The aim of this assignment is to show knowledge and skills involved in my working practise as a Registered Mental Health Nurse in the administration of drugs to a Service User within and area of legal and ethical matters. In line with clause 5 of the nursing and midwifery council (NMC) (2004) code of professional conduct details of the service user will be confidential I certify that confidentiality has been maintained by use of pseudonyms. For purposes of this assignment the service user will be known as Winifred Clark.
I will be examining the area of Covert Medication in a Dementia Patient. Dictionary reference of Covert is: Not openly acknowledge or displayed. Dictionary reference of Medication is: a drug or other form of medicine that is used to treat or prevent disease. (Oxford dictionaries online) Therefore it would be determined that there is an attempt to deceive the patient into accepting medication unknown to them, this statement although true, doesn’t mean all that all nurses who use covert medication are deceptive in their actions.
The Nursing and Midwifery Council (NMC) (2002) gave a position statement on covert medication, in that disguising medication in the absence of informed consent maybe regarded as deception. However, a clear distinction should always be made between those patients/clients who have the capacity to refuse medication and whose refusal should be respected and those patients who lack this capacity.
It is this area in which I will be examining, how we establish capacity and whether using medication covertly is legal and ethical, does it make it easier to abuse and use as a ‘chemical cosh’ and looking at the legal and ethical issues related to pill crushing which goes hand in hand with Covert medication. Griffiths et al (2003) states that “administration of medicines is a key element of nursing care”. 7,000 individual doses are administered daily in a ‘typical’ hospital; and up to 40 per cent of nurses’ time is spent administering medicines with thousands more self administered by patients in their own homes (Audit Commission 2002).
I work for a large Mental Health Trust Organisation at a Day Hospital for the Elderly. Its primary function is to assess both holistically and individually, provide treatment on a needs based assessment that covers both functional and organic illnesses. The Day Hospital offers a minimum 8 week assessment period for service users to attend 1 or more day’s dependent upon their need and the requirement of the assessment into their mental state, problems or difficulties.
The assessment will include a full physical health check and also various cognitive, mood, behavioural and risk assessments needed to provide diagnosis, future care planning and/or treatment. Referrals at the Day Hospital for Service Users are received from various array of sources such as Consultants:- from either Domiciliary visits or Outpatients ;From Community Mental Health Teams for further more in depth assessment or upon their discharge from Mental Health Inpatient Wards adhering to the discharge care plan.
The Royal College of Psychiatrist Report ‘Raising the Standard’ Specialist Services for Older People with Mental Illness (2006) states that “Day Hospitals play an important role in the assessment and management of people living in the community and the rehabilitation of patients suffering from, acute and severe Mental Illness who are discharged from hospital”. The Day Hospital offers a rapid assessment and treatment plan for the Dementia Patient plus long term support for the service users who are unable to use alternative day care placements due to severe behavioural and psychological problems.
This ensures the carer can still receive some respite as well as providing the Dementia Patient with a stimulating and therapeutic environment. They will also continue to receive ongoing assessments including medication reviews and assessment for Anti-Cholinesterase Inhibitors and where indicated receive the treatment. Winifred Clark is an 87 year old lady, married with 3 daughters, all who live local. Born in 1923 and brought up locally. Married in 1949, worked mainly as a housewife.
There was no evidence of psychiatric illnesses before her being diagnosed at Out Patients Clinic in 2005 with Senile Dementia Alzheimer’s Type. Overshott and Burns (2005) described Dementia as a chronic and progressive clinical syndrome characterised by cognitive impairment, inability to perform activities of daily living and neuropsychiatric features. Recent data by the Alzheimer’s Society (www. Alzheimers. org. uk/demography) suggests that the number of people with dementia will continue to increase.
