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Nigel's surgery 96: Covert administration of medicines
There have been no changes to legislation or guidance which affect prescribing medicines for covert administration during the COVID-19 pandemic.
Covert administration is when medicines are disguised. This is so a patient doesn’t know they are taking them.
Medicines could be hidden in food, drink or given through a feeding tube without the knowledge or consent of the person receiving them. The person is unknowingly taking a medicine. Every person with capacity has the right to refuse their medicine. This is even if that refusal appears ill-judged to staff or family members who are caring for them.
GP practices may have requests to prescribe medicines for covert administration. Requests can be from care homes, or from the families and carers of people living in their own homes. They may also become aware of this happening through conversations with professional or family carers.
Mental Capacity Act 2005
You should test decisions and actions against the five key principles under the Mental Capacity Act 2005. You should do this before considering covert administration.
- 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.
- 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.
- 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.
- Anything you do or decide for or on behalf of a person who lacks mental capacity must be in their best interests.
- 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
If you are asked to authorise covert administration of medicines, you must first make sure a capacity assessment has been carried out. A competent person must do this. They must conclude that the patient lacks capacity to make the specific decision about taking their medicines. You can request a copy of this assessment or do one yourself.
- A prescriber should not normally authorise covert administration in isolation. They should take part in a multi-disciplinary ‘best interest meeting’ involving care staff, family members or advocates, and a pharmacist.
- Use this meeting to agree whether administering each medicine covertly is in the person's best interests.
- This meeting can take place remotely. For example by email, but clear records should be kept of who was involved and what was agreed.
Ask for advice
- Crushing medicines or putting them in food or drink can alter their therapeutic properties and effects. They could become unsuitable or ineffective.
- Crushing a tablet or opening a capsule before administration may make its use ‘off-licence’. This means the clinical and legal responsibility on healthcare professionals may be greater than when they prescribe within the terms of a medicine’s licence.
Always take appropriate pharmaceutical advice, to make sure medicines remain safe and effective when prescribed for covert administration.
You must identify the need for covert administration for each medicine prescribed. Each time new medicines are added or dosages changed to existing medicines you must:
- identify the need again
- make and record further ‘best interest’ decisions.
This will help to make sure treatment continues to be in the person’s best interest.
Consider deprescribing. This should be a collaborative process. It encourages safe and effective withdrawal of medicines that are no longer appropriate, beneficial or wanted. It is guided by a person-centred approach and shared decision-making.
Use covert administration for as short a time as possible. Consider if the person’s capacity to consent changes.
Plan regular formal reviews of whether covert administration is still needed. Set review timescales on individual circumstances. Record the review outcome.
When we inspect
GP practices should make sure medicines are prescribed:
- in accordance with individual best interest decisions.
This relates to our key lines of enquiry:
Areas to consider:
- Partnership working with healthcare professionals and care home staff:
- what support is offered?
- how does the practice respond to requests from care homes?
- are pharmacy professionals involved in the decisions?
- Support for people experiencing poor mental health:
- how is fluctuating capacity managed?
- are individual assessments maintained?
- Appropriate support and advice for carers of patients who are having their medicines covertly administered:
- how does the practice identify patients at risk?
- how are the best interests of patients considered?
- Nigel's surgery 10: GPs and the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards
- Adult social care medicines: Administering medicines covertly
- Consent: patients and doctors making decisions together, part 3 - Capacity issues (GMC)
- English Deprescribing Network Resource Paper (Specialist Pharmacy Service)
- Quality statement 6: Covert medicines administration (NICE)
- Last updated:
- 28 September 2020