- Email: [email protected]
Concealing medication in patients' food
VIEWPOINT
Viewpoint
Concealing medication in patients’ food Adrian Treloar, Michael Philpot, Barbara Beats
Introduction The practice of administering medication within the food or drink of patients has rarely been described.1–3 However, a recent study by our group1 showed that the practice is widespread, occurring in 79% of a sample of long-stay care settings for the elderly. Concern was expressed about the lack of openness and poor recording that surrounds the issue. In a companion study1 94% of carers of patients with dementia considered the practice to be justified. In 1996, Kellett2 reported the disciplinary action taken by a UK national health service (NHS) trust after a nurse had concealed haloperidol, prescribed by a consultant, in a patient’s drink, to provide treatment in an urgent and complex clinical situation. Although the patient later expressed clear gratitude for the action taken, the nurse effectively lost her career, and the consultant was strongly censured. Another more recent report described the administration of clozapine in drink in an intensive psychiatric care unit.3
Current legal framework in the UK Ethical opinion on the Kellett case from the Mental Health Act Commission Consent to Treatment Committee and the UK Central Committee for Nursing, Midwifery and Health Visiting agreed with the view that administering medication in the patient’s drink was justified in that case.2 Independent comment also agreed that the practice was acceptable,4,5 and one reviewer1 wrote that the practice was surely routine and uncontroversial. In opposition to this view, the Alzheimers’ Society (H Cayton, personal communication) has said that “We have serious concerns about the level of over prescribing of drugs to people with dementia in hospitals and care homes” and that “if medication is disguised, the likelihood of inappropriate administration of drugs, particularly sedative and anti-psychotic drugs, is increased.” It might be assumed that all medical treatment must be given after valid consent by a competent individual, or be given under the auspices of the Mental Health Act. This does not, however, address the problem identified in the Bournewood judgment, which states that the Mental Health Act did not necessarily apply in situations in which patients could not consent to treatment by reason of dementia or learning disability.
Lancet 2001; 357: 62–64 Oxleas NHS Trust and Guy’s, King’s, and St Thomas’ Medical Schools, Memorial Hospital, Shooters Hill, London SE18 3RZ (A Treloar MRCPsych); South London and Maudsley NHS Trust, and the Institute of Psychiatry, London (M Philpot FRCPsych); and St Martin’s Hospital, Canterbury, and Guy’s, King’s, and St Thomas’ Medical Schools, London, UK (B Beats MRCPsych) Correspondence to: Dr Adrian Treloar (e-mail: [email protected])
62
The UK Central Committee Standards for the Administration of Medicines7 state that “. . . the practitioner administering a medicine . . . can reasonably expect that the prescription . . . is based, whenever possible, on the patient’s awareness of the purpose of the treatment and consent (commonly implicit) . . . and that the practitioner . . . is able to justify any actions taken”. The standards do not deal with patients who are unable to give valid consent to treatment. The Mental Health Act Code of Practice8 states that medical treatment for mental illness may only be given informally to patients with mental capacity who consent to such treatment. Those without the capacity to consent are treated under common law by doctors discharging their “duty of care”. British Medical Association guidelines9 reflect the view that doctors have a duty to provide the best possible care to those who cannot choose for themselves. It has been argued that treatment in these circumstances should be carried out under the auspices of the Mental Health Act.6 However, the Percy Commission6 took a strongly libertarian view, restricting the use of the Mental Health Act only to those who had to be detained in hospital. Goff and colleagues6 believed that this implied that incapable patients should not automatically be detained under the Mental Health Act. This view is, in some ways, welcome because it would be impractical to transfer all incapacitated adults treated at home, and in most residential and nursing homes, to settings registered for the purpose of the Mental Health Act. The view does, however, leave a so called gap in the law that protects the incapacitated as Steyn6 pointed out in his judgement on the Bournewood case. Legal developments in the UK have recently established more clearly the definition of mental incapacity. In Re C this definition was further refined to include the ability to understand and retain information relevant to the decision in question, to believe that information, and to weigh the information in the balance in arriving at a choice. After the cases of Re C10 and Re MB,11 Scottish legislation12 and proposed legislation in England and Wales13 define mental incapacity as “. . . the inability by reason of mental disability, to make a decision on the matter in question, or to communicate that decision.” In essence, incapacity legislation recognises that individuals with severe learning disabilities or dementia may not be able to make valid choice about their health care and that society has a duty to provide good quality care for them in “the least restrictive fashion”.13 Up to now in the UK this has been carried out under common law.14 The proposed legislation may provide the opportunity to use statute law to the same effect. New legislation should not be enacted, however, unless the legislation genuinely improves the situation of the incapacitated patients. The incorporation of the Human Rights Act [1998]15 into UK law means that, in the absence of statute law, any action infringing the liberty of a person has redress in court. Thus, a doctor discharging his duty of care to an incapacitated patient may have to
THE LANCET • Vol 357 • January 6, 2001
For personal use only. Not to be reproduced without permission of The Lancet.
