Ehics In Health Care
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Like every other professional endeavour that particularly affect human lives, the field of healthcare is well guided by fundamental professional, ethical and legal obligations that explain and limit the roles, functions and duties of the healthcare professional. The most fundamental of these, mostly relates to individual autonomy, the right to decision making and self determination; Beneficence, to always act in the best interest of the patient, at all times; and Non – Maleficence, always act to prevent harm to self and others (Treloar et al, 2001:444; Welsh and Martin, 2002:123).
In most cases, the treatment of younger people with the competence and capacity to make informed decisions does not usually pose any serious ethical problem; except, of course, in the most unusual cases. However, the same cannot be said about treatment for the older population, who in most cases, are physically frail and mentally incapable of making informed decision. Considering the fact that the elderly, though constitute just about 18% of the population, receive more than 45% of the drugs prescribed in the UK (Treloar et al, 2001:444), treatment for the elderly poses the greatest ethical challenge for healthcare professionals, especially nurses who are always in charge of these patients due to their need for long term care.
Furthermore, the prevalence of mental conditions such as dementia among the older population is considerably higher; Macdonald (1998) reports that 5% of people aged 65 and above in the community and 80% in residential or nursing homes suffer from dementia. Apparently, this makes the prescription and administration of medications to this population more tasking and challenging, as the nurse has to weigh the balance between the right to self determination of the patients, and the duty to act in the ‘best interest’ of the patient. In situations where mentally ill elderly patients cannot give a valid consent or refuses to receive medication, the problem is further compounded.
However, according to Treloar et al (2000), mental incapacitation and the inability to give a valid consent should not deprive a patient the benefit of good quality healthcare. In this light, administering medications to mentally ill elderly patients disguised in food, drinks or beverages has become an increasing situation that is always justified by acting in the patients’ ‘best interest’.
This practice of ‘covertly administering’ medications to patients is arguably an issue of current concern in healthcare practices in the UK, considering the facts that, one, it touches on legal and ethical issues of patients’ competence, autonomy and insight; two, it is a healthcare practice that is shrouded in secrecy making it difficult to document or regulate the practice; and three, it has taken prominence in adult mental health nursing.
In a study carried out by Treloar et al (2000) covering 34 residential, nursing and inpatient units in southeast England, 71% (24 units) have had to resort to covert drug administration at one time or the other. The author further stated that this appears to be an underestimate, because in 3units that said they have never resorted to covert administration, other staff remarked that covertly administering medications to patients, indeed, occur daily.
Another study by Kirkevold and Engedal (2004) surveyed 1,362 caregivers for dementia patients in Norwegian nursing homes. They found that 11% and 17% of the patients received covertly administered drug at least once per week. The increasing resort to the use of covert drug administration for elderly mentally ill patients has generated hot debates about the ethical and legal implications of this healthcare practice.
While proponents of the practice have severally argued that acting in the patients’ best interest involves administering necessary medications to help the patient get well, even if it is against his/her wish; on the other hand, antagonists posit that covert drug administration is overtly paternalistic and an abuse of powers on the side of the healthcare professional. This paper therefore intends to provide a critical appraisal of the ethical and legal issues that surrounds the covert administration of medication to elderly mentally ill patients, with particular reference to patients with dementia.
In this regard, the rest of the paper will be structured as thus: the next section will briefly look at the issues and challenges with administering drugs to elderly patients with dementia and other conditions of cognitive impairment, thereby elucidating the need for covert administration of medications. This shall be followed by an overview of covert drug administration, then the professed advantages and disadvantages of this healthcare practice. The fourth section of the paper will provide a detailed appraisal of the ethical issues concerning covert administration of medications to elderly mentally ill patients. The last section of the paper shall provide the opinions of the writer and then a concluding remark.
Drug Administration to the Elderly with Dementia
As noted earlier on, the aged population constitute an important part of every nation’s population medically. In the UK, as reported by Treloar and his colleagues (2001) the elderly take up just about 18% of the population, but interestingly, they receive 45% of prescribed drugs. Also, about 78% of these patients receive their medication through a repeat prescription system without even seeing the physician making the prescription. Elaborating on the challenges with prescribing and administering drug to the elderly mentally ill in the population, Treloar and others report that a substantial proportion of the elderly do not live in their homes, but in residential or nursing homes, while small proportion live in the hospital. Prescribing and administering drugs in each of these settings, therefore, poses different challenges.
Macdonald (1998) and Lothian and Philip, (2001) have identified the tasking challenges of prescribing and administering medications to the elderly and mentally ill. Lothian and Philip (2001) explain that the pharmacokinetics and pharmacodynamics of drugs greatly differ in the elderly patient when compared with a younger person with similar condition.
