patients in the community, 48 (96%) thought the practice sometimes justifiable, but 47 believed that doctors ... Midwifery, the Mental Health Act Commission and.
PRACTICE
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A pill in the sandwich: covert medication in food and drink Adrian Treloar MRCPsych MRCP
Barbara Beats MRCPsych MRCP 1
Michael Philpot FRCPsych 2
J R Soc Med 2000;93:408±411
SUMMARY
The covert administration of medicines in food and drink has been condemned by some and condoned
by others. We used questionnaires to ascertain the views of people caring for patients with dementia in institutions and in the community. In 24 (71%) of 34 residential, nursing and inpatient units in south-east England, the respondent said that medicines were sometimes given in this way. It was often done secretly and without discussion, probably for fear of professional retribution. Few institutions had a formal policy on the matter. Of 50 people caring for demented patients in the community, 48 (96%) thought the practice sometimes justi®able, but 47 believed that doctors should consult with carers before deciding. Even if, as most carers and some authorities believe, covert medication can be justi®ed, the poor recording and secrecy surrounding the practice in institutions are cause for concern.
INTRODUCTION
METHODS
The covert administration of medication within foodstuffs has led to disciplinary action against medical and nursing staff1. Despite grave concern about the issue, however, the United Kingdom Central Council for Nursing and Midwifery, the Mental Health Act Commission and others regard the practice as justi®able in certain circumstances1,2. Mentally incapacitated patients should expect goodquality care even if unable to give valid consent or refusal3. To accept or refuse treatment a patient should satisfy three criteria: he or she must be able to understand and retain information on the treatment proposed, its indications, and its main bene®ts, as well as possible risks and the consequences of non-treatment; must be shown to believe that information; and must be capable of weighing up the information in order to arrive at a conclusion4. For example, a patient with severe learning disability develops epilepsy and, not understanding the need for anticonvulsant medication, refuses treatment. The stark choice is either to let the patient experience further seizures and suffer harm or to medicate by giving the drugs covertly. Such dilemmas clearly arise in several different settings5. We have tried to determine how often covert administration occurs in institutions for the care of patients with dementia, and also to ascertain the views of relatives caring for such patients in the community.
The study comprised two parts. In the ®rst, we identi®ed 34 residential, nursing and National Health Service (NHS) units across south-east England providing care for people with dementia. To increase the likelihood of accurate responses we selected units with which we had a trusting working relationship. From each, one member of the senior nursing or care staff was asked to complete a con®dential questionnaire. In the second part we gave questionnaires to a sequential sample of people caring for a demented person in the community, encountered by researchers during their work in community mental health teams. Carers gave written informed consent for the interview and use of data. The study was approved by the local research ethics committees.
Old Age Psychiatry, Oxleas NHS Trust & Guy's, King's & St Thomas' Medical Schools, Memorial Hospital, Shooters Hill, London SE18 3RZ; 1Old Age Psychiatry, St Martin's Hospital, Canterbury, CT1 1TD, and Guy's King's & St Thomas' Medical Schools, London; 2Old Age Psychiatry, South London &
408
Maudsley NHS Trust & Institute of Psychiatry, London SE5, UK Correspondence to: Dr Adrian Treloar
RESULTS
Of the 34 units, 7 were NHS inpatient wards, 6 NHS continuing-care homes, 5 elderly mentally in®rm (EMI) nursing homes, 3 conventional nursing homes, 5 EMI residential homes and 8 conventional residential homes. According to the questionnaires, 24 units (71%) sometimes resorted to concealing medicines in food or drink. (This was an underestimate since, in 3 units that said `never', other staff remarked that it happened every day.) When asked what made the practice acceptable, respondents most often cited prevention of mental distress (14), physical harm (4) or `risk of harm' (5). 11 said that the practice was justi®able only in mentally incapacitated patients. Factors cited less often included the prevention of agitation, the consent of the next-of-kin and the maintenance of the patient's dignity. 2 interviewees emphasized that the practice should not be used for the
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Table 1 Survey of elderly care settings (n=34) Question
Response
N
Frequency with which medication covertly administered
Never
10*
Less than monthly
10
Between weekly and monthly Between daily and weekly Persons involved in decision to give medication covertly
Individuals informed if medication covertly administered
Homes in which next-of-kin are informed {
Homes in which any speci®c record of covert administration is made {
10*
Nurse on duty only
10
Nurse on duty with others
14
Ward/home manager
14
Next-of-kin
14
Doctor
10 3
Ward/home manager
20
Doctor
14
Director of nursing/senior care manager
8
Pharmacist
3
Chief executive
2
Never
1
Occasionally
5
Often
10
Always
11
On drug chart Elsewhere
Homes with a policy on covert drug administration
2
Daily or more
Pharmacist {
2
1 10 4
*In 3 homes which denied the practice other sources indicated that it was a daily occurrence { 5 homes said these questions were not applicable since the practice never happened
bene®t of staff, 1 that it was reasonable if ordered by the doctor. Other results are shown in Table 1. Among the methods of disguising medication described, most intriguing was a request that marshmallows be available on the drug trolley so that capsules could be `popped inside'. We heard that tablets administered in sandwich quarters were more likely to be swallowed if placed in the second quarter. In some (mainly EMI) settings these practices were daily events for a substantial minority of patients. Despite the possible interaction of drugs with foodstuffs and the pharmacological implications of crushing tablets only 3 respondents had ever consulted a pharmacist. Some staff reported that the practice remained hidden through fear that the home might lose its registration or that staff would be dismissed. In 10 the decision to disguise medication was made by the nurse on duty alone. In only 11 were next-of-kin invariably informed. Respondents expressed concern that the practice had considerable potential for abuse, despite believing it to be necessary and appropriate for certain patients. In the light of the Bournewood ruling6,7 (see Discussion) we asked whether patients should be ®rst detained and then treated under the Mental Health Act.