VIEWPOINT
defend himself in court. If further safeguards were required, it may be sensible to incorporate them into a package of measures for the mentally incapacitated such as those currently developed in Scotland12 and awaiting legislation in England and Wales. Procedures need to be sufficiently streamlined to enable treatment without unnecessary obstruction by cumbersome legal processes.
Covert drug administration in other countries In a search of medical literature we found no references to the methods in which drugs are administered to resistive but mentally incapable patients in other countries. This is surprising, because there is an ever-growing number of publications on the use of antipsychotic drugs in the treatment of behavioural and psychiatric symptoms in dementia (BPSD).16,17 In the USA, where the Omnibus Budget Reconciliation Act of 198718 (which incorporated the Nursing Homes Act) radically changed psychotropic prescribing practice in nursing homes, the issue may simply require the permission of the next-of-kin in some districts. In others (D Kamholz, personal communication) there may be a wider discussion. Where the decision involves a legal process this process may involve the appointment of a health-care guardian (B Kamholz, Br Reifler, personal communication). In Australia it is expected that the use of psychotropic medication is discussed with a relative or advocate, whether or not the incapacitated patient is compliant. Technically, the relatives’ consent is not required in law, though statutory processes of guardianship are used in small numbers for limited periods (D W O’Connor, personal communication). In Israel, the local clinical ethics committees are empowered to allow the covert administration of medicines in food. Administration has to be justified to the committee by the responsible physician on a case-by-case basis and is not a routine general procedure (Y Barak, personal communication).
Balancing the ethical viewpoints There are two conflicting views. The first holds that all deception is wrong and that patients like Joan (panel) should not be secretly given medication against their wishes, as it is a breach of her trust. The second is that because Joan is not able to comprehend the result of her refusal and is not making a valid choice, duty of care implies, that she should be deceived as a means of relieving her suffering in the least restrictive way. How can these two viewpoints be reconciled? We believe that the argument against deception is a strong one. If health-care staff decide that they can deceive their patients, then there is a high risk of abuse and consequently poor care. Indeed, the concern about concealing medication almost certainly derives from a fear that doctors, nurses, and others will misuse their powers and authority to the detriment of the patient. However, allowing a patient who cannot make a choice about treatment to refuse a difficult-to-swallow tablet, or a foul-tasting medicine, is to give an incapacitated patient Case example Joan is a 30-year-old woman with severe learning disabilities and epilepsy. She always refuses to take tablets or liquid medicines, but without antiepileptic medications she suffers from severe fits, and injures herself as a result. Without treatment she needs constant nursing attention and cannot be managed at home. With treatment her fits are controlled and she can live at home where she has a better quality of life. Her parents give her medication three times a day in her food, otherwise she will not take it.