As a result, drug interaction, side effects and even adverse drug reactions are more likely and perhaps worse in the older patient. Again, a large proportion of the elderly patient suffer from dementia, Macdonald (1998) puts the value at 5% of people over 65years of age in community and 80% in residential or nursing homes. This raises the issue of compliance and drug adherence in this population of patients. There is also the issue of consent and mental capacity to rightly choose or reject treatment and the problem of how best to treat such patients, as this is perhaps, the most challenging of the issues identified.
For mentally competent patients, it is undoubtedly clear that administration of medications or any other form of treatment without a valid consent is unethical and illegal (Griffith, 1996; Welsh and Martin, 2002; Honkanen, 2001). Unfortunately, such a categorical statement cannot be made with regards to treatment for the elderly and mentally ill. Patient’s right to self determination and autonomy demands that the health professional, the nurse in this regard, openly discus the treatment, its benefits, risk and potential harms (Treloar, 2001; Honkanen, 2001).
The idea of such a discussion is based on the ability and capacity of the patient to comprehend the medical information, to make sense of the treatment options and the benefits or potential risks of each option, and the ability to make an informed decision based on the provided information (Honkanen, 2001). These are prerequisites to autonomy and self determination that is obviously not possessed by most elderly and mentally ill patients.
However, Treloar et al (2001) places the issue of capacity for autonomy and self determination in a wider context. They argue that the capacity to give valid consent for treatment is a somewhat flexible concept that depends on mental abilities of the patient, the complexity of the medical information being provided and the gravity of possible consequences with or without the treatment. Based on this differential level of capacity, the authors identified four levels of agreement to treatment that a patient can possibly give – consent, assent, dissent and refusal.
Consent is when complete mental capacity is present and the patient agrees to treatment based on full information and adequate mental capacity, this is rarely the case with elderly and mentally ill patients. Assent is when the patient complies with treatment, but without the mental capacity to reject or accept the treatment. Most elderly patient with dementia falls in this category.
As Treloar et al notes, these are patients that will take whatever is given to them, irrespective of the purpose, action or possible adverse effects of such drugs. Although this group of elderly and mentally ill patients does not constitute any ethical challenge for nurses, they are obviously the most vulnerable group. The tendency to take whatever drug is given to them exposes these patients to possible abuse. Dissent is the rejection of treatment by a patient who lacks sufficient mental capacity to make such a choice. This group of patients constitute the most ethically challenging to treat.
Acting in the best interest of these patients demand that treatment be enforced, however, the patients’ right to autonomy and self determination demands that the patient should not be treated against his/her will. Weighing both sides and finding a convenient balance has made several nurses and care-givers resort to covertly administering drugs to elderly, mentally incapacitated patients (Lamnari, 2001; Honkanen, 2001; Treloar et al, 2000; Whitty and Devitt, 2005). The most common methods of covert administration involve mixing medications with drinks or adding it to foodstuffs. The ethical and legal issues concerning this practice will be discussed in the next sections. Refusal entails the rejection of treatment based on full medical information and mental capacity to make such decisions.
Beside the problems with mental capacity and consent to treatment that makes administering drug to elderly and mentally ill patients cumbersome, Welsh and Martin (2002) highlighted two developments in medical ethics that have further heightened the current dilemma in providing care for the elderly.
First, is the increasing importance accorded to respect for autonomy, second, is the loss of what is referred to as ‘parens patriae’ jurisdiction of the courts. This term, which literally mean ‘parent of the country’ initially permitted a court to consent to or reject treatment on behalf of a patient who is mentally incapable of making the choice on his/her own. The revocation of such powers vested on the court means that nobody is legally permitted to give consent or reject treatment on behalf of an incapacitated patient (Mason and McCall, 1999).
From the foregoing, it is clear that administration of medications to the elderly, mentally ill is tasking and challenging. When consent is not a problem, drug compliance and adherence is. Most patients with dementia and other forms of cognitive impairment who decide and agree to take medications do forget to do so, in several occasions. Even when compliance and drug adherence is as expected, polypharmacy is another issue to worry about. Obviously, medications are essential and very useful in elderly patients with dementia; however, several ethical and legal issues arise with drug administration and compliance.
While ‘acting in the patients’ best interest’ have always been used to justify several healthcare practices that affect quality of care received by the elderly, there has always been grave concerns abuse and misuse of power. Unfortunately, this is a very delicate area to tread on; for while safeguards and regulations must be properly put in place to protect the elderly from abuse, care must also be exercised to ensure that such safeguards are not so restrictive as to prevent or limit access to good quality care for these patients (Treloar et al, 2001).
