Those of us who have kids, worked in aged care and for difficult clients in any setting might have seen pills being crushed between two spoons and added to food or “treats” in order to actually get the patient to take required medication.
Of course we know there are risks, sometimes it is just a case of “how we do things here”, sometimes we reckon it is the only option but it would be worth being able to justify the action and demonstrate a good understanding of the risks versus benefits of doing this.
A report from the UK, “What legal and pharmaceutical issues should be considered when administering medicines covertly?’’ got me thinking. A key aspect to the concept of covert, is administration of a medicine disguised in food or drink to a patient without their knowledge or consent. Often meds are given crushed because the patient cannot physically take it unless it is reduced to a manageable form. It is when such an action is undertaken because the client will not actually consent to taking the medication things move into murky legal waters.
No matter why it is done, then are risks pharmacologically with crushing or emptying capsules. It might not be very easy to find facts about the stability of a medicine added to food or whether in fact the medicine loses potency as a result. Getting the facts would be a good first step. Contact the pharmacist or even the manufacturer. The report recommended checking the Handbook of Drug Administration via Enteral Feeding Tubes as a resource. Of course, that is a UK publication but you get the idea.
If meds are crushed then matters of taste need to be considered; some drugs taste terrible when their protective shell is lost, others can have anaesthetic effects on the oral mucosa. The temperature of food or fluids can denature the drug, the absorption may be inhibited by being given with food. Some drugs are incompatible with foods or fluids.
I felt these facts were scary enough without even addressing the legal risks.
First and foremost always remember if a competent person refuses a treatment/intervention/medication you must respect that decision. It does not matter whether you agree or not, if they are capable of understanding the risks and consequences of refusal they are competent and their decision must be respected. If you use tricks to hide the medication in food then you have administered without consent, you have committed trespass and you have denied the patient rights.
If the person lacks the ability to understand and is incompetent then – even if you are busy and pill rounds are the bane of your day, you had better take the time to get support from the medical officer, the family or the team. Do not go ahead and implement this action without discussion and documentation. If the family disagree, if unanticipated drug reactions occur or questions about the ethics of covertly administering medications arise, then you will be covered. The prescribing doctor or patient’s own doctor should be involved. In the real world, we do know that might be a time issue or even a critical problem but note it and report it. Document what the pharmacist recommends, what the family understood and agreed to. Of course, it would be essential to document the fact that the client genuinely lacks capacity.
It will take a few minutes of discussion or phone calls, a few lines in the patient notes but with a bit of thought those steps could save you a great deal of trouble given how many problems could arise.