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• To recognise the ethical issues associated with administering antipsychotic medicines to people with dementia
• To learn about the main elements of various ethical frameworks and theories commonly used in nursing
• To enhance your understanding of how you could apply ethical frameworks to your practice
Antipsychotic medicines are often prescribed ‘as required’ to manage behavioural and psychological symptoms of dementia, despite evidence that these medicines have little benefit for people with dementia and have numerous adverse side effects, including sedation. It is the nurse’s role to decide if and when to administer antipsychotic medicines that have been prescribed on an as required basis. This decision-making is underpinned by complex ethical considerations such as mental capacity, chemical restraint, quality of life and autonomy. Adopting a person-centred approach and considering the ethics, guidelines and legislation related to such decisions can support nurses to act in patients’ best interests. This article uses two ethical frameworks – the four principles of biomedical ethics and the ‘four quadrants’ approach – to examine this complex issue and to demonstrate their use in the context of ethical decision-making in nursing practice.
Nursing Older People. doi: 10.7748/nop.2023.e1440
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Vaughan J (2023) Ethical decision-making in the administration of ‘as required’ antipsychotics to people with dementia in care homes. Nursing Older People. doi: 10.7748/nop.2023.e1440
Published online: 10 May 2023
Nurses regularly encounter ethical dilemmas in their practice and therefore require the ability to apply the principles of biomedical ethics – that is, autonomy, non-maleficence, beneficence and justice (Beauchamp and Childress 2001) – to their decision-making. These principles are reflected in The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council (NMC) 2018), the 6Cs – care, compassion, courage, communication, commitment and competence (NHS England 2015) – and the principles, values and pledges outlined in the NHS Constitution for England (Department of Health and Social Care (DHSC) 2021a).
Caring for people with dementia can present nurses with ethical dilemmas, including if and when to administer antipsychotic medicines that have been prescribed on an ‘as required’ basis. More than 90% of people with dementia experience behavioural and psychological symptoms of dementia (BPSD), which can include agitation, aggression, hallucinations and delusions, while nearly two thirds of people with dementia living in care homes will be experiencing these symptoms at any one time (Alzheimer’s Society 2018).
National Institute for Health and Care Excellence (NICE) (2018) guidelines recommend using psychosocial interventions for the initial management of BPSD and state that antipsychotic medicines such as haloperidol or risperidone should only be prescribed for people with dementia who are experiencing severe agitation or distress and for whom first-line interventions have failed to reduce their symptoms (NICE 2022). Over the past 15 years, several national strategies and reviews have called for a drastic reduction in antipsychotic prescribing in people with dementia and an increase in the use of non-pharmacological approaches to the management of BPSD (Department of Health (DH) 2009a, 2009b, 2015). However, despite such guidelines and strategies, pharmacological interventions such as antipsychotics are still often used as a first-line treatment in practice (Alzheimer’s Society 2018).
When antipsychotics are prescribed on an as required basis, it is the nurse’s role to decide if and when the person should be given these medicines (Care Quality Commission (CQC) (2022a). This is a complex decision-making process involving various ethical considerations. This article provides an overview of some of the ethical issues involved in nurses’ decision-making regarding the administration of as required antipsychotics to people with dementia living in care homes. It discusses some ethical theories and illustrates how nurses can use two ethical frameworks – the four principles of biomedical ethics (Beauchamp and Childress 2001) and the ‘four quadrants’ approach (Jonsen et al 1998) – to consider various moral and legal issues related to decision-making in this context.
• Antipsychotics should only be considered as a last resort for the management of behavioural and psychological symptoms of dementia and only as the least restrictive option
• When antipsychotics are prescribed ‘as required’, nurses can apply ethical theories and ethical frameworks to support their decision-making about if and when to administer these medicines
• Two widely used ethical frameworks in healthcare decision-making are the four principles of biomedical ethics (autonomy, non-maleficence, beneficence and justice), and the ‘four quadrants’ approach
• The four quadrants approach incorporates the four principles of biomedical ethics and comprises medical indications, patient preferences, quality of life and contextual features
Healthcare professionals use a range of ethical theories and frameworks that offer them access to a ‘common morality’ or ‘set of principles that can be applied to any biomedical issue’ to support their decision-making (Herring 2020). Two important ethical theories related to decision-making in healthcare are utilitarianism, also referred to as consequentialism, and deontological (non-consequentialist) ethics. Utilitarianism theorises that decisions should be made based on their consequences, where the ‘morally right’ consequences are those that produce the greatest good for the greatest number (Avery 2013). In contrast, according to deontological ethics, actions or decisions based on duties and obligations are inherently morally right or wrong regardless of the consequences (Misselbrook 2013).