Covert Drug Administration
Non adherence to treatment is a problem that has long plagued the medical profession, especially the field of psychiatry (Whitty and Devitt, 2005). Nursing care for elderly patients is generally acknowledged to be tasking, but treating the elderly mentally ill is perhaps a more challenging task. Welsh and Martin (2002) posit that the interventionist approach of psychiatric nursing carries with it several ethical issues, which is further compounded by the high rate of non adherence to treatment that exists among psychiatric patients. Estimated rates of non adherence among all psychiatric patient is conservatively put at 20-50%, however, this figure is agreeably higher among elderly patients suffering dementia (Whitty and Devitt, 2005).
Non adherence to treatment and refusal to accept treatment among elderly patients with dementia and other cognitive impairments is a very thorny issue for the nurse. Adams and Howe (1993) reports that treatment non adherence is associated with poor patient outcomes, yet efforts at improving compliance and adherence to treatment among this category of patients have not been essentially fruitful.
While a particular study reports that compliance therapy based on motivational interviewing successfully improved adherence to medication, attitudes to treatment and insight after a six months period (Kemp et al, 1998), another study carried out on the same topic by O’Donnell et al (2003) was unable to replicate such results. To further worsen this dilemma, a recent review by Zygmunt et al (2002) concluded that current clinical interventions aimed at improving adherence to medication and insight on the part of the patients, such as psychoeducation and predischarge contracts, requires frequent repetition and even with that, on their own, these methods are not likely to improve medication adherence in cognitively impaired patients.
With such a situation, the stark reality is to respect the patient’s right to autonomy and leave him/her untreated, or to act in the best interest of the patient and force or deceive him/her into taking the necessary medication (Levin, 2005; Lamnari, 2001). Thus, in the bid to act in the patients’ ‘best interest’ and to ensure that the elderly, with severe mental conditions get good quality care, nurses (and in some cases, family members) sometimes resort to concealing medications in food, beverages or drinks; a practice known as ‘covert drug administration’.
This practice borders on several legal and ethical issues. Although, it is not unusual to give treatment without consent, such as in emergency or life threatening situations, and in paediatric cycles, but in adults and stable patients, the case is different, even when the patient in question is mentally incapacitated and unable to give a valid consent. To further complicate this challenge, the Mental Health Act (1983) does not cover such practices, as a result, there is virtually to professional guide on such practices.
Since there is virtually no guide on how and when it is right to covertly administer medications to elderly patients with severe mental illness, the fear of professional censure has often meant that this practice is carried out in secret and without the necessary documentation (Treloar et al, 2000; Kellet, 1996). As a result, studies evaluating the prevalence of this practice have been very scanty. However, Whitty and Devitt (2005), Treloar et al (2001) argue that the practice is far more prevalent than can be imagined.
In the study carried out by Treloar et al (2000), of 34 residential, nursing and inpatients units in south east England, 71% reports resorting to covert administration of medications at one time or the other. In the same study, 79% of carers of elderly mentally ill patients (94% for patients with dementia) report resorting to covert administration of medications at some time. While in another study, 38% of 21 psychiatrists admitted to have participated in covert administration of drugs. Though Whitty and Devitt (2005) argues that this could be an underestimate as nurses and physicians are often reluctant and uncomfortable about admitting their participation in covert administration.
The study carried out by Kirkevold and Engedal (2004) gave better insights into the practice of covert drug administration. This study researched the types of drugs most usually administered covertly, reasons most frequently cited for covert administration and patients most likely to receive drugs by covert administration. The study concluded that patient characteristics such as degree of dementia, aggression, and low function in activities of daily living were the strongest explanatory factors for covert administration.
Furthermore, patients in special care units had a higher risk of being given drugs covertly. The risk was lower for patients living in teaching nursing homes or in wards with a relatively high staff: patient ratio (Kirkevold and Engedal, 2004:3).
This is buttressed by Welsh and Martin’s argument that in residential settings, sedating or tranquilising medications might be seen as a cheap way out of inadequate staffing or an essential, and perhaps, least restrictive means of managing unpredictable, violent outbursts against staff and fellow patients (Welsh and Martin, 2002:124). Also, Antiepileptics, antipsychotics, and anxiolytics were shown as drugs most likely to be given to patients who got covert administration of medications (Kirkevold and Engedal, 2004:3).
