It is a busy morning at the nursing care center. The RN has the responsibility of passing medications and completing morning assessments before the physician makes his rounds. She starts to administer medications to her assigned 20 residents. Halfway through the medication pass, one of her residents refuses medication. The nurse hesitates for a moment before making the decision to secretly mix the medication into the resident’s breakfast food.
In this context, Rebecca chose to administer this resident’s medication covertly. The literature describes covert medication administration (CoMAd) as hiding, disguising, or concealing medications to residents in the absence of clear consent (Treloar, Beats, & Philpot, 2000). Consent for medical treatments including medications is a complex process in resident populations where cognitive illness is prevalent, such as long-term care settings. A literature review on this practice reveals serious concerns about the ethical and moral implications of CoMAd and lack of adequate regulations to guide professional actions of nurses in long-term care settings.
Federal guidelines support long-term care residents’ rights to refuse treatment; however, if medications are covertly administered, the resident is not provided an opportunity to refuse. The practice of CoMAd has been documented in a small number of research studies, primarily in long-term care settings, where nurses routinely administer medications to large groups of residents. In this setting, nurses reported hiding medication in food or drink for a variety of reasons, with higher occurrences noted in those residents who lacked decision-making capacity (Tweddle, 2009). A literature review of this phenomenon found a small amount of research documenting this practice in long-term care settings in the United Kingdom and Norway (Kirkevold & Engedal, 2004; Treloar et al., 2000). In these studies, reasons for CoMAd were nonadherence and difficulty swallowing. However, in many cases, reasons for CoMAd were not provided. Findings from this research, as well as public and professional commentary, suggest that the phenomenon of CoMAd frequently occurs in secret, and reasons for hiding the medication from residents is unclear. The purpose of this article is to review available literature on the topic of covert medication administration and identify ethical and legal implications for bedside nurses.
The right of mentally competent residents to give or refuse consent to medical treatment is an accepted standard in health care. Long-term care facilities do not typically solicit specific consent for routine medication administration during resident care. The few studies conducted in the United Kingdom and Norway suggest that residents in long-term care settings receive medication hidden in food and drink on a regular basis (Kirkevold & Engedal, 2004, 2009; MacDonald, Roberts, & Carpenter, 2004). Published commentary by public health officials, health care experts, and members of the medical community suggest that residents in long-term care settings who lack decisional capacity because of cognitive decline, dementia, or psychiatric disorders are particularly vulnerable to CoMAd (Tweddle, 2009). The practice of hiding medications from residents in long-term care settings has significant ethical, legal, pharmacological, professional, and provider issues that should be explored.
Although public and professional commentary regarding CoMAd exists, scientific research by Treloar et al. (2000, 2001) stimulated a series of research studies documenting the practice in Norway and the United Kingdom. Subsequent research supported their findings that CoMAd is often done in secret, and formal institutional policies regarding the practice are rare (Kirkevold & Engedal, 2004, 2009; MacDonald et al., 2004). This body of science also identifies poor documentation of CoMAd, as well as inconsistent consultation with prescribing providers and residents’ significant others. Nurses discuss swallowing difficulties, behavioral disturbances, and loss of the resident’s ability to consent as rationale for the practice of CoMAd (Kirkevold & Engedal, 2004); CoMAd may occur more often for residents with swallowing difficulties or cognitive impairments due to nurses’ perception that hiding medications saves time.
We believe occupational factors that might influence CoMAd decisions include increased number of assigned residents, complexity of resident care, pressure to perform, and a perspective that health care providers know what is best for residents in long-term care. Nurses may face criticism, regardless of the action they take; for example, they may be criticized by administration for taking additional time to problem-solve situations with residents who refuse medications. Prescribing clinicians may be critical of alterations in dose form and timing resulting in CoMAd or of failing to administer medications when a resident has refused. Families may express concern that their loved one should get their medication despite resident refusal. Residents may become distrustful by having medications hidden from them.
