You should:

• review the person’s medicines and stop any that are not needed
• find out why the person is refusing medication – for example, are the tablets too large, or are there too many of them?
• consider whether you can change the person’s medicines so that they agree to take them – for example, changing formulation or switching to a different medicine

You must:

• formally assess the person’s capacity to make decisions about their treatment; the Mental Capacity Act Code of Practice has guidance on doing this
• document the decision

Remember:

• a competent person must make the assessment
• capacity is specific to the decision being made
• capacity can change, people can regain capacity they have lost, temporarily or permanently

If the person has the capacity to make decisions about their medicines at the time you intend to administer them, you cannot do so covertly. This applies even if refusing medicines may harm their health.

The Mental Capacity Act Code of Practice has guidance on deciding what is in a person’s best interests.

Carers or care staff must not give, or decide to give, medicines covertly without authorisation and documented instructions.

Assess the person’s mental capacity before making a Best Interests Decision. You can only make a Best Interests Decision if the person lacks the capacity to decide for themselves. This assessment must be recorded before a Best Interests Decision is made, except in urgent situations.

The decision needs to be made by the prescriber with a multidisciplinary team of healthcare professionals. Covert medication is only likely to be necessary when:

• it is the option least restrictive of the person’s rights and freedom of action
• the person is actively refusing to take their medicines
• the benefits to the person outweigh the risks
• the medicine is necessary for the person’s health and wellbeing
• The decision is usually made during a Best Interests Meeting.

In an urgent situation, NICE states that a less formal discussion can occur between the care staff, prescriber and family or advocate. You must record any decisions made and hold a formal meeting as soon as possible afterwards.

The clinician in charge of the person’s care usually initiates the meeting, but a family member or another healthcare professional can also request the meeting. Ideally, the meeting should also involve:

• the person if possible
• those close to the person and/or appointed representatives
• healthcare professionals in the multi-disciplinary team (MDT) involved in the person’s care

The meeting should include discussion and agreement of:

• is action needed at all?
• options for each medicine, including stopping, changing formulation, or changing medicine
• whether covert administration is necessary and the least restrictive option
• the risk of the person refusing food or drink, either because they do not want it or because they think it contains medicine
• a management plan (see step 5)
• when and under what circumstances decisions will be reviewed
• where the record of the meeting will be kept

The meeting can occur remotely or by email, but there must be a clear record of who was involved and what was agreed.

For further guidance, see:

• British Medical Association Toolkit for doctors: Best interest decision-making for adults who lack capacity
• British Psychological Society guideline: Supporting people who lack mental capacity: A Guide to Best Interests Decision Making

This usually includes:

• a prescriber’s review of the person’s medicines
• a pharmacist’s advice on whether the medicine can be given covertly and doing so safely – Choosing medicines formulations in swallowing difficulties provides advice
• the schedule and criteria for review of the need to continue covert administration
• what to do if the person regains capacity or their capacity fluctuates – you must not give medicines covertly to a person who has capacity

Review and record the need for covert medication:

• when a dose is changed, or a new medicine is added
• if the person regains the capacity to make decisions about their medicines
• regularly, even if nothing has changed

A prescriber must authorise the covert administration of medicines.

Covert administration may involve altering medicines, such as crushing tablets or opening capsules, and/or adding medicines to food or drink. This is usually an unlicensed (off-label) activity. A relevant prescriber must authorise this, preferably in writing.

Prescribing medicines for off-label use affects the prescriber’s professional and legal responsibility (liability). See GMC guidance on unlicensed and off-label prescribing for details.

Only an independent prescriber can authorise off-label use of medicines. Other healthcare staff or professionals may give advice but cannot authorise the action.

Giving a medicine in an off-label way without authorisation could be professional misconduct.

As a minimum, record:

• the mental capacity assessment outcome
• any decisions made during the Best Interests Meeting
• who was involved

Update the person’s care plan to reflect the decisions made and provide clear authorisation to carers and care staff to give medicines covertly.

Record the mental capacity assessment, Best Interests Decision and management plan in the person’s GP records. Transmit to other healthcare settings when necessary.

Carers or care staff should document each time they give a medicine covertly, as well as any unsuccessful attempts to give a medicine covertly.

DoLS are outside the remit of this page. For further information, see the BMA’s Deprivation of Liberty Safeguards guidance.