Medical co-morbidities are very common in patients with psychiatric conditions. Although respecting one's autonomy to make treatment decisions is the ethical default position, the capacity to make such decisions may need to be assessed, especially when patients are in relapse of their psychiatric condition, and/or when the decisions made are high-risk and possibly fatal. This case report highlights the ethical issues of refusing potential life-saving treatment in a patient who is in relapse of her schizoaffective disorder. In particular, the assessment of decisional capacity and the role of the doctors (if the patient lacks capacity) are discussed. Recommendations are also made on how to better manage such situations.
Adult ; Female ; Humans ; Kidney Failure, Chronic ; therapy ; Mental Competency ; Patient Care ; ethics ; Patient Participation ; psychology ; Personal Autonomy ; Schizophrenia

Cognition Disorders ; diagnosis ; Decision Making ; Humans ; Mental Competency ; legislation & jurisprudence ; Physicians ; Singapore

INTRODUCTION: The use of electroconvulsive therapy (ECT) in Singapore dates back to 1947. However, there is little local information on the clinical practice of ECT and its standards. We aimed to conduct a comprehensive national survey of ECT practice in Singapore. METHODS: A cross-sectional structured questionnaire assessing the types of ECT (e.g. electrode placement, stimulus parameters), indications, anaesthetic technique, dosing methods, monitoring of outcomes and credentialing was sent in 2015 to all ECT centres in Singapore via email to collect qualitative and quantitative data regarding ECT. RESULTS: Data was obtained from all ECT centres (n = 6), which represented that ECT was available in 23.1% of all hospitals and 50.0% of all psychiatric specialist centres. The rate of ECT was 5.89 treatments per 10,000 residents per year, and each patient received an average of 5.4 ECT per course. Only 7.0% of ECT was administered for continuation/maintenance ECT. The most common indication for ECT was depression in 5 (83.3%) out of six centres, with schizophrenia being the second most common. In 5 (83.3%) out of six centres, ECT was brief (0.5 ms) bitemporal ECT with age-based dosing, and 93.0% of the sessions were conducted in an inpatient setting. All ECT was conducted under general anaesthesia, with propofol (66.7%) being the most common type of anaesthetic used. CONCLUSION The practice of ECT in Singapore was highly uniform. The rates and indications for ECT were consistent with those of other developed countries, with greater use of ECT for schizophrenia. Future advances for ECT in Singapore include the use of individualised dosing based on empirical seizure threshold titration, expanded electrode placements and increased utilisation of continuation/maintenance ECT.