THE LANCET • Vol 357 • January 6, 2001
the responsibility of capacity. Should the patient or others suffer as a result? and is it appropriate to hold the patient responsible for the outcome? The scrupulous attempt to avoid deception may, therefore, lead the doctor or nurse to deceive themselves that the patient has chosen to suffer harm. The argument in favour of proven treatments being given to those who cannot choose to accept or reject them is therefore, in our view, the over-riding one. In extreme circumstances this may well mean that treatment is concealed so that it is given in the least distressing or least restrictive fashion. The alternative, to repeatedly restrain and administer injections to a severely demented person who forgets what has happened before the net treatment, is cruel. A further ethical problem is the difference between medication for psychiatric disorder and that for physical disorder. The sense that antipsychotics change the mind whereas antibiotics heal the body, suggests that this might be the case. However, the ultimate aim of any treatment must be a reduction in distress and, where possible, an improvement in health. Moreover, physical ailments such as infections can have serious effects on mental state in patients with dementia. For these reasons we do not believe that there is a major ethical difference between psychiatric and physical medications in this respect.
Possible safeguards Advance directives may perhaps help provide some indication as to a patient’s views on covert medication. However, few of those making out an advance directive will have enough understanding of the potential problems that might arise. Most advance directives are written to preclude treatment, covert or otherwise. However, an advance directive that resulted in substantial harm to the patient would have to be challenged and rebutted before necessary treatment could be given.19 If this rebuttal was not possible then the patient might suffer unintentionally. The proposed Continuing Powers of Attorney12,13 may, strangely, increase the power of attorneys to require such practices, and would therefore need stringent safeguards to ensure that the attorney acts purely for the benefit of the patient. The protracted timescale, involving the use of these instruments, and the lack of apparent safeguards in current proposals, may mean that the use of common law remains the best, most flexible, and most transparent means of managing these problems. We believe that, in exceptional circumstances, professional carers may need to administer medications covertly to undertake their duty of care to mentally incapable patients. However, simply allowing this to occur without question risks abuse of patients. Putting medicine in cups of tea, rather than taking the time and effort to persuade and work with distressed patients may be time efficient but may also reinforce tolerance of poor staffing levels and standards in an elderly care setting. A recent inquiry highlighted this problem.20 To give a necessary treatment covertly requires a transparent procedure that can be open to question and scrutiny, and be framed within a local policy. First, it must be explicit that the patient is incapacitated with regard to the decision in hand. Second, the proposed method of administration must be discussed with relatives or advocates, and other involved professionals. Third, the practice should be part of the patient’s care plan and each occasion recorded so that monitoring and audit can be carried out.
Conclusion Carers have been shown to support the principle that medication may be concealed in foodstuffs in extreme
63
For personal use only. Not to be reproduced without permission of The Lancet.
VIEWPOINT
circumstances.1 Ethical analysis also supports this view. However, the secrecy currently surrounding this practice is not helpful. We believe that the secrecy results in professional-care staff failing to discuss the issue with others, and is a potential form of patient abuse. Covert administration of medication should be the subject of local, perhaps national, policy, and regulated.
9 10 11 12 13
14
References 1 2 3 4 5 6 7
8
64
Treloar A, Beats B, Philpot M. A pill in the sandwich: covert medication in food and drink. J Roy Soc Med 2000; 93: 408–11. Kellett J. A nurse is suspended. BMJ 1996; 313: 1249–50. Pereira S, Beer D, Paton C. Enforcing treatment with clozapine: a survey of views and practice. Psychiatr Bull 1999; 23: 342–45. Griffith D, Bell A. Treatment was not unethical. BMJ 1996; 313: 1250. Valmana A, Rutherford J. Over a third of psychiatrists had given a drug surreptitiously or lied about a drug. BMJ 1997; 314: 300. R v Bournewood Community and Mental Health NHS Trust. House of Lords Judgement 25; London: June, 1998. United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Standards for the administration of medicines. London: UKCC, 1992. Department of Health and the Welsh Office. Mental Health Act (1983) code of practice. London: HM Stationery Office, 1999.