There are currently around 750,000 people in the United Kingdom with a form of dementia. 16,000 people under the age of 65 and statistics show that 1 in 14 people over the age of 65 and 1 in 6 people over the age of 80 has a form of dementia. The Alzheimer’s society projected growth predicts that by 2021 there will be 1 million people with dementia in the United Kingdom and this is expected to rise to 1. 7 million by 2051. Alzheimer’s is known to be the most common cause of Dementia
Winifred was monitored via Out Patients and Community Mental Health Team in her continued follow up for a number of years, until her behaviour began to deteriorate and this necessitated an assessment at The Day Hospital. In her symptoms she presented as agitated, restless, kicking and biting and screaming, mainly on nursing or carer intervention. There was evidence of paranoid and persecutory ideation and this led to her diagnosis also being changed to one of Behavioural and Psychological Symptoms of Dementia (BPSD).
Behavioural and Psychological symptoms of Dementia include aggression, agitation, biting, delusions, depression, kicking and screaming all of which Winifred was displaying. She was originally placed on the antidepressant Mirtazapine 15mg and also on an antipsychotic which was Quetiapine 25mg to try and modify her mood and behaviour, she continued to be monitored at The Day Hospital and her home After 2 weeks her behaviour had continued to deteriorate to the point where her family felt they couldn’t cope with her mood and behaviour and were considering Residential Care.
A review was held for all involved with her care. The outcome of that review was to admit Winifred under section 2 of the Mental Health Act (MHA) (1983) for assessment to an impatient unit of the Mental Health Trust, as she did not agree to admission voluntarily. It was felt that in order to monitor any changes of medication which was to include other antipsychotic and/or psychotropic medication, being admitted was in the best interest of Winifred to therefore have a period of Inpatient assessment and to try and improve her mood and behaviours she was displaying and prevent her going into residential care.
She was on the impatient assessment unit for over 6 weeks her condition improved and her Mental Health Act Section 2 was allowed to lapse. She was discharged home. The initial recommendation was for Residential Care but her family wanted to take her back home as her behaviour was more manageable. Her discharge care plan included continued monitoring of mood and behaviour at The Day Hospital for two days and her discharged medication was Lorazepam 0. 5mg bd and Mirtazapine 30mg daily. The incident that led to this assignment is as follows:
Her family had been unable to get Winifred to accept her medication of Lorazepam and Mirtazapine and Digoxin so they sent them with her on her day of attendance, for Day Hospital staff to administer. As per Trust medication policy the medication has to be in the prescribed box and blister packs as they receive them from the Pharmacy. This was explained to the Family by the escort who collected Winifred to escort her to the Day Hospital. The Medication was her morning Dose, either once daily or twice daily medication; on arrival at the Day Hospital she was to receive her medication.
On trying to administer the medication I found that Winifred refused to accept her tablets, she became agitated and distressed. Winifred could not understand why she needed the medication and was adamant that she wasn’t taking any tablets and was quite strong in her actions. The Family were contacted to see if they had a particular method in which they got Winifred to accept and understand the need for the medication and take it willingly. They informed me that they crushed the tablets and give it to her in food and drink!
I double checked the information with them and they said it was a recent thing as she had been refusing to take her medication. They found that if they crushed the medication and put them in her food she would accept them. As far as they were concerned as long as she got her medication it didn’t matter how she got them as the medication she took was important to her health, wellbeing and made it easier to manage her. The Multi-Disciplinary Team was informed which led to a capacity assessment being done, under the Mental Capacity Act (2005).
Winifred had been found to lack capacity in this area as she did not understand why she needed to take the medication, nor could she weigh up the information, could not retain the information and therefore could not communicate a decision about it. The Mental Capacity Act (MCA) (2005) became fully implemented April 2009. It provides a framework to protect vulnerable people over the age of 16 who are not able to make decisions. Before this Act the law was very complicated but it can now offer protection for people in this situation who do not have the capacity to make certain decisions. It has 5 key principles.
Everyone is presumed to have capacity unless proved otherwise. Individuals must be supported to make their own decisions and must be given all of the information before it is decided they do not have the capacity. People have the right to make unwise or eccentric decisions. Anything that is done for someone who lacks capacity must be done in their best interest and anything done for someone without capacity must be done in the least restrictive of their basic rights and freedom. The Act lays down a test for assessing capacity it is a ‘decision specific’ test concerned only with the decision to be made.
