Healthcare team reviewing a covert medication plan with pharmacy input

Covert Medication: The Legal and Ethical Checks Student Nurses Should Know

What Is Covert Medication?

Covert medication is the administration of medicine in a disguised form without the person’s knowledge or informed consent. It may involve hiding medicine in food or mixing it into a drink so that the person does not realise they are receiving it.

Simply mixing medicine with food does not automatically make it covert. If the person knows what the medicine is, understands why it is being mixed and agrees to take it that way, it is not being administered covertly.

Covert medication is a serious ethical, legal and clinical intervention. It interferes with autonomy and should never be used simply because someone refuses medication, is considered “difficult” or because covert administration would make the medication round easier.

A person who has capacity to decide about the medication has the right to refuse it, even if healthcare professionals believe that refusal is unwise.

Which laws apply?

The legal framework differs across the UK.

In England and Wales, covert medication is principally considered under the Mental Capacity Act 2005. If the person lacks capacity to decide about the medication, any decision made for them must be in their best interests and represent the least restrictive option.

In Scotland, the Adults with Incapacity (Scotland) Act 2000 applies to many treatment decisions involving adults who are incapable of consenting. Scotland does not use the Mental Capacity Act “best interests” test. Instead, the treatment must benefit the adult, that benefit must not be reasonably achievable without intervention and the intervention must be the least restrictive option.

Treatment in Scotland will normally require appropriate legal authority, such as a section 47 certificate of incapacity and, where necessary, an accompanying treatment plan. Different authority may apply when treatment is being provided under mental health legislation.

Northern Ireland has a separate legal framework and is not covered in detail in this article.

When might covert medication be considered?

Covert medication should only be considered in exceptional circumstances.

Before planned covert administration begins, the team should establish that:

  • the person lacks capacity or is incapable of deciding about the relevant medication;
  • all practicable support has been provided to help the person decide;
  • the person is refusing the medication;
  • the medication is clinically necessary and likely to benefit the person;
  • not receiving it would create a significant risk to the person’s health;
  • reasonable alternatives have been explored;
  • covert administration is necessary and proportionate;
  • it is the less or least restrictive available option;
  • appropriate legal authority and professional agreement are in place; and

  • there is a clear plan for administration, recording and review.

A diagnosis of dementia, learning disability, delirium or severe mental illness does not automatically establish lack of capacity.

Capacity must be assessed in relation to the particular medication decision at the time it needs to be made.

A capacitous refusal must be respected

This is the line that should never become blurred.

If a person has capacity to decide about the medication, healthcare professionals must respect their refusal. The fact that the medication is beneficial or that refusing it may carry risk does not remove the person’s right to decide.

The team should make sure that the person has received understandable information about:

  • what the medication is;
  • why it has been recommended;
  • its expected benefits;
  • important risks or side effects;
  • reasonable alternatives; and
  • the possible consequences of refusing it.

The person should be given an opportunity to ask questions and reconsider without pressure. However, covert administration must not be used to avoid a valid refusal.

Covert medication should be a last resort

Before covert administration is considered, the team should explore why the person is refusing.

Are they frightened? Do they dislike the taste? Are they experiencing side effects? Are they having difficulty swallowing? Do they understand what the medication is for? Is the timing causing distress?

The answer may reveal a safer and less restrictive solution.

Communication

Could the medication be explained more clearly?

The team might:

  • use plain language;
  • provide information in an accessible format;
  • arrange an interpreter;
  • use pictures or communication aids;
  • involve a familiar staff member;
  • give the person more time; or
  • return to the conversation when the person is less distressed or confused.

Timing and environment

A person who refuses medication during a noisy or rushed medication round may respond differently in a calmer setting.

Where clinically appropriate, the team might consider:

  • offering the medicine at a different time;
  • reducing distractions;
  • approaching the person through a trusted staff member; or
  • avoiding repeated approaches that increase distress.

Reviewing the medication

The prescriber should consider whether the medication remains necessary.

Questions might include:

  • Is it still providing a meaningful benefit?
  • Can the medicine be stopped?
  • Can the regimen be simplified?
  • Is another medicine more suitable?
  • Could the frequency of administration be reduced?
  • Is an unwanted side effect contributing to the refusal?

Covert administration should not be used to continue medication that no longer has a clear clinical purpose.

Formulation

Some medicines are available as liquids, dispersible tablets, patches or other formulations. However, changing the formulation does not remove the need for the person’s agreement when they have capacity.

A pharmacist must be consulted before tablets are crushed, capsules are opened or medicine is mixed with food or drink.

England and Wales: the best-interests process

Under the Mental Capacity Act 2005, a planned decision to administer medication covertly should follow an appropriate capacity assessment and best-interests process.

The discussion should consider:

  • the person’s past and present wishes and feelings;
  • their beliefs and values;
  • whether capacity is likely to return;
  • the benefits and risks of the medication;
  • the risks of not providing it;
  • reasonable alternatives;
  • the proposed method of covert administration; and
  • whether a less restrictive approach is available.

Depending on the circumstances, the discussion may involve:

  • the prescribing clinician;
  • registered nurses;
  • a pharmacist;
  • care staff;
  • family members or carers;
  • an attorney or deputy with relevant authority; and
  • an advocate or Independent Mental Capacity Advocate where legally required.

Family members can provide important information about the person’s wishes and preferences, but they do not automatically have authority to consent on the person’s behalf.

Planned covert administration will normally require a structured, multidisciplinary decision. If an urgent decision has to be made before a formal meeting can take place, the reasons, legal basis and people involved must be clearly documented, with a fuller review arranged as soon as practicable.

