae, while the treatment nurse and other members of the team place leads for various monitors. One member of the team should 5 provide explanation of the procedure as it occurs. Dual channel EEG monitoring is recommended by the Royal College of Psychiatrists (RCP). One electrode is placed to the side of the forehead and the other is behind the ear, on either side. ECG, pulse oximeter and blood pressure monitoring are also recommended by the RCP. Capnograph is also recommended by the RCP, in the event of a patient needing to be intubated. A peripheral nerve stimulator and a means of measuring the patient’s temperature should also be available for use. Some ECT machines incorporate monitoring equipment for movement when the seizure is induced. An initial recording of the patient’s blood pressure, pulse and oxygen saturation should be made at this stage. The psychiatrist or nurse cleans areas of the patient’s head with alcohol swabs and / or gel at the sites of electrode contact as per local protocol. This is to reduce impedance and improve the contact of the electrodes with the patient’s head. The areas being cleaned should be either both the temples for bilateral ECT, or the temple on the non-dominant side of the brain for unilateral ECT. Exact placement of electrodes for unilateral ECT is dependent on RCP guidelines and local policy. The anaesthetic, muscle relaxant and oxygen are administered. A disposable or autoclavable bite block is inserted into the patient’s mouth prior to the delivery of the stimulus to prevent tooth, tongue or gum damage or joint dislocation. One member of the treatment team records the time elapsed during the seizure. A local stimulus dosing policy should be in use. Local protocols for missed seizures and termination of prolonged seizures should be adhered to. If required and in the absence of the psychiatric trainee, the nurse can assist the treating psychiatrist by pressing the test / treat button on the ECT machine, whilst the psychiatrist holds the electrodes on the patient’s head. The nurse must have been trained and deemed competent by the consultant psychiatrist responsible for ECT. A local protocol, to ensure the psychiatrist is aware of the nurse’s actions at each stage of the procedure and to check the dose given, should be adhered to. This protocol must have been approved by the consultant psychiatrist responsible for ECT. Once the anaesthetist is satisfied that the patient is breathing again and maintaining their own airway or able to do so with assistance, he / she will be transferred to the recovery area. 6 POSTTREATMENT NURSING CARE The recovery area should be next to the treatment room to allow access for the anaesthetic staff in the event of an emergency. Oxygen should be administered routinely to the patient. The area must contain, suction, monitoring and emergency equipment as recommended by the RCP. The nurse should maintain the patient’s airway and monitor / record vital signs at regular intervals or more frequently if complications arise. The patient should be observed by a staff member in close proximity until he or she awakens. The number of staff in the recovery area should exceed the number of unconscious patients by one. (9) A post-operative checklist prompts nurses to check for the presence or absence of common or worrying side-effects at regular intervals after treatment. (11) The patient may not remember having the treatment, and their thinking may be somewhat concrete. The nurse should provide frequent reassurance and reorientation until the patient retains the information. (1) When interacting with the patient, brief distinct direction is best. Note, in some instances the patient may never retain some information. Simple cognitive testing pre and post treatment should give some indication of any abnormality as a result of ECT. The patient may become restless, agitated, aggressive (post-ictal confusion) and / or disorientated for a short period of time. The nurse should maintain the patient’s safety. Verbal interaction is usually ineffective. When the episode has resolved the patient should be reoriented. A small dose of a benzodiazepine may be effective. (10) When the patient is ready he or she should be escorted to a final stage area for refreshments and rest until the recovery staff deem him or her fit to return to the ward. The recovery nurse should pass on information to the ward nurse / escort about the patient’s condition, medication administered, patient’s behaviour, untoward procedures or treatment response. This information should be recorded in the ECT notes. A lengthy seizure may cause an increase in time of patient being disorientated or confused. A longer time for rest and reorientation may be required. Closer observation may be required. The patient should be assessed on return to the ward regarding level of observation required and degree of orientation. If the patient complains of a headache, muscle soreness, analgesia such as paracetemol may be administered. The patient should be encouraged to rest. Nausea may be treated with an anti-emetic. Ward staff should continue to provide support, reminders to the patient of the treatment and reorientation to eliminate patient distress from post treatment amnesia. The cognitive 7 impairments associated with ECT treatment mostly reflect changes in memory – i.e. temporary anterograde amnesia and retrograde amnesia. Memory deficits do not seem to be restricted to personal autobiographical memory. (13) Memory loss may be distressing to the patient. The nurse should reinforce that the majority of the memory difficulties will pass within several