Two widely used ethical frameworks in healthcare decision-making are the four principles of biomedical ethics, comprised of autonomy, non-maleficence, beneficence and justice (Beauchamp and Childress 2001), and the four quadrants approach (Jonsen et al 1998). The four quadrants approach incorporates the four principles of biomedical ethics and offers a ‘more practical and clinically oriented approach to ethical challenges’ (Teven and Gottlieb 2018) through analysis of four domains: medical indications, patient preferences, quality of life and contextual features. Using these frameworks together can support nurses to make complex ethical decisions.
The following sections of this article explore each of the four quadrants in relation to administration of antipsychotics to people with dementia living in care homes.
The first quadrant involves analysis of the benefits and risks of a healthcare intervention based on the principles of beneficence and non-maleficence (Jonsen et al 1998). Beneficence in this context means to provide a benefit or ‘do good’ for the patient, while non-maleficence is the principle of causing no harm or distress (Herring 2020).
Antipsychotics should only be considered as a last resort for the management of BPSD (NHS England 2022) and only as the least restrictive option (CQC 2022b), which is in line with principle five of the Mental Capacity Act 2005: ‘Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action’ (Department for Constitutional Affairs 2007).
NICE (2018) guidelines state that before commencing medicines for the management of non-cognitive symptoms of dementia, for example agitation or distress, an assessment should be undertaken to explore the reasons for the person’s distress, including clinical and environmental causes such as delirium or pain. The Abbey Pain Scale (Abbey et al 2004) was designed to identify pain in people who are unable to communicate their needs, and nurses can use this tool to identify or rule out pain in the person displaying BPSD. Organic causes of agitation or distress such as constipation, inadequate nutrition or infection should also be assessed and managed, in collaboration with the person’s GP if required (Oxford Health NHS Foundation Trust 2019).
Following this initial assessment, psychosocial and environmental interventions should be used to reduce symptoms of distress (NICE 2018). Resources such as the Reducing Antipsychotic Prescribing in Dementia Toolkit (PrescQIPP 2014) and the Alzheimer’s Society (2018) best practice guide on optimising treatment and care for people with BPSD describe a range of non-pharmacological approaches to the management of BPSD. Such approaches include distraction and/or stimulation with activities, conversations, games, looking at photographs or going for walks (Alzheimer’s Society 2018). However, workload pressures and time constraints can sometimes mean that nurses and other professionals are unable to implement such approaches (Rapaport et al 2018, Watson and Hatcher 2021), meaning that antipsychotics may be used instead.
If a person’s BPSD do not improve an antipsychotic may be prescribed – in the UK, haloperidol and risperidone are the only antipsychotics licensed for the treatment of non-cognitive symptoms of dementia (NICE 2022). NICE (2018) guidelines state that these medicines should only be administered if the person is at risk of harming themselves or others or experiencing agitation, hallucinations or delusions that are causing them severe distress.
Where an antipsychotic is prescribed as required, the nurse can educate themselves about the indications for such medicines, and ensure they are ‘satisfied that the medicines or treatment serve that person’s health needs’ (NMC 2018), by referring to toolkits and best practice resources such as those mentioned previously. This will help to ensure that their decision-making is based on the principles of beneficence and non-maleficence (Jonsen et al 1998).
Policies and strategies aimed at reducing antipsychotic prescribing for people with dementia and increasing the use of non-pharmacological interventions (DH 2009a, 2009b, 2015, Medicines and Healthcare products Regulatory Agency 2014) emphasise that healthcare professionals have a duty or obligation to achieve these aims (Herring 2020). Therefore, from a deontological perspective, the nurse could argue that the existence of such policies means that any use of antipsychotics with people with dementia is morally wrong.
Antipsychotics can have numerous adverse effects on the person with dementia – including drowsiness, increased risk of falls, reduced cognitive function, increased risk of stroke and death (Alzheimer’s Society 2021, NICE 2022, Electronic Medicines Compendium 2023) – while evidence suggests that they provide little benefit for people experiencing BPSD (DH 2009b). Although BPSD can vary in intensity and frequency, dementia is a progressive neurological condition and symptoms will not improve over time, so people with the condition require long-term symptom management. However, in the UK antipsychotics are only licensed for use as a short-term treatment for the management of BPSD; risperidone may only be used for up to six weeks, while the use of haloperidol must be reviewed after six weeks (NICE 2018). Continuation of antipsychotics after this period should only be considered where there is ‘severe risk or extreme distress’ (Alzheimer’s Society 2018). Therefore, the nurse could argue that administration of antipsychotics is not an appropriate treatment approach for people who require long-term management.
