Covert administration of medicine is the disguising of medication on food and drink. The practice of administering covert medication is controversial. In mentally capable patients it is a breach of autonomy and likely to constitute assault. For people who lack capacity (either permanently or temporarily), the question is whether the best interest of the individual is justification enough for covert practices.
Within my practice area, there is a client who occasionally gets his medication covertly. When client needs ‘as prescribed’ Lorazepam and Haliperidol it is offered as oral medication in first instance, but if this is refused, in exceptional instances, to prevent any increases in aggression it may be placed in clients food or drink.
AnalysisWithin this situation it is good that giving covert medication will help maintain client and staffs’ safety and prevents an increase in aggression. It also reduces the risk of the use of restraint and I.M medication. It is good practice that the use of covert medication is discussed with the multi-disciplinary team, which it has and has got approval from the psychiatrist. A protocol is put in place and it is all documented. There are also legal guidelines as client is detained under the Mental Health Act with a Compulsory Treatment Order and is under Adults with Incapacity.
It is still hard to agree whether this is ethically right, as although the situation is for the clients best interest and follows guidelines, it is still going against someone’s human rights to autonomy. There could also be an issue between staff as to what constitutes an ‘exceptional instance’, staff might interpret this differently and a concern would be that if the practice is condoned in a few exceptional cases, as in an emergency, this could lead to a rise in the abuse of practice.
EvaluationThe NMC has produced advice on the administration of covert medication, saying that as a general principle, by disguising medication in food or drink, the patient /client is being led to believe that they are not receiving medication, when in fact they are. The registrant will need to be sure that what they are doing is in the best interests of the patient /client, and be accountable for this decision. The registrant will need to ascertain whether they have the support, or otherwise, of the rest of the multi-professional team, and make their own views clear. It is inadvisable for registrants to make a decision to dispense medication in this way in isolation. Even with completed risk assessments and guidelines, and following the involvement of all relevant parties, it is imperative that good record keeping should support duty of care arguments. The emphasis throughout the guidelines is on the best interest of the client. (NMC, 2007). Within this case this has been followed and all staff appear to be aware of why the administration of medication might occasionally need to be covertly.
For patients/clients detained under the relevant mental health legislation, the principles of consent continue to apply to any medication for conditions not related to the mental disorder for which they have been detained. The assessment of their capacity to consent to or refuse such medication therefore remains important. This assessment of capacity to make a decision applies equally to those people with a learning disability who may not have a mental illness. However, in relation to medication for the mental disorder for which the patient/ client has been detained, medication can be given against a patient’s/clients wishes during the first three months of a treatment order or afterwards if sanctioned by a Second Opinion Approved Doctor (SOAD). The principle of second opinion should be maintained for informal patients/clients as this would be a sound endorsement of good practice and make it easier to defend.
This second opinion is provided within the legislation by medical practitioners appointed by the appropriate statutory mental health commission to provide second opinions on treatment under part VI of the Act. They are known as Second Opinion Appointed Doctors (SOAD). (NMC 2007)However, can the practice of disguising a person’s medication such that he or she is unaware of its administration ever be justifiable by appeal to principles of beneficence and non-maleficience in incapacitated patients, or to concepts of least restrictive to person’s freedom and action?One way of approaching the problem is through a casuistic perspective. Consider an adult with learning disability who consistently rejects all oral medication, including anticonvulsants. Nursing staff, although aware of the prohibition of covert medication, administer such essential medication by suppository on a daily basis or consider a male client who due to his mental illness represents a significant risk of harm to him-/herself or to others.
Could benefit outweigh harm if the practice of covertly administering anticonvulsant and sedative drugs, respectively, is in fact judged to be the least restrictive measure to maximise each patient’s liberty and dignity (i.e. less than that accorded by suppository, or restraint followed by intramuscular injection)? (Welsh & Deahl, 2002)This then leads on to whether in the long term covert medication is the least restrictive. Take for instance restraint, repeatedly having to restrain a client will increase the chance of injury to staff and client, it could also lead to the burn out of staff and therefore staff off sick.
There could also be adverse effects of long term IM medicationArguably, in residential settings, tranquillising medication might be seen as a cheap means of managing inadequate staffing levels (and thus ensuring a quiet shift), or an essential (and least restrictive?) means of managing unpredictable, violent outbursts against staff and fellow patientsConclusionA balance has to be struck between the potential harm to a patient of not having the medication versus the breach of patient autonomy. Clear policies on when it might be appropriate to use covert medication need to be in place to avoid ‘underground’ practices. Guidelines need to be provided to medical professionals and carers of adults with incapacity about how to act if the use of covert medication is considered.
The UKCC has issued guidelines which say that disguising medication in food or drink can be justified in the best interests of patients who actively refuse treatment. As such covert medication may be considered to prevent a patient from missing out on essential treatment where the patient is incapable of consent.
There exists a fundamental ethical and legal obligation in medicine to respect autonomous decision-making. The issue of covert administration of medication given to an autonomous individual against his/her will is, both legally and ethically, entirely unacceptable. Where doubt exists would be in
a situation relating to non-autonomous individuals who, through incapacity, are rendered unable to give informed consent to receive or refuse medication per se.
If medication is prescribed under ‘best interests’ principles, is there any difference (ethically) between a patient passively accepting medication and having it disguised in some way following refusal? Is all medication, however administered, ‘covert’ in reality if the individual is not capable of giving informed consent?
sNMC (2007) Covert administration of medicines – disguising medicine in food and drink. A-Z Advice.NMCWelsh, S & Deahl, M. (2002) Covert medication – ever ethically justifiable? Psychiatric Bulletin 26: 123-126
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