THE ADMINISTRATION OF MEDICATION IN FOOD OR DRINK TO PEOPLE UNABLE TO GIVE CONSENT TO OR REFUSE TREATMENT ADMINISTERED IN THIS WAY

Introduction

This policy applies to the administration of medication to inpatients/clients who cannot give consent to treatment who are refusing to take tablets or syrup when openly presented to them, and for whom medication is then administered in food such as jam or in flavoured drinks or other substances.

Treatment may be given to adults who lack mental capacity to consent to treatment if it is considered to be in their best interests under the Common Law Doctrine of Necessity. Treatment must be - necessary to save life or prevent a deterioration or ensure an improvement in the patient's/client's physical or mental health and - in accordance with the practice accepted at the time by a reasonable body of medical opinion skilled in that particular form of treatment in question (ReF 1990) and Part IV of the Mental Health Act 1983 (see Code of Practice paragraph 15.8). Although there is legal support under certain circumstances to prescribe medication to adults who mentally cannot consent to treatment there are no nationally agreed protocols or standards for the administration of such medication in food or drink. It is left to local Services to develop their own protocols and standards.

The Royal College of Psychiatrists Ethics Sub-committee has stated that the practice of disguising medication in the patient's food of patients who are unable to give consent should not take place. It is therefore clear that the disguising of medication in food so that the person receiving medication does not know that they are in receipt of medication is considered unethical and should not happen. It therefore seems necessary to distinguish between a deceitful process of hiding medication in food, and a co-operative process where patients find taking medication when presented to them in the usual way difficult (either because they find it difficult to swallow pills or tablets, if they find the medication distasteful or they do not understand cognitively what to do with medication when it is presented to them) but they are more willing to take medication when it is delivered in either food or drink and this acceptance continues even when they are told that they are receiving medication.

It is clear that offering medication in food or drink could still be perceived as being deceitful and could be open to abuse and requires particular guidelines to be established locally to ensure that when this practice happens it has been properly considered, proper consultations have been made and that the practice is transparent and open to public scrutiny and audit.

Context of Care

1. There are those patients/clients who are clearly refusing to take treatment who if they are told that they are taking medication administered in food or drink would refuse to eat it. There is a second group of patients/clients who are refusing to take treatment because they find it difficult to swallow the size of the tablet or the taste of the liquid they find unpalatable, they have swallowing difficulties or they don't understand what to do when they are presented with a pill or a spoonful of syrup. These latter patients/clients do not appear to be actively refusing to take treatment but find the treatment unpalatable or difficult to take because of physical difficulties, or don't understand what to do when presented with treatment. This group of patients/clients are not actively refusing treatment but are having difficulty in complying with taking treatment and if they knew that they were taking medication administered in food or drink they would consume the treatment. There is a third group of patients who refuse because they do not understand in broad terms the consequences of refusal.

The importance of the medication to the health and/or quality of life of that person.

Procedure for all patients/clients who are refusing treatment given the usual way

In accordance with the Code of Practice it is the responsibility of the R.M.O. to ensure that the following assessments are undertaken:

  1. The patient's ability to consent to and/or refuse treatment. This policy only applies to patients who cannot give consent to treatment. Patients with capacity to consent, can consent themselves to receiving medication in food or drink.
  2. A review of the importance of the medication and whether it is essential to continue with it should also be made. A judgment about the importance of the treatment to the patient's/client's quality of life and general health should be formulated to decide whether to give the treatment or to discontinue it.
  3. An assessment should consider whether the patient/client is actively refusing to take treatment or having difficulty complying with treatment. This should include checking whether the patient/client understands what the treatment is, what it is hoped it will do and how nursing/care staff are promoting this awareness at each medication giving.
  4. The wishes of the nearest relative/carer or a patient's advocate should be sought.

The results of the assessment should be brought to the Multidisciplinary Team for action.

For patients/clients who are having difficulty complying with treatment where remedial factors are present an attempt should be made to alleviate these initially before taking any further action. For example, physical difficulty in swallowing medication could lead to a referral to Speech Therapy and difficulties in understanding the reasons for treatment could lead to intensified efforts to provide further information to the patient/client about the nature of their condition and the need for treatment. If such measures do not help treatment administered in food should only be given once it is openly acknowledged both in the medical notes and on the medication chart that medication is being given in this way with Multidisciplinary and family discussion and approval. During medication giving the patient/client must be told that they are receiving medication and staff should not leave them until the medication has been consumed.

For patients/clients who are clearly actively refusing to take treatment for whom treatment is considered essential for their quality of life and health, it is suggested that medication cannot be administered in food but that multidisciplinary discussion should take place as to how to proceed. Options include working with the patient/client and family to try and gain their understanding and consent over time, obtaining a second opinion or dealing with the matter under the provisions of the Mental Health Act and the Code of Practice published March 1999, chapter 16.

Pharmacy Department

If it is decided that medication is to be given in food/drink the Pharmacy Department should be consulted about what type of preparation should be used to ensure appropriate delivery of treatment. Medication can only be given in food or drink where specific instructions to do so are written under "Additional Instructions" section of the medication card by the prescribing doctor.