Legal and ethical risks of CoMAd include violation of resident autonomy and loss of the therapeutic alliance between residents and health care providers (Honkanen, 2001; Tweddle, 2009). Several factors complicate the legal and ethical risks. The presence of formal institutional guidelines is inconsistent, and no specific regulatory guidelines are available for bedside nurses. CoMAd is not specifically addressed in nursing practice guidelines in the United States by state practice boards or long-term care regulations. Blanket statements that advocate for resident rights include that all residents, regardless of mental capacity, have the right to determine their own care. Unfortunately, unless a resident consistently refuses care or a support person raises concerns, residents may be vulnerable to CoMAd on a routine basis.
Prevalence, Contributing Factors, and Potential Consequences
The suspected high prevalence of CoMAd remains secreted in nursing practice with little direction for bedside nurses to navigate situations in which hiding medication is considered. In the United Kingdom, CoMAd was found to be a common practice in long-term care settings, affecting 1.5% to 17% of residents and occurring in up to 71% of facilities reviewed (Treloar et al., 2000). Without analogous research in the United States, it is difficult to assess the frequency of this practice. The contributing factors and potential consequences of this nursing practice remain unclear.
Evidence from the literature cites the following contributing factors: (a) staff statements that the practice was only used to prevent physical or mental harm, and (b) the practice was justified in situations in which mental capacity was compromised (Treloar et al., 2000). Due to the hidden nature of CoMAd, there is rarely documentation of the decision-making process used to justify the practice. Research suggests that the prescribing authority was rarely involved in the decision to covertly administer medication; the practice was poorly documented; and nurses did not generally consider their actions inappropriate (Haw & Stubbs, 2010; Treloar et al., 2000).
High-risk resident populations likely to have medications covertly administered were those with severe mental illness or dementia (Haw & Stubbs, 2010; Kirkevold & Engedal, 2009). These populations more often received antiepileptic, antipsychotic, and anxiolytic agents that are usually administered for behavior control (Haw & Stubbs, 2010). Residents with these disease processes or behaviors are further compromised in their ability to voice reasons for refusal and may be viewed as incapable of contributing to their plan of care. At this juncture, consultation with family members and prescribing clinicians can assist in problem-solving resident refusal. However, this practice is seldom used (Treloar, Philpot, & Beats, 2001). In addition, few nurses indicated that they had consulted a pharmacist about the implications of altering dose form when covertly administering medication (Barnes et al., 2006; Treloar et al., 2000). Nurses who choose to covertly administer medications to individuals with questionable mental capacity without consulting prescribing clinicians or pharmacists may risk violations of resident autonomy and professional practice expectations (Tweddle, 2009).
Regulatory, Ethical, and Legal Implications
Ethical nursing actions are those that benefit the resident, reduce harm, and respect resident independence and dignity. Whitty and Devitt (2005) warned that it is unethical to covertly administer medication to residents with compromised mental capacity. Conversely, providers may argue that if the resident were cognitively intact, he or she would have consented. Honkanen (2001) referred to this as a paternalistic perspective that has ethical and legal implications. Some experts argue that medication can be given in the absence of consent in individuals who lack decision-making capacity if it is in the resident’s best interest (Dimond, 2004; Griffith & Davies, 2003; Griffith, Griffiths, & Jordan, 2002; Tweddle, 2009). The use of CoMAd as a chemical restraint has been justified when resident behavior is considered a risk to themselves or others and requires documentation of that behavior (Allen, Currier, Carpenter, Ross, & Docherty, 2005; Lewin, Montauk, Shalit, & Nobay, 2006). These differing perspectives create a dilemma for nurses passing medications in the absence of clear guidelines.
Nurses in the United Kingdom have the legal authority to act under the Consumer Protection Act of 1987 and the right to administer medication under their license issued by the state board of nursing in which they practice. In England, the Mental Capacity Act directs that the harm of not administering must be greater than the harm of covert administration (Haw & Stubbs, 2010). More abstractly, U.S. legislation includes the Patient Self-Determination Act of 1990, the Omnibus Budget Reconciliation Act of 1987, and the Americans with Disabilities Act of 1990. These acts include propositions that residents have rights regarding consent to care and participation in decisions regarding the plan of care. Despite a variety of legal and ethical position statements, no specific guideline exists for decisions regarding routine CoMAd in the United States. Due to inconsistent presence of institutional policies regarding CoMAd, making decisions for residents—even when the care provider believes that his or her actions are in the resident’s best interests—is questionable at best.
