In addition to a careful history, physical examination, and appropriate blood work, an ECG and a chest radiograph are useful. Functional cardiac testing may be needed in selected cases where ischemic disease is suspected (159). Optimal medical therapy in preparation for ECT is mandatory to minimize risk during and after treatment. Usual cardiac medication should be continued, unless there are specific contraindications (7). Particular attention must be directed at controlling blood pressure and heart rate by avoiding dehydration and hypotension. Medications to lower cardiovascular risk for anesthesia may be needed, including sympatholytics, other antihypertensives, anticholinergics, and short-acting nitrates (7). Lidocaine should be avoided if possible, due to its potent anticonvulsant effect (7). Anticoagulation with heparin or warfarin may be safely administered during ECT for patients at risk for embolization (160). Cardiac pacemakers generally have a protective effect during ECT, improving the heart’s rate and rhythm. A fixed-rate or demand pacemaker can protect against asystole during excessive vagal tone with ECT (161). Using a magnet, some physicians convert a demand pacemaker to a fixed mode to prevent unnecessary triggering and tachycardia at the time of ECT (162). Implanted defibrillators are also not problematic with ECT (7,163), but a cardiac electrophysiologist should be consulted prior to treatment. Oxygen administration during ECT protects the myocardium from ischemia (100).

Consent Issues for ECT in Special Patient Populations

Obtaining informed consent from patients involves ethical and legal obligations, which have been described in the APA’s conceptual framework (164) and the most recent task force report (7). These include providing adequate information to a patient who is capable of understanding and acting reasonably on such information and providing the opportunity to consent in the absence of coercion. Obtaining informed consent for ECT from special patient populations is often challenging due to their lack of capacity to provide it. Determining capacity to consent is therefore vitally important in these patients, who are often impaired due to their special clinical situation (165).

Frequently, they are elderly patients suffering with significant extra burden of medical illness, cognitive dysfunction, and impaired decision-making ability. The difficult question in some cases is the effect of depression on the right to refuse life-saving medical treatment (166). In these situations, conflicts between medical and psychiatric treatment goals are challenging to resolve (167). In the special case of pregnancy, the capacity involves the ability to consider the needs of the unborn baby, as well as the mother herself (59). Young children and adolescents also frequently lack the ability to fully understand and appreciate the procedure and its potential consequences. ECT, however, should not be considered different from other medical or surgical procedures with comparable risks and benefits. If the patient is incapable, appropriate substitute consent must be promptly obtained to prevent unnecessary suffering, physical morbidity, and possible fatality (168). Local legal requirements must be met in each case, but judicial and political efforts should be made to correct overregulation (169).