When an elderly patient repeatedly refuses to take his medication, spitting it out or hiding it under his bedding, health-care staff decide to employ a little subterfuge.
The next day, nurses conceal the drugs in the patient's scrambled eggs, doing covertly what the man would not let them do overtly.
It is the kind of guile parents often use on small children, but administering medication by deception has become surprisingly common in Canada's health-care system, say some ethicists, lawyers and geriatric specialists. The practice is sparking debate over what is justifiable in treating unco-operative patients, especially those impaired by dementia.
A bioethics professor and lawyer who discussed the issue at a recent conference warn that giving drugs without consent risks harming the relationship between patients and health workers, and could actually undermine the safety of treatment.
"If I as a family member found out that medication was being given this way … I would start raising questions about 'Well, what else are you doing?'," said Dr. Christy Simpson, head of Dalhousie University's bioethics department. "It becomes a broader question of trust, and all of us have an interest in trusting our health-care institutions."
Doctors respond that the practice can be essential for ensuring the health and safety of those getting the drugs, as well as of other patients and staff, and is done with careful thought and planning.
Patients could die if they failed to take hypertension, diabetes or heart pills — or cause themselves or others harm without psychiatric medication, they said.
"It's no different than deciding to give the patient medication orally or … giving it to them intravenously," said Dr. Nathan Herrmann, head of geriatric psychiatry at Toronto's Sunnybrook Health Sciences Centre. "It is not deception, it is a practical way of administering a medically indicated therapy."
The controversy seems a little manufactured, added Dr. Michael Gordon, both a geriatric expert and head of medical ethics at Toronto's Baycrest.
"Even deception is a created paradigm," he said. "When someone has severe dementia, everything is deception."
Regardless, the practice is likely to become more prevalent in coming years, as the population ages and hospitals and nursing homes become increasingly populated by old people with Alzheimer's disease or other forms of dementia, doctors agree.
No one has documented exactly how often medicine is given covertly to patients in Canada. A smattering of studies in Europe, however, suggests it is relatively routine, principally among those who are mentally incapacitated.
A 2010 British review of previous research found that 43-71% of nursing homes surveyed gave pills secretly to residents. Incomplete documentation of the practice was common, and nursing staff alone often made the decision to do it, the review concluded.
Dr. Simpson and Martina Munden, a Halifax health-care lawyer, said they decided to talk about the issue at the Canadian Bioethics Society conference last month after hearing of several recent instances of covert drug administration in both hospitals and nursing homes.
Most cases were similar to one they outlined at the forum, said Dr. Simpson.
It involved a long-term-care resident who stopped taking his medications, became agitated and unwell and had to be hospitalized. In response, nurses gave the drugs in his tea, the patient eventually growing calmer, more co-operative and healthier. Staff had not, however, determined that the man was incapable of consenting to treatment, the pair said.
As well as potentially undermining trust, secreting drugs in food or hot drinks risks the dosage being altered or patients not taking the correct amount, said Ms. Munden.
There are times when deception may be justified with mentally incompetent patients, but only as a last resort and after staff obtain consent from family members, said Dr. Simpson.
Physicians specializing in geriatric care confirmed that the practice is relatively common with patients judged to be mentally incompetent, both for their own good and occasionally that of neighbours at risk from violent behaviour.
"Sometimes we have to curtail the autonomy of an individual, so as not to harm the people around them," said Dr. Mireille Norris, a geriatrics professor at the University of Toronto.
Family members would have to consent to particular drugs being given to the individual, though not necessarily to actually hiding it in food or drinks, said Doctors Herrmann and Gordon.
Christine Taylor, a gerontologist who runs the nursinghomeratings.ca website, said she has never received a complaint about covert drug administration, and doubts that any family member would mind, if it ensured their loved one received a needed drug.