Wednesday 16 February 2011

Covert Medication

Do we use this enough?

At the moment I've no patients who are receiving medication covertly. I have lots of patients who have a mental disorder, within the meaning of the ammended Mental Health Act 1983. I have lots of patients who have an impairment of, or a disturbance in the functioning of, the mind or brain, as set out within section 2(1) of the Mental Capacity Act 2005. In fact all of my patient can fit in to one of the categories of mental disorder/impairment/disturbance of mind/brain.

It was put to me that since all my patients are mentally unwell, if they stop taking medication, can't they be made to take medication? Well no, no they all can't. But it got me thinking that yes, some of the could, but I don't force this. This led to me being chided for not treating vulnerable patients who couldn't make valid choices on treatment.

If you're in a care home or hospital, say, and you have dementia, you probably are fine to make valid decisions on medication you're offered/continue to take. But you might struggle to make valid decisions on medication as dementia progresses or when you have a UTI, chest infection, constipation, pain, dehydration or other cause for acute confusion that makes your thinking worse.

What happens then?

Usually medication's offered to you, even though you're confused and can't give/withhold valid consent on the use of medication. If you accept it, you keep receiving it. If you refuse it, you're allowed to and it's documented as declined and you don't get medication. So whether you receive medication or not isn't based on clinical decision making, it's based on how stroppy you seem and how much nurses/care assistants respond to this. In acute wards it's also about pressures on qualified nurses' time which is now so pressured that even if staff wanted to sit down and explain/support a confused patient with medication, they don't have the 20 to 30 minutes that might take.

The pharmacist and manager givig me grief over this were reckoning that this arbitary giving/not giving medication on how compliant/stroppy a patient is seen to be isn't good. It should be on clinical evidence. If someone is confused and can't give (or withhold) valid consent, they're managed under the Mental Capacity Act 2005 framework and medication can be given when this is in their best interests. Rather than not giving it, the least restrictive means should be used. Instead of section 3 and depot antipsychotic given under Part IV of the MHA 1983, wouldn't orodispersible olanzapine in their tea be a much better option?

I rarely advocate for covert medication to be used. Maybe I'm wrong.


hlw said...

Hmm I'd say that whilst covert medication may be less hassle for medical staff, less distressing for the patient and in their best medical interests, there's also a lot more to lose if it goes wrong.
Medical professionals elicit a certain sort of trust from people. We often trust them with all sorts of intimate details and let them perform various uncomfortable and sometimes painful procedures because we know that they are being honest with us and doing what they think is best. I have had medical professionals do things against my will before when I wasn't capable of making decisions, but I still have a decent relationship with them, I really don't feel like that would be the case if I found out that they had been secretly medicating me.

The Shrink said...

That's the crux of my reasoning too, Heidi, which is why I'm loathe to be enthusiastic in covert medication use, despite there being some valid reasons for use, some fo the time.

hyperCRYPTICal said...

Okay - I take your argument on board - but let's say the demented resident in a care home has diabetes or epilepsy and refuses to take their meds - where would you stand now?

Before the onset of dementia (the resident) had willingly taken their meds realising they were conjusive to their physical wellbeing; but after dementia didn't want to take same as they were uncomfortable with the alien feel in their mouth. Where would you stand then?

So are you saying that a person who is not aware of their (best interests through dementia) should be allowed to die?

Would you want this outcome for someone you love - or would you expect that they be cared for?

Puzzled from Portsmouth or alternatively Anna :o]

Quacktitioner said...

I remember the discussions on whether to do this in a forensic setting several years ago (the answer was no in the end, pretty much because of the likely damage to trust etc).

On a practical note one problem was how to record administration, particularly if the patient left part of the meal/drink etc. And, perhaps quite relevant in older adult settings, what if someone else then came along and finishes the tea?!

Jean said...

Yes, I agree that there might possibly be some valid reasons to consider giving covert medication some of the time, but I think these would be exceptions.

I would run a mile from psychiatrists if I thought they were secretly medicating me (no wonder patients get paranoid!) and I would never again trustingly seek psychiatric help (in fact I would never voluntarily seek their help again anyway, but for different reasons).

It's good to see that not all psychiatrists agree with covert medication.

Mark p.s.2 said...

Antipsychotic Drugs for Dementia To Be Curbed in U.K. By Michelle Fay Cortez - November 12, 2009
"About 180,000 elderly people with dementia in the U.K. are given the antipsychotic drugs each year, and just 20 percent improve because of the treatment, Banerjee said at a press conference in London. As many as two-thirds of the patients don’t derive any benefit from the pills, which boost the risk of early death and carry a range of side effects including sedation, stiff muscles, and trouble thinking and speaking clearly, the report found.

"'We need to be sure that only the people who benefit from these drugs get them, and they get them at the lowest possible dose for the shortest period of time,' Banerjee said. 'It is clear that these medications are being prescribed to deal with behavior and psychological symptoms in dementia rather than just for psychosis,' he wrote in the report."