Concealing Medication: Pharmacist's Response

by Flora Bessey, Pharm.D., BCGP

Concealing medications, a pharmacist’s response….

As a consultant pharmacist, facilities depend on us to show them the way with regards to medications.  One issue as described in a vignette by Dr. Luxenberg last month deals with hiding of important psychotherapeutic medications in the resident’s food to ensure consumption.  The short and simple answer to this is we can’t do it. Period.  No matter how vital the medications are, no matter how sick the resident is, they retain their right to refuse.  This appears in the law and across regulations. (42 CFR §483.10(f)(2)

The only exception may be if the resident is conserved.  Conservatorship is vastly different from authorization granted by the responsible party or family.  With conservatorship, the patient has been deemed incapable of making their own decisions and the court has appointed a conservator.  This person may be a family member, but it is someone who has been appointed by the court.

Another issue is the question of “mandatory dose reduction” in the case of antipsychotics. In this case, the resident had a history of a MEDICAL condition, schizophrenia. Let’s substitute two words in the above vignette, and see how we as clinicians would react: A 78-year-old nursing home resident with mild dementia and a long history of hypertension controlled with an oral beta blocker was given a trial of beta blocker tapering and discontinuation by her primary care physician. Anyone have a problem with that? Of course we do! In many cases, our residents have a documented history of a mental illness (not just “aggression secondary to dementia,” or “agitation secondary to dementia”). If the physician in this case had merely written a single short paragraph in the chart, this whole issue could have been mitigated. “This resident has a DSM-V diagnosis of schizophrenia. She is stable on her current antipsychotic, and no dose reduction is indicated. A dose reduction is clinically contraindicated.”

Although we as health care providers want to do all we can to ensure the best outcomes for a resident, we have to remember in most cases they have retained their right to refuse. In the case of acute agitation, we can do a one-time dose of a liquid or injectable but that too only if the resident is an acute danger of inflicting harm upon themselves or others.

We need to be mindful the right action for a resident as we see it may not be the resident’s choice and we must respect that.

Concealing Medication: A Case Vignette