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It is a busy morning at the nursing care center. The RN has the responsibility of passing medications and completing morning assessments before the physician makes his rounds. She starts to administer medications to her assigned 20 residents. Halfway through the medication pass, one of her residents refuses medication. The nurse hesitates for a moment before making the decision to secretly mix the medication into the resident's breakfast food.
In this context, Rebecca chose to administer this resident's medication covertly. The literature describes covert medication administration (CoMAd) as hiding, disguising, or concealing medications to residents in the absence of clear consent (Treloar, Beats, & Philpot, 2000 ). Consent for medical treatments including medications is a complex process in resident populations where cognitive illness is prevalent, such as long-term care settings. A literature review on this practice reveals serious concerns about the ethical and moral implications of CoMAd and lack of adequate regulations to guide professional actions of nurses in long-term care settings.
Federal guidelines support long-term care residents' rights to refuse treatment; however, if medications are covertly administered, the resident is not provided an opportunity to refuse. The practice of CoMAd has been documented in a small number of research studies, primarily in long-term care settings, where nurses routinely administer medications to large groups of residents. In this setting, nurses reported hiding medication in food or drink for a variety of reasons, with higher occurrences noted in those residents who lacked decision-making capacity (Tweddle, 2009 ). A literature review of this phenomenon found a small amount of research documenting this practice in long-term care settings in the United Kingdom and Norway (Kirkevold & Engedal, 2004 ; Treloar et al., 2000 ). In these studies, reasons for CoMAd were nonadherence and difficulty swallowing. However, in many cases, reasons for CoMAd were not provided. Findings from this research, as well as public and professional commentary, suggest that the phenomenon of CoMAd frequently occurs in secret, and reasons for hiding the medication from residents is unclear. The purpose of this article is to review available literature on the topic of covert medication administration and identify ethical and legal implications for bedside nurses.
The Issue
The right of mentally competent residents to give or refuse consent...