Discussion of the practise of covert administration of medication in

nursing and the legal and pharmaceutical issues that should be

considered when administering medicines covertly

Covert administration is not simply the mixing of a medicine with food or drink to make it more
palatable to a patient at their request. By its definition, a medicine is given covertly to a patient in
a disguised form without their knowledge but in their best interest. Only those who lack capacity
to consent to treatment should be use. It involves a formal by caregiver and medical staff. It is
important distinguish between covert administration and disguised administration of medication
the will knowledgeable to the patient.
A medicines policies including:
1. Mental capacity assessments
Before consideration is given to covert administration of medicines to a patient, a mental
capacity assessment, in line with the Mental Capacity Act 2005[7], must be undertaken. At
this stage, it is important to consider if a patient has an active advance decision to refuse
treatment (ADRT) that enables someone aged 18 years and over, while still capable, to
refuse specified medical treatment for a time in the future when they may lack the
capacity to consent to or refuse that treatment. If the patient has an ADRT, it should be
adhered to
a capacity assessment is completed in two stages. First, it must be proven that a patient is unable
to make a decision because of an impairment of, or disturbance in, the functions of the mind or
brain. If this is the case, a patient will be considered legally to lack mental capacity to make a
decision or consent if they are unable to:

 Understand in simple language what the medicine is, its purpose and why it is being prescribed;
 Understand the benefits and risks of the medicine and whether there are any suitable alternatives;
 Understand in broad terms what the consequences of not receiving the proposed medicine will
be;
 Retain the information for long enough to make an effective decision or communicate their
decision in any way.

2. Best interests decision

When a patient is proven to lack capacity and is unlikely to regain

capacity (i.e. the impairment of, or disturbance in, the functions of the
mind or brain are not caused by a temporary or reversible change of
mental state), then the process to make a decision may proceed. At
this stage, all medicines should be reviewed for clinical need.
However, an appropriately skilled specialist clinical pharmacist
 would be just as suitable to complete this comprehensive medication
review.

3.Best interests meeting

Once this medication review has been undertaken, a meeting about
the patient’s best interests can be held. Attendees at this meeting will
usually include the prescriber, a nurse or senior carer from the care
home, and a patient representative. If a patient has a nominated
power of attorney for health and welfare, this person must be
consulted about all treatment decisions. A patient’s next of kin may be
invited to this meeting or, if the patient has no representatives who
wish to attend, an independent mental capacity advocate (IMCA)
should be invited to represent the patient. IMCAs are a legal
safeguard for people who lack the capacity to make specific
important decisions (including about where they live and about
serious medical treatment options). IMCAs are mainly instructed to
represent people when there is no one independent of services, such
as a family member or friend, who is able to represent the person.
At this meeting, individuals in attendance will consider the current and
future interests of the patient to decide the best course of action. The
Mental Capacity Act 2005 provides a checklist that practitioners must
follow when making a best interest decision for someone.The checklist
ensures that practitioners involved in making best interest decisions:

 Consider all the relevant circumstances, ensuring that the patient’s age,
appearance and behaviour are not influencing the decision;
 Consider delaying the decision if there is a possibility that the person may
regain capacity;
 Involve the patient in the decision as much as possible.
 Consider the past and present beliefs and values of the individual, and
the patient’s history of decision making;
 Take into account views of family and informal carers, as well as IMCAs or
other relevant people;
 Demonstrate that the decision made is the least restrictive alternative or
intervention.
4.Care plan for covert administration
Once a decision to administer medicines covertly has been made, advice should be sought from a
pharmacist about the suitability of each medicine for covert administration. Pharmacists should
refer to the summary of product characteristics (SPC) for the medicine or medicines concerned
and other appropriate reference sources

A care plan for administering medicines covertly should be completed. This should explain
exactly how medicines should be offered to the patient (i.e. not covertly in the first instance) and
then exactly how medicines should be disguised. This care plan, including the need for covert
administration, should regularly be reviewed and updated. National guidelines and frameworks
do not state a suggested minimal timescale for review, therefore, the period between reviews
should consider individual patient factors

5.Deprivation of Liberty Safeguards

The Mental Capacity Act 2005 includes deprivation of liberty safeguards (DoLS). DoLS are a set
of checks that apply to patients in a hospital or care home, who lack capacity about their care and
treatment. They aim to make sure that when care restricts a person’s liberty, with the aim of
preventing harm or providing treatment, it is both appropriate and in their best interests. It is the
responsibility of care home staff to ensure appropriate DoLS are in place, a process that includes
at least two assessments, one by a best interest’s assessor and one by a mental health assessor,
usually appointed by the local authority.

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, and if it restricts a patient’s freedom.

The Court of Protection recently provided guidance to be followed when providing covert
medication to patients subject to a DoLS authorisation. The principles outlined in the NICE
guidance remain the same, but in addition:

 Best interest decision meetings must include the relevant person’s representative (RPR) outlined
in the DoLS authorisation. The RPR will usually be a relative or friend of the person who is
being deprived of their liberty. If there is no appropriate friend or relative, the RPR will be
someone appointed by the supervisory body (e.g. an IMCA);
 If there is no agreement about whether medicines should be given covertly, there should be an
application made to the Court of Protection;
 The use of covert medication within a care plan must be clearly identified within the DoLS
assessment and authorisation;
 If a standard authorisation of DoLS is granted for a period longer than six months, there should
be a clear provision for regular — possibly monthly — reviews of the care plan involving family
and healthcare professionals;
 The care home must notify the supervisory body of changes to the covert medication regime,
including changes to the nature, strength or dosage of medications being administered covertly.
Such changes should always trigger a review of the authorisation;
 If there is an RPR, they should be fully involved in these discussions or reviews, so they can
apply to the supervisory body for a review of the DoLS authorisation if appropriate.

Practical considerations for pharmacists and pharmacy technicians

Best practice points for covert administration are included in ‘Box 2: Best practice points for
covert administration’. Important practical considerations for pharmacists and pharmacy
technicians include:

 If receiving a request for information about crushing or disguising medicines, explore the
circumstances behind the original request. It may be unwise to facilitate the covert administration
of medication when the formal process has not been followed.
 When giving advice about administration of medicines, be clear to nurses and care staff that
administering medicines covertly should be quantifiable. For example, if mixing with yoghurt, it
is advisable to mix the medicine with only one or two spoonfuls to ensure the person
administering can quantify that the whole dose has been taken. Furthermore, avoid mixing
multiple medicines together if possible.
 There is not much evidence in the literature about crushing medicines or mixing them with food
or drinks. However, important considerations include:
o Avoiding administering medicines with food or drink when there are known interactions (e.g.
milk with ciprofloxacin, tetracyclines);
o Investigating the patient’s likes, dislikes and daily routines before advising how medicines can
be disguised. Just because a medicine can be mixed with orange juice, the patient will not drink
it if he or she does not like orange juice;
o There is not always a licensed way to give a medicine covertly to a patient because tablets
become unlicensed when crushed and most liquids are not licensed to be mixed with other
liquids. All decisions about formulation should be made with regard to the individual patient.
o If you are worried about the absorption or effect being altered and cannot find any information,
consider whether the effect of the medicine can be measured (using physical parameters,
observations or blood work) and advise that more frequent monitoring may be required. If there
is no way to establish the potential effect that the medicine is having, discuss this with the
prescriber.
Even if it is disguised, consider the acceptability of the crushed dose form to the patient. For
example, crushed sertraline tablets can have a bitter taste and numbing effect that may put a
patient off food