Covert medication

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]

Medical use

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.

Medication is only likely to be administered covertly where:

• The patient actively refuses their medicine
• It is determined to be essential to the patient's mental or physical health, and therefore in their best interest
• The patient is deemed to lack capacity to understand the repercussions of refusing the medication.^[3]

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.

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 is mixed with food or drink to make it more acceptable.^[4]

In dementia, patients suffer from 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 need to 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 needed to reduce risk of harm to self or others. Medication is covertly given with respect to best interest when these patients refuse treatment.^[5]

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.^[6]

Medicolegal implications

Covert medication has many medicolegal and ethical aspects to it.

Application

In the UK, NHS trusts may publish guidelines concerning administration of covert medication. Guidelines often include flowcharts to aid decision making.^[9][10]

"Covert administration should be: A last resort – only implemented when there is no viable alternative; Medicine specific – the need must be identified for each medicine prescribed; Time limited – it should be used for as short a time as possible, and the need should be reviewed regularly."

The decision-making process should be in the best interests of the patient, transparent and inclusive.^[11]

NICE recommends care home providers have a care home medicines policy that includes guidance on covert administration of medications by care home staff.^[12]

Pharmacology

Covert administration of medication typically involves mixing the medication with food or drink. This can have an impact on the absorption of the drug.^[13] Absorption of some medicines, such as antibiotics, can be reduced when mixed with food, particularly dairy products.^[14] Some medicines are incompatible with various minerals including calcium, iron, magnesium, and zinc, all of which may reduce absorption.^[15] Crushing slow-releasing tablets or enteric coated medicines may also reduce absorption of the medicines.^[16]

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.^[17] This alters drug levels in the blood which may cause side effects or make the drug less effective.

References