A person lacks capacity if they cannot understand information relevant to the decision, remember the information to make the decision, weigh up the information relevant the decision and communicate the decision, either by talking, sign language or by other means of communication. Because Winifred lacked the capacity The Day Hospital staff could now administer her medication covertly. Also, the Medication Information team based at the Trust Pharmacy were contacted and her medication of Mirtazapine, Lorazepam and Digoxin were checked to see if crushing them and administering them covertly was within legal, ethical and statute guidelines.
Lorazepam belongs to the Benzodiazepine are a class of psychoactive drugs that act as Central Nervous System depressants. They are used for a wide variety of purposes mainly in anxiety and insomnia. Lorazepam is an Anxiolytic used for short-term treatment of anxiety and sleeping problems. According to British National Formulary (BNF) Benzodiazepines are indicated for use of two to four weeks only of anxiety that is severe, disabling or causing the patient unacceptable distress occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic Illness.
The indications, cautions, contra-indications side effects and dosage information is described in Appendix (1) Benzodiazepines act as GABAa and GABAb receptor sites. GABA is Gamma-aminobutyric acid; it is one of the key neurotransmitters of the brain. It is the major inhibitory transmitter in the brain. GABAergic neurons are widespread and are involved in the control of fear, anxiety and arousal. Benzodiazepines increase the effect of GABA by binding to the Benzodiazepine receptor. They make it easier to open the chloride channel, increasing the frequency of the channel opening.
Anxiolytic effects occur when the dosage is low as opposed to sedative action. Benzodiazepines also have muscle relaxation action. Alcohol will increase the severity of the pharmacological effect of Benzodiazepine. Benzodiazepine has low toxicity unless taken with alcohol. A lethal overdose is difficult with Benzodiazepine alone. With Alcohol it makes it easier. Lorazepam has an onset of 15-45 minutes orally, 15-30 minutes intra-muscally and rapid onset intravenously and has duration of up to 48 hours. Lorazepam is almost completely absorbed from gastro-intestinal tract and peak serum levels are reached in 2 hours.
The elimination ? life is about 12 hours. It is about 90% bound to plasma proteins. Lowest effective does should be prescribed for the shortest time possible. The duration of the treatment varies from a few days to 4 weeks including tapering off process. Extension of treatment should not take place without evaluation for continued use. Mirtazapine is a Noradrenalin and specific serotonin Anti depressant (NASSA) it is used in the treatment of episodes of major depression. Mirtazapine may increase the sedating properties of Benzodiazepines. It increases the Noradrenergic and serotonergic neurotransmission.
The histamine H1 – antagonistic activity and practically no effect on the cardiovascular system. Pharmacokinetically after oral administration it reaches peak plasma levels after 2 hours binding to plasma proteins is approximately 85%. The half life of elimination is 20-40 hours. The half life justifies once a day dosing. Food intake has influence on its pharmacokinetics. It is extensively metabolised and eliminated via the urine and faeces within a few days. The clearance of mirtazapine may be decreased. The indications, cautions, contra-indications side effects and dosage information is described in Appendix (2) (for Digoxin Appendix (3)
As a person gets older, medication has both different pharmacokinetic and pharamacodynamic effects than it has on younger people. In absorption there is reduced saliva, decrease gastric acidity, increased gastric emptying time, reduced gastric surface, reduced gastro intestinal motility and reduced active transport mechanisms. Because of this, sublingual/buccal doses can take longer to act. Gastro intestinal changes lead to slower absorption of most drugs with the exception of Levadopa in which absorption is increased and the absorption vitamin B12, in which calcium and iron is reduced.
