March 18, 1997 Star-Telegram

State Faults Area Hospitals In Use Of Shock Treatments

By Lou Chapman

FORT WORTH--Hospitals in Fort Worth and Dallas that use electroshock therapy to ease severe depression have given individual patients too many treatments, administered the therapy despite patient refusals and performed inadequate medical screenings, according to state records reviewed by the Star-Telegram.

The violations, which occurred in late 1995 and last year, were uncovered by a random audit of hospital records by the state Health Department and have been corrected, officials said. At one Dallas hospital, two elderly, terminally ill patients were treated with electroconvulsive therapy -- or ECT--even though they were medically unstable or would not benefit from the treatment, Health Department records show. Both died of medical complications within two weeks of their last ECT.

Other state data show a striking increase in the number of patients receiving ECT at age 65 -- when most Americans generally become eligible for Medicare. Hospital officials and proponents of ECT said they cannot explain the increase. They dismissed critics who say hospitals are snaring patients once they become eligible for Medicare reimbursements.

The state issued no sanctions in any of the cases involving violations. And, in many instances, the infractions were considered clerical errors or record-keeping problems that were fixed on the spot, said Eloise Harris-Teas, the Health Department's manager of hospital psychiatric services. In more serious cases, hospitals submitted plans to correct violations and prevent further infractions, Harris-Teas said.

Still, at the request of a nonprofit advocacy group that opposes ECT therapy, the state attorney general's office is examining the Health Department's findings to determine whether to pursue possible state violations. "We've received a lot of data, a lot of information, and we're looking at it," said Ward Tisdale, a spokesman for Attorney General Dan Morales. "That's really the stage we're at right now." The revelations come three years after Texas strengthened its regulations of the use of ECT and began requiring hospitals and psychiatric facilities to provide the state with detailed patient information, including age, race, number of treatments and types of side effects. The disclosures also come as the Legislature is considering a bill that would ban ECT and psychosurgery, prefrontal sonic sound treatment or any other convulsive or coma-inducing therapy. Other ECT data provided to the Texas Department of Mental Health and Mental Retardation show that for the three years that ended Aug. 31, 1996, the number of patients receiving the treatment multiplied anywhere from two to four times between ages 64 and 65, the qualifying age for Medicare.

"Don't let the hospitals tell you there's not a financial incentive to doing electric shock therapy, especially when Medicare pays and there's a hospital stay," said Jerry Boswell, executive director of the Austin office of the Citizens Commission on Human Rights. The commission asked the attorney general to investigate whether hospitals have performed the treatment unnecessarily on people who turn 65, and whether they have violated regulations concerning patients' rights, medical screenings and treatment methods. Co-founded by the California- based Church of Scientology, Boswell's organization generally opposes the use of modern psychiatry. The California-based group previously spearheaded investigations in Texas that uncovered a systematic abuse of patients' rights and referral kickbacks in psychiatric hospitals in Texas.

"It's just too coincidental that there's this spike in numbers at age 65," Boswell said. The deaths related to ECT were recorded at Doctor's Hospital in Dallas, where Health Department investigators reported "poor examination or medical attention" before or during treatment. A 73-year-old woman who got ECT was terminally ill with severe respiratory problems and throat cancer, which eventually caused her death. She also received psychoactive drugs despite her refusal, and consented to ECT after the hospital exerted "undue influence" on her, state records say. The Health Department audit found that she was too ill to benefit from ECT. A 72-year-old man who had refused therapy but whose wife consented on his behalf was in renal failure when he was admitted for psychiatric treatment. He developed blood clots in his urine after a double treatment of ECT and died of medical complications within two weeks of receiving the treatment.

The 72-year-old man and two other patients received two ECT treatments in one session without a second psychiatrist's opinion, as state law requires. One of those patients was a 31- year-old woman who forgot how to feed herself after her treatments, records said.

Doctors provided correction plans to the Health Department, which visited the hospital again in December and found no deficiencies.

"They were deficiencies related to documentation, and we addressed those concerns with the medical and professional staff," said Mary Sellers, a hospital spokeswoman. "I'm sure there was some training, some policies were put into place, or at least were re- emphasized." In the three years that ended Aug. 31, 1996, 5,141 people in Texas received ECT therapy. Used to lift severe depression temporarily, ECT sends a one- to four-second jolt of electricity through electrodes on a patient's scalp. The shock induces a short- lived convulsion that some scientists believe counteracts or interrupts the electrical processes that cause some types of mental illness. The procedure is solidly embraced by mainstream medicine, including the American Psychiatric Association and the National Institutes of Health, as a treatment for severely depressed patients who don't respond to drug therapy or psychotherapy.