weeks, with a minimal amount of memory problems lasting up to 6 months. STAFFING A trained nurse with relevant experience must be present at each stage of the treatment. ECT should be administered only in a suitably equipped unit by professionals who have been trained in its delivery and in the anaesthetic techniques required for the administration of ECT. (15) In busy ECT clinics it is advisable to use nursing assistants to assist the “core team” with low skill tasks. (11) E.g. Assisting with moving a patient, ensuring the patient receives refreshments post ECT, telephone communication. All nursing staff working in the ECT team should receive Basic Life Support training (6 monthly), Moving and handling training (annual), Mental Health Act competency (annual). (14) Recovery nursing staff should receive local recovery skills training inclusive of airway management, aspiration and suction techniques (6 monthly). Their competency in recovery must have been assessed. All staff should be familiar with ECT policies and procedures. The same team should work in the clinic every week for the purposes of continuity. (9) A budget for staff training specific to ECT, should be available. Staff should be encouraged to keep up to date with best practice and their training needs should be formally assessed by appraisal. ECT nursing staff should attend appropriate training and conference events, e.g. regional ECT nurse group meetings, ECT nurse training conferences and the RCP ECT training course. THE ECT CLINC NURSE MANAGER (ECT NURSE) This nurse (minimum grade F RMN or equivalent) is responsible for the development and implementation of a cohesive ECT service acting as a clinical and functional lead. Therefore, he / she should have appropriate ECT related knowledge / experience and have undergone an induction programme covering ECT policies and procedures, medical equipment safety and clinical management. He / she should have an up to date job description with clearly defined roles and responsibilities. 8 He / she should ensure that the patients, equipment and personnel are prepared and organised for the session. Emergency resus equipment and drugs should be checked weekly, or as per local policy. The ECT machine output and electrodes should be checked. The ECT nurse should ensure that the ECT machine functioning and maintenance is checked and recorded at least every year or according to machine guidance. (9) A record of ECT administration should be maintained for quality assurance. An example of good practice in this area is the Scottish ECT Audit Network. (16) Appropriate induction and on-going training of staff should be maintained, e.g. ECT policies and procedures, CPR, Moving and Handling, Mental Health Act, Control and Restraint. The nurse should offer clinical advice to services across the Trust and assist with liaison between the ECT clinic team and the patient’s own team.. The nurse should have designated sessional time for the clinics, auditing, teaching student nurses, risk assessments, administration, supervising and research into best practise in ECT. He / she should support the ECT consultant with the training of junior doctors. The ECT nurse should be able to spend time with patients and relatives in order to provide support and information. User / carer support groups related to ECT should be supported by the ECT nurse. He / she should receive regular supervision and maintain a personal development plan related to ECT. He / she should attend specific ECT training sessions, e.g. Royal College Psychiatrists Training Days, and / or become actively involved in their regional ECT Nurse Group. The nurse should have protected time to carry out all of the above duties and should not be expected to be covering a ward or other responsibilities on the days of treatment. There should be a nominated trained deputy to cover the absence of the ECT nurse. Stephen Finch RMN; RGN With advice and contributions from : North West ECT Nurse Group & The Glasgow ECT Nurses Forum. 9 REFERENCES 1. Stuart GW, Sundeen SJ : Somatic therapies and psychiatric nursing. In Duncan L (ed): Principles and Practice of Psychiatric Nursing, ed 4. St. Louis, CV Mosby, 1991, pp 688-693 2. Baxter LRJ, Roy-Byrne P, Liston EH, et al: Informing patients about electroconvulsive therapy: Effects of a videotape presentation. Convulsive Therapy 2:25-29, 1986 3. Royal College of Nursing: RCN nursing guidelines for ECT. Convulsive Therapy 3: 158-160, 1987 4. Health Service Circular: Good practice in consent. NHS Executive. 2001 5. Code of Practice. Mental Health Act 1983. DOH. 6. Ahern L: Electroconvulsive therapy: An effective treatment. AORN J 24:463-470, 1981 7. Barker P, Baldwin S: Shock story. Nursing Times 86 (8): 52:55, 1990 8. Fine M, Jenike MA: Electroshock: Exploding the myth. RN 48:5866, 1985 9. ECTAS standards for the administration of ECT. Dec. 2004. www.rcpsych.ac.uk/cru 10.Litwack K, Jones EE: Practical points in the care of the post electroconvulsive therapy patient. Journal of Post Anaesthesia Nursing 3: 182-184, 1988 11.Royal College of Psychiatrists: ECT handbook: 114-121, 1995 12.Royal College of Nursing: ECT – Guidance for nurses, 1996 13.The UK ECT Review Group: Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The Lancet 361:799-807, 2003 14.North West ECT Nurse Group Standards, RCN Mental Health Zone website, 2003. 15.Guidance on the use of electroconvulsive therapy: NICE, April 2003. www.nice.org.uk 16.www.sean.org.uk 17.Recommendations for standards of monitoring during anaesthesia and recovery. Association of anaesthetists of Great Britain and Ireland. December 2000. 10