It can be very frustrating to offer a tablet to a client only for them to refuse to take it or be unwilling to swallow it. While the live-in carer may know the benefit of the medication, sometimes it seems that the client may be unaware of the importance of taking it. It can be very easy at this point to resort to disguising the tablet in food, chocolates and desserts, but should we be doing this?

The Care Quality Commission describes disguising medication as ‘covert administration’ and the name suggests that this is frowned upon, if not blatantly disagreed with.

Why is hiding or disguising an issue?

There are several reasons why disguising and hiding medication can be a problem. According to the CQC any medication can be hidden in food so that the person eating or drinking does not know they are taking them. 

When a person has the mental capacity to know whether they take medication or not, disguising them is unlawful as they have the right to refuse medication if they so choose.

This is the main issue with disguising medication, because when there is no longer mental capacity, this issue changes.

Covert administration or disguising medication is likely to be necessary and appropriate when:

• a person actively refuses their medication, and
• the person has been assessed to not have mental capacity to understand the consequences of refusing, and
• the medication is deemed essential to the health and well-being of the person.

This capacity is determined by the Mental Capacity Act 2005. 

The CQC states that a functional assessment needs to be carried out to understand if possible why the person refuses to take their medication and if given covertly it should be by using the least restrictive option, and only after trying all other options.

What does the Mental Capacity Act 2005 say?

There are five key elements under the Mental Capacity Act which you should test your decisions against. This act is the legal framework for anyone over the age of 16 and who lacks the capacity to make decisions for themselves.

• Every adult has the right to make his or her own decisions. You must assume they have capacity to do so unless it is proved otherwise. You must not assume someone lacks capacity because they have a medical condition or disability.
• A person is not to be treated as unable to decide unless all practicable steps to help them do so have been taken without success. You should make every effort to encourage and support people to make the decision for themselves. If you establish lack of capacity, it is important to involve the person as far as possible in making decisions.
• A person must not be treated as unable to decide merely because he or she makes an unwise decision. People have the right to make decisions that others might regard as unwise. You cannot treat someone as lacking capacity for this reason. Everyone has their own values, beliefs and preferences which may not be the same as those of other people.
• Anything you do or decide for or on behalf of a person who lacks mental capacity must be in their best interests.
• When deciding or acting on behalf of a person who lacks capacity, you must consider:
  1. whether there is a way that would cause less restriction to the person’s rights and freedoms of action, and
  2. whether there is a need to decide or act at all

Any intervention should be the result of the person’s circumstances.

Points to consider

There are some medications which, when mixed with certain food or liquids, can become ineffective. Additionally, crushing tablets can sometimes change the characteristics of the drug and affect the usefulness.

It is useful to know that timed release drugs, when crushed will result in a quicker release which may cause an overdose in some people.

Always talk to either the doctor or the chemist about disguising the medication so that you know which are safe to disguise and which will be harmful.

Cover yourself as a carer

No matter what route you need to follow with medication, it is vital that as a live-in carer you cover yourself at all times. You must record any decisions and these should also be reflected in the Care Plan. 

The process of covertness with any medication should be clearly documented so that incoming carers know exactly what to do.

If you have been given permission to disguise medication then you need to record the changes correctly.

You must include in the Care Plan the following:

• Every action that you take to give medication in the normal manner
• A description as to how the medicines will now be administered
• Permission from the doctor stating that you are allowed to crush or mix medication
• A note of whether the medication is palatable or not
• Any swallowing issues and adverse effects whether they are real or perceived
• A note on your client’s lack of understanding as to why they refuse the medication
• Any ethical, religious or personal beliefs regarding medication
• What you have done when they have refused medication

Final thoughts

Medication disguising and altering is a very tricky affair and must be handled professionally. Never be tempted to simply chop a tablet in half and pop it into fruit yogurt to disguise it unless you have written permission from the doctor to do so. 

If you do have permission to do this then also make sure that your own records are always in order, and following carers know exactly how to disguise the medication.

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