Module 2 of 2 · 45 minutes
Covert administration and refusal, done lawfully
By the end of this module you will be able to
- Explain when covert administration may lawfully be used
- Describe the full process required before a medicine is given covertly
- Respond to refusal in a person with capacity
- Recognise unlawful covert administration and report it
Work through it
1 interactive for this module, built on the WAJD Teach engine. Nothing moves until you ask it to, and every one has a written version if you would rather read it.
Amara Covert administration. Just hearing the phrase makes people uncomfortable.
Nadia It should make people careful rather than uncomfortable, because it is sometimes exactly the right thing to do. What is dangerous is doing it casually.
Amara Define it for me.
Nadia Giving a medicine disguised in food or drink without the person's knowledge or consent. And it is lawful only in narrow circumstances, after a defined process.
Amara What are the circumstances?
Nadia Three conditions, all of them required. The person lacks capacity for the specific decision about that medicine. The medicine is necessary for their health. And it has been agreed through a best interests process.
Amara And if the person has capacity?
Nadia Then it is assault. I want to be as blunt as that, because it is done with kindness all the time. A woman with capacity refuses her tablets, and a carer who cares about her puts them in the yoghurt. That is unlawful, however good the intention, and it is a safeguarding matter.
Amara Walk me through the process that has to happen first.
Nadia A capacity assessment for this specific decision, written down. A best interests meeting involving the prescriber, the pharmacist, the care team, and family or an advocate. Consideration of less restrictive options.
Amara What counts as less restrictive?
Nadia Whether the medicine is still needed at all, which is a question worth asking far more often. Whether the formulation could change, so a liquid or a patch instead of a tablet. Whether the timing could change. Quite often the whole problem is that somebody is being offered eleven tablets at eight in the morning and is overwhelmed.
Amara Why does the pharmacist have to be involved?
Nadia Because crushing and mixing is not neutral. It can alter absorption. It is dangerous with modified release preparations, where crushing can deliver a whole day's dose in one go. And it usually takes the medicine outside its product licence, which is a decision a prescriber has to make knowingly.
Amara And then?
Nadia A written plan. Which medicines, how, in what, by whom. And a review date, because the failure I see most often is not an unlawful start. It is a lawful start that nobody ever revisits, and two years later a person is still being medicated covertly with no one able to say why.
Amara Let us go back to refusal in someone with capacity. What am I actually meant to do?
Nadia Not secure compliance. That is not your job and it never was. Your job is to make sure the refusal is informed, find out why, and report it.
Amara Why does the reason matter so much?
Nadia Because the reason almost always has a fix and the refusal does not. Nausea. A horrible taste. A tablet the size of a sugar cube that they cannot swallow. A belief that this one caused their rash. Depression. Or the commonest of all, that nobody has ever told them what it is for.
Amara That last one is depressing.
Nadia It is very common. And notice that every one of those is solved by a conversation with the prescriber, not by persuasion at the bedside.
Amara Are there refusals I should escalate immediately?
Nadia Yes, and this list is worth learning. Anticoagulants. Antiepileptics. Insulin. Parkinson's medication. Cardiac medicines. And steroids, where stopping abruptly is dangerous.
Amara You paused on Parkinson's.
Nadia Because it is the one care settings get wrong most often, and the consequences are fast and severe. Parkinson's medication is time critical. Not roughly on time. Time critical. A dose given an hour late on a busy round can leave somebody unable to move or swallow, and it can take days to get back on top of.
Amara Last thing. I see a colleague put a tablet in somebody's custard and there is no plan I know of.
Nadia Then that is a safeguarding concern and you report it as one. Not a quiet word. Not a note to the manager next week. It goes down the safeguarding route, exactly as any other concern would, however kindly it was meant and however fond of that resident your colleague is.
The written material
What covert administration is
Covert administration is giving a medicine disguised in food or drink without the person's knowledge or consent. It is not automatically wrong, and in some circumstances it is the compassionate and correct course. But it is lawful only in narrow circumstances and only after a defined process.
It may only be considered where the person lacks capacity for the specific decision about that medicine, where the medicine is necessary for their health, and where it has been agreed through a best interests process. It can never be used for a person who has capacity and is refusing. That is assault.
The process that must happen first
A capacity assessment for this specific decision, recorded. A best interests meeting involving the prescriber, the pharmacist, the care team, and family or an advocate. Consideration of less restrictive options, including whether the medicine is still needed at all, whether the formulation can change, or whether the timing can change.
Pharmacist advice on the specific medicine, because crushing or mixing can alter absorption, can be dangerous with modified release preparations, and usually takes the medicine outside its product licence. A written plan naming which medicines, how, in what, and by whom. And a review date, because covert administration must never become permanent by default.
- Capacity assessment for this decision, documented
- Best interests meeting with prescriber, pharmacist, team and family or advocate
- Less restrictive alternatives considered and recorded
- Pharmacist advice on the specific preparation
- Written plan and a review date
Refusal in a person with capacity
A person with capacity may refuse any medicine, including one that keeps them alive. Your task is not to secure compliance. It is to make sure the refusal is informed, to find out why, and to report it.
The reason usually matters more than the refusal. Nausea, a taste, difficulty swallowing a large tablet, a belief that the medicine caused a symptom, depression, or simply not having been told what it is for. Most of those have a fix, and the fix is usually a conversation with the prescriber rather than persuasion at the bedside.
Critical medicines and escalation
Some refusals need escalating the same day rather than at the next medication review. Anticoagulants, antiepileptics, insulin, Parkinson's medication where timing is critical, cardiac medicines, and steroids where abrupt withdrawal is dangerous.
Parkinson's medication deserves particular mention because it is frequently given late in care settings and the consequences of delay are severe and rapid. Time critical means time critical.
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