Covert medication

Last updated

Covert medication (also called concealed, hidden or surreptitious medication), the covert administration of medicines is when medicines are administered in a disguised form, usually in food or drink, without the knowledge or consent of the individual receiving the drug. [1] [2] The decision-making processes surrounding covert medication should be in the best interests of the patient, transparent and inclusive. [3]

Contents

Research suggests that covert administration of drugs is an embedded practice in nursing homes for the elderly in New Zealand. [4] 43-71% of nursings homes in the United Kingdom acknowledge the practice. [5] : 1 

Forms

Medication is sometimes administered covertly by crushing pills and adding them to food or drink. [4]

Covert administration of medication is practised in a range of medical specialities and across a variety of care settings including psychiatry, paediatrics, geriatric medicine and care homes.[ citation needed ] In the care of paediatric patients, young children may be unwilling to take medication with an unpleasant taste or smell, or due to fear of the unfamiliar. In these cases, the medication may be mixed with food or drink to make it more acceptable. [6]

In dementia, patients experience memory loss and can have impaired decision-making skills. As a result, their capacity to consent to medication is impaired. In these cases medication may be covertly administered, as is the case in nursing homes. Impaired capacity is also seen in patients with intellectual disability. These patients may exhibit behaviours that challenge or symptoms of mental ill health, for which medication is used to reduce risk of harm to self or others. The best interest of the patient are considered when making decisions. [7] Patients with mental health disorders, such as schizophrenia or bipolar affective disorder, may lack insight into their mental health symptoms. They refuse medication due to the belief it is not needed. [8]

Safety

Covert administration of medication typically involves mixing the medication with food or drink. This can have an impact on the absorption of the drug. [9] Absorption of some medicines, such as antibiotics, can be reduced when mixed with food, particularly dairy products. [10] Some medicines are incompatible with various minerals including calcium, iron, magnesium, and zinc, all of which may reduce absorption. [11] Crushing slow-releasing tablets or enteric coated medicines may also reduce absorption of the medicines. [12]

Mixing medications with food or drink may also affect the metabolism of the drug. For example, grapefruit juice changes the bioavailability of many medicines by decreasing the rate of elimination. [13] This alters drug levels in the blood which may cause side effects or make the drug less effective.

Decision-making

In the UK guidelines state that individuals should be medicated covertly for as short a period of time as possible and their medication should be reviewed regularly, with decision making documented. [14] In New Zealand there is not any guidance on decision making surrounding covert medication for nurses. [4] : 7  There is no legislative guidance in Ontario in Canada for deception in healthcare. [15] : 194 

In the UK, NHS trusts may publish guidelines concerning administration of covert medication. Guidelines often include flowcharts to aid decision making. [16] [17] NICE recommends care home providers have a care home medicines policy that includes guidance on covert administration of medications by care home staff. [18]

Nursing guidelines in the New Zealand state the overriding a patient's wishes to not receive medication if the healthcare worker perceives it to be in the patient's best interest. [4] : 3  In the United Kingdom, only patients who have been deemed to lack mental capacity can be covertly medicated; capacity may be assessed by the prescriber of the medication. [19]

In some facilities in New Zealand, it is standard practice for nurses to ask a pharmacist before crushing medication. [4] : 7 

It can be inferred from the Universal Declaration of Human Rights that all persons have the right to refuse medication, and this right is often enshrined in national law. In some situations, patients may lack capacity to make decisions about accepting or refusing medication. In these situations, it may be appropriate to covertly administer medication, after other measures have been attempted.[ citation needed ]

Medication is only likely to be administered covertly where:

United Kingdom

The Human Rights Act, part of UK law, incorporates the European Convention of Human Rights and has several implications for mental health patients. Relevant articles concerning mental health and covert medicine administration in the Human Rights Act are listed below:

Article 3

"No one shall be subjected to torture or to inhumane or degrading treatment or punishment" [20]

Article 5

"Right to liberty and security" [20]

5(1) "Everyone has the right to liberty and security of person save ... (e)the lawful detention...of persons of unsound mind..."

5(2) "Everyone who is arrested shall be informed promptly, in a language which he understands, of the reasons for his arrest..."