All but 2 judged that this would unnecessarily limit the choice of residential and nursing home placement available to the patient. The home carers study comprised interviews with 50 carers. No carers declined to participate. The Mini Mental State Examination8 score of the patients was 12.9 (range 0±28). Table 2 summarizes the responses. Nearly all carers thought that it would be right to put medicines in foodstuffs if this was the only way to ensure treatment. We had thought that relatives would be more cautious about psychotropic medication than about physical medications. This was not so; indeed, one respondent favoured giving medicines for mental distress while opposing, say, antibiotics that might prolong onerous care and suffering. 6 carersÐout of the 15 who had had dif®culty in getting their relative to take medicinesÐhad put medicines in foodstuffs. To test for consistency we asked the reverse question: in view of the patient's `right to choose', should the covert administration of medicines in foodstuffs never be allowed? The strong opinion against prohibition increased our con®dence in the general validity of the results.
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Table 2 Results from carer study (n=50) Strongly disagree
Statement
Dementia may be so severe that patients cannot choose
Disagree
1
Relatives should make choices for patients with severe dementia
Strongly agree
10
39
13
37
Doctors should make choices for patients who cannot choose
3
21
26
Doctors should consult with carers before reaching a decision
3
9
38
Patients who refuse medication should be treated in the least distressing way if they have a treatable life-threatening illness
1
7
42
Patients who refuse medication should be treated in the least distressing way if they suffer severe treatable mental distress
2
7
41
Life-saving medicines should be given in foodstuffs if necessary Medicines for severe mental distress should be put in foodstuffs if necessary Any helpful medicine should be put in food if necessary All patients have the right to choose and should never be given medicine in foodstuffs
8
42
1
8
41
2
13
35
18
25
4
3
Never
Rarely
Weekly
Daily
Frequency with which carers had had problems giving medicines to relatives
30
5
4
11
Frequency with which carers were putting medicines in foodstuffs
44
1
2
3
DISCUSSION
410
Agree
Covert administration of drugs in food and drink was widespread in this survey, although the practice involved only a few patients in each setting. Carers in both settingsÐ institutions and the communityÐseemed to regard it as acceptable for both physical and mental disorders, as a last resort. We were, however, concerned about the secrecy and lack of controls, and about the absence of discussion with pharmacists regarding advisability. Moreover, covert medication is often based on the judgment of a single nurse, and relatives may well be kept in ignorance. This disturbing picture may be attributable to a culture of fear surrounding covert medication, in which written guidelines are lacking and concern about litigation drives the practice underground. The ethical principles relevant to these ®ndings are those of autonomy and the duty of care3. At face value, the principle of autonomy implies that all deception is wrong, even if serious harm might arise from a refusal of care. However, to seek consent from the incapacitated is futile8. If we insisted on consent, patients might suffer from being denied care they could not validly reject. Can the existing legal structures help to protect individuals in these circumstances? The Mental Health Act is not the answer, since most settings where covert medication occurs are outside the remit of the ActÐand most of the treatments are for physical rather than mental ills. Nor is the proposed revision of the Act9 likely to help. In the Bournewood case6 an autistic man was admitted
informally to a mental health unit after displaying agitated behaviour and was subsequently detained. The question was whether the patient's absence of dissent to detention could be construed as informed consent6. Ultimately the Law Lords declared the detention legal under the common law `doctrine of necessity'Ði.e. the duty of care7. The revision of the Act does not focus on issues of long-term capacity such as were raised in this case and does not cover most settings in which covert medication occurs10. `Advance directives' are likewise an unpromising approach, since few people will have the knowledge to overrule the intuitive wish never to be deceived by doctor or nurse. The proposed `continuing power of attorney'11,12 might allow appointees to authorize such practices, but safeguards would be necessary to ensure that the decision was in the patient's best interests. Even though carers seem to approve of covert drug administration in certain circumstances, the secrecy in which it is shrouded and the lack of policies governing its use must be questioned. The potential for abuse is heightened when practices go unrecorded and unmonitored. We suggest that in incompetent resistive patients, medication should be given covertly only after discussion within the nursing and medical care team, and with the family. The practice should be recorded and regularly monitored. Acknowledgment We thank Professor Ian Norman for advice on the design of the study.
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REFERENCES
1 Kellett J. A nurse is suspended. BMJ 1996;313:1249±50 2 Grif®th D, Bell A. Treatment was not unethical. BMJ 1996;313: 1250 3 BMA and Law Society. Assessment of Menal Capacity. Guidance for Doctors and Lawyers. London: BMA, 1995 4 Re C (adult refusal of treatment), [1994] 1 WLR 290 5 Valmana A, Rutherford J. Over a third of psychiatrists had given a drug surreptitiously or lied about a drug. BMJ 1997;314: 300 6 Shah A, Dickenson D. The Bournewood case and its implications for health and social services. J R Soc Med 1998;91:349±51
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7 Shah A, Dickenson D. The Bournewood case [Letter]. J R Soc Med 1998;91:507±8 8 Folstein M, Folstein S, McHugh P. Mini Mental State: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:180±98 9 St George's Healthcare and Mental Health NHS Trust v S [1998] 3 All ER 673 10 Department of Health. Reform of the Mental Health Act: Proposals for Consultation. London: Stationery Of®ce, 1999 11 Scottish Executive. Making the Right Moves; Rights and Protection for Adults with Incapacity. London: Stationery Of®ce, 1999 12 The Lord Chancellor. Making Decisions: the Government's Proposals for Making Decisions on Behalf of Incapable Adults. London: Stationery Of®ce, 1999
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