Considering the resident’s perspective may shed some light on the potential risks of CoMAd. Symptoms such as gastric upset, dizziness, or pain in association with a medication given covertly may not be adequately expressed due to diminished mental capacity. Administering medication covertly may worsen these symptoms and confuse residents, as they thought they had refused it. If residents only receive medication covertly, they may perceive they are not receiving medication at all. The pressure to perform tasks in an efficient manner may prevent nurses from considering these factors. Some of the reasons nurses may choose to conceal medications from residents are noted in the left column of Table 1. Before nurses make the choice to engage in CoMAd, the literature suggests considering the implications associated with this practice (right column of Table 1).
Table 1: Covert Medication Administration (CoMAd) in Long-Term Care: Potential Rationale and Considerations for Nurses
No specific guidelines regarding covert medication administration exist for nursing practice from U.S. health care or government organizations. The American Nurses Association (ANA, 2001) does not specifically address covert medication in nursing practice outside of the general mandate for safe administration of medication. The Nursing and Midwifery Council of the United Kingdom has issued position statements citing that CoMAd in food or drink should follow an assessment of the resident’s best interests and that the purpose of the medication is life saving, essential to the prevention of illness, or will significantly improve health status (Nursing and Midwifery Council, 2007). Both the Nursing and Midwifery Council and the ANA Code of Ethics hold the administering nurse personally accountable for his or her practice regarding medication administration (ANA, 2001; Nursing and Midwifery Council, 2009). Little research regarding this practice is available in the United States, and the prevalence of individual facility policies is unknown. Additional discussion from national nursing organizations is essential to providing clarity for bedside nurses. Until this is accomplished, recommendations based on available information can protect nurses from ethical and legal compromise.
Navigating the Issue
Returning to the example at the beginning of the article, did the nurse make an appropriate decision to covertly administer the medication? What else could have been done? A prudent nurse might begin by evaluating this situation in terms of mental capacity, medication orders, type of medication, and resident assessment data. CoMAd has several physical implications on resident status that should be considered in the decision-making process. During CoMAd, the properties of the medication may change when crushed and mixed with food or drink items. Nurses can consult with the prescribing clinician and pharmacist for advice regarding alteration of dose forms. It is also important to consider whether the medication changes the taste and texture of the food item with which it is mixed. A dietician can be useful to make recommendations and assist in monitoring the resident for changes in intake. Emotionally, nurses should consider that residents may become suspicious and lose trust in their caregiver if they suspect covert medication in their food (Tweddle, 2009). Additionally, residents who are not given the opportunity to voice their choice regarding medication may also lose the opportunity to voice allergies, questions about the medication, and report of side effects.
Further consideration might include whether the resident had previously taken the medication without dissent and whether a guardian or power of attorney could have been consulted. In the absence of specific guidelines in situations in which the resident has a guardian or power of attorney, the American Medical Association’s (2001) Code of Ethics supports family decision making. Discussing resident refusal of medications with the resident’s primary health care provider, family, or support system is an important part of protecting the resident. Collaboration may provide insight into encouraging medication adherence, reveal hidden history of medication allergies, and give additional opportunity for teaching regarding medication regimens. Some experts argue that the possibility of CoMAd should include members outside of the care team due to concerns that direct care providers do not have an objective perspective (McGrath & Jackson, 1996). Honkanen (2001) recommended that if CoMAd is used with residents who are unable to provide clear consent, it should be done with specific reference to advanced directives or by appointed health care proxies.
In situations in which there are no directions from residents or a support system, institutions may consider a process of documenting that CoMAd was done in the resident’s best interests and with thoughtful consideration of the positive and negative aspects. Griffith et al. (2002) outlined the following process to determine whether CoMAd is in the resident’s best interests:
- First, determine and document whether the resident is incapable of consenting to treatment according to standard consent procedures.
- Second, document reasons why the medication is necessary in the resident’s best interests and that all other methods of administration has been tried unsuccessfully. If the facility has an ethics board, this group may be able to assist in understanding the ethical implications for the resident and facility regarding CoMAd. Consultation with the prescribing provider is important to determine which medications are considered essential, and—when other options fail—are to be administered covertly.