5(4) "Everyone who is deprived of his liberty...shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful." [20]

Article 8

"Right to respect for private and family life" [20]

The Mental Health Act is an Act passed through Parliament in the United Kingdom which applies to people in England and Wales. In specific circumstances, this overrides certain fundamental human rights mentioned above. For example, those with mental health problems can be sectioned under the Mental Health Act to be kept in hospital, possibly against their wishes, particularly if they are at risk of harm to themselves, harm to others and harm from others. The Mental Health Act is limited to treatments of a patient's mental health. Under the Mental Health Act, it is not appropriate to give medicines covertly to treat physical health, only mental health.

Generally, to receive any kind of health treatment, you need to give consent. In England and Wales, the Mental Capacity Act 2005 sets out legislation criteria and procedure for patients who do not have the capacity to make decisions for themselves. [21] In this situation, a management plan is agreed in the best interests of the patient. This involves a meeting with healthcare professionals, care home staff and an independent reviewer, such as a family member, friend or independent mental capacity advocate. [2] Capacity should be assessed each time a new medical decision is made, as the ability to give valid consent can fluctuate, particularly in those with mental health disorders.

Covert administration is only necessary and appropriate where:

  • A person actively refuses a medicine.
  • It is safe to do so
  • The medication is deemed essential to their health and wellbeing.
  • The person is judged not to have the capacity to understand the consequences of their refusal, determined by the Mental Capacity Act 2005. [22]

The Mental Capacity Act applies to the administration of medication and treatment for any condition covertly. This is in contrast to the Mental Health Act, which applies to mental health, as above.

Ethics

Guidry-Grimes, Dean and Victor theorize that covert medication may damage relationships and as a result an individual's identity that may depend on these relationships, particular if medication is covertly added to food since food, its production and its mutual consumption can be an element of relationships. [23]

Regarding covert medication within families, Guidry-Grimes, Dean and Victor argue that covert medication by a family member may cause more relational damage and represent a greater violation of trust. [24] : 2  [5] : 4  They argue that the lack of healthcare services, such as in India, may contribute to covert medication by family members. Responding, Pickering argues that certain cultures may be more collectivist and less individualistic than others with the family acting as a form of collective which could reduce the sense of violation if a family member engages in covert medication towards another family member. [24] : 3 

Related Research Articles

<span class="mw-page-title-main">Advance healthcare directive</span> Legal document

An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. In the U.S. it has a legal status in itself, whereas in some countries it is legally persuasive without being a legal document.

<span class="mw-page-title-main">Do not resuscitate</span> Legal order saying not to perform CPR if heart stops

A do-not-resuscitate order (DNR), also known as Do Not Attempt Resuscitation (DNAR), Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), no code or allow natural death, is a medical order, written or oral depending on the jurisdiction, indicating that a person should not receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Sometimes these decisions and the relevant documents also encompass decisions around other critical or life-prolonging medical interventions. The legal status and processes surrounding DNR orders vary in different polities. Most commonly, the order is placed by a physician based on a combination of medical judgement and patient involvement.

<span class="mw-page-title-main">Intravenous therapy</span> Medication administered into a vein

Intravenous therapy is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrients for those who cannot, or will not—due to reduced mental states or otherwise—consume food or water by mouth. It may also be used to administer medications or other medical therapy such as blood products or electrolytes to correct electrolyte imbalances. Attempts at providing intravenous therapy have been recorded as early as the 1400s, but the practice did not become widespread until the 1900s after the development of techniques for safe, effective use.

Palliative care is an interdisciplinary medical caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses. Within the published literature, many definitions of palliative care exist. The World Health Organization (WHO) describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain, illnesses including other problems whether physical, psychosocial, and spiritual". In the past, palliative care was a disease specific approach, but today the WHO takes a broader patient-centered approach that suggests that the principles of palliative care should be applied as early as possible to any chronic and ultimately fatal illness. This shift was important because if a disease-oriented approach is followed, the needs and preferences of the patient are not fully met and aspects of care, such as pain, quality of life, and social support, as well as spiritual and emotional needs, fail to be addressed. Rather, a patient-centered model prioritizes relief of suffering and tailors care to increase the quality of life for terminally ill patients.

