ECT For Patients Lacking Capacity to Consent: Outcome Data From Japan
Out on PubMed, in JECT, from researchers in Japan and Belgium, is this study:
Electroconvulsive Therapy for Patients With Depression Who Lack Capacity for Consent: Doing Good and Doing No Harm.
Methods: A retrospective chart review was conducted to collect data from patients who received ECT to treat their depressive episodes between April 2012 and March 2019. Differences in clinical characteristics and short-/long-term clinical outcomes between patients who received ECT with their relatives' consent and patients who received ECT by their own consent were examined. The short-/long-term clinical outcomes were determined by clinical global impression scores and readmission rate, respectively.
Results: Of 168 patients with depressive episodes, 34 (20.2%) received ECT with their relatives' consent. Those patients were older, had lower body mass index, and had shorter episode duration. They also exhibited more frequent psychotic, melancholic, and catatonic features. The main indication for ECT in this population was the need for rapid recovery. Patients lacking capacity for consent showed similar remission (61.8%) and response (82.4%) rates to those with capacity for consent. Readmission rate was not significantly different between groups.
Conclusions: There were no significant differences in short-/long-term ECT effectiveness between patients with/without capacity for consent. Electroconvulsive therapy is the only established and effective treatment in clinical settings for the most severe cases, wherein patients are incapable of giving consent but need rapid recovery. A general rejection of this practice due to concerns surrounding consent may be unethical under the ethical principles of medical care.
And from the text:
for Consent
In the current study, the patients lacking capacity for consent showed a higher prevalence of psychotic, melancholic, and catatonic features. Our results are in line with a previous case-control study, which reported a higher prevalence of psychosis in involuntary patients.16 Psychotic symptoms in depression have consistently been reported to be related to better ECT response. According to the current study and previous studies, a certain proportion of patients with psychotic depression and lacking capacity to consent received ECT with their relatives' or legal guardians' consent. These results suggest that clinicians may face a dilemma wherein patients with psychotic depression cannot always provide legal consent in real-world clinical practice, although they are considered good candidates for ECT and will do poorly on medication.
We found that the patients lacking capacity were older, had lower BMI, and had later-onset cases as compared with the patients capable of giving consent. In addition, the patients lacking capacity had shorter durations of their current episode. These clinical characteristics may reflect the severe psychiatric condition of this population.
Ethical Issues Surrounding ECT in Patients Lacking
Capacity for Consent
The ethical aspects of using ECTwith patients lacking capacity for consent should be considered. In general, physicians should follow the ethical principles of medical care: beneficence (doing good), nonmaleficence (not doing harm), autonomy (respect for the individual), and justice (being fair).31,32 Because providing ECT without patients' consent seems to conflict with the principle of autonomy, some healthcare professionals may consider ECT to be unethical in such cases. Although medical treatments should comply with all the ethical principles, it is necessary to set priorities among them if it is deemed impossible to follow allof them in certain situations. The principle of beneficence can be considered more important than respect for autonomy in some clinical situations where failure to treat patients effectively could lead to deterioration, prolonged illness, or even death.
This is an excellent paper with two expected findings (patients without capacity to provide consent are sicker and do equally well with ECT as those with capacity) and one conclusion that many would find counterintuitive (that it is unethical to withhold, i.e NOT do, ECT in severely ill patients). Another point made by the authors is that patients with capacity to consent are per force excluded from research protocols, so this population needed to be studied in the current project.
The terms "with capacity" and "lacking capacity" may be more descriptive and neutral than "voluntary" and "involuntary" but refer to the same situations, the second category often being clinical emergencies.
This manuscript is an important contribution to the ECT literature and deserves a full read by all practitioners, ~15 minutes.
Comments
Post a Comment