NUR09722: Mr. Smith, aged 84 years, was admitted to the hospital with a chest infection. He had known dementia, but on admission: Exploring the Theory and Application of Law and Ethical Reasoning in Nursing Practice Assignment, ENU, Singapore

Mr. Smith, aged 84 years, was admitted to the hospital with a chest infection.  He had known dementia, but on admission, he had a higher level of confusion due to the infection. The nurses responsible for his care were becoming increasingly concerned as they were unable to administer his medication.

Any attempts to administer any medication resulted in increased agitation and refusal of the medication. The nurses attempted to talk to Mr. Smith about his medication in order to establish if he understood why he needed the medication and what would be the likely consequences of refusing.

However, it became evident that he was unable to understand or retain the information and he was not able to communicate what would happen if he continued to refuse. Mr. Smith’s daughter was extremely concerned and upset at how ill and confused her father had become and asked if the essential medication could be hidden in a drink or yogurt.

This ethical scenario raises the ethical concern that by treating Mr Smith’s chest infection the nurses were being asked to disguise his medication in food and drink, therefore it would be given to him without his knowledge or consent.

Between 22% to 89% of patients with dementia may have delirium superimposed on their dementia as a result of another condition or infection. This can present challenges when administering medications. The ethical principle that persons have “autonomy” makes it clear that patients have the right to make decisions about their consent to treatment and this should be respected.

However, the likely consequence of Mr. Smith refusing medication increases the risk of significant harm as a result of his chest infection.  The nurses and his daughter clearly wish to act in a “beneficence” manner to provide him with the best care and treatment, therefore it was suggested that the medication should be given covertly. Indeed, there is the widespread use of giving patients with dementia medications covertly and it is reported that as many as 17% of patients in institutional care receive their medications disguised in food and drink.

Before covert administration of the medications can be considered, decisions and actions must be carried out under the Mental Capacity Act to determine the patient’s decision-making capacity.  Although Mr. Smith’s discussion with the nurses suggests that he may not have the capacity to make a decision about taking his medication, it is a requirement to establish the cause of this impairment before proceeding with giving covert medication. It is also important to be aware that capacity may vary depending on the time of day, the person’s mood, and the level of familiarity with people and surroundings.