Covert administration of medicines

Covert administration is when medicines are administered in a disguised format.

Medicines could be hidden in food, drink or given through a feeding tube without the knowledge or consent of the person receiving them. This means the person does not know they are taking a medicine. When a person has mental capacity to make the decision about whether to take a medicine, they have the right to refuse that medicine. They have this right, even if that refusal appears ill-judged to staff or family members who are caring for them.

Covert administration is only likely to be necessary or appropriate where:

• a person actively refuses their medicine and
• that person is assessed not to have the capacity to understand the consequences of their refusal. Such capacity is determined by the Mental Capacity Act 2005 and
• the medicine is deemed essential to the person’s health and wellbeing.

Covert administration must be the least restrictive option after trying all other options. Carry out a functional assessment to try to understand why the person is refusing to take their medicines. You should also consider alternative methods of administration.

You should follow the principles of the Mental Capacity Act. If a person is assessed as lacking the relevant capacity, you should follow the best interest process. Record decisions and reflect these in a management plan. Consider how covert medicines, such as sedatives, may be a factor in depriving a person of their liberty.

The decision-making process must be easy to follow and clearly documented.

Mental Capacity Act 2005

Before considering covert administration, you should test decisions and actions against the five key principles under the Mental Capacity Act 2005 and apply the Code of Practice. The legal framework for acting and making decisions on behalf of individuals who may lack capacity for certain decisions applies to all people aged over 16.

1. 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 medical condition or disability.
2. A person is not to be treated as unable to decide 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.
3. A person must not be treated as unable to decide 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.
4. Anything you do or decide for or on behalf of a person who lacks mental capacity must be in their best interests.
5. When deciding 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
• whether there is a need to decide or act at all

Any intervention should be the result of the person’s circumstances.

Policy

The medicine policy should include a clear explanation of your covert medicines process. The policy should be specific and up to date. Your staff must read, understand and follow the policy.

Best interest

All decisions must be in the person’s best interest. Consider the impact on the person’s health and wellbeing. It must be a multi-disciplinary team decision:

• you can hold a ‘best interest’ meeting remotely but you should keep clear records of who was involved and what was agreed
• involve care staff, the health professional prescribing the medicines, and a family member or advocate, to agree whether administering medicines covertly is in the person's best interests
• the decision must not be taken alone.

Medicine specific

You must identify the need for covert administration for each medicine prescribed. Each time new medicines are added or the dose changes of an existing medicine, 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.

Some medicines can become ineffective when mixed with certain foods or drink. Crushing a tablet or opening a capsule before administration may make its use ‘off-licence’. You must tell the prescriber if medicines are being administered in this way. Altering the characteristics may change a person’s response to the medicine.

For example, crushing a tablet designed to release slowly over 24 hours might result in overdose. Or it could increase any adverse effects due to the whole dose being released too quickly.

Always take pharmaceutical advice from an appropriate healthcare professional. You must make sure medicines remain safe and effective when prescribed for administration covertly.

Regular reviews

Use covert administration for as short a time as possible. Consider what action you will take if the person has fluctuating capacity. If a person has fluctuating capacity, the service should have a covert plan in place. You must only use the plan when the person lacks capacity.

You should regularly reassess the need for continued covert administration. Make sure:

• regular formal reviews are scheduled to confirm whether covert administration is still needed. You should base the timescale of reviews on the person's individual circumstances
• that you record and regularly review assessments of mental capacity.

Records

Include in a medicine care plan:

• actions taken to give medicines in the normal manner
• how medicines will be administered covertly
• specialist input to show suitability of the method chosen, for example crushed or mixed with certain food or drinks
• 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
• what to do if the person refuses food or drinks.

Medicines administration records should clearly record which medicines you administer covertly and when. This is particularly important for people with fluctuating capacity.