Finally, although the United Kingdom Central Council for Nursing and Midwifery, the Mental Health Act Commission and some others consider covert administration of medications to be justifiable in certain situations (Griffith, 1996, Treloar et al, 2000), several nurses have faced disciplinary actions as a result of this practice. The question is, can covert administration of drugs be ever ethically justified in any situation? Answering this question requires one to critically weigh the professed benefits and dangers of this practice and to critically appraise the ethical issues related to this practice.
Before presenting any argument for the ethical justification or otherwise of covert administration of drugs, it is pertinent to set the record straight by looking at the potential or expressed advantages and disadvantages of this healthcare practice. Perhaps, part of the dilemma with this practice is the fact that even the most ardent enemies of covert drug administration admit that it is a practice that, indeed holds some positive implications for the mentally ill patient.
Whitty and Devitt (2005) posit that serious clinical risks and substantial costs are associated with delay in treating patients with serious mental impairment. Covert administration provides a fast and easy way of making sure that the patient receive good quality healthcare. Besides, the toxic effects of untreated psychosis, for instance, are well acknowledged. Therefore, delaying treatments in such patients could have the negative effects of increased morbidity and poorer outcomes with respect to prolonged patient suffering, increased risk of harm to self and others, deterioration of the therapeutic relationship between the nurse and patient and in some cases, increased physical assault by the patient (Kelly et al, 2002; Whitty and Devitt, 2005).
From another perspective, delaying treatment for patients with mental illness due to consent and mental capacity can lead to demoralisation of the nurse and consequently, redirection of the limited healthcare resources to non-therapeutic activities. In this regard, covertly administering drugs provide the opportunity to adequately intervene at an early stage to forestall relapse.
Also, covertly administering medications prevent the need to frequently restrain and forcibly administer medications to the patient. As a result, carers for mentally impaired patients are often more satisfied with this form of medication, as it greatly reduces their burden and reduce the need for the use of seclusion and restraint (Whitty and Devitt, 2005). Particularly, in the case of dementia patients who forget to take their medication out of cognitive decline, covert administration of drugs would be seen as a better alternative to the use of restrain (Treolar et al, 2001).
Unfortunately, the disadvantages of covert drug administration are almost as grave. Whitty and Devitt (2005) believe that covert drug administration runs the risk of denying the patient the opportunity of gaining insight. They argue that in most cases, insight improves only after recurrent relapses, which enables the patient to establish a relationship between non adherence to medication and the recurrent relapse. Apart from this, covert administration of drugs might also serve to reinforce the belief of the patient that he/she does not require treatment to get well, or that illness is not even present.
On the part of the patient, covert administration of drugs might be seen as granting too paternalistic powers to the healthcare professional, and this might discourage patients from seeking treatment for their mental illness. Also, on the part of healthcare professionals, the practice might be construed as an easy and cheap means of managing patients under poor staffing conditions, thus encouraging poor healthcare practices. Furthermore, resorting to covert administration of mediations could encourage nurses to overlook the importance of research into why patients are non-compliant and therefore not improve on the understanding of factors driving non compliance among mentally ill patients (Whitty and Devitt, 2005:482).
The fundamental ethical issue that plague covert administration of medication is the right to autonomy and self determination that every patient possesses. Of course, in patients mentally and physically capable of giving a valid consent, the issue of the acceptability or not of covert drug administration does not arise. However, in situations where doubts exist as to the mental capacity of the patient to exert his/her right to decision making, such as in patients mentally incapacitated due to severe mental illness, the question of whether acting under the principle of ‘best interest’ and deceitfully administering drugs to the patient is right becomes a very difficult one to answer.
Welsh and Martin (2002) set the question right when they asked if there was a difference between a patient passively accepting medication and one having medication disguised in some way, following refusal. Or if the principles of beneficence and non-maleficence were appropriate and strong enough to justify the practice of deceitfully administering drugs to mentally impaired patients against their will.
While some authors believe that covert administration can be justified, for instance, Whitty and Devitt (2005) suggest that “the paramount principle is ensuring the well-being of a patient who lacks the competence to give informed consent;” others believe that “there could be no excuse for violating norms of patient autonomy and professional ethics” (Levin, 2005). Striking a balance between these two extreme positions is obviously a herculean task.
Again, Welsh and Martin (2002) provided an objective method of approaching this problem. They presented the case of an adult with learning disability who consistently rejects all oral medication, including anticonvulsants. The nursing staff in charge, in appreciation of the ethical issues with covert drug administration, administers such required medication by suppository on a daily basis.
