Covert administration of medicines
Medicines should not be administered to people without their knowledge if they have the capacity to make a decision about their treatment and care.
In some circumstances, covert administration (where medicines are given without the knowledge of the recipient) may be necessary, in the best interests of an individual who lacks capacity or understanding of the impact on their health if the medicine is not taken.
The decision to administer medicines covertly must always follow a good practice framework to protect both the individual and the carer. To support this, Sunderland CCG has produced an aide memoire to guide care home staff and prescribers to make an appropriate decision.
The aide memoire aims to support care home staff and healthcare professionals in making appropriate decisions on when to use covert administration of medication.
Covert administration of a medication occurs when medicines are administered without the knowledge or consent of the person receiving them, in a disguised format, for example in food or drink.
Patients with swallowing difficulties may need medication administered with soft food. Administering medication in this way would not be considered as covert if the patient is fully aware and has consented to having their medication administered in this way.
The full North of England CCG guidance is available here: www.sunderlandccg.nhs.uk/about-us/prescribing/pharmacy-guidelines/
Best interests discussions must consider the following giving each equal consideration:
Patient’s wishes – this may have been previously expressed or documented in an advance statement
Patient representative – this may be through relatives, friends, carers, advocates, LPA’s. If no family or friends to give a view on best interest an Independent Mental Capacity Advocate may be required to support the decision making process.
Could patient regain capacity
Ensure patient is encouraged to use all existing skills
Deprivation of Liberty Safeguards (DoLS)
The Mental Capacity Act 2005 includes Deprivation of Liberty Safeguards (DoLS).
They are a set of checks that apply to patients in a hospital or care home, who lack capacity about their care and treatment.
DoLS aim to make sure that any care that restricts a person’s liberty, in order to prevent harm or to provide treatment, is both appropriate and in their best interests.
Covert administration of medications to a patient may add to a package of care that amounts to a deprivation of their liberty. This is more likely if the medication alters mental state, mood or behaviour, whether intentional or as an adverse drug reaction and it restricts a patient’s freedom e.g. antidepressants, antipsychotics, sedative medications
Expert pharmacy advice
A pharmacist will be able to consider the best method that meets patient’s needs and preferences taking into account which will cause the least distress.
This advice can be sought from the community pharmacy supplying the care home, your practice pharmacist and from the care home medicines optimisation team from IntraHealth (email: NECSU.Intrahealthsunderlandintegratedcareteam@nhs.net )
It is essential that the decision process is fully documented. The MAR chart must also be annotated with the necessary instructions for administrating the medicine.
It must be clearly documented and highlighted that the patient has their medications covertly administered when transferring between care settings, for example on admission to hospital. It is recommended that GP practices flag the patient record to ensure the information is included in any admission documents.
The effects of the decision must be reviewed especially for patient deterioration or declining food and drink. Review must also be carried out a regular basis as to the need for continued covert administration of medicines. A plan for review should be included in the documentation.
CPPE provide a training package on covert administration of medication that would be useful to complete.