If antipsychotics are prescribed for longer periods than they are licensed for, the prescriber assumes full responsibility for the decision (CQC 2022b). However, this still raises an ethical dilemma for the nurse responsible for administering the medicine. In such a situation, the nurse can draw on the principle of non-maleficence by ensuring that the person receives regular medication reviews and is referred to a specialist, such as a clinical psychologist, and by advocating for a gradual reduction in the use of the antipsychotic (Alzheimer’s Society 2018). Bjerre et al (2018) have developed an antipsychotic deprescribing algorithm that can support deprescribing decision-making.
This quadrant considers the patient’s preferences and mental capacity, as well as the biomedical ethical principle of autonomy (Jonsen et al 1998), which relates to people’s right to make their own decisions (Herring 2020). The principle of autonomy can be linked with Article 5 of the Human Rights Act 1998, which protects people’s right to liberty and security, and Regulation 11 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which states that: ‘Care and treatment of service users must only be provided with the consent of the relevant person’.
Under the Mental Capacity Act 2005 a person is regarded as lacking capacity to make a decision if they are unable to: understand the information relevant to the decision; retain that information; use or weigh that information as part of the process of making the decision; and/or communicate their decision (Department for Constitutional Affairs 2007). People with advanced dementia often lack capacity and are therefore unable to state their preferences or give consent to treatment (Oxford Health NHS Foundation Trust 2019). However, a person’s capacity can fluctuate and should therefore be regularly assessed (Social Care Institute for Excellence 2017a).
The nurse may be able to establish the person’s preferences through discussion with family members, or by determining if the person has made an advance care plan or an advance decision with regards to refusal of specific medical treatments. It is important to be aware that an advance decision is a legally binding document under the Mental Capacity Act 2005. In the absence of an advance care plan or an advance decision, UK law allows the administration of medicines to people who lack capacity under the Mental Capacity Act 2005 if it is deemed to be in their best interests (Department for Constitutional Affairs 2007). Determining a person’s best interests is complex and the Mental Capacity Act 2005 requires several steps to be followed each time an action or decision is required (Department for Constitutional Affairs 2007).
Chemical restraint is an additional ethical issue in this context. If a medicine has a sedative effect and is used to control behaviour, under the Mental Health Units (Use of Force) Act 2018 it is regarded as a form of chemical restraint even if the person has not refused to take it (DHSC 2021b). In this case a Deprivation of Liberty Safeguards application will be required, which is an additional safeguard within the Mental Capacity Act 2005 to ensure that any restrictions on a person’s liberty are in their best interests (Social Care Institute for Excellence 2017b, Alzheimer’s Society 2023). With regards to the principle of autonomy, Watson and Hatcher (2021) asserted that chemical restraint of people with dementia reduces their liberty by impairing communication, increasing confusion and reducing opportunities for them to contribute to decision-making about their care or to engage with alternative therapeutic approaches. This underlines the recommendation that an antipsychotic should only be used as a last resort when patients pose a risk to themselves or others or are in extreme distress (NICE 2018, 2022).
The third quadrant brings together the principles of autonomy, non-maleficence and beneficence to consider how the benefits, risks and effects of a decision or action will affect the person’s quality of life (Jonsen et al 1998). However, quality of life is subjective and therefore challenging to quantify. Although there are multiple quality of life measurement tools, the interpretation of outcomes can vary among healthcare professionals and between disciplines (Haraldstad et al 2019). For example, one healthcare professional may believe that administering an antipsychotic will improve a person’s quality of life by reducing their BPSD, while another may believe it would not improve the person’s quality of life because the medicine might reduce their alertness and therefore adversely affect their autonomy. This emphasises the importance of referring to the person’s previously expressed beliefs and wishes where possible, which is underlined by the World Health Organization (1995) definition of quality of life as ‘an individual’s perception of their position in life… in relation to their goals, expectations, standards and concerns’.
Healthcare professionals can seek the opinion of the person’s next of kin to inform their decision-making. Family members may be concerned if their relative is regularly given medicine that has a sedative effect. If the person is not alert when family members visit, this may jeopardise Article 8 of the Human Rights Act 1998, the right to respect for private and family life. In such a situation, a best interests meeting involving all relevant parties would be required (Oxford Health NHS Foundation Trust 2019). By remaining person-centred and identifying the person’s values, the nurse can make decisions about administering antipsychotics that are aligned with the person’s wishes and are therefore in their best interests.
