`Where a patient withdraws consent he or she should receive a clear explana-
tion, which should be recorded in the patient's records:
...
#7) of the likely consequences of not receiving the treatment;
#8) that a second medical opinion ... may or will be sought, if applicable, in
order to authorise treatment in the continuing absence of the patient's
consent;
#9) of the doctor's power to begin or continue urgent treatment under [the
emergency provisions] until a second medical opinion has been obtained,
if applicable.' [18]The need to check Form 38 is not only relevant to continued consent, but assists in
highlighting those cases where the drug or its dosage listed has changed since the
form was originally signed. In this situation the treatment may be unlawful. While
the MHA itself does not require specific drugs to be named, or specific dosages, the
Code of Practice does suggest that medication should be listed by name. However,
the Code of Practice goes on to state that the rmo should [ensure] that the number of drugs authorised in each class is indicated, by the classes described in the British National Formulary #BNF). The maximum dosage and route of adminis- tration should be clearly indicated for each drug or category of drug.' [19] Where specific drugs are named, no further drug may be administered unless a new Form 38 is completed. To avoid this problem most SOADs when signing Form 3 9do not list specific drugs, but categories according to the BNF, and do not specify the dosage unless it will exceed the recommended BNF upper limit. Little mention has been made of ECT, and it is true that ECT is in a minority of section 58 treatments insofar as SOAD activity is concerned. The Mental Health Act Commission's Eighth Biennial Report also highlights a striking difference in the usage of ECT between the genders with 15.4% of requests for men compared to 42.7% for women [20]. When second opinions are requested, it is unusual for them not to be provided regardless of whether ECT or medication is at issue. Whether this implies improper collusion or an acceptable recommendation for treatment at the outset is not clear. For ECT, clear indicators for its use are documented. The Code of Practice now requires patients who are being treated with ECT to have beengiven a leaflet which helps them to understand and
remember, both during and after the course of ECT, the advice about its nature,
purpose and likely effects' [21]. The requirement of the Code of Practice for the
maximum number of proposed ECT applications to be included within the
patient's treatment plan should be seen to be both good practice and consistent
with a participative approach to patient care. However, it is worth noting that
Fennell queries whether there are `appropriate and effective safeguards' [22] so far
as ECT is concerned.
The nurse may not play a major role in the administration of ECT but will clearly
have a role in the assessment of whether the treatment should take place. As with
administration of medicine, the patient may consent to ECT. If so, and the nurse
were concerned about the patient's capacity to consent, the first step would seem
to be to raise it with the rmo. If this has no effect, the suggestion of seeking the
involvement of a SOAD would seem sensible. If, however, this is not done,
Mental Health Nursing 165