For adults who are unable to consent to investigation or treatment

All sections to be completed by the health professional proposing the procedure

Patient's details (or pre-printed label)

Patient's surname/family name:

Patient's first names:

Date of birth:

Responsible health professional:

Job title:

NHS number (or other identifier):

Male ⎕ Female ⎕

Special requirements:

(e.g. other language/communication methods)

Signature of health professional proposing treatment

The procedure, detailed overleaf, is, in my clinical judgement, in the best interests of the patient, who lacks capacity, to consent for himself or herself. Where possible and appropriate I have discussed the patient's condition with those close to them and taken their knowledge of the patient's views and beliefs into account in determining their best interests.

⎕ I have/have not sought a non-statutory second opinion (see below). (Delete as appropriate.)

⎕ I confirm that I have read the legislation table and have taken account of all the issues governing the administration of ECT as pertaining to the Mental Capacity Act 2005 and where relevant the Mental Health Act 1983.

Signature: Date:

Name (print): Job title:

Where second opinion sought, the patient should sign below to confirm agreement:

Signature: Date:

Name (print): Job title:

Where the patient is detained under the MHA 1983:

A Has a Second Opinion been requested from CQC? Yes / No

B Is a T6 completed and attached? Yes / No Date completed:

C Has a Section 62 Form been completed? Yes / No

(A) Name of proposed procedure or course of treatment

Electroconvulsive therapy: Unilateral ⎕ Bilateral ⎕ Either ⎕

(Please tick laterality)

(B) Assessment of patient's capacity

I confirm that:

⎕ The patient is unable to comprehend and retain information material to the decision; and/or

⎕ The patient is unable to use and weigh this information in the decision-making process; or

⎕ The patient is unable to communicate their decision (whether by talking, using sign language or any other means)

⎕ The patient is unconscious

Please provide details (excluding where patient unconscious): for example of how above judgements were reached; which colleagues consulted; what attempts made to assist the patient make their own decision and why these were not successful.