We will always administer medication on a consenting basis with the full agreement of the individual and their relatives wherever possible. However, we do recognise that occasionally exceptional circumstances may arise, where a person, by virtue of their mental state or frailty, is unable to give consent despite the best efforts of the staff to obtain it.
In these situations, we accept that the administration of medication without a person’s consent may be necessary. At Derbyshire House, covert medicines will only be administered in accordance with the Mental Capacity Act 2005, the Mental Health Act 1983 and according to the Nursing and Midwifery Council (NMC) guidelines. This will help to ensure that the resident receiving the medication is protected as well as the staff administering the medication.
The procedure for covert medication is as follows: –
Medication will always be administered by consent and with the full agreement and understanding of the individual. Every effort will be made to obtain consent and the individual will be presumed to have capacity to consent to treatment unless proved otherwise. It will be explained to the individual –
- What the medication is for, in a format that is easy for them to understand, which may enable them to reconsider their decision.
- What will happen if they refuse their medication and the risks of doing so.
- Asked why they are refusing their medication to see if there is any reason i.e., struggling to swallow the medication then alternative formulations of the medicine or alternative medication can be explored. This can be done by speaking to the individual’s GP and pharmacist.
- If the individual has capacity, they do have the right to refuse their medication, even if it presents risks to their well-being and this decision should be recorded on the Medication Administration Record (MAR) chart, in the individual’s care plan and the Registered Manager should be informed.
- The senior will contact the GP for advice and where refusal falls within a defined course of treatment, the GP will be informed after the individuals first refusal.
If the individual refuses medication that is essential to their health and well-being for two consecutive days or more, a mental capacity assessment specific to the person’s refusal of medication will be undertaken, in line with the Mental Capacity Act 2005 as follows: –
- An urgent discussion will take place between Derbyshire House and the GP to support any decision making, ultimately the final decision will be made by the GP.
- The two-stage capacity assessment will be completed by the GP in consultation with the home, individual, individuals’ family member/advocate and other healthcare and/or social care professionals to see if they are unable to understand any one of the following:
- Retain information
- Receive Information
- “Weigh-up” the information as part of the decision
- If the assessment indicates a lack of capacity, it is the responsibility of the GP under the services duty of care to use the best interest’s checklist in accordance with section 4 of the Mental Capacity Act and this decision will be risk assessed and detailed in their care plan.
- If a decision is made to covertly medicate this should only be considered after all other options have been fully explored and only medication which is regarded as essential for the individual’s health and well-being, or for the safety of others, will be considered for administration in a covert way.
- It will be established if an advanced decision to refuse treatment has been made by the individual, if so, staff will secure a valid copy in the individuals care plan.
- In certain circumstances covert administration may need permission of the courts. The GP would know if this would be required.
It is important that all appropriate documentation is in place as the decision made can be challenged by inspecting bodies. The following information will be documented: –
- Evidence that an assessment of mental capacity has been undertaken.
- Evidence of a best interest meeting with a multidisciplinary team.
- Evidence of why mental incapacity has been decided.
- Proposed treatment plan agreed and recorded in the individual’s care plan.
- Clear documentation will be in the MAR chart that the individual is having medication covertly, this will have been written by the GP, which medications it applies to and in what form it is being disguised in i.e., what food or drink and/or whether the tablet can be crushed, which will have been written by the pharmacist and kept with the MAR chart to ensure all medication givers are aware of the correct process. This will also be added to the individuals care plan.
- Kitchen staff will be made aware of a person being given medication covertly as dietary changes may be needed.
- The MAR chart will be signed for each medication given covertly at the right time.
- Dates for reviewing the decision will be agreed.
Please note: An individual does NOT need to have a Deprivation of Liberty Safeguard (DoLS) in place to be administered their medication covertly. Where a DoLS authorisation has been granted, the decision to covertly medicate following such authorisation, or a decision to change or introduce other medication covertly needs to trigger a review of that DoLS authorisation. This can be done by using a DoLS Form 10 (Review of a Standard Authorisation). The individual’s relevant person’s representative must be included in the decision-making process. It is best that advice is sought in each individual’s circumstances to ascertain if this is necessary.
We will always strive to ensure that dignity and respect is maintained whilst administering medication covertly. Staff will be supported by healthcare professionals so that they are able to deliver care appropriately and consistently, with due regard to their accountability and avoiding any potentially abusive situations. Only staff who are trained to administer medication will do so covertly and will consider the following points when covert administration has been deemed necessary: –
- An individual will be offered their medication overtly each time, especially where fluctuating capacity is evident.
- Staff will be aware of personal preferences for administration through the care plan. If the individual continues to refuse after appropriate steps have been taken then medication can be administered covertly as per the care plan.
- In general medication(s) which are administered covertly will be mixed with the smallest volume of food or drink possible (rather than the whole portion) as this increases the likelihood that the prescribed dose has actually been taken. Not all drinks are suitable e.g., tea or milk interacts with some medications and this will be documented clearly after discussing with the pharmacist first.
- The medication will be administered immediately after mixing it with food or drink. It will not be left for the individual to manage themselves. If the person is able to feed themselves, they will be observed to ensure it is consumed.
- Each time medication is administered covertly in accordance with the care plan it will be clearly documented on the MAR chart.
- Refusal of the food or drink containing medication will be recorded on the MAR chart as refusal and reported to the GP. It will also be noted if it is partially consumed as the dose is then uncertain.
- Robust record keeping is evidence to enable the GP to review the continued need for covert administration.
The decision to administer covertly will be reviewed at regular intervals as individuals’ mental capacity can change. The dates for review will be documented in the care plan.
Good Practice for Covert Medication
Last Resort – covert medication is the least restrictive when all other options have been tried
Medication Specific – the need will be identified for each medication prescribed
Time Limited – it will be used for as short a time as possible
Regularly Reviewed – the continued need for covert administration will be regularly reviewed within specified time scales as will the persons capacity to consent
Transparent – the decision-making process will be easy to follow and clearly documented
Inclusive – the decision-making process will involve discussion and consultation with appropriate advocates for the individual. It will not be a decision taken alone
Best Interest – all decisions will be in the person’s best interest with due consideration to the individual’s cultural preferences and impact on their health & well-being