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By Barbara Mackey-Zeigler, BSN, RN, CCM

Reflecting on my experiences and with my own family, a couple of things come to mind: Are we asking the right questions? What are we missing when we talk with patients about their medications? What aren’t they telling us? I learned firsthand from my mother that things aren’t always what they seem.

My Mom was a wonderful woman, highly educated, an artist who was not afraid of color! She could brighten a room like no other with a can of paint and a brush. She wore all the colors of the rainbow and changed her hair color often, all before this was fashionable. She was always telling me to add color to my every day in any way that I could. I talked to her on the phone nearly every day. In addition to daily events, we talked about her health, her medications, her doctor’s appointments and preventative care.  The nurse in me always came out in our conversations.

Mom was able to review her medication list with me over the phone, assured me she understood her meds, the side effects and was taking them as directed. She and her husband, Bill, had downsized from a home and transitioned into an independent living apartment, which had the options of assisted living and skilled care as needs changed. It seemed like a good fit for them. Mom brought her apartment to a new level of life as she added multiple splashes of color to her walls and to every room.

The holidays had arrived and Mom welcomed me with open arms on my first visit to her new independent living apartment. With her pink aluminum Christmas tree in the corner of the room along with the many splashes of color on the walls, I knew I was “home.”  The Christmas tree color wheel was spinning and illuminating the tinsel tree in multiple colors throughout her apartment.  We had a wonderful visit and she invited me to stay for refreshments at her small beautifully decorated table.

As I joined Mom and Bill at the table, I noticed a beautiful large cut crystal bowl filled with multiple colors inside. From a distance, it looked like a bowl of M & M’s!  My mouth began to water; she knew how much I loved chocolate and I was sure she had meant the treat for me!  Sitting down, I inched myself closer to the beautiful bowl. As I reached my hand out toward the bowl, I realized in horror that the colorful display was not chocolate but an arrangement of loose medications of many colors and sizes.

I looked over at Mom with her bright red hair, ornamental earrings and bracelets up and down her arms that jingled on the table: "Mom, what are you thinking? Are these your pills?"

"Oh honey, do you like the arrangement? I think they are so colorful!"
"But Mom, how do you know which pills to take and when?" Mom dismissed me with her hand, fingers covered with beautiful handmade sterling rings. Shaking her head, "Oh, honey please don’t worry; I put Bill's pills in the bowl too. They add so much more color, don’t you think? We both just take a handful when we need them." She giggled and squeezed Bill’s hand. They looked like two starstruck lovebirds gazing into each other’s eyes and smiling with not a care in the world.

I must tell you that the nurse in me was having a heart attack! How did it come to this and what did I miss while talking with Mom every day?  She checked all the boxes in my book; she was able to recite a list of her medications, to tell me the side effects, able to afford them and to report she was taking them as directed.  However, she was also decorating her new home over the holidays with a colorful crystal bowl of pills with absolutely no concern of possible interactions and consequences of ingesting too many and/or the wrong pills.

Although it took time to sort out all the medication issues with Mom and Bill, it gave me insight as to what was important to them and their lack of understanding. Mom loved color and thought she had created a beautiful table arrangement and an easy way to take medications. She and Bill had no idea how dangerous medications can be when mixed with others and taken a handful at a time from a large bowl. No matter how many pill boxes and locked med boxes were set up for Mom and Bill, they were resistant to change. Consequently, the best and safest option was to have the nursing staff at the facility administer all medications.

Whether at the bedside, the doctor’s office, in the home setting or over the phone, reviewing medications with our patients is a priority.  As nurse case managers, we also have an opportunity to educate and ask questions. In addition, we help our patients organize a medication list, encourage them to take it with them to review at their office visits. We suggest methods to safely dispense medications such as a pill box and explore additional resources that may assist with medication costs.

I find myself asking: are we moving so quickly through our assessments and checking our boxes that we forget to ask patients what is important to them? What are we overlooking? I missed a great deal with my own mother and seeing the crystal bowl of pills was spine-chilling. Thankfully, she and Bill had no life-threatening interactions and their medication regimen was able to be well controlled.

But I bet you’re wondering, what are the right questions? I’ve given it thought, searched my heart and I'm still not sure I have answers. To this day, I still question myself on how I missed what wasn't said with Mom. Perhaps if I asked Mom how she was decorating her new home for the Christmas holiday, she may have shared about her beautiful table arrangement and the crystal bowl full of an array of colorful pills. Maybe if I included more open-ended questions rather than my checklist, I would have sensed safety issues: "Mom, can you tell me a little bit about your morning routine and when you take your medicines?  What is the best way for you to store medicines?" Mom was using her pillbox; she just failed to tell me how. She was filling it with an assortment of beads, crystals and tiny pieces of silver she used on her many art projects. Another question I should have asked: "What is most important to you about your medications?" Color was important to Mom and pills come in so many colors! The takeaway for me is that I no longer rush through my checklist of questions with medication reconciliation. I take more time to inquire, explore and encourage patients to share with me their medication regimen to better identify what they might not be telling me and how I can help.

Although Mom is gone now, I cherish the many memories we had together. She continued to splash color in different ways in her home and during her lifetime. Her creative outlook and zest for life was amazing! She taught me a great lesson: never stop asking questions of any kind and things are not always what they seem!

Barbara Mackey-Zeigler, BSN, RN, CCM, is a Certified Case Manager. She is currently working as a telephonic case manager in managed care. Barbara has been an active member in her local chapter, Southern Ohio Valley Case Management Society of America (SOV-CMSA), since its inception. She has served on the board of her local chapter in multiple positions. Barbara is passionate about case management, advocating for the profession and making a difference in the lives of others.

How can you improve adherence? Motivational Interviewing. To learn more about this 8-hour online course and the discount for CMSA members, go to https://cmsa.org/mi-learning/