Compared to another elderly patient with cognitive impairment and who is acutely disturbed, representing a significant risk of harm to himself and others. In this condition, would the benefits of covertly administering the required anticonvulsants and sedative drugs not outweigh the harm, if infact, covert administration of the drugs have been judged to be the least restrictive measure to maximise the patient’s liberty and dignity. Of course, covertly administering medication is likely to be seen as the best option in such scenario. Then another question arises, is such circumstances ethically specific to individual circumstances or is it subject to generalisations?
Lamnari (2001) presents an interesting viewpoint. Presenting what was referred to as the “sliding scale” of risk versus benefit, Lamnari argue that if for instance, “a cognitively impaired patient objects to being moved from a television lounge, we are likely to just let the patient be. Suppose, however, that the room is on fire. This alters the risk-benefit balance dramatically, and now we would remove the patient from that room regardless of how much he objects and would even use force if necessary. Here, it is ethically acceptable—indeed, imperative—to breech the patient’s autonomy” (Lamnari, 2001:228).
The sense in all these is that no matter the ethical issues that complicate covert administration of medications, there reasonably cannot be a valid ground to completely disregard the value and benefits of this practice in the care for the elderly and mentally ill patients. As noted earlier, even the most ardent enemies of the practice, one way or the other, admits that there are situations and circumstances where disguising medications is the most reasonable option in the patients’ best interest.
Treloar (2000) in a study examining the prevalence of covert drug administration, concluded that though on the face value, the ethical issue of autonomy means that any form of deception is unethical, however, to seek consent from mentally incapacitated patients is impossible; therefore, insisting on getting valid consent for treatment or refusing to covertly administer the required medications to the patient could mean denial of treatment that the patient is not likely to reasonably have rejected if he/she had the mental capacity.
Also, considering the fact that the right to autonomy is the primary ethical issue at stake in covert administration of drugs, Lamnari (2001) argue that how it is possible to reasonably think of autonomy of a patient with dementia. Such right is probably non existent under such situations. The author argued that the patient’s right to autonomy is obviously limited by the presence of severe mental impairment. Furthermore, it should be noted that to enjoy the right to autonomy and by extension the power to validly reject or consent to treatment, a patient must satisfy three primary conditions.
First, the patient must be able to understand and retain information on the treatment proposed, its indications, its benefits as well as the potential risks and adverse effects, and also the consequence of non adherence to treatment. Secondly, the patient must be seen to evidently believe such information; and third, must be capable of weighing up the information to arrive at a concrete decision.
In elderly patients with mental illness none of these conditions are satisfied, obviously the issue of autonomy in such scenarios does not hold much ground (Treloar et al, 2000). For example, when a patient with severe dementia develops epilepsy and not having the capacity to understand the need for anticonvulsant medications, refuses such treatment. Under such scenarios, would the benefits of patient autonomy outweigh the necessity to stop further seizures and harm to the patient by covertly administering the required medications? The most reasonable and obvious answer is a ‘NO’.
Furthering this line or argument, Lamnari (2001) assert that the key to interactions with the elderly with dementia is sensitivity. It is pertinent to reflect on what the rejections in these patients reflect. Lamnari contend that in some cases, elderly patients with dementia reject treatments because they harbour deep rooted desires to die, so instead of taking medications to help themselves, they would rather let ‘nature takes it course’.
In some other cases, refusal is predicated on problems like difficulty with swallowing the pills, the perceived unpleasantness of the pills in the mouth or a delirium that could have been caused by an underlying illness. Obviously, under such conditions, the Common Law principle of acting in the best interest of the patient supersedes any concern with patient autonomy. Based on this argument, it is convenient to assert that it is ethically justifiable to covertly administer drugs to elderly patients with dementia, provided that, in the words of Lamnari, “we remain sensitive and respectful of our patients and act truly with their best interests at heart” (Lamnari, 2001:228).
The most critical issue with covert drug administration is the patient’s right to autonomy and self determination. As a result, no matter the reason for covert drug administration, the nurse must evaluate the ability and capacity of the patient to give a valid consent, on an ongoing basis. If for instance, a patient regains mental capacity as a result of covertly administered medications, he/she has the right to be involved in future treatment decisions. The nurse is therefore duty bound to seek the patient’s consent. Also, the secrecy and lack of documentation that shrouds the practice should be critically looked into.
The risk of potential abuse increases when an healthcare practice goes undocumented and unregulated. Therefore, covert administration of medication to elderly patients with mental impairment should be discussed and decided in a multidisciplinary team, this would have the added advantage of ensuring the decision is indeed in the patient’s best interest. In a word, the problem with covert administration of medications is that of regulation and documentation, and not that of right or wrong. With proper regulation, the practice could improve the quality of healthcare available to the elderly and mentally impaired.
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