In distribution there is reduced water content, reduced cardiac output, decreased renal blood flow, altered volume of distribution and reduce serum albumin levels. Fat soluble drugs, like Diazepam get increased tissue levels and therefore have an increased duration of effect. Water soluble drugs, like Digoxin, increase plasma levels. In metabolism there are more changes such as an increase in half-lives, active metabolites and reduced first pass effects due to poor hepatic blood flow.
Less of the drug is delivered to the liver and metabolised, increasing plasma levels. Hepatic metabolism can be reduced by 60% therefore increasing plasma levels and half-lives. In elimination, the kidneys are reduced in size. Renal impairment can have a marked effect on drugs that are renal excreted, such as Digoxin. Pharmacodynamic changes make it more likely to get postural hypotension and the brain is more sensitive, making confusion a common side effect in the use of hypnotic, anti depressant and anti psychotic medication.
Hypnotics are widely used in the older adult; it increases the risk of adverse drug reactions, such as falls, confusion, persistent drowsiness, incontinence, delirium, amnesia, dependence, cognitive impairment, respiratory depressant. It is better to use drugs with shorter half-lives. James (2004) reported that in order to conceal medication in patients food it is often found to be quicker to pick up a pill crusher that to reorder a soluble or liquid version of a particular medication. Crushing a pill can upset a medications complex system therefore making it at best, useless, and at worst give serious side effects that can be fatal.
Wright (2002) surveyed 540 Nurses who worked in Nursing homes. He discovered that 15% of residence had some form of swallowing difficulties, 5% always chewed their medicine, 5% spat them out and 1% regularly hid them. He found that 80% of Nurses regularly crushed tablets to overcome these obstacles. He found that Nurses would crush tablets rather than find alternative administration in either liquid or dispersible form. Many of the Nurses would also never ask for advice before crushing a tablet!. There are obviously legal implications on the back of ‘pill crushing’.
The Medicines Act (1968) (Cited in Griffiths & Davies 2003) stipulates that medicines intended for use by humans are subject to a product license. The Act also requires that prescription medication be given in accordance with the directions of an appropriate practitioner who has prescribing authority. Crushing the tablet or opening capsules contrary to the prescribing practitioner would be a breach of the Medicines Act 1968. (Griffiths & Davies 2003) Manufacturers assume no liability should any harm happen to a patient if medication is administered by crushing.
The opening of a capsule or crushing of a tablet before administration makes the tablet in most cases unlicensed. Only medical practitioners according The Medicines Act 1968 can authorize administration of ‘unlicensed’ medicine to humans. In order to avoid liability the practitioner should therefore consult a pharmacist regarding the crushing of a tablet or opening of a capsule and should consider liquid or soluble preparation wherever possible. The prescriber should approve the crushing or opening of a capsule where there is no alternative product.
The pharmacist is in the best position to offer alternative routes of administration. Medications marketed in the United Kingdom must have a product licence from the Medicine and Healthcare products Regulatory Agency (MHRA) . Doctors are free to prescribe licence drugs outside what the drug is originally intended for. The Royal College of Psychiatrist Report (2007) states “There are no drugs specifically licensed for the treatment of psychotic and behavioural symptoms in patients with Dementing Disorders”.
It reported also that 66% of its doctors use psychotropic drugs for this application from response to questionnaires from its members. There are also potential dangers to the patient in administering crushed pills. Should the practitioner crush a patient’s medication and the action lead to an adverse reaction, they will be held legally responsible for the act of negligence. There are some drugs that should not be crushed. These include Extended Release medicines, Enteric Coated medicines and Hormonal Cytotoxic Steroidal medicines.
The risk to the patient include preventing the pills from working properly, burning the oesophagus, releasing too much medication too soon therefore leading to dangerously high levels in the system. Modified released drugs often contain a higher dose than is required to treat the patient, this is necessary to pass through the digestive system and liver. If a tablet is crushed the absorption rate is affected. Administration of medication to Older People can be dangerous in many ways. Age related multiple physical conditions may require treatments for numerous amounts of medication for each condition.