The fourth quadrant considers the wider context of a decision, for example the influence of external factors such as resources and the concepts of loyalty and fairness, which can relate to the needs of others (Jonsen et al 1998). This quadrant can be linked to Beauchamp and Childress’s (2001) ethical principle of justice, which is described as the fair distribution of resources ‘determined by justified norms that structure the terms of social cooperation’. In the context of UK healthcare, fairness involves ensuring that individuals receive appropriate treatment that meets their clinical needs (DHSC 2021a). However, as the NHS has finite resources, the notion of fair distribution of resources is complex (Herring 2020).
The increasing numbers and clinical complexity of people in care homes have increased the demands on resources, staff time and workload (DH 2009b). If more of a care home’s resources are devoted to one person because of their BPSD, this could be regarded as an unfair allocation. An Australian study, conducted in two acute care settings, found that nurses felt pressured to administer antipsychotics to older people experiencing delirium because of their high workload, competing care priorities and lack of staff, as well as to protect the time available to care for other patients (Tomlinson et al 2021).
The Banerjee report (DH 2009b), which reviewed the use of antipsychotics in people with dementia, called for further training in psychosocial therapies for healthcare professionals and additional resources to enable provision of such therapies, as well as increased input from dementia specialists and pharmacists in care homes. Additionally, NICE (2018) guidelines and the Framework for Enhanced Health in Care Homes (NHS England and NHS Improvement 2020) recommend training in the management of BPSD for care home staff, while the CQC (2022b) requires care homes to provide person-centred guidance for staff in relation to administration of as required antipsychotics. However, despite these recommendations and requirements, such training does not appear to take place regularly in practice, partly due to high staff turnover (Rapaport et al 2018), and the use of antipsychotics as a first-line treatment for BPSD remains widespread (Alzheimer’s Society 2018).
There is evidence that increasing the overall number of staff and the amount of specialist staff input to provide one-to-one care interventions for people with dementia can reduce the frequency of BPSD symptoms such as agitation and restlessness (Goonan et al 2019). However, several contextual factors prevent implementation of such person-centred interventions, including a task-oriented healthcare culture, high workloads and low staffing levels (Rapaport et al 2018). Additionally, where BPSD have escalated, some nurses do not believe that non-pharmacological management approaches make enough of a difference compared with the instant symptom-reducing effects of antipsychotics (Tomlinson et al 2021).
The decision to administer antipsychotics can also be influenced by the needs of other residents and caregivers, when behaviours such as loud or continuous vocalisations are perceived as distressing to others in the vicinity (Watson and Hatcher 2021). Some nurses have reported that they feel judged by colleagues if they cannot stop disruptive behaviours and believe they need to minimise the effect of such behaviours on other people (Rapaport et al 2018, Tomlinson et al 2021). Tomlinson et al (2021) found that prescribers felt pressured to prescribe antipsychotics for people experiencing delirium due to their desire to assist nurses and carers, despite knowing the potential side effects of such medicines. Additionally, nurses may experience feelings of stress, powerlessness and fear when people demonstrate behaviours that challenge, so safety may be a factor in decision-making (Alzheimer’s Society 2018, Rapaport et al 2018).
Proponents of utilitarianism would argue that the moral action would be to achieve the best outcome for the majority (Avery 2013). In the context of administering antipsychotics, using these medicines to manage one person’s behaviour might enhance the quality of life of more people, for example other residents and staff. The English philosopher John Stuart Mill advocated for this approach in his ‘harm principle’, the notion that others are ‘justified in interfering in individual liberties to avoid harm to third parties’ (Holland 2014). However, this idea of basing decisions on achieving the greatest good for the greatest number appears at odds with the NHS Constitution’s focus on the needs of the individual (DHSC 2021a). It is often challenging for nurses to achieve a balance between providing a patient with the care they need, not compromising the care of other patients and considering the feelings of other staff members.
Antipsychotics should only be used as a last resort in the management of BPSD, where psychosocial interventions have failed to reduce such symptoms and/or where the person is displaying extreme distress or putting themselves or others at risk. However, these medicines are still widely prescribed for people with dementia, despite guidelines, national strategies and reviews that aim to reduce antipsychotic prescribing in this population and increase the use of non-pharmacological approaches to the management of BPSD.
When antipsychotics are prescribed on an as required basis, nurses have to make complex decisions about if and when to administer them. Nurses can apply ethical theories and ethical frameworks to support their decision-making. Such theories and frameworks can assist nurses to analyse the potential benefits and risks of a decision, consider the person’s preferences and mental capacity, reflect on the effects their decision may have on the person’s quality of life and consider wider contextual factors, such as resources and the needs of colleagues or other residents.
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