15 16
17
18
19 20
BMA and Law Society. Assessment of mental capacity: guidance for doctors and lawyers. London: BMA, 1995. Re C (adult refusal of treatment). [1994] 1 WLR 290. Re MB (Medical Treatment) [1997] 2 FLR No 3. The Scottish Executive. Making the right moves: rights and protection for adults with incapacity. Edinburgh: HM Stationery Office, 1999. The Lord High Chancellor. Making decisions: the governments proposals for making decisions on behalf of incapable adults. London: HM Stationery Office, 1999. Jones R. Mental Health Act Manual, 6th Edition. London: Sweet and Maxwell, 1999. Dyer C. UK Human Rights Act will allow challenges to treatment refusals. BMJ 1998; 317: 1339. Gormley N, Howard P. Should neuroleptics be used in the management of nursing home residents with dementia? Int J Geriatr Psychiatry 1999; 14: 509–11. DeDeyn P, Rabheru K, Rasmussen A, et al. A randomised controlled trial of risperidone, placebo and haloperidol for behavioural symptoms of dementia. Int J Geriatr Psychiatr 1999; 14: 459–66. Colenda C, Streim J, Greene J, et al. The impact of OBRA ‘87 on psychiatric services in nursing homes: joint testimony of the American Psychiatric Association and the American Association for Geriatric Psychiatry. Am J Geriatr Psychiatr 1999; 7: 12–17. Treloar A. Advance directives: limitations upon their validity in elderly care. Int J Geriatr Psychiatr 1999; 14: 1039–43. The North Lakeland Healthcare NHS Trust External Review. London: North Lakeland Healthcare. North Cumbria NHS Health Authorityh and the NHS Executive, 2000.
THE LANCET • Vol 357 • January 6, 2001
For personal use only. Not to be reproduced without permission of The Lancet.
Viewpoint
Concealing medication in patients’ food Adrian Treloar, Michael Philpot, Barbara Beats
Introduction The practice of administering medication within the food or drink of patients has rarely been described.1–3 However, a recent study by our group1 showed that the practice is widespread, occurring in 79% of a sample of long-stay care settings for the elderly. Concern was expressed about the lack of openness and poor recording that surrounds the issue. In a companion study1 94% of carers of patients with dementia considered the practice to be justified. In 1996, Kellett2 reported the disciplinary action taken by a UK national health service (NHS) trust after a nurse had concealed haloperidol, prescribed by a consultant, in a patient’s drink, to provide treatment in an urgent and complex clinical situation. Although the patient later expressed clear gratitude for the action taken, the nurse effectively lost her career, and the consultant was strongly censured. Another more recent report described the administration of clozapine in drink in an intensive psychiatric care unit.3
Current legal framework in the UK Ethical opinion on the Kellett case from the Mental Health Act Commission Consent to Treatment Committee and the UK Central Committee for Nursing, Midwifery and Health Visiting agreed with the view that administering medication in the patient’s drink was justified in that case.2 Independent comment also agreed that the practice was acceptable,4,5 and one reviewer1 wrote that the practice was surely routine and uncontroversial. In opposition to this view, the Alzheimers’ Society (H Cayton, personal communication) has said that “We have serious concerns about the level of over prescribing of drugs to people with dementia in hospitals and care homes” and that “if medication is disguised, the likelihood of inappropriate administration of drugs, particularly sedative and anti-psychotic drugs, is increased.” It might be assumed that all medical treatment must be given after valid consent by a competent individual, or be given under the auspices of the Mental Health Act. This does not, however, address the problem identified in the Bournewood judgment, which states that the Mental Health Act did not necessarily apply in situations in which patients could not consent to treatment by reason of dementia or learning disability.
