Alle. Cnty. Pa. XIV app L
under Civil Commitment
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: | ) |
) | |
) No._____of________________ | |
*10 | ) |
an alleged incapacitated person. | ) |
PETITION FOR ORDER OF COURT AUTHORIZING ELECTRO-CONVULSIVE THERAPY AS REQUIRED BY 55 PA. CODE § 5100.54, ARTICLE VI 2(b) (4)
Your Petitioner, * _____________________ , pursuant to 50 Pa. §§ 7102, 7104, and 7305, and 55 Pa. Code § 5100.54, Article VI, 2 (b), hereby requests that this Court issue an Order authorizing electro-convulsive therapy for the Respondent, * _____________ and in support of such request, avers and represents as follows:
1. * ________________ , is a * _____ year old patient at * _____________________ , having been admitted to * ___________________ on * ________________ Under an involuntary commitment order issued pursuant to Section * _____ of the Mental Health Procedures Act (50 P. S. §* _____).
2. By Order of Court dated * ______________ , the Respondent * _______________ was found to be * ___________________ , and was committed or recommitted to * ____________________ for involuntary in-patient care, for a period not to exceed *____ days, pursuant to Section ________ of the Mental Health Procedures Act (50 P.S. §* ______). See Commitment Order and underlying Commitment Petition, attached as Exhibit 1. _______________________10 Sections marked by asterisk (*) must be completed by counsel before Court presentation.
3. * _______________ 's domicile prior to admission to * ________________ was * _____________ .
4. * ____________________ carries a diagnosis of * _______________ which has been poorly responsive to treatment.
5. Over the last * _____ , * ___________________ has had a number of treatment regimens of * _________ which have failed to significantly improve *his/her symptoms.
6. * ___________ 's recent symptoms have included refusing to * _______________ .
7. _________________ 's treatment team has recommended electro- convulsive therapy (ECT) to treat *his/her psychiatric condition, and it has been documented in *his/her record that all reasonable and less intensive treatment modalities have been considered, and that ECT represents the most effective therapy for * __________________ at this time.
8. * ____________________ , M.D., * ___________________ 's treating psychiatrist who has experience and training related to ECT, has evaluated * _______________________ and has recommended ECT for * _____________ . See Notarized Statement by Doctor * __________ , attached as Exhibit 2.
9. Attempts have been made to give * ________________ a full explanation of the anticipated nature and duration of the ECT, and why the treating psychiatrist is recommending ECT.
10. * _______________ has been told that *he/she has the right to accept or refuse ECT, and that if *he/she consents, *he/she has the right to revoke *his/her consent for any reason at any time prior to or between treatments.
11. * ___________________ has, to date, been unwilling and/or unable to discuss the recommended ECT treatment with Doctor * __________________ or other * ________________ clinical personnel, and has neither consented to or refused the recommended ECT.
12. Because of *his/her psychiatric condition, * ___________________ clinical personnel believes that Respondent, * ______________ lacks the capacity to provide informed consent to the recommended medical treatment - i.e. ECT.
13. It is recommended by * _______________ that the ECT be begun as soon as possible; the ECT would be performed at * _________________ .
14. Prior to initiating ECT for * _______________ , * _____________________ , in accordance with standard procedure, would evaluate * ___________________ , and would make an independent medical determination of the need for and duration of ECT. See Exhibit 2.
15. This Petition is brought pursuant to 55 Pa. Code § 5100.54, Article VI (2)(4), which provides that when a patient's psychiatrist determines that the patient could benefit from ECT, but also believes that the patient does not have the capacity to give informed consent to ECT, a Court order authorizing ECT must be obtained before ECT can be administered to the patient.
WHEREFORE, your Petitioner prays that this Court issue an Order authorizing the administration of ECT to the Respondent, * __________________________.
Respectfully submitted,
By _____________________________________
Counsel for Petitioner
Dated: __________________________
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: * , | ) |
Respondent | ) No. |
) |
PRELIMINARY ORDER OF COURT
NOW, this ____ day of _____________ , the foregoing Petition having been presented, upon consideration thereof and on motion of counsel for the Petitioner, it is ORDERED and DECREED that a hearing be held to consider the Petitioner's request. The time and place of hearing on this Petition are fixed for the ____ day of ___________________ , beginning at ________ o'clock, __.M., prevailing time, in the Orphans' Court Division, 17th Floor, Frick Building, 437 Grant Street, Pittsburgh, Pennsylvania 15219.
The Respondent shall be given notice of the hearing on this Petition by serving *him/her personally with this Preliminary Order of Court and a copy of the foregoing Petition prior to the time of the hearing.
BY THE COURT:
_______________________ J.
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: * , | ) |
Respondent | ) No. |
) |
ORDER OF COURT AUTHORIZING ELECTRO-CONVULSIVE THERAPY
NOW, this ____ day of ______________________ , this Court having reviewed and considered the Respondent's current mental condition, the treatment that has been provided to Respondent to date and the results of such treatment, and the recommendation by &his/her treatment team and treating psychiatrist for electro- convulsive therapy, and having found that Respondent, due to a psychiatric condition which significantly impairs *his/her capacity to receive information effectively and to make and communicate decisions concerning *his/her medical and psychiatric treatment is unable to make or communicate an informed decision regarding treatment by electro-convulsive therapy, this Court, in accordance with 55 Pa. Code § 5100.54, Article VI 2(b)(4), hereby authorized ____________________ to provide electro-convulsive therapy to Respondent, in accordance with their medical judgment, for a period not to exceed days from the date of this Order.
BY THE COURT:
_______________________ J.
Alle. Cnty. Pa. XIV app L