- Third, document an interdisciplinary team discussion of the circumstances in which CoMAd is used to administer medications, which medications are safe to use in this manner, and how this situation will be managed in the future.
Schwartz, Vingiano, and Perez (1988) stated that medication refusal is a clinical issue that should be directed by the treatment team rather than a judicial body. In light of research that reveals lack of documentation, it is important that steps to consult with the various stakeholders be carefully documented in the resident care record on the medication chart. Nurses should recognize that the inability to consent to medication may fluctuate according to changes in disease process and should consistently attempt to discuss medication teaching and obtain consent. For these reasons, institutional policies regarding this possibility can help guide members of the health care team. Having a plan of care that anticipates these situations is more realistic than convening the team each time the patient refuses a medication. These actions are consistent with resident advocacy and assist nurses in developing a strong therapeutic alliance.
Implications for Nurses
Table 2 provides a list of suggested actions that protects both the nurse and resident to help bedside nurses with decision making when considering CoMAd. When faced with a resident who refuses a medication, it is important to involve the resident’s family, physician, as well as those in other disciplines in determining the best course of action. Dietary and pharmacy professionals are also important team members to recruit for decisions regarding CoMAd. Additionally, consultation with members of the ethics committee may be beneficial and contribute to the development of institutional policies and procedures. These activities serve to limit legal and ethical risks of CoMAd and provide opportunities to individualize the resident care plan.
Table 2: Nursing Recommendations for Residents Who Refuse Medication
The hidden practice of CoMAd raises a number of legal and ethical issues that can be difficult for nurses to navigate. Members of the professional and scientific community agree that the practice of CoMAd is controversial, complex, and inadequately researched. The limited amount of scientific research on both practice guidelines for and implications of CoMAd prevents understanding of this complex issue. Additional research is needed to uncover factors that contribute to this practice and inform guidelines to help nurses make decisions that protect residents’ rights to consent to medical treatment.
- Allen, M.H., Currier, G.W., Carpenter, D., Ross, R.W. & Docherty, J.P. (2005). The expert consensus guideline series: Treatment of behavioral emergencies 2005. Journal of Psychiatric Practice, 11(Suppl. 1), 5–108. doi:10.1097/00131746-200511001-00002 [CrossRef]
- American Medical Association. (2001). AMA’s code of medical ethics. Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page
- American Nurses Association. (2001). Code of ethics for nurses with interpretative statements. Retrieved from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf
- Americans With Disabilities Act of 1990, Pub. L. No. 101-336, § 2, 104 Stat. 328 (1991).
- Barnes, L., Cheek, J., Nation, R.L., Gilbert, A., Paradiso, L. & Ballantyne, A. (2006). Making sure the residents get their tablets: Medication administration in care homes for older people. Journal of Advanced Nursing, 56, 190–199. doi:10.1111/j.1365-2648.2006.03997.x [CrossRef]
- Dimond, B. (2004). Medicinal products and consent to treatment by the older person. British Journal of Nursing, 13, 41–43.
- Griffith, D. & Davies, R. (2003). Tablet crushing and the law: The implications for nursing. Professional Nurse, 19, 41–42.
- Griffith, R., Griffiths, H. & Jordan, S. (2002). Administration of medicines part 1: The law and nursing. Nursing Standard, 18, 47–54,56.
- Haw, C. & Stubbs, J. (2010). Covert administration of medication to older adults: A review of the literature and published studies. Journal of Psychiatric and Mental Health Nursing, 17, 761–768. doi:10.1111/j.1365-2850.2010.01613.x [CrossRef]
- Honkanen, L. (2001). Point-counterpoint: Is it ethical to give drugs covertly to people with dementia? No: Covert medication is paternalistic. Western Journal of Medicine, 174, 229. doi:10.1136/ewjm.174.4.229 [CrossRef]
- Kirkevold, Ø. & Engedal, K. (2004). Concealment of drugs in food and beverages in nursing homes: Cross sectional study. BMJ, 330, 20–22. doi:10.1136/bmj.38268.579097.55 [CrossRef]
- Kirkevold, Ø. & Engedal, K. (2009). Is covert medication in Norwegian nursing homes still a problem?: A cross-sectional study. Drugs & Aging, 26, 333–344. doi:10.2165/00002512-200926040-00004 [CrossRef]
- Lewin, M.R., Montauk, L., Shalit, M. & Nobay, F. (2006). An unusual case of subterfuge in the emergency department: Covert administration of antipsychotic and anxiolytic medications to control an agitated patient. Annals of Emergency Medicine, 47, 75–78. doi:10.1016/j.annemergmed.2005.11.026 [CrossRef]
- MacDonald, A.J., Roberts, A. & Carpenter, L. (2004). De facto imprisonment and covert medication use in general nursing homes for older people in South East England. Aging Clinical and Experimental Research, 16, 326–330.
