Treatment-Refractory Catatonia, ECT, and Parenteral Lorazepam

To the Editor: I read with interest the Clinical Case Conference by John Boronow, M.D., et al. (1). In the case presented, ECT clearly appeared to be the next reasonable treatment option; however, the patient refused to have ECT administered. The authors noted that a judicial review process exists for involuntary medications, which was used in the case discussed. However, the treatment team’s only alternative for involuntary ECT was to ask the family to obtain legal guardianship in order to obtain consent for ECT from a judge. The family refused the request.

In Minnesota, a guardian may not consent to ECT, even under judicial review, for a nonconsenting patient. I believe this is for the best, because, as Dr. Boronow et al. pointed out, it puts the family or guardian in a situation that could have undesired consequences. The family or guardian’s relationship with the patient (or with other family members who do not agree with the procedure) could be strained. Instead, in Minnesota, ECT can be petitioned directly to a court if the patient is under a civil commitment. (The case presented certainly could have been considered for a civil commitment on the basis of Minnesota’s Commitment and Treatment Act.) In that situation, both parties (the physician or hospital and the patient) may have representation and present their petition(s) to a judge. Any family members could also be part of the testimony if they wish. It appears that this alternative was not available, which was very unfortunate. After reading this case, I wondered what the outcome would have been had this patient lived where I practice.