Scotland: benefit and legal authority

Scotland does not use the Mental Capacity Act best-interests framework.

Under the Adults with Incapacity (Scotland) Act 2000, the team must consider whether the treatment will benefit the adult and whether that benefit can reasonably be achieved without the proposed intervention. Covert administration must be the least restrictive option available.

The adult’s past and present wishes must be considered, along with the views of relevant people where it is reasonable and practical to consult them.

These may include:

  • the nearest relative;
  • primary carer;
  • welfare attorney;
  • welfare guardian;
  • named person;
  • independent advocate; or
  • another person with an interest in the adult’s welfare.

Treatment will usually require a section 47 certificate of incapacity. Where several treatments are covered, an accompanying treatment plan may be required. Scottish guidance identifies it as good practice for the certificate or treatment plan to record that covert administration may be necessary.

The individual medicines or treatments must be properly identified. Writing only “covert medication” on a section 47 certificate does not adequately describe the treatment being authorised.

If medication is being provided under the Mental Health (Care and Treatment) (Scotland) Act 2003, different documentation and safeguards may apply.

The pharmacist’s role

Pharmacists play an essential role in covert medication planning.

Some tablets must not be crushed, and some capsules must not be opened. Altering a medicine may:

  • change how quickly it is absorbed;
  • release the dose too quickly;
  • reduce its effectiveness;
  • make it unstable;
  • produce an unpleasant taste;
  • interact with food or drink;
  • expose staff to hazardous medication; or
  • result in the person receiving only part of the intended dose.

Modified-release and enteric-coated preparations are particular examples of medicines that may be unsafe or unsuitable to crush, although every medicine must be checked individually.

The pharmacist can advise on:

  • whether the medicine can safely be altered;
  • whether mixing it with food affects absorption;
  • which foods or drinks are suitable;
  • alternative formulations;
  • interactions between medicines;
  • safe handling; and
  • the exact administration instructions that should be documented.

The prescriber must also be involved because crushing, opening or mixing a medicine may result in its use outside the terms of its product licence.

Never improvise by crushing a tablet or opening a capsule without checking.

Documentation: more than a note on the MAR

Covert medication should never become an informal ward habit.

The documentation should clearly identify:

  • the medication-related capacity or incapacity assessment;
  • the legal basis for treatment;
  • the outcome of the best-interests process in England and Wales;
  • the benefit and least-restrictive assessment in Scotland;
  • the people consulted;
  • each medicine authorised for covert administration;
  • why each medicine is necessary;
  • alternatives that were considered;
  • pharmacy advice;
  • how each medicine should be administered;
  • how administration should be recorded;
  • the agreed review date; and
  • circumstances that should trigger an earlier review.

The Medication Administration Record (MAR) or electronic prescribing system should clearly indicate that covert administration has been authorised and direct staff to the relevant care or treatment plan.

Local wording and documentation systems differ, so a phrase such as “administer covertly” on the MAR is not enough by itself. Staff must be able to locate the supporting capacity assessment, legal documentation, multidisciplinary decision and pharmacy instructions.

Placement tip: pause and check

If you see medicine being hidden in food or drink, check that the person is actually unaware of it. Medicine mixed openly with the person’s knowledge may be an agreed administration method rather than covert medication.

If it is being given covertly, check for:

  • a decision-specific capacity or incapacity assessment;
  • the appropriate legal authority;
  • a care or treatment plan;
  • authorisation for the particular medicine;
  • clear pharmacy instructions; and
  • directions on the MAR or electronic medication record.

If the documentation is missing, unclear or does not match what is happening, do not improvise or administer the medicine independently. Pause and speak to the supervising registered nurse or nurse in charge.

A useful rule for students is:

If the authority or plan is unclear, pause and escalate.

Regular review is essential

A covert medication decision should not continue indefinitely simply because it was once approved.

The team should review it at agreed intervals and whenever:

  • the person’s capacity changes;
  • the person begins accepting medication openly;
  • the medication is changed;
  • the clinical need changes;
  • side effects develop;
  • the administration method stops working;
  • the person’s care setting changes; or
  • new information becomes available about their wishes.

Every review should ask:

  • Does the person now have capacity to decide?
  • Is the medicine still necessary?
  • Is covert administration still providing a meaningful benefit?
  • Is there now a less restrictive alternative?
  • Can the medicine be administered openly?
  • Is the current method still pharmaceutically safe?

The aim should always be to stop covert administration as soon as it is no longer necessary or legally justified.

Why this matters for student nurses

Covert medication is not simply about “getting the medicine into the patient.”

It involves autonomy, consent, capacity, legal authority, medication safety and professional accountability. It may also damage trust if the person discovers that medicine has been hidden from them.

Student nurses are not expected to authorise covert medication. However, they should understand the safeguards, follow the agreed plan and raise concerns when practice does not match the documentation.

This includes recognising that:

  • a diagnosis does not automatically mean lack of capacity;
  • a capacitous refusal must be respected;
  • relatives do not automatically have authority to consent;
  • a MAR instruction alone may not be sufficient;
  • medication must not be crushed or mixed without pharmacy advice; and
  • covert administration must be regularly reviewed.

What to remember

Covert medication is an exceptional intervention, not a convenient solution to refusal.

The key questions are:

  • Does the person lack capacity or decision-making ability concerning this medication?
  • Have all practicable steps been taken to support them?
  • Is there proper legal authority?
  • Is the medication necessary and likely to benefit the person?
  • Have less restrictive alternatives been tried?
  • Has a pharmacist approved the proposed method?
  • Is everything clearly documented and regularly reviewed?

If any part of that process is unclear, the answer is not to hide the medication and hope for the best.

Pause, check and escalate.

References

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