<span class="mw-page-title-main">Intramuscular injection</span> Medical injection into a muscle

Intramuscular injection, often abbreviated IM, is the injection of a substance into a muscle. In medicine, it is one of several methods for parenteral administration of medications. Intramuscular injection may be preferred because muscles have larger and more numerous blood vessels than subcutaneous tissue, leading to faster absorption than subcutaneous or intradermal injections. Medication administered via intramuscular injection is not subject to the first-pass metabolism effect which affects oral medications.

<span class="mw-page-title-main">Prescription drug</span> Medication legally requiring a medical prescription before it can be dispensed

A prescription drug is a pharmaceutical drug that is permitted to be dispensed only to those with a medical prescription. In contrast, over-the-counter drugs can be obtained without a prescription. The reason for this difference in substance control is the potential scope of misuse, from drug abuse to practicing medicine without a license and without sufficient education. Different jurisdictions have different definitions of what constitutes a prescription drug.

<span class="mw-page-title-main">Geriatrics</span> Specialty that focuses on health care of elderly people

Geriatrics, or geriatric medicine, is a medical specialty focused on providing care for the unique health needs of the elderly. The term geriatrics originates from the Greek γέρων geron meaning "old man", and ιατρός iatros meaning "healer". It aims to promote health by preventing, diagnosing and treating disease in older adults. There is no defined age at which patients may be under the care of a geriatrician, or geriatric physician, a physician who specializes in the care of older people. Rather, this decision is guided by individual patient need and the caregiving structures available to them. This care may benefit those who are managing multiple chronic conditions or experiencing significant age-related complications that threaten quality of daily life. Geriatric care may be indicated if caregiving responsibilities become increasingly stressful or medically complex for family and caregivers to manage independently.

<span class="mw-page-title-main">Injection (medicine)</span> Method of medication administration

An injection is the act of administering a liquid, especially a drug, into a person's body using a needle and a syringe. An injection is considered a form of parenteral drug administration; it does not involve absorption in the digestive tract. This allows the medication to be absorbed more rapidly and avoid the first pass effect. There are many types of injection, which are generally named after the body tissue the injection is administered into. This includes common injections such as subcutaneous, intramuscular, and intravenous injections, as well as less common injections such as intraperitoneal, intraosseous, intracardiac, intraarticular, and intracavernous injections.

In medicine, specifically in end-of-life care, palliative sedation is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying person's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route.

<span class="mw-page-title-main">Polypharmacy</span> Use of five or more medications daily

Polypharmacy (polypragmasia) is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions. The term polypharmacy is often defined as regularly taking five or more medicines but there is no standard definition and the term has also been used in the context of when a person is prescribed 2 or more medications at the same time. Polypharmacy may be the consequence of having multiple long-term conditions, also known as multimorbidity and is more common in people who are older. In some cases, an excessive number of medications at the same time is worrisome, especially for people who are older with many chronic health conditions, because this increases the risk of an adverse event in that population. In many cases, polypharmacy cannot be avoided, but 'appropriate polypharmacy' practices are encouraged to decrease the risk of adverse effects. Appropriate polypharmacy is defined as the practice of prescribing for a person who has multiple conditions or complex health needs by ensuring that medications prescribed are optimized and follow 'best evidence' practices.

Psychiatric nursing or mental health nursing is the appointed position of a nurse that specialises in mental health, and cares for people of all ages experiencing mental illnesses or distress. These include: neurodevelopmental disorders, schizophrenia, schizoaffective disorder, mood disorders, addiction, anxiety disorders, personality disorders, eating disorders, suicidal thoughts, psychosis, paranoia, and self-harm.

A methadone clinic is a medical facility where medications for opioid use disorder (MOUD) are dispensed-—historically and most commonly methadone, although buprenorphine is also increasingly prescribed. Medically assisted drug therapy treatment is indicated in patients who are opioid-dependent or have a history of opioid dependence. Methadone is a schedule II (USA) opioid analgesic, that is also prescribed for pain management. It is a long-acting opioid that can delay the opioid withdrawal symptoms that patients experience from taking short-acting opioids, like heroin, and allow time for withdrawal management. In the United States, by law, patients must receive methadone under the supervision of a physician, and dispensed through an Opioid Treatment Program (OTP) certified by the Substance Abuse and Mental Health Services Administration and registered with the Drug Enforcement Administration.

