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Administering medicines covertly

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  • Organisations we regulate

Covert administration is when medicines are administered in a disguised format.

The medicines could be hidden in food, drink or through a feeding tube without the knowledge or consent of the person receiving them. As a result, the person is unknowingly taking a medicine. Every person has the right to refuse their medicine, even if that refusal appears ill-judged to staff who are caring for them.

Covert administration is only likely to be necessary or appropriate where:

  • a person actively refuses their medicine
  • that person is judged not to have the capacity to understand the consequences of their refusal. Such capacity is determined by the Mental Capacity Act 2005
  • the medicine is deemed essential to the person’s health and wellbeing

Covert administration of medicines should be a last resort. You must make reasonable efforts to give medicines in the normal manner. You should also consider alternative methods of administration. This could include, for example, liquid rather than solid dose forms.

Administering medicines in food or drink can alter their therapeutic properties and effects. They could become unsuitable or ineffective. Always take advice from a healthcare professional to make sure medicines are safe and effective.

Mental Capacity Act 2005

Before considering covert administration, you should test decisions and actions against the five key principles under the Mental Capacity Act 2005:

  1. Every adult has the right to make his or her own decisions. You must assume they have capacity to do so unless it is proved otherwise. You must not assume someone lacks capacity because they have a particular medical condition or disability.
  2. A person is not to be treated as unable to make a decision unless all practicable steps to help them do so have been taken without success. You should make every effort to encourage and support people to make the decision for themselves. If you establish lack of capacity, it is important to involve the person as far as possible in making decisions.
  3. A person must not be treated as unable to make a decision merely because he or she makes an unwise decision. People have the right to make decisions that others might regard as unwise. You cannot treat someone as lacking capacity for this reason. Everyone has their own values, beliefs and preferences which may not be the same as those of other people.
  4. Anything you do or decide for or on behalf of a person who lacks mental capacity must be in their best interests.
  5. When making a decision or acting on behalf of a person who lacks capacity, you must consider:
  • whether there is a way that would cause less restriction to the person’s rights and freedoms of action
  • whether there is a need to decide or act at all

Any intervention should be the result of the person’s particular circumstances.

Best practice principles and examples

Policy

Your setting’s medicines policy should include a clear explanation of your covert medicines administration process. The policy should be specific to the setting and up to date. Your staff must read, understand and follow the policy.

Best interest

All decisions must be in the person’s best interest. Give due consideration to the holistic impact on the person’s health and wellbeing.

  • hold a ‘best interest meeting’ involving staff, the health professional prescribing the medicines, pharmacist and family member or advocate, to agree whether administering medicines covertly, is in the person's best interests. Keep records of what was discussed at the meeting
  • if the situation is urgent, it is acceptable for a less formal discussion to occur between the staff, prescriber and family or advocate to make an urgent decision. A formal meeting should be arranged as soon as possible

Last resort

Covert administration must be the least restrictive option when all other options have been tried. You could carry out a functional assessment to try to understand why the person is refusing to take their medicines.

  • record the reasons for presuming mental incapacity and the proposed management plan, including consideration of Deprivation of Liberty Standards when medicines, such as sedatives, are to be given covertly

Medicine specific

You must identify the need for covert administration for each medicine prescribed. Each time new medicines are added, you must identify the need again.

  • hold ‘best interest meetings’ when new medicines are prescribed or doses changed. This will help to make sure treatment continues to be in the person’s best interest

Time limited

Use covert administration for as short a time as possible. Consider fluctuating capacity.

Regularly reviewed

Regularly review the continued need for covert administration within specified timescales. You should also review the person’s capacity to consent.

  • regular formal reviews of whether covert administration is still needed should be set with a timescale based on individual circumstances
  • record and regularly review assessments of mental capacity

Transparent

The decision making process must be easy to follow and clearly documented.

Inclusive

The decision making process must involve discussion and consultation with appropriate advocates for the person. It must not be a decision taken alone. It must be a multi-disciplinary team decision.

  • plan how medicines will be administered covertly, with detailed and recorded specialist input to show suitability of the method chosen:
    • some medicines can become ineffective when mixed with certain foods or drink
    • crushing a tablet or opening a capsule before administration may make its use ‘off-licence’. Those prescribing and administering medicines in this way should be aware of this, as altering the characteristics may change a person’s response to the medicine. For example, crushing a tablet designed to release slowly over 24 hours might result in overdose or increased adverse effects due to the whole dose being released too quickly

Records

Maintain a clear record of which medicines are administered covertly and when. This is particularly important for people with fluctuating capacity.

  • record actions taken to give medicines in the normal manner. Include how you considered:
    • whether the medicine is unpalatable
    • adverse effects (actual or perceived)
    • swallowing difficulties
    • lack of understanding about what the medicine is for
    • lack of understanding of the consequences of refusing to take a medicine
    • ethical, religious or personal beliefs about treatment
Last updated:
28 September 2018

 


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