# 32 - Summary of process # Summary of process 696 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 6 When considering covert use of psychiatric medication the following must be considered:11 1. If the patient meets the criteria for the MHA, this must be used in preference to the MCA. 2. The MCA might be used to provide authority for covert medication for physical health whether or not the patient is detained under the MHA. The MCA can be used as authority for covert use of psychiatric medication in patients not under the MHA if the medication is necessary to prevent deterioration or ensure an improvement in the patient’s mental health and it is in the person’s best interest to receive the drug. The usual procedures for covert medication, including documentation of capacity assessment, Best Interests meeting and pharmacist’s review, should be followed. 3. Caution is needed in the use of medication that may sedate or reduce a patient’s physical mobility, as use of such drugs may constitute a deprivation of liberty and require the patient to be under the DoLS framework. Documentation of whether the proposed use of a covert psychiatric drug constitutes a deprivation of liberty is important. Note that if a patient is found to lack capacity to consent to the admission and does not meet the criteria for detention under the MHA, DoLS should be used, so most in-­patients who lack capacity to consent to medication will already be under the MHA or DoLS, although there may be some who can consent to admission but not to medication. However, even if the patient is already under the MHA or MCA as part of their admission, there still needs to be the same approach and considerations as documented here with regard to medication being given covertly. Summary of process The process for covert administration of medicines should include: ■ ■The assurance that all efforts have been made to give medication openly in its normal form before considering covert administration. ■ ■Assessment of capacity of the patient to make a decision regarding their treatment with medication. If the patient has capacity their wishes should be respected and covert medication not administered. ■ ■A record of the examination of the patient’s capacity must be made in the clinical notes, and evidence for incapacity documented. ■ ■If the patient lacks capacity there should be a Best Interests meeting which should be attended by relevant health professionals and a person who can communicate the views and interests of the patient (family member, friend or independent mental capacity advocate). These meetings can be held virtually. If the patient has an attorney appointed under the MCA for health and welfare decisions then this person should be present at the meeting. ■ ■Those attending the meeting should ascertain whether the patient has made an ‘advance decision’ refusing a particular medication or treatment which can be used to guide decision-­making. Prescribing in older people CHAPTER 6 ■ ■The Best Interests meeting should consider whether a formal legal procedure such as the MHA or DoLS is appropriate. Discussion of the indications and use of this legislation in the context of covert medication is outside the scope of this guidance but specialist psychiatric and/or legal opinion should be sought in individual circumstances if necessary. However, the other considerations given here – including the involvement of pharmacy, the recording of medication being given covertly on the drug chart, the dispensing nurse ensuring the covert medication is taken by the patient and regular reviews – apply for all patients, whichever legal framework is being used to give medication covertly. ■ ■Medication should not be administered covertly until a Best Interests meeting has been held. If the situation is urgent, it is acceptable for a less formal discussion to occur between carer/nursing staff, prescriber and family/advocate in order to make an urgent decision, but a formal meeting should be arranged as soon as possible. ■ ■After the meeting, there should be clear documentation of the outcome of the meeting. If the decision is to use covert administration of medication, a check should be made with the pharmacy to determine whether the properties of the medications are likely to be affected by crushing and/or being mixed with food or drink.12 The medication chart and electronic prescribing and medicines administration record should be amended to describe how the medication is to be administered. ■ ■When the medication is administered in foodstuffs, it is the responsibility of the dispensing nurse to ensure that the medication is taken. This can be facilitated by direct observation or by nominating another member of the clinical team to observe the patient taking the medication. ■ ■A plan should be made to review on a regular basis the need for continued covert administration of medicines. Additional information ■ ■For patients in care homes, the NICE guideline ‘Managing medicines in care homes’ should be referred to.13,14 The basic principles of this NICE guidance are the same as the policy discussed in this section. Mental health practitioners have a duty to inform the care home manager if they suspect the correct procedures are not being followed as regards covert medication, and to discuss with their team leader possible safeguarding referral if the home manager does not act on their advice. The role of mental health teams supporting care homes is to support the care homes and prescriber (usually GP) in carrying out this guidance. For patients with complex mental health needs, it may be appropriate that they attend or contribute to the Best Interests meeting. However, it should be the prescriber (usually the GP), care home staff and care home pharmacist who manage the process. ■ ■There are no specific restrictions to state that relatives or other informal carers cannot give medication covertly and in certain cases it may be acceptable as long as they have been advised to do so by a health professional (e.g. GP) and all standards of the policy have been met. Figure  6.2 provides an algorithm for determining whether or not to administer ­medicines covertly. 698 The Maudsley® Prescribing Guidelines in Psychiatry CHAPTER 6 Consider second opinion or ethics forum or legal advice Is there agreement at ‘Best Interest’ discussion? Reason established and resolved Give medication as normal DO NOT GIVE: Seek alternative preparation Unable to resolve USE ALTERNATIVE No No No No No No Yes Yes Yes Yes Yes Yes Establish why the patient does not want to take medication Is medication essential? Is there a viable alternative? Does the patient have mental capacity? Yes Is there a Lasting Power of Attorney (LPA)* or Advance Decision to Refuse Treatment (ADRT)? DO NOT GIVE DO NOT GIVE DO NOT GIVE Does attorney or ADRT prevent or conflict with treatment plan medication? Have pharmacy confirmed how to give covertly? Give medication covertly (ensure covert medication care plan is in place) Document and review regularly *LPA covering health and welfare decisions. NB Any deprivation of liberty would need to be authorised by a legal framework, e.g. Mental Health Act, Deprivation of Liberty Safeguards or Court of Protection, as appropriate. No Figure 6.2  Flow chart for the use of covert medication.