It is important that staff who provide social care services understand that every person has the right to refuse their medicine, even if that refusal appears ill-judged to staff who are caring for them.
Covert administration is only likely to be necessary or appropriate where:
A person actively refuses their medicine.
That person is judged not to have the capacity to understand the consequences of their refusal. Such capacity is determined by the Mental Capacity Act 2005.
The medicine is deemed essential to the person’s health and wellbeing.
What is covert administration of medicines?
Medicines that can be hidden in food, drink or through a feeding tube without the knowledge or consent of the person receiving them. As a result, the person is unknowingly taking a medicine.
Administering medicines in food or drink can alter their therapeutic properties and effects. They could become unsuitable or ineffective. Staff should always take advice from a healthcare professional to make sure medicines are safe and effective.
Testing decisions before the use of covert administration
CQC guidance emphasises that covert administration of medicines should be a last resort. Staff must make reasonable efforts to give medicines in the normal manner. They should also consider alternative methods of administration. This could include, for example, liquid rather than solid dose forms.
Before considering covert administration, staff should test decisions and actions against the five key principles under the Mental Capacity Act 2005:
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, staff 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.
Covert Administration Policy
The services medicines policy should include a clear explanation of the covert medicines administration process. The policy should be specific and up to date and followed by staff who have read, understand and follow the policy.
The Policy should include:
Under normal circumstances all medication should be administered with the full knowledge and consent of service users and every effort should be made by staff to obtain that consent.
Covert medication should only be used when the service user lacks the capacity to consent and is refusing treatment which has been deemed to be essential for their health and wellbeing.
Covert medication should be seen as a last resort and as an emergency procedure, rather than routine and will only be used for a shortest time as possible.
Decision making
All decisions must be in the person’s best interest. Due consideration to the holistic impact on the person’s health and wellbeing. Best interest meeting involving staff, the health professional prescribing the medicines, pharmacist and family member or advocate, to agree whether administering medicines covertly, is in the person’s best interests. Records of what was discussed at the meeting
Reviews and Records
Regularly reviews of the continued need for covert administration within specified timescales should be carried out. Staff must maintain a clear record of which medicines are administered covertly and when. This is particularly important for people with fluctuating capacity.
Record actions taken to give medicines in the normal manner. Include how you considered:
Whether the medicine is unpalatable.
Adverse effects (actual or perceived).
Swallowing difficulties.
Lack of understanding about what the medicine is for.
Lack of understanding of the consequences of refusing to take a medicine.
Ethical, religious or personal beliefs about treatment.
Albert Cook Albert Cook BA, MA & Fellow Charted Quality InstituteManaging Director Bettal Quality Consultancy