Lancet 2001; 357: 62–64 Oxleas NHS Trust and Guy’s, King’s, and St Thomas’ Medical Schools, Memorial Hospital, Shooters Hill, London SE18 3RZ (A Treloar MRCPsych); South London and Maudsley NHS Trust, and the Institute of Psychiatry, London (M Philpot FRCPsych); and St Martin’s Hospital, Canterbury, and Guy’s, King’s, and St Thomas’ Medical Schools, London, UK (B Beats MRCPsych) Correspondence to: Dr Adrian Treloar (e-mail: [email protected])
62
The UK Central Committee Standards for the Administration of Medicines7 state that “. . . the practitioner administering a medicine . . . can reasonably expect that the prescription . . . is based, whenever possible, on the patient’s awareness of the purpose of the treatment and consent (commonly implicit) . . . and that the practitioner . . . is able to justify any actions taken”. The standards do not deal with patients who are unable to give valid consent to treatment. The Mental Health Act Code of Practice8 states that medical treatment for mental illness may only be given informally to patients with mental capacity who consent to such treatment. Those without the capacity to consent are treated under common law by doctors discharging their “duty of care”. British Medical Association guidelines9 reflect the view that doctors have a duty to provide the best possible care to those who cannot choose for themselves. It has been argued that treatment in these circumstances should be carried out under the auspices of the Mental Health Act.6 However, the Percy Commission6 took a strongly libertarian view, restricting the use of the Mental Health Act only to those who had to be detained in hospital. Goff and colleagues6 believed that this implied that incapable patients should not automatically be detained under the Mental Health Act. This view is, in some ways, welcome because it would be impractical to transfer all incapacitated adults treated at home, and in most residential and nursing homes, to settings registered for the purpose of the Mental Health Act. The view does, however, leave a so called gap in the law that protects the incapacitated as Steyn6 pointed out in his judgement on the Bournewood case. Legal developments in the UK have recently established more clearly the definition of mental incapacity. In Re C this definition was further refined to include the ability to understand and retain information relevant to the decision in question, to believe that information, and to weigh the information in the balance in arriving at a choice. After the cases of Re C10 and Re MB,11 Scottish legislation12 and proposed legislation in England and Wales13 define mental incapacity as “. . . the inability by reason of mental disability, to make a decision on the matter in question, or to communicate that decision.” In essence, incapacity legislation recognises that individuals with severe learning disabilities or dementia may not be able to make valid choice about their health care and that society has a duty to provide good quality care for them in “the least restrictive fashion”.13 Up to now in the UK this has been carried out under common law.14 The proposed legislation may provide the opportunity to use statute law to the same effect. New legislation should not be enacted, however, unless the legislation genuinely improves the situation of the incapacitated patients. The incorporation of the Human Rights Act [1998]15 into UK law means that, in the absence of statute law, any action infringing the liberty of a person has redress in court. Thus, a doctor discharging his duty of care to an incapacitated patient may have to
THE LANCET • Vol 357 • January 6, 2001
For personal use only. Not to be reproduced without permission of The Lancet.
VIEWPOINT
defend himself in court. If further safeguards were required, it may be sensible to incorporate them into a package of measures for the mentally incapacitated such as those currently developed in Scotland12 and awaiting legislation in England and Wales. Procedures need to be sufficiently streamlined to enable treatment without unnecessary obstruction by cumbersome legal processes.