- McGrath, A.M. & Jackson, G.A. (1996). Survey of neuroleptic prescribing in residents of nursing homes in Glasgow. BMJ, 312, 611–612. doi:10.1136/bmj.312.7031.611 [CrossRef]
- Nursing & Midwifery Council. (2007). Covert administration of medicines: Disguising medicine in food and drink. Retrieved from http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Covert-administration-of-medicines
- Nursing & Midwifery Council. (2009). Code of conduct for members 2009. Retrieved from http://www.nmc-uk.org/Documents/CouncilPapersAndDocuments/Council2011/NMC-Code-of-conduct-for-members-2009.pdf
- Omnibus Budget Reconciliation Act of 1987, Pub. L. No. 100-203, §2, 101 Stat. 1330 (1987).
- Patient Self Determination Act of 1990. 42 U.S.C. §4449 (1990). Retrieved from http://thomas.loc.gov/cgi-bin/query/z?c101:H.R.4449.IH:
- Schwartz, H.I., Vingiano, W. & Perez, C.B. (1988). Autonomy and the right to refuse treatment: Patients’ attitudes after involuntary medication. Hospital & Community Psychiatry, 39, 1049–1054.
- Treloar, A., Beats, B. & Philpot, M. (2000). A pill in the sandwich: Covert medication in food and drink. Journal of the Royal Society of Medicine, 93, 408–411.
- Treloar, A., Philpot, M. & Beats, B. (2001). Concealing medication in patients’ food. Lancet, 357, 62–64. doi:10.1016/S0140-6736(00)03578-9 [CrossRef]
- Tweddle, F. (2009). Covert medication in older adults who lack decision-making capacity. British Journal of Nursing, 18, 936–939.
- Whitty, P. & Devitt, P. (2005). Surreptitious prescribing in psychiatric practice. Psychiatric Services, 56, 481–483. Retrieved from http://ps.psychiatryonline.org/data/Journals/PSS/3639/481.pdf doi:10.1176/appi.ps.56.4.481 [CrossRef]
Covert Medication Administration (CoMAd) in Long-Term Care: Potential Rationale and Considerations for Nurses
|Potential Rationale for CoMAd
If I wait to administer this medication, the resident’s physical or mental status may be compromised.
I believe that this resident would take the medication if the resident were in his or her “right mind.”
They need this medication to relieve physical or mental suffering.
I don’t have time to figure out why the resident doesn’t want the medication.
As a nurse, I know what is best for this resident.
Everybody else does it.
If I don’t discuss this with the resident, he or she doesn’t have the opportunity to tell me about side effects and allergies.
Hiding medication is a violation of resident rights.
This practice may worsen paranoia.
The resident may refuse to eat due to changes in the taste, smell, or consistency of food.
This practice could be interpreted as assault and battery.
If I hide the medication, I am not being truthful.
I should use this as an opportunity to discuss the plan of care and develop strategies to include the resident or support person in decisions.
Nursing Recommendations for Residents Who Refuse Medication
Consider reasons why the resident has refused.
Identify environmental factors that may influence resident understanding, such as extraneous noise, low lighting, or presence of symptoms such as gastric upset or pain; assess for medication side effects.
Document and discuss resident refusal with members of the team immediately.
Discuss and document conversations with resident’s power of attorney, family, or support system.
Consult with primary care providers, pharmacists, and dietary staff regarding whether the route of covert medication is safe.
Consider alternative medications or routes before covertly administering.
After discussion and documentation with interdisciplinary team members, hide only essential medications.
At each encounter, offer medications to resident before covert administration.
Document episodes of covert medication administration on medication records and in resident care notes, which should include any pertinent assessment data.