Beneficence

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).

Non-maleficence

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.

Mental capacity

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).

Resources

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).

Needs of others

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.