Covert administration of medication is the practice of hiding medication in food or beverages so that it will be undetected by the person receiving the medication. For example, tablets may be crushed or medication in liquid form may be used. This practice exclusively applies to individuals who are not capable of consenting to treatment (see section below regarding consent). It is intended to ensure that individuals refusing treatment as a result of their illness will have access to effective medical treatment.

It is sometimes necessary and justified to administer medication covertly but should never be exercised with people who are capable of deciding about their medical treatment.

KEY POINTS:

 Every adult must be presumed to have the mental capacity to consent or refuse treatment.

 Care staff must obtain consent where possible to administer medication and explain any information beforehand if needed.

 No medication should be given without consent and consent may be verbal or non-verbal.

 A competent adult has the legal right to refuse treatment, even if a refusal will adversely affect his or her health or shorten his or her life.

 The refusal of Medicine by a resident who has capacity should be respected.

 If a resident is refusing their medicines they should be asked why they have decided to do this to establish if there are issues that can be addressed.

 Covert administration can only occur where the resident has been assessed and there has been careful assessment of patient’s needs by a multi-disciplinary team.

 Residents may have indicated consent or refusal at an earlier stage, while still competent, in the form of a living will or advance care statement or plan.

 The decision to administer medication covertly must not be considered routine.

 Written agreement and reasons for the decision to administer covertly to a specific resident, the action taken and the names of all parties concerned (including the residents GP and relatives/advocate) should be obtained and documented in the resident's care plan.

 It is important that care staff have sought the professional guidance of a pharmacist who is in the best position to advise on whether a particular medicine can be mixed with food or drink and the advice is documented in the care plan.

 Care homes must have a clear policy and procedure on covert administration.

 Crushing medicines and mixing medicines with food or drink to make it more palatable or easier to swallow is different to covert administration and residents must always be informed medication is being administered in food. When a resident has consented to this, it does not constitute covert administration.

CONSENT - what does it mean?

Every adult must be presumed to have the mental capacity to consent or refuse treatment, including medication, unless he or she:

 is unable to take in and retain the information about it provided by the treating staff, particularly as to the likely consequences of refusal

 or is unable to understand that information

 or is unable to weigh up the information as part of the process of arriving at a decision.

The assessment of ‘capacity to give consent’ is primarily a matter for the treating clinicians, but other practitioners and carers retain a responsibility to participate in discussions about this assessment. No medication should be given without consent and consent can be verbal or non-verbal e.g. resident opening mouth when told ‘it’s time to take medication’. Nobody, not even a spouse, can consent for someone else, although the views of family and close friends may be helpful in clarifying a resident’s wishes and establishing his or her best interests.

A competent adult has the legal right to refuse treatment, even if a refusal will adversely affect his or her health or shorten his or her life. Therefore, care staff must respect a competent adult’s refusal as much as they would his or her consent. Failure to do so may amount not only to criminal battery or civil trespass, but also to a breach of their human rights.

When a resident is considered incapable of providing consent, or where the wishes of the mentally incapacitated resident appear to be contrary to the best interests of that person, the registered responsible person should provide an objective assessment of the resident’s needs and proposed care or treatment. He or she should consult relevant people close to the resident, such as relatives, carers and other members of the multi-disciplinary team including GP and pharmacist, and respect any previous instructions. In some cases the resident may have indicated consent or refusal at an earlier stage, while still competent, in the form of a living will or advance care statement or plan. Where the resident’s wishes are known, registrants should respect them, provided that the decision in the living will or advance care statement is clearly applicable to the present circumstances and there is no reason to believe that the resident has changed their mind. The ultimate decision to administer medicines covertly must be one that has been informed and agreed by the multidisciplinary team caring for the resident.

A resident may be mentally incapacitated for various reasons. These may be temporary reasons, such as the effect of sedatory medicines, but more commonly, it is because of long term mental health illness such as dementia or Alzheimer’s disease. It is important to remember that capacity may fluctuate, sometimes over short periods of time, and therefore capacity to consent should be regularly reassessed by the clinical team treating the resident. The need for covert administration should be reviewed on a weekly basis initially and if the requirement for covert medication does persist, full reviews at less frequent intervals should take place.

Thing to consider:

 What instructions are written on MAR charts?

 What training have staff had regarding the covert administration of medicines?

 How are medicines crushed such as with tablet crushers, metal spoons, mortar and pestle?

 Any medical, cultural or religious dietary requirements should be complied with (e.g. gluten-free for patients with coeliac disease, avoidance of animal gelatine for vegetarian, Jewish or Muslim patients)?

 Which foods to use to hide medicines in and where are these foods stored? e.g. jam, yoghurt, juice?

 Does the care plan carry an assessment of the resident's capacity and identifies who carried out the assessment and when?

 Does the care plan reflect the person's assessed needs and any agreements to administer medicines in food or drink are clearly documented?

 There are agreed review dates and reviews take place.

Nurses

Where registered nurses are involved in the administration of medicines in a care home, nurses need to be clear that they are accountable for the decision to administer medicines covertly, and that this is in the patient’s best interests. The nurse also needs to determine whether these decisions are supported by the rest of the multi-disciplinary team as above, as well as voicing their own opinion on this practice for a particular resident. It is advised that nurses do not covertly administer medicines in isolation.

Difficulty swallowing?

Crushing medicines and mixing medicines with food or drink to make medication more palatable or easier to swallow is different to covert administration and patients must always be informed medication is being administered in food in such cases. When a resident has consented to this, it does not constitute covert administration. It is good practice for GPs to clarify this in dosage instructions e.g. 'Take one tablet twice each day. Crush and mix with jam for ease of swallowing before administering’.

Documentation

Details of any assessments and those carrying out assessments of ‘capacity to give consent’ should be kept in the resident’s care plan. Written agreement of the decision to administer medication covertly, the action taken and the names of all parties concerned should be obtained and documented in the resident's care plan and medicines profile. The decision should also be documented on the resident’s MAR chart so that all staff administering the resident’s medicines are aware of the reasons and method for covert administration for each medicine concerned.

REFERENCES:

1 The Nursing and Midwifery Council, Covert administration of medicines: Disguising medicine in food and drink, Nov 2007 [http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Covert-administration-of-medicines/].

2 Care Quality Commission Guidance logs [http://www.cqc.org.uk/_db/_documents/20091027Guidance_Log_Care_Homes_for_Older_People_v_002-09_-_FINAL_201002113350.pdf].