Covert drug administration in other countries In a search of medical literature we found no references to the methods in which drugs are administered to resistive but mentally incapable patients in other countries. This is surprising, because there is an ever-growing number of publications on the use of antipsychotic drugs in the treatment of behavioural and psychiatric symptoms in dementia (BPSD).16,17 In the USA, where the Omnibus Budget Reconciliation Act of 198718 (which incorporated the Nursing Homes Act) radically changed psychotropic prescribing practice in nursing homes, the issue may simply require the permission of the next-of-kin in some districts. In others (D Kamholz, personal communication) there may be a wider discussion. Where the decision involves a legal process this process may involve the appointment of a health-care guardian (B Kamholz, Br Reifler, personal communication). In Australia it is expected that the use of psychotropic medication is discussed with a relative or advocate, whether or not the incapacitated patient is compliant. Technically, the relatives’ consent is not required in law, though statutory processes of guardianship are used in small numbers for limited periods (D W O’Connor, personal communication). In Israel, the local clinical ethics committees are empowered to allow the covert administration of medicines in food. Administration has to be justified to the committee by the responsible physician on a case-by-case basis and is not a routine general procedure (Y Barak, personal communication).
Balancing the ethical viewpoints There are two conflicting views. The first holds that all deception is wrong and that patients like Joan (panel) should not be secretly given medication against their wishes, as it is a breach of her trust. The second is that because Joan is not able to comprehend the result of her refusal and is not making a valid choice, duty of care implies, that she should be deceived as a means of relieving her suffering in the least restrictive way. How can these two viewpoints be reconciled? We believe that the argument against deception is a strong one. If health-care staff decide that they can deceive their patients, then there is a high risk of abuse and consequently poor care. Indeed, the concern about concealing medication almost certainly derives from a fear that doctors, nurses, and others will misuse their powers and authority to the detriment of the patient. However, allowing a patient who cannot make a choice about treatment to refuse a difficult-to-swallow tablet, or a foul-tasting medicine, is to give an incapacitated patient Case example Joan is a 30-year-old woman with severe learning disabilities and epilepsy. She always refuses to take tablets or liquid medicines, but without antiepileptic medications she suffers from severe fits, and injures herself as a result. Without treatment she needs constant nursing attention and cannot be managed at home. With treatment her fits are controlled and she can live at home where she has a better quality of life. Her parents give her medication three times a day in her food, otherwise she will not take it.
THE LANCET • Vol 357 • January 6, 2001
the responsibility of capacity. Should the patient or others suffer as a result? and is it appropriate to hold the patient responsible for the outcome? The scrupulous attempt to avoid deception may, therefore, lead the doctor or nurse to deceive themselves that the patient has chosen to suffer harm. The argument in favour of proven treatments being given to those who cannot choose to accept or reject them is therefore, in our view, the over-riding one. In extreme circumstances this may well mean that treatment is concealed so that it is given in the least distressing or least restrictive fashion. The alternative, to repeatedly restrain and administer injections to a severely demented person who forgets what has happened before the net treatment, is cruel. A further ethical problem is the difference between medication for psychiatric disorder and that for physical disorder. The sense that antipsychotics change the mind whereas antibiotics heal the body, suggests that this might be the case. However, the ultimate aim of any treatment must be a reduction in distress and, where possible, an improvement in health. Moreover, physical ailments such as infections can have serious effects on mental state in patients with dementia. For these reasons we do not believe that there is a major ethical difference between psychiatric and physical medications in this respect.
Possible safeguards Advance directives may perhaps help provide some indication as to a patient’s views on covert medication. However, few of those making out an advance directive will have enough understanding of the potential problems that might arise. Most advance directives are written to preclude treatment, covert or otherwise. However, an advance directive that resulted in substantial harm to the patient would have to be challenged and rebutted before necessary treatment could be given.19 If this rebuttal was not possible then the patient might suffer unintentionally. The proposed Continuing Powers of Attorney12,13 may, strangely, increase the power of attorneys to require such practices, and would therefore need stringent safeguards to ensure that the attorney acts purely for the benefit of the patient. The protracted timescale, involving the use of these instruments, and the lack of apparent safeguards in current proposals, may mean that the use of common law remains the best, most flexible, and most transparent means of managing these problems. We believe that, in exceptional circumstances, professional carers may need to administer medications covertly to undertake their duty of care to mentally incapable patients. However, simply allowing this to occur without question risks abuse of patients. Putting medicine in cups of tea, rather than taking the time and effort to persuade and work with distressed patients may be time efficient but may also reinforce tolerance of poor staffing levels and standards in an elderly care setting. A recent inquiry highlighted this problem.20 To give a necessary treatment covertly requires a transparent procedure that can be open to question and scrutiny, and be framed within a local policy. First, it must be explicit that the patient is incapacitated with regard to the decision in hand. Second, the proposed method of administration must be discussed with relatives or advocates, and other involved professionals. Third, the practice should be part of the patient’s care plan and each occasion recorded so that monitoring and audit can be carried out.
