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Nigel's surgery 96: Covert administration of medicines
Covert administration is when medicines are disguised 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 from care homes, or from the families and carers of people living in their own homes, to give medicines covertly. They may also become aware of this occurring through conversations with professional or family carers.
Mental Capacity Act 2005
Before considering covert administration, test decisions and actions against the key principles under the Mental Capacity Act 2005:
- Individuals are presumed to have capacity.
- All practical steps must be taken to support someone in decision-making.
- A person is not to be treated as lacking capacity merely through making an unwise decision.
- An action taken on behalf of a person must be in their best interests.
- Is the act or decision the least restrictive of a person's rights and freedoms?
- 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. Covert administration must be the least restrictive option when all other options have been tried
- a need to decide or act at all
Best practice principles
If you are asked to administer medicines covertly, you must first make sure a capacity assessment has been carried. 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 carry one out yourself.
- A prescriber should not normally authorise covert administration in isolation. You 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. Keep a record of what was discussed at the meeting and the reasons for the decision taken.
- If the situation is urgent, a less formal discussion is acceptable to make an urgent decision. Arrange a formal meeting as soon as possible and keep a record.
Ask for advice
- Crushing medicines or administering 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 license.
Always take pharmaceutical advice, to make sure medicines remain safe and effective when prescribed for administration covertly.
You must identify the need for covert administration for each medicine prescribed. Each time new medicines are added or dosages changed 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 is a collaborative process with the patient and/or their carer. 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 and 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 and record the review outcome.
When we inspect
GP practices should take measures to make sure medicines are prescribed:
- in accordance with individual best interests 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 do practices 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:
- 26 September 2019