Older People continually report swallowing difficulties and this with large amounts of medication can lead to poor adherence. Morris (2005) reported that 11% of people over the age of 75 stated that they had difficulties swallowing tablets and capsules. Dementia patients may sometimes refuse to swallow medication that is essential to their health and wellbeing or more so in order to control behaviour and psychological problems. In order to ensure the Dementia patients continues to receive good quality care even though they refuse medication, it may therefore be deemed necessary to administer the medication covertly.
In the United Kingdom there are a number of Organisations that have issued guidance on covert medication such as the Royal College of Psychiatrists report (2004) and the NMC statement (2007) and others such as Alzheimer’s Society. Giving medication to a patient covertly has been described as an insidious and deceitful practice that violates every tenet of the doctor-patient relationship. (Ahern and Van Tosh 2005) and this may also account for the Nurse –patient relationship too.
This statement is correct, however covert medication can be deemed appropriate in patients who lack capacity. It should be avoided wherever and whenever possible but can be a better solution to a dementia patient refusal to take medication and then being subjected to restraint, becoming distressed and creating a bad experience for the Dementia patient. First line treatment for BPSD has been psychotropic medication mainly antipsychotics. Ballard and Cream (2004) state their concerns over the use of antipsychotics and there effects on the Dementia patient, as it increases ognitive decline heightens the risk of stroke and arrhythmias, increases the risk of falls and mortality. Antipsychotic drugs are not licensed to treat the behavioural symptoms of Dementia. The question that has to be asked is, how can Psychotropic medication, also known as chemical cosh, that can drastically affect the Dementia patient both mentally and physically and therefore increasing the risks of cognitive decline, strokes, falls, and mortality be considered in the best interest of the Dementing patient. What is actually meant by covert medication?
As a general principle it is disguising medication in food and drink and the fact that the patient is being led to believe that they are not receiving medication when in fact they are. We should not be confused with the administration of medication against someone’s consent. Service users/patients who cannot give consent to treatment by reason of ‘lack of capacity’ and who are refusing or unable to take prescribed medication when openly presented to them therefore may require it to be disguised in order for them to receive the medication prescribed. These are the recipients of covert medication.
Consent is “The voluntary and continuing permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature, likely effects and risks of the treatment including the likelihood of its successes and any alternative to it. Permission under any unfair or undue pressure is not consent. (MHA 1983 Code of Practice) The Nursing & Midwifery Council guidance (NMC 2002) clearly states that a distinction needs to be made with patients who have mental capacity to refuse medication, where refusal needs to be respected and those who do not have this capacity.
Where patients do lack capacity this also needs to be further established into those who do not need to have their medication administered covertly. Relative of an incapable patient do not have a legal right to consent, so the decision for acting in the patients best interest lies with the person responsible for the patients care. (Griffiths 2003) The guidance from the Nursing & Midwifery Council ( NMC 2002) makes it very clear that nurses are accountable for the decision to administer the medication covertly and that this is in the patient’s best interest. It cannot be a decision a Nurse undertakes alone.
It must be supported by the multi-disciplinary team and it is advised that Nurses do not covertly administer in isolation. In a residential setting, tranquilising medication can be seen as an easier way of addressing inadequate staffing levels and thus enabling the Nurse to manage the unit or as an essential but probably least restrictive way of managing, unpredictable violent outbursts towards fellow patients and staff. There are not many who would go against the moral issue of ensuring that a patient with epilepsy gets an anti-convulsant, another patient receives their insulin or their cardiac and respiratory medication in the covert way.
Why is this not the same for behavioural management of a Dementia patient? Carers of a Dementia patient did not differentiate medication for psychiatric disorder and that of a physical disorder. (Treloar et al 2000) Treloar et al (2001) goes on further to state that nearly all carers thought it would be right to put medicines in foodstuff if it was the only way to ensure treatment. It was thought that relatives would be more cautious about psychotropic medication.