Involuntary treatment refers to medical treatment undertaken without the consent of the person being treated. Involuntary treatment is permitted by law in some countries when overseen by the judiciary through court orders; other countries defer directly to the medical opinions of doctors.

In medicine, patient compliance describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance, but it can also apply to other situations such as medical device use, self care, self-directed exercises, or therapy sessions. Both patient and health-care provider affect compliance, and a positive physician-patient relationship is the most important factor in improving compliance. Access to care plays a role in patient adherence, whereby greater wait times to access care contributing to greater absenteeism. The cost of prescription medication also plays a major role.

<span class="mw-page-title-main">Self-care</span> Taking care of ones own health

Self-care has been defined as the process of establishing behaviors to ensure holistic well-being of oneself, to promote health, and actively manage illness when it occurs. Individuals engage in some form of self-care daily with food choices, exercise, sleep, and hygiene. Self-care is not only a solo activity, as the community—a group that supports the person performing self-care—overall plays a role in access to, implementation of, and success of self-care activities.

<span class="mw-page-title-main">Caregiver</span> Person helping another with activities of daily living

A caregiver, carer or support worker is a paid or unpaid person who helps an individual with activities of daily living. Caregivers who are members of a care recipient's family or social network, and who may have no specific professional training, are often described as informal caregivers. Caregivers most commonly assist with impairments related to old age, disability, a disease, or a mental disorder.

End-of-life care (EOLC) refers to health care provided in the time leading up to a person's death. End-of-life care can be provided in the hours, days, or months before a person dies and encompasses care and support for a person's mental and emotional needs, physical comfort, spiritual needs, and practical tasks.

A chemical restraint is a form of medical restraint in which a drug is used to restrict the freedom or movement of a patient or in some cases to sedate the patient. Chemical restraint is used in emergency, acute, and psychiatric settings to perform surgery or to reduce agitation, aggression or violent behaviours; it may also be used to control or punish unruly behaviours. Chemical restraint is also referred to as a "Psychopharmacologic Agent", "Psychotropic Drug" or "Therapeutic Restraints" in certain legal writing.

Travel health nursing is a nursing specialty which promotes the health and safety of national and international travelers. Similar to travel medicine, it is an interdisciplinary practice which draws from the knowledge bases of vaccines, epidemiology, tropical medicine, public health, and health education. Travel nursing has experienced an increase in global demand due to the evolution of travel medicine. Travel health nursing was recognized during the 1980s as an emerging occupation to meet the needs of the traveling public, and additional education and training was established. Travel health nurses typically work in "private practice, hospital outpatient units, universities, the government, and the military", and have more opportunities and leadership roles as travel has become more common. However, they also experience organizational and support-related conflicts with general practitioners and patients in healthcare settings.

The treatment and management of COVID-19 combines both supportive care, which includes treatment to relieve symptoms, fluid therapy, oxygen support as needed, and a growing list of approved medications. Highly effective vaccines have reduced mortality related to SARS-CoV-2; however, for those awaiting vaccination, as well as for the estimated millions of immunocompromised persons who are unlikely to respond robustly to vaccination, treatment remains important. Some people may experience persistent symptoms or disability after recovery from the infection, known as long COVID, but there is still limited information on the best management and rehabilitation for this condition.

