The aim of this assignment is to show knowledge and skills involved in my working practise as a Registered Mental Health Nurse in the administration of drugs to a Service User within and area of legal and ethical matters. In line with clause 5 of the nursing and midwifery council (NMC) (2004) code of professional conduct details of the service user will be confidential I certify that confidentiality has been maintained by use of pseudonyms. For purposes of this assignment the service user will be known as Winifred Clark.
I will be examining the area of Covert Medication in a Dementia Patient. Dictionary reference of Covert is: Not openly acknowledge or displayed. Dictionary reference of Medication is: a drug or other form of medicine that is used to treat or prevent disease. (Oxford dictionaries online) Therefore it would be determined that there is an attempt to deceive the patient into accepting medication unknown to them, this statement although true, doesn’t mean all that all nurses who use covert medication are deceptive in their actions. The Nursing and Midwifery Council (NMC) (2002) gave a position statement on covert medication, in that disguising medication in the absence of informed consent maybe regarded as deception. However, a clear distinction should always be made between those patients/clients who have the capacity to refuse medication and whose refusal should be respected and those patients who lack this capacity. It is this area in which I will be examining, how we establish capacity and whether using medication covertly is legal and ethical, does it make it easier to abuse and use as a ‘chemical cosh’ and looking at the legal and ethical issues related to pill crushing which goes hand in hand with Covert medication. Griffiths et al (2003) states that “administration of medicines is a key element of nursing care”. 7,000 individual doses are administered daily in a ‘typical’ hospital; and up to 40 per cent of nurses’ time is spent administering medicines with thousands more self administered by patients in their own homes (Audit Commission 2002).
I work for a large Mental Health Trust Organisation at a Day Hospital for the Elderly. Its primary function is to assess both holistically and individually, provide treatment on a needs based assessment that covers both functional and organic illnesses. The Day Hospital offers a minimum 8 week assessment period for service users to attend 1 or more day’s dependent upon their need and the requirement of the assessment into their mental state, problems or difficulties. The assessment will include a full physical health check and also various cognitive, mood, behavioural and risk assessments needed to provide diagnosis, future care planning and/or treatment. Referrals at the Day Hospital for Service Users are received from various array of sources such as Consultants:- from either Domiciliary visits or Outpatients ;From Community Mental Health Teams for further more in depth assessment or upon their discharge from Mental Health Inpatient Wards adhering to the discharge care plan. The Royal College of Psychiatrist Report ‘Raising the Standard’ Specialist Services for Older People with Mental Illness (2006) states that “Day Hospitals play an important role in the assessment and management of people living in the community and the rehabilitation of patients suffering from, acute and severe Mental Illness who are discharged from hospital”. The Day Hospital offers a rapid assessment and treatment plan for the Dementia Patient plus long term support for the service users who are unable to use alternative day care placements due to severe behavioural and psychological problems. This ensures the carer can still receive some respite as well as providing the Dementia Patient with a stimulating and therapeutic environment. They will also continue to receive ongoing assessments including medication reviews and assessment for Anti-Cholinesterase Inhibitors...
Cited: in Griffiths R 2007)
This means the decision to proceed must be in accordance with practise accepted by a responsible body of professional opinion and be in the best interest of the patient. (Griffiths 2007)
Griffiths (2007) also states ‘Article 8 of the Human Rights Act respect for a private life, may also be considered to be breached by the use of covert medication but it can be justified on the grounds of the persons health as a proportionate response to the medical needs of the patient’. Other aspects of the human rights act may also be infringed by covert medication such as Article 2, the right to life and Article 5, the right to liberty and security.
Following Winifred’s capacity assessment it now made it possible to administer her medication in line with the guidelines and protocols both nationally and locally. She continued to attend Day Hospital and administering her medication was not a weekly routine. It was only done on the odd occasion. We would try to administer in the normal way and only when she refused did we have to do it covertly. Winifred would willingly take the Digoxin elixir and the Mirtazapine Orodispersible but would not take Lorazepam in liquid form either willingly or covertly, so the Lorazepam tablet had to be crushed and administered covertly which she accepted.
The treatment of older people is currently a hot media topic, in particularly medication in the elderly and covert medication to. Covert medication has advantages and disadvantages in treating people with Dementia who have behavioural and psychological problems. There are ethical and moral issues with a potential scope for abuse also issues related to consent, capacity, autonomy and best interest and these are all elements that require stringent guidelines. There is a duty of care to the patients and the professional standard that the Nurse who uses covert medication should never use it as a routine response to someone refusing to take medication it must be done as a last resort when all other methods have failed and the multi-disciplinary team is consulted with a pharmacist to confirm that it is safe to do so. Medication should never be crushed when there is a viable substitute method of administration.
With the Mental Capacity Act, covert medication to informal patients requires a best interest checklist and the need for chemical restraint to be in proportion and also be necessary. Media information in the use of psychotropic medication makes relatives and carers more aware of the harm it can cause. More information is required for then in the use of psychotropic medication used covertly and the harm it can cause covertly or not.
As clinicians we act in ‘the best interest of our patients’. We need to improve the need for non pharmacological interventions as a first line of treatment; we very often reach far too easily for the medicine bottle which when refused leads to covert administration.
Only if it is essential to prevent deterioration both mentally and physically should medicine be administered covertly, not to be used in any other way to justify control of behaviours, then this requires the support of carers, relatives and the multi-disciplinary team and is reviewed regularly and not accepted as the norm.
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