Consent to administer psychotropic medication in nursing homes is not legally required, often leaving families in the dark about the powerful drugs their loved one has been given.
An issue that has come up several times during the royal commission is the giving of psychotropic medications to a resident in aged care without the consent of either the individual or their family or guardian.
Often the first time family knew their loved one was being administered the powerful drugs was when they saw the item on the pharmacist’s invoice.
Guidelines say consent should be granted
The Department of Health and Ageing’s decision-making tool for using restraints in aged care says consent should be obtained, unless the situation is an emergency.
“The decision to use restraint in a residential aged care home is a clinical decision which, with the consent of the resident or their legal representatives…, may be made by a competent person in order to protect the resident, or other residents and staff, and where there is no reasonable alternative.”
Similarly, the Royal Australian and New Zealand College of Psychiatrists’ guidelines for prescribing antipsychotic medications say informed consent should be gained.
“When prescription of a medication is being considered, informed consent is essential. Therefore, it is necessary that information about the risks and benefits of prescribing a medication to a person with dementia is conveyed to the person or their substitute decision maker, and that this is understood,” the guidelines state.
So, with guidelines recommending consent, why is it so often overlooked in nursing homes?
That is the “million dollar question”, Dr Juanita Westbury, senior lecturer at the Wicking Dementia Research and Education Centre, told HelloCare.
Confusion about consent
Dr Westbury said there is confusion about who has the responsibility of gaining consent, or if consent is even required.
Aged care staff “will tell you that they are unsure about whose job it is to get the consent or even if it is needed,” Dr Westbury said. “Does the GP gain it? Or the home? It is legally required?”
Consent is not legally required: new regulations
Perhaps the confusion arises from the fact that, even though the guidelines recommend consent, new national regulations for the use of chemical restraint don’t require informed consent before chemical restraints are prescribed or administered.
“When new federal legal principles don’t require consent to be gained – just for homes/GPs to inform residents/relatives (if practicable) – why would they have to?” Dr Westbury said.
The new regulations require the GP or nursing home to inform the resident or their legal representative about the use of the medication if it is practicable to do so, but they do not have to obtain consent before prescribing it.
“This goes against basic human rights and certainly goes against the federal government’s own guidance publication they re-promoted just last week and the psychiatrist’s professional practice guidelines,” Dr Westbury said.
“I think they got the principles so right for physical restraint [which does require prior consent] but so wrong for chemical restraint,” Dr Westbury said.
“Why make it so much easier to chemically restrain? It’s almost as if they are saying drugs are a better option. I can see that belts/safety rails are more confronting than a snoozy resident but chemical restraint is insidious and comes with the risk of dying earlier, incontinence, stroke, movement disorders, impaired communication etc.
“It’s frankly concerning that drugging someone out is preferable and easier to do than the act of putting up a bed rail to restrict movement. I don’t think the types of restraint and principles governing use should be separated,” she said.
Administering psychotropic medication without consent is “against human rights”
Administering strong medications without consent is “against basic human rights,” Dr Westbury said. “Would you want to be doped up or have medication without giving permission?” she asked.
“Under emergency situations, like a psychotic episode or when safety is severely impacted, sure. But this is often regular use for months and months on end. Without monitoring, with the use of multiple agents, without end.”
Nurses believe medication is effective and aren’t aware of side effects
Dr Westbury said there is also confusion about why psychotropic medications are prescribed.
“The nurses blame the GPs saying that they write the scripts. The GPs say the nurses ask for them [psychotropic medications]. Rellies are often unaware a script for these medications have been written. Pharmacists are not involved,” she said.
Nursing staff may ask for psychotropic medications to be prescribed because they believe the “medications are more effective than they are”, Dr Westbury said, and they may not be fully aware of their side effects.
“They don’t know the guidelines for use or about the adverse effects associated with their use (tremor, sleepiness, confusion, falls, pneumonia, incontinence, stroke etc). These sort of effects are seen at higher rates in older sick people in any case,” she said, making it difficult to attribute them to the medication.
A culture of reaching for the medication first
“There is a culture within many homes to reach for the medications first – a belief that medical intervention is necessary to fix a problem, as opposed to detailed assessment for pain, infection and working out why the person is agitated, aggressive, wandering, unsettled, or anxious.”
Poor communication between staff, doctors and families also prevents alternatives to medication from being found, Dr Westbury said.
There is not enough time or staff to do the proper assessments, to communicate with doctors and relatives, and try other things before going for the medications, she said.
What does informed consent require?
Consent should preferably given in writing, Dr Westbury said.
“If a phone call is all that can be achieved, it’s better than nothing. But writing is preferable so there is evidence that consent is gained.”
Informed consent need not be complicated, Dr Westbury said. Describing the basic risks and expected benefits is enough.
Psychotropic medications are appropriate in some situations
“Psychotropic medication is not only given to people with dementia – its given for anxiety, depression, agitation, sleep disturbance and a whole raft of other reasons – and also to people who really need it, those with severe mental illness such as schizophrenia and bipolar disorder. Not all use is inappropriate,” Dr Westbury said.
“And it needs to be stressed that there are times when giving psychotropic medication is the best option and it would be wrong not to use it. But that is when a resident is very distressed or poses a risk of harm, or when they have a delusion or psychotic hallucination that causes upset,” she said.
Coping when someone living with dementia acts out their frustrations
When someone living with dementia is acting out their frustrations, “it’s important to first assess for pain, infection, other medical causes” keeping in mind that medication can actually “aggravate” the situation, Dr Westbury said.
“Then (or at the same time) talk to the family, friends if you can – see if they know what is upsetting the resident or causing behaviours. What do they do if this happens? Can they suggest strategies?
“Check the environment is not causing distress – is it too hot, too noisy, too cold, of perhaps the resident cant reach for a drink or the TV remote. Is the resident lonely or do they need space? Make sure you are providing resident-centred care.”
Dr Westbury said the government-funded Dementia Behaviour Management Advisory Service (DBMAS) is available for nursing homes that are having trouble coping with a resident acting out their frustrations. DBMAS has a fast response team.
“When a psychotropic medication is given, make sure you gain consent, monitor for effect (is it working?), look for adverse effects, and agree on an exit plan (how long it’s being used for?),” Dr Westbury recommends.