Conclusion Carers have been shown to support the principle that medication may be concealed in foodstuffs in extreme
63
For personal use only. Not to be reproduced without permission of The Lancet.
VIEWPOINT
circumstances.1 Ethical analysis also supports this view. However, the secrecy currently surrounding this practice is not helpful. We believe that the secrecy results in professional-care staff failing to discuss the issue with others, and is a potential form of patient abuse. Covert administration of medication should be the subject of local, perhaps national, policy, and regulated.
9 10 11 12 13
14
References 1 2 3 4 5 6 7
8
64
Treloar A, Beats B, Philpot M. A pill in the sandwich: covert medication in food and drink. J Roy Soc Med 2000; 93: 408–11. Kellett J. A nurse is suspended. BMJ 1996; 313: 1249–50. Pereira S, Beer D, Paton C. Enforcing treatment with clozapine: a survey of views and practice. Psychiatr Bull 1999; 23: 342–45. Griffith D, Bell A. Treatment was not unethical. BMJ 1996; 313: 1250. Valmana A, Rutherford J. Over a third of psychiatrists had given a drug surreptitiously or lied about a drug. BMJ 1997; 314: 300. R v Bournewood Community and Mental Health NHS Trust. House of Lords Judgement 25; London: June, 1998. United Kingdom Central Council for Nursing, Midwifery and Health Visiting. Standards for the administration of medicines. London: UKCC, 1992. Department of Health and the Welsh Office. Mental Health Act (1983) code of practice. London: HM Stationery Office, 1999.
15 16
17
18
19 20
BMA and Law Society. Assessment of mental capacity: guidance for doctors and lawyers. London: BMA, 1995. Re C (adult refusal of treatment). [1994] 1 WLR 290. Re MB (Medical Treatment) [1997] 2 FLR No 3. The Scottish Executive. Making the right moves: rights and protection for adults with incapacity. Edinburgh: HM Stationery Office, 1999. The Lord High Chancellor. Making decisions: the governments proposals for making decisions on behalf of incapable adults. London: HM Stationery Office, 1999. Jones R. Mental Health Act Manual, 6th Edition. London: Sweet and Maxwell, 1999. Dyer C. UK Human Rights Act will allow challenges to treatment refusals. BMJ 1998; 317: 1339. Gormley N, Howard P. Should neuroleptics be used in the management of nursing home residents with dementia? Int J Geriatr Psychiatry 1999; 14: 509–11. DeDeyn P, Rabheru K, Rasmussen A, et al. A randomised controlled trial of risperidone, placebo and haloperidol for behavioural symptoms of dementia. Int J Geriatr Psychiatr 1999; 14: 459–66. Colenda C, Streim J, Greene J, et al. The impact of OBRA ‘87 on psychiatric services in nursing homes: joint testimony of the American Psychiatric Association and the American Association for Geriatric Psychiatry. Am J Geriatr Psychiatr 1999; 7: 12–17. Treloar A. Advance directives: limitations upon their validity in elderly care. Int J Geriatr Psychiatr 1999; 14: 1039–43. The North Lakeland Healthcare NHS Trust External Review. London: North Lakeland Healthcare. North Cumbria NHS Health Authorityh and the NHS Executive, 2000.
THE LANCET • Vol 357 • January 6, 2001
For personal use only. Not to be reproduced without permission of The Lancet.