THE ADMINISTRATION OF MEDICATION IN FOOD OR DRINK TO PEOPLE UNABLE TO GIVE CONSENT TO OR REFUSE TREATMENT ADMINISTERED IN THIS WAY

1. The hiding of medication in food or drink is prohibited.

2. Treatment can only be administered in food or drink following an assessment co-ordinated by the R.M.O. Assessment must cover the following areas:

(a) a review of the importance of medication to the patient's/client's quality of life and general health to determine whether medication should be continued.

(b) Assessment of the patient's/client's capacity to take treatment. Irrespective of the patient's/client's capacity to consent if the patient/client is refusing to take treatment then treatment should not be administered in food or drink.

(c) If the patient/client is not refusing to take treatment and having difficulty in complying with it what is the nature of this difficulty and can it be remedied to avoid the need to administer medication in food or drink.

3. Treatment administered in food or drink should never be given to patients/clients who are clearly refusing to accept treatment irrespective of whether they have capacity to consent. Such patients/clients should be dealt with by consulting a second opinion with a view to whether this should be dealt with under Part IV of the Mental Health Act 1983.

4. The decision to administer medication in food or drink is a Multidisciplinary Team decision. This decision will be based upon the fact that medication should be continued because of its importance to the patient's/client's quality of life and general health, the patient is willing to continue to take treatment but is having difficulty in taking it and that these difficulties cannot be remedied. The Multidisciplinary Team must involve discussion with the nearest relative/carer and in the absence of a nearest relative/carer with the patient's/client's advocate. Where doubt exists a second medical opinion will be sought.

5. Medication can only be administered in food or drink when this manner of administration of medication has been prescribed by a doctor using the "Additional Comments" part of the prescription chart. Medication cannot be administered in food or drink unless this part of the medication chart has been clearly filled in.

6. A decision to administer medication in food or drink must be clearly entered into the medical notes. Details of the condition being treated and the likely benefits of treatment, results of assessments indicating the nature of the patient's/client's difficulty in taking medication openly, and indicating who else has been consulted, particularly referring to consultations with the Multidisciplinary Team and nearest relatives/carers where possible.

7. No patient/client should receive medication without being aware of it. Patients/clients receiving medication administered in food or drink must be told at each medication giving that they are being given medication, what it is and why they are receiving it.

8. Patients/clients receiving medication administered in food or drink must not be left until the medication has been consumed. The first level nurse or carer administering medication must remain with the patient/client until the medication is consumed.

9. Medication should not be administered in food or drink without prior consultation with the Pharmacy Department about the suitability of preparations to be administered in this way. This consultation must be entered into the Notes.

10. The number of patients/clients receiving medication administered in food or drink will be audited on a yearly basis by the Drugs & Therapeutics Committee and the information published on a yearly basis. The aim is for the Trust to be transparent in its use of this medication giving technique. The Drug & Therapeutics Committee of the Trust must be notified of all patients/clients who are receiving medication administered in this way at the time the decision is taken to do so.

Donated by Christine Hastie, April 2001.

In addition, Christine noted the following issues in a letter:

Dear XXXX,

Re: Disguising medicines in food and drink

Thank you for your letter of XX.YY.ZZ. I believe both the disguising and crushing of medicines in nursing homes is widespread and is of serious concern. I can usually find out the extent of crushing by the crushing tools present in the home and by asking which patients have problems and what medicines require crushing. Disguising medicines is more difficult to note although I recently came across a home with a dozen glass bowls in the drug trolley and discovered that they were stirring up the medicines in honey. Occasionally I have come across jam and yoghurt in drug trolleys.

I think it would be an excellent idea to have standards and procedure/protocol for the administration of medicines in food and drink which can be used or adapted by nursing and residential homes.

In addition to your very pertinent details, my thoughts on reading your draft policy (from a registered home point of view) are:

·         to make clear that written permission must be obtained for the administration of medicines in food or drink to patients who are able to give consent

·         all alternative avenues have been explored

·         that, as you state, the treatment is necessary

·         that, as far as possible, the reason for refusal is sought - this is particularly relevant with mental health and learning disability clients where it might well be side effects but they are unable to communicate

·         if the decision is ultimately taken to administer in a food or drink, the decision is reached by a multidisciplinary team

·         that permission in writing is granted by the prescribing doctor

·         that the medicine is administered in a food or drink which has no deleterious effect on the efficacy of the medicine and does not cause an interaction.

·         that clear records are kept of what is being administered and a procedure could be along the lines of:

1. ascertain why the medicine is refused

2. if unable to swallow:   

      a) is it available in a different form e.g., capsule or liquid

      b) can it be sprinkled on food

      c) can it be changed to a similar medicine

3. taste consider alternative preparation

4. causes side effects counselling (may only last a week or two), other preparation

5. frequency once a day preparation

6. consequences how important is it? Counselling

7. when to refer

8. who is included in the consultation process

9. consent

10. records