In addition to Doctor's Hospital, other infractions found in Dallas facilities included:

St. Paul Medical Center, part of Harris Methodist Health System, gave ECT patients insufficient medical screenings. One woman was 84, dependent on a feeding tube and losing weight. She later suffered an adverse reaction to ECT, the report says.

In response, St. Paul rewrote admission criteria for its psychiatric unit "to specifically exclude anyone too ill to participate in the program," spokeswoman Paula Davis said. The hospital also received invalid informed consent from three patients, each more than 70 years old and each too confused, disoriented or feeble-minded to understand what they were signing, according to Health Department records.

Davis said the hospital had received verbal consent from the patients, but that the permission was not documented in records reviewed by the state. To correct the problem, St. Paul developed consent forms to be used specifically for ECT patients, she said. St. Paul also gave three patients small jolts of ECT to test their reaction to a certain type of muscle relaxant, but did not notify them properly that the procedure was experimental, records said. Davis said the hospital revised its consent forms to comply with state regulations. Parkland Memorial Hospital did not give one patient full information on the nature of ECT or its possible side effects and did not include information on the nature or seriousness of the patient's illness in his medical records.

The Health Department noted in its deficiency report that Parkland has developed a plan to ensure that workers know what information state law requires patients to have.

In Tarrant County, the Health Department found that:

At Huguley Memorial Medical Center, only one of four physicians who performed ECT had proper credentials "according to hospital policy."

The state's deficiency report notes that the hospital's medical director, Dr. Thomas DePorter, told department investigators that he had properly "proctored" the other doctors on the use of ECT but had not completed the paperwork necessary for the hospital's internal review procedures. "We wouldn't ever entertain letting someone do the procedure unless they had been properly trained," DePorter said.

Columbia Plaza Medical Center twice gave patients treatments exceeding the number allowed by state law over a certain time and provided erroneous information in its monitoring reports. ECT in Texas is limited to 24 treatments in 12 months or 15 in eight consecutive weeks for an individual, with some exceptions. The Health Department said two Columbia Plaza patients each received 36 treatments in 12 months.

Osteopathic Medical Center of Texas submitted incomplete monitoring reports in one quarter. Officials for Columbia Plaza and Osteopathic Medical Center did not return phone calls to discuss the reported violations or any other aspect of ECT. The reports did not identify the patients involved.

Patient age data reported to Texas MHMR meanwhile show that from 1994 through 1996, the number of patients receiving ECT more than doubled statewide between ages 64 and 65. Individual case reports to the state were incomplete, but at least 86 of the 5,141 ECT patients during the three-year period were 64 years old, and more than twice that many--at least 195 -- were 65 when they got ECT.

In Fort Worth, the number jumped more than 31/2 times, according to records at the Texas Department of Mental Health and Mental Retardation. "I'm really very surprised at those numbers," said Dr. Herbert Rush, medical director for All Saints Behavioral Health Services in Fort Worth. "You shouldn't see any difference between those two ages that I can think of. I would not have thought there would be any significant difference." In the three years reviewed, All Saints Medical Center gave ECT to five patients who were 64 years old, and to 16 who were 65, according to state MHMR records. Dr. Steve Shon, Texas MHMR medical director, said his agency has not analyzed the reported data and cannot say whether an unusually high number of patients older than age 65 are being treated.

In addition to All Saints, the reports show the ensuing breakdown, by hospital for Tarrant County:

Saint Joseph Hospital, which was bought by Columbia/HCA in 1994 and closed in 1995, treated two 64-year-old patients and no one who was 65.

Columbia Plaza Medical Center treated one patient who was 64 and seven who were 65.

Osteopathic Medical Center of Texas had no 64-year-old patients, but seven who were 65.

Huguley Memorial Medical Center treated two patients at 64 and six at 65. Huguley's DePorter said most patients already have private insurance when they become eligible for Medicare, so there's no reason for the program to influence care. "And I've never had an insurance company deny ECT," he said.