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Lawmakers want to halt unnecessary treatments
The Dallas Morning News
Sat, May 24 1997
AMARILLO - The death of a chronically ill 79-year-old woman in a mental hospital has focused new attention on the emotional debate over electroshock therapy as a treatment for depression.
The woman, whose identity is protected by confidentiality laws, died 24 hours after a shock treatment Dec. 30, 1995. Medical records described her as confused and disoriented when she signed into The Pavilion on Dec. 27.
The Pavilion is an 85-bed, private psychiatric hospital in Amarillo, the heart of the Texas Panhandle. The woman was kept in the hospital's locked geriatric ward.
State legislators are pointing to her death and others like it across the state as they consider new laws to prevent hospitals and psychiatrists from giving unnecessary shock treatments to elderly people covered by Medicare.
"It {shock therapy} could be a moneymaker for those who use it unscrupulously," said Sen. Jerry Patterson, R-Pasadena, who is sponsoring legislation to put more regulations on shock therapy for the elderly.
Pavilion administrators deny that shock therapy is a high-profit procedure. They say medical reviews found no evidence that shock treatment contributed to the the woman's death.
Still, critics have designated Amarillo and The Pavilion as "the shock capital of Texas."
State records say psychiatrists gave the treatment to 201 Pavilion patients during the year ending Aug. 31, 1996 - more than any other Texas hospital. Memorial Southwest Hospital in Houston ranked second with 126 shock patients.
Under fire from Texas and federal regulators, the hospital announced that it stopped providing shock therapy May 1.
"It is a corporate business decision," said Richard Failla, The Pavilion's top administrator. "There has been a lot of {anti-shock therapy} propaganda over the last 18 months. And harassment of hospitals that do it."
State records kept during a three-year period ending Sept. 1, 1996, show that 17 Texas mental patients died within 14 days of receiving a shock treatment. The records, which include the Amarillo woman, do not allege cause-and-effect between the treatments and death.
Mr. Patterson's bill would require two doctors to certify that shock treatment is medically necessary for patients 65 or older. It also requires the doctors to inform patients or their legal guardian whether shock treatment might worsen other medical conditions.
The proposed law passed the Senate last month and was reported out of a House committee with no amendments. It awaits consideration by the full House. The Legislature adjourns June 2.
Patient gave consent
Texas Department of Health inspectors examined a random series of patient records at The Pavilion in February and March. The 79-year-old woman was among them.
Inspectors said she had undergone knee replacement surgery, suffered a post-surgical heart attack and "an exacerbation of congestive heart failure." She also had a urinary tract infection.
The woman was put in a nursing home. Records said her medical problems had stabilized and that depression had become "her major health problem."
The nursing home transferred her to The Pavilion on Dec. 27, 1995. Medical records said she was suffering from unstable blood sugar related to diabetes, incontinence, bedsores on her buttocks and swollen hands and feet.
"She was able to ambulate only 3-4 steps only with maximum assistance, choking easily on food or fluid, needing total assistance with personal care." She was also disoriented and confused, according to inspection reports.
"This patient, although not competent to give informed consent, was allowed to sign herself into the psychiatric unit and to sign for {shock therapy}," inspectors wrote.
Inspectors said The Pavilion violated a 3-year-old state law by allowing the woman and several other mentally incompetent patients to sign themselves into the hospital and then sign papers consenting to shock therapy.
The woman took her first shock treatment Dec. 29 - two days after arriving at The Pavilion. Nurses found her "unresponsive" at 7:15 a.m. the next day. She died several hours later.
The federal Health Care Financing Administration, which monitors the Medicare program, considered the case serious enough to put the hospital on "the short track" toward terminating Medicare reimbursements for patient care.
Andrew R. Perez, a federal official who monitors hospital quality, sent The Pavilion a warning letter April 11. He said the hospital constituted "a serious and immediate jeopardy to patient health and safety." He gave The Pavilion 10 days to submit a corrective plan of action or face loss of its Medicare privileges by May 8.
"The case itself is terrible, obviously," Mr. Perez said. "It's very serious anytime we take an action like this."
Health care experts say most hospitals depend on Medicare for 35 percent to 50 percent of annual revenue. Termination would be devastating for a hospital, they say.
Regulators oversee 500 Texas hospitals. The Pavilion was one of 11 put on the short termination track since July, federal officials said.
Dr. Michael Jenkins, The Pavilion's medical director, said the hospital changed its admitting policy. Patients must now be "factually competent" - meaning they must know the time, place, who they are talking to and the nature of their medical problem - before they can sign themselves into the hospital.
The new policy leaves few treatment options, Dr. Jenkins said.
"These rules tell me to send the patient back to the nursing home," he said. "Medical literature tells me to treat the patient. So what do I do?"
Inspectors came back to The Pavilion early in May and found enough positive changes to take it off the termination track.
Some say therapy safe
The health care industry's formal name for shock treatment is electro-convulsive therapy, or ECT. Psychiatrists say they prescribe it only after psychoactive drugs fail to relieve debilitating depression or manic depression.
To the chagrin of shock treatment opponents, nationally recognized professional associations of psychiatrists and physicians all recognize ECT as safe and effective.
The therapy typically comes in a series of five to 10 treatments - a treatment every other day over a two- or three-week period. Sometimes, doctors give a single "maintenance treatment" on an outpatient basis.
Psychiatrists administer the procedure in a hospital's surgical suite. After anesthesia, electrodes are attached to the unconscious patient's head. At the other end of the wires is a briefcase-sized machine that provides the electric pulse. The electricity is applied for about a second, inducing a seizure that lasts 20-30 seconds.
Opponents say those seizures can result in brain damage, epilepsy and prolonged memory loss.
ECT advocates say the electricity-induced seizure changes the brain's chemistry for the better, eliminating suicidal tendencies and improving the patient's life.
Last month, the Texas Senate's committee on health and human services heard testimony on Mr. Patterson's bill requiring two physicians to review medical records before the elderly receive ECT.
Some patients said ECT is the only thing standing between them and suicide.
"It is better for me to have the treatments because the other choice I have is death," Virginia West, a manic depressive, told the committee.
Others said ECT impaired their ability to think, work or perform routine tasks such as getting dressed.
"It has devastated my life," said Jane Betzen, a former ECT patient. "It's inhumane. It needs to be stopped."
Numbers questioned
State regulators accused The Pavilion of giving shock treatment to too many patients. Pavilion administrators said the number - 201 patients in the most recent 12-month reporting period - looked big because the hospital serves a vast area of the Texas Panhandle, western Oklahoma, southern Colorado, eastern New Mexico and the southwest corner of Kansas.
Pavilion administrators say their company didn't even own the hospital when the 79-year-old woman died Dec. 30, 1995.
Records show Pennsylvania-based Universal Health Services Inc. bought the Pavilion and its parent, Northwest Texas Hospital, from the publicly owned Amarillo Hospital District about a year ago - some four months after the death.
The Pavilion and 45 other Texas hospitals reported giving shock treatments to 1,781 patients from Sept. 1, 1995, to Aug. 31, 1996, according to reports on file at Texas Department of Mental Health and Mental Retardation.
County, state and federal tax dollars paid for a vast majority of the treatments.
Copyright 1997, The Dallas Morning News.