Involuntary Treatment and Forcibly Restraining Patients

Mdm. W is a 57-year-old married Singaporean woman with an established history of bipolar disorder. She is from a mixed Indian-Malay family and has two adult daughters. Her husband and family are very supportive and have played a significant role in decisions relating to her treatment in the past.

Despite being compliant with her regime of combined mood stabilisers (lithium and sodium valproate), she developed a severe depressive episode with psychotic symptoms and persistent suicidal ideation. She gave consent to be hospitalised but her condition worsened and her current hospitalisation has been characterised by periods of withdrawal and agitation. She expressed feelings of worthlessness and guilt over being unable to produce a son for her husband. She also believed that she is “one of the world’s greater sinners” and should die to atone for her “sins”. She talked often about wanting to end her life and, at times, refuses to eat and drink in pursuit of this objective. The laboratory investigations revealed no abnormalities.

The psychiatrist in charge, Dr. J, has decided that electroconvulsive therapy (ECT) would be the best option for Mdm. W at this time. He forms this decision in view of her persistent and severe depressive symptoms despite therapeutic doses of mood stabilisers and antidepressants, and the clear and present risk of suicide. However, when Dr. J presented this option to Mdm. W and her family, she vehemently refused to consent.

Mdm. W’s family is deeply concerned and tried to persuade her that ECT would help her feel better, to no avail. They believed that the illness is preventing her from making the right decision and her husband insists on providing consent for the treatment on her behalf. Dr. J informed the family that the procedure would involve the placement of two electrodes on the patient’s scalp, between which a mild current will pass to produce a generalised seizure that would last for approximately one minute. Mdm. W would feel no discomfort during this procedure as she will receive a general anaesthetic. The number of treatments would depend on how well she responds, but are typically given three times a week over two weeks.

Dr. J also informed the family that Mdm. W would need to fast for at least eight hours prior to the procedure to reduce the risk of aspiration during the administration of general anaesthesia. He expressed concerns that Mdm. W will not comply with the restriction on food and drink and may have to be physically restrained to prevent her from eating or drinking. The family agrees to these measures, and Dr. J has ordered the nursing staffing to restrain Mdm. W for the eight-hour period prior to the first ECT.