The pharmacist's role
By definition, covert administration involves the disguising of medication, principally through the use of food or drink. This raises some key questions over the stability of any medication administered in this way and the legal and clinical responsibilities of healthcare professionals. Pharmacists who are asked for information about covert administration should consider the legal, ethical and pharmacokinetic implications of this method of administration.
Legal implications
Before providing advice on covert administration, pharmacists should determine whether the patient's mental capacity has been assessed and that a 'best interests' meeting has taken place. Healthcare professionals should respect that patients have the right to make decisions about their treatment irrespective of the impact of that decision on the patient. Where a patient has been assessed as having mental capacity and able to give informed consent covert administration must not occur. Covert administration to a competent patient may amount to criminal battery, a civil wrong of trespass and a breach of the patient's human rights because the patient would not have consented to the administration.
Similarly, previous decisions about treatment made when the patient had capacity, in the form of an advance decision, must also be respected even after the patient is considered to no longer have capacity. Advance decisions are documents made in advance of a particular condition arising, or a condition deteriorating, that show the person's treatment choices, including the decision not to accept further treatment in certain circumstances.
It should also be considered that covert administration often involves crushing of tablets or opening of capsules. Crushing tablets, opening capsules or mixing medicines with food will usually be outside of the medicine's product licence and the supplying pharmacist will share liability for any harm incurred with the prescriber and person administering the medication.
Pharmaceutical implications
Pharmacists should consider any possible reasons why a patient refuses medication as well as the pharmacokinetic consequences of covert administration.
Possible reasons could include some or all of the following:
- The medication is unpalatable.
- The patient is experiencing either actual or perceived side-effects.
- They have swallowing difficulties with their current formulation.
- They do not understand what the medication is for, or what to do when presented with a tablet or medicine spoon.
- They do not understand the consequences of not taking the medication.
- Personal, religious or ethical beliefs prevent them from taking the medication.
Overcoming these obstacles or finding alternative products could result in the patient accepting their medication, avoiding the need for covert administration. Alternative routes of administration such as transdermal, buccal, topical or liquid preparations should always be considered as they may be more acceptable to the patient enabling them to take their medication as prescribed.