References

  1. ↑ Hung EK, McNiel DE, Binder RL (1 April 2012). "Covert medication in psychiatric emergencies: is it ever ethically permissible?". The Journal of the American Academy of Psychiatry and the Law. 40 (2): 239–245. PMID   22635297.
  2. 1 2 "Medicines management in care homes". NICE Guidance. NICE. Retrieved 23 March 2019.
  3. ↑ Kelly-Fatemi B (19 September 2016). "Covert administration of medicines in care homes". The Pharmaceutical Journal. Retrieved 23 March 2019.
  4. 1 2 3 4 5 Garratt SM, Jonas MF, Peri K, Kerse N (September 2021). "To crush, or not to crush? Unauthorised covert administration of medication in nursing homes". International Journal of Older People Nursing. Wiley. 16 (5): e12393. doi:10.1111/opn.12393. PMID   34114361. S2CID   235403377.
  5. 1 2 Guidry-Grimes, Laura; Dean, Megan; Victor, Elizabeth Kaye (2021-06-01). "Covert administration of medication in food: a worthwhile moral gamble?". Journal of Medical Ethics. 47 (6): 389–393. doi:10.1136/medethics-2019-105763. ISSN   0306-6800. PMID   32060208.
  6. ↑ Akram G, Mullen AB (April 2015). "Mixing medication into foodstuffs: identifying the issues for paediatric nurses". International Journal of Nursing Practice. 21 (2): 125–131. doi:10.1111/ijn.12222. PMID   24219078.
  7. ↑ Raghavan R (2010). "Ethical issues of psychotropic medication for people with intellectual disabilities". Advances in Mental Health and Intellectual Disabilities. 4 (3): 34–38. doi:10.5042/amhid.2010.0541.
  8. ↑ Kala AK (July 2012). "Covert medication; the last option: A case for taking it out of the closet and using it selectively". Indian Journal of Psychiatry. 54 (3): 257–265. doi: 10.4103/0019-5545.102427 . PMC   3512364 . PMID   23226851.
  9. ↑ "Good Practice Guide: Covert Medication" (PDF). Mental Welfare Commission for Scotland. Spring 2017. Retrieved 23 March 2019.
  10. ↑ Bushra R, Aslam N, Khan AY (March 2011). "Food-drug interactions". Oman Medical Journal. 26 (2): 77–83. doi:10.5001/omj.2011.21. PMC   3191675 . PMID   22043389.
  11. ↑ Ötles S, Senturk A (2014). "Food and drug interactions: a general review". Acta Scientiarum Polonorum. Technologia Alimentaria. 13 (1): 89–102. doi: 10.17306/j.afs.2014.1.8 . PMID   24583386.
  12. ↑ "Pharmaceutical Issues when Crushing, Opening or Splitting Oral Dosage Forms" (PDF). www.rpharms.com. Royal Pharmaceutical Society. Retrieved 23 March 2019.
  13. ↑ Bailey DG, Malcolm J, Arnold O, Spence JD (August 1998). "Grapefruit juice-drug interactions". British Journal of Clinical Pharmacology. 46 (2): 101–110. doi:10.1046/j.1365-2125.1998.00764.x. PMC   1873672 . PMID   9723817.
  14. 1 2 "Covert administration of medicines - Care Quality Commission". www.cqc.org.uk. Retrieved 2023-04-20.
  15. ↑ Abdool, Rosalind (Roz) (2017). "Deception in Caregiving: Unpacking Several Ethical Considerations in Covert Medication". Journal of Law, Medicine & Ethics. 45 (2): 193–203. doi:10.1177/1073110517720648. ISSN   1073-1105.
  16. ↑ "Covert medication flow chart". Coventry and Rugby Clinical Commissioning Group. Retrieved 23 March 2019.
  17. ↑ "Covert Administration of Medication Flowchart" (PDF). Cardiff and Vale University Health Board. Retrieved 23 March 2019.
  18. ↑ "Managing medicines for adults receiving social care in the community". NICE guideline [NG67]. Retrieved 23 March 2019.
  19. ↑ Giving medicines covertly (PDF). National Institute for Clinical Excellence. 2019.
  20. 1 2 3 4 "Human Rights Act 1998". www.legislation.gov.uk. Open Government Licence.
  21. ↑ "Mental Capacity Act 2005". www.legislation.gov.uk. Open Government Licence. Retrieved 23 March 2019.
  22. ↑ "Administering medicines covertly | Care Quality Commission". www.cqc.org.uk. Care Quality Commission. Retrieved 23 March 2019.
  23. ↑ Pickering NJ (December 2020). "Covert medication and patient identity: placing the ethical analysis in a worldwide context". Journal of Medical Ethics. 47 (12): e59. doi:10.1136/medethics-2020-106695. PMC   8639955 . PMID   33335071.
  24. 1 2 Pickering, Neil John (2021). "Covert medication and patient identity: placing the ethical analysis in a worldwide context". Journal of Medical Ethics. 47 (12): e59. doi:10.1136/medethics-2020-106695. ISSN   0306-6800. PMC   8639955 . PMID   33335071.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.