Problem 14: Advise to convert medicine administration during transfer of care Flashcards
Define the principle of covert administration
Covert administration of medicines is a complex issue and involves disguising the administration of a medicine (e.g. in food or drink) to a patient lacking the capacity to consent to treatment.
Covert administration should not be confused with disguising the administration of a medicine against a competent patient’s wishes, which would constitute a tort or civil wrong of trespass to the person
Discuss and summarise guidelines covering covert administration
“When it is agreed to be in a person’s best interests, the arrangements for giving medicines covertly must be in accordance with the Mental Capacity Act 2005”
NICE guidelines: Adults who live in care homes and have been assessed as lacking capacity are only administered medicine covertly if a management plan is agreed after a best interests meeting.
In a care home, covert administration is only suitable when process for the following has been undertaken: assessing mental capacity
holding a best interest meeting involving care home staff, the health professional prescribing the medicine(s), pharmacist and family member or advocate to agree whether administering medicines without the resident knowing (covertly) is in the resident’s best interests
recording the reasons for presuming mental incapacity and the proposed management plan
planning how medicines will be administered without the resident knowing
regularly reviewing whether covert administration is still needed.
Identify and explain any pharmaceutical issues when considering covert administration
consider the risks of the medicine degrading in food/drink versus the risks of not giving the medicine at all. When medicine is added to food, it is recommended that it is added to the first mouthful of food, so that the full dose is received .
Acceptability to the patient: for example, sertraline tablets can be crushed and mixed with food for administration, but have a bitter taste and an anaesthetic effect on the tongue which might not be acceptable to the patient.
Absorption of the medicine when administered with food: for example phenoxymethylpenicillin should be taken an hour before food or two hours after food as absorption may otherwise be reduced
Incompatibility of medicines with foods or beverages: for example phenytoin absorption can be affected by some foods and this may affect the plasma phenytoin concentration. Or some medications are incompatible with calcium, magnesium etc
Safety of crushing tablets: there have been concerns regarding crushing hormonal, cytotoxic or steroid formulations due to the potential risk of a small amount of the resulting powder coming into either direct contact with the administrator, or through dust being aerosolised
Useful reference sources for advice on the administration of medicines with food or drink include The NEWT Guidelines (11) and the Handbook of Drug Administration via Enteral Feeding Tubes
How would you assess a patient’s mental capacity? Demonstrate your understanding of advance decisions and Lasting Power of Attorney
In conjunction with the Mental Capacity Act 2005;
Does the patient have an advance decision to refuse treatment (ADRT) in place? Capacity assessment may be undertaken
First, it must be proven that a patient is unable to make a decision because of an impairment of, or disturbance in, the functions of the mind or brain. If this is the case, a patient will be considered legally to lack mental capacity to make a decision or consent if they are unable to:
Understand in simple language what the medicine is, its purpose and why it is being prescribed;
Understand the benefits and risks of the medicine and whether there are any suitable alternatives;
Understand in broad terms what the consequences of not receiving the proposed medicine will be;
Retain the information for long enough to make an effective decision or communicate their decision in any way.
An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.
It lets your family, carers and health professionals know your wishes about refusing treatment if you’re unable to make or communicate those decisions yourself.
Planning ahead Your wellbeing Advance decision (living will) An advance decision to refuse treatment lets your healthcare team know your wishes if you aren't able to communicate them. What is an advance decision? Who makes an advance decision? Is an advance decision legally binding? How does an advance decision help? Does it need to be signed and witnessed? Who should see my advance decision? CPR and a 'do not attempt CPR' decision What is an advance decision?
An advance decision (sometimes known as an advance decision to refuse treatment, an ADRT, or a living will) is a decision you can make now to refuse a specific type of treatment at some time in the future.
It lets your family, carers and health professionals know your wishes about refusing treatment if you’re unable to make or communicate those decisions yourself.
The treatments you’re deciding to refuse must all be named in the advance decision.
You may want to refuse a treatment in some situations, but not others. If this is the case, you need to be clear about all the circumstances in which you want to refuse this treatment.
An advance decision isn’t the same as an advance statement. Read about advance statements.
Deciding to refuse a treatment isn’t the same as asking someone to end your life or help you end your life. Euthanasia and assisted suicide are illegal in England.
Life-sustaining treatment
You can refuse a treatment that could potentially keep you alive, known as life-sustaining treatment.
This is treatment that replaces or supports ailing bodily functions, such as:
ventilation – this may be used if you can’t breathe by yourself
cardiopulmonary resuscitation (CPR) – this may be used if your heart stops
antibiotics – this can help your body fight infection
You may want to discuss this with a doctor or nurse who knows about your medical history before you make up your mind.
Who makes an advance decision?
You make the advance decision, as long as you have the mental capacity to make such decisions.
You may want to make an advance decision with the support of a clinician.
If you decide to refuse life-sustaining treatment in the future, your advance decision needs to be:
written down
signed by you
signed by a witness
Legally binding is complies with Mental Capacity Act, is valid and applies to the situation.
Power of Attorney: A power of attorney is a legal document that allows someone to make decisions for you, or act on your behalf, if you’re no longer able to or if you no longer want to make your own decisions.
Discuss how medicines are optimized in palliative care
Assessing and managing physical symptoms; determine impact of each symptom on patients life and comfort. Ensure that drug selection for treatment is pragmatic and straightforward as possible. Bear in mind that all symptoms can be worsened by insomnia, exhaustion, anxiety and depression.
Avoids medication that is no longer required e.g.statins.
If a symptom is persistent, prescribe regular prophylactic treatment as opposed to treatment on an ‘as required’ basis.
Discuss and agree on achievable goals with the patient. Assess the persons psychological state continuously.
What are the best interest considerations to take with covert administration
Consider all the relevant circumstances ensuring that age, appearance, behaviour etc. are not influencing the decision
Consider a delay until the person regains capacity
Involve the person as much as possible
Not to be motivated to bring about death
Consider the individual’s own past and present wishes and feelings
Consider any advance statements made
Consider the beliefs and values of the individual
Take into account views of family and informal carers
Take into account views of Independent Mental Capacity Advocate (IMCA) or other key people
Show it is the least restrictive alternative or intervention.