In this study they found that it was acceptable to administer medication covertly for both physical and mental disorders as a last resort. Covert medication was also found to be a judgement based on a single Nurse with no discussion with pharmacists and the relatives may be kept in ignorance. This could be for fear of litigation! Medication that is used to control behaviour in the Dementing behaviour has become known in the media as ‘Chemical Cosh’ ‘Chemical Cosh’ for dementing patients can be said to make it easier for the carers or relatives to look after them.
In the media both newspapers and television have long held campaigns about the treatment of the elderly. One newspaper – The Daily Mail- has regularly campaigned about the treatment of the elderly including dementing patients in efforts to raise awareness about how they are treated and new discoveries of treatments. The British Broadcasting Corporation (BBC) reported in its news in June 2011 about ‘Chemical cosh’ and Dementia drug concerns.
In his Parliamentary Campaign, Care Services Minister, Paul Burstow MP has campaigned to cut the use of the so called Chemical cosh drugs, stating that “Reducing the use of antipsychotic medication is one of the coalition government four key priorities for Dementia” The National Institute for Health and Clinical Excellence (2011) also backed the cause to cut the use of ‘Chemical cosh’ Dementia drugs quoting their National Institute for Clinical Excellence(NICE)(2006) guidelines that Dementia patients should not be prescribed antipsychotic drugs because of the ossible increased risks of Cerebro-Vascular Adverse events and death. Where a patient lacks capacity, covert medication would not be unlawful provided it can be shown it is necessary medically. Under the Human Rights Act 1998 covert administration of medication would not engage the right to be free from torture, inhumane or degrading treatment under Article 3 of European Convention of Human Rights if the therapeutic necessity of the intervention can be convincingly shown to exist. Herczegfalvy v Austria 1993)(Cited in Griffiths R 2007) This means the decision to proceed must be in accordance with practise accepted by a responsible body of professional opinion and be in the best interest of the patient. (Griffiths 2007) Griffiths (2007) also states ‘Article 8 of the Human Rights Act respect for a private life, may also be considered to be breached by the use of covert medication but it can be justified on the grounds of the persons health as a proportionate response to the medical needs of the patient’.
Other aspects of the human rights act may also be infringed by covert medication such as Article 2, the right to life and Article 5, the right to liberty and security. Following Winifred’s capacity assessment it now made it possible to administer her medication in line with the guidelines and protocols both nationally and locally. She continued to attend Day Hospital and administering her medication was not a weekly routine. It was only done on the odd occasion. We would try to administer in the normal way and only when she refused did we have to do it covertly.
Winifred would willingly take the Digoxin elixir and the Mirtazapine Orodispersible but would not take Lorazepam in liquid form either willingly or covertly, so the Lorazepam tablet had to be crushed and administered covertly which she accepted. Conclusion The treatment of older people is currently a hot media topic, in particularly medication in the elderly and covert medication to. Covert medication has advantages and disadvantages in treating people with Dementia who have behavioural and psychological problems.
There are ethical and moral issues with a potential scope for abuse also issues related to consent, capacity, autonomy and best interest and these are all elements that require stringent guidelines. There is a duty of care to the patients and the professional standard that the Nurse who uses covert medication should never use it as a routine response to someone refusing to take medication it must be done as a last resort when all other methods have failed and the multi-disciplinary team is consulted with a pharmacist to confirm that it is safe to do so.
Medication should never be crushed when there is a viable substitute method of administration. With the Mental Capacity Act, covert medication to informal patients requires a best interest checklist and the need for chemical restraint to be in proportion and also be necessary. Media information in the use of psychotropic medication makes relatives and carers more aware of the harm it can cause. More information is required for then in the use of psychotropic medication used covertly and the harm it can cause covertly or not. As clinicians we act in ‘the best interest of our patients’.
We need to improve the need for non pharmacological interventions as a first line of treatment; we very often reach far too easily for the medicine bottle which when refused leads to covert administration. Only if it is essential to prevent deterioration both mentally and physically should medicine be administered covertly, not to be used in any other way to justify control of behaviours, then this requires the support of carers, relatives and the multi-disciplinary team and is reviewed regularly and not accepted as the norm.