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Charting a Transgender Patient

July 11, 2018 | What Would Lillie Do?

Name: Teri
Position: Nurse Navigator
Subject: Patient seeking help contacted ONN

Question:
The wife of a patient who was in emotional distress sought out my help as an ONN to try to get the patient’s sentinel node pathology report after receiving no calls from the surgeon or RN case manager for several days after the results were posted. My attempts to remedy this with the surgical team were unsuccessful, so when the patient contacted me a second time I discussed the path with her, calmed down the situation, and notified the surgeon. I do not work directly with the surgical team but navigate at the center. I am now in trouble. WWLD?

Answer:
Although you were clearly serving as the patient advocate, you crossed over your boundaries into an area that likely is the exclusive domain of the surgeons. And because you don’t work FOR the surgeon, this is where the “trouble” part came into play. Keep in mind, too, that the results of the nodal status could have made her more alarmed if the pathology report showed they were positive; and if negative, the patient may have assumed there would be no need for medical oncology treatments.

With that said, I would have paged the surgeon or case manager. They would have a phone number for urgent matters, including if they were even out of town, which patients are to use when an urgent medical issue arises. Although this was not an issue of that specific type (eg, bleeding, high fever), it was still urgent to make the surgeon aware that the patient has now contacted you twice. The surgeon then could do 1 of 2 things—call the patient himself or give you the authority to provide the patient with the results AND if the latter, also tell you what, specifically, to tell the patient is the next step based on the path results. In addition, it would give you an opportunity to form a closer relationship with the surgeon/case manager and create a policy of how to handle such calls that occur in the future. Now it is time to mend this fence so that the surgeon/case manager will be comfortable with you interacting with their patients in general. Of course, document this situation, and report it to your immediate supervisor.


Name: Valerie
Position: Nurse Navigator
Subject: Transgender patients

Question:
For documentation purposes for a trans-masculine patient, is the pronoun in charting “she” or “he”? Our LCSWs are using “he,” when she has not had the reassignment surgery because she is essentially dying but identifies as a male. I want to be accurate in charting. Thoughts?

Answer:
It’s sad that the remaining surgery to complete the reassignment isn’t possible before this patient dies. To avoid having to label, most people will chart “the patient,” and not specific gender in such cases. I have also been reading about the preferred use of the word “they” instead of “he” or “she.” Technically speaking, to answer your question, it would be “she.”


Name: Amber
Position: Nurse Navigator
Subject: Workflow

Question:
I am pretty new to nurse navigating. I strictly deal with prostate cancer patients. I was wondering if you could give me some tips/pointers on how to be the best I possibly can be at my role. What do other navigators do/use to help them from day to day?

Answer:
Spend some dedicated time with a surgical oncology nurse, medical oncology nurse, and radiation oncology nurse who specialize in the care of this patient population. You need to be an expert in educating patients about the various types of treatments they may be receiving, as well as well-versed on side effects and complications.

The patient needs to see you as their advocate, and not as a woman. This is because men don’t like discussing sensitive topics like sex, incontinence, and the like with a female of any kind. You, however, must feel very comfortable discussing these topics and must do so in a way that makes the patient comfortable, as well.

You must get to know the patient’s spouse/partner as well as the patient you are navigating. These wives have more questions than the men will state, but may not be comfortable talking about them in front of their husbands. It doesn’t matter if they have been together for 6 months or 40 years, women avoid discussing sexuality, intimacy, and hygiene issues that they are witnessing and experiencing, and have no clue how to address. So you need to be really comfortable in this arena. Consider yourself the future Dr Ruth!

You will also be dealing with patients who are diagnosed but will not undergo treatment and will be in the monitoring program instead of the treatment program. These patients must be honest about any symptoms they are experiencing that are new or progressing. You must treat this subject matter like you would talking about a neutral topic, like washing a car.

You also, of course, must learn to what degree the doctors who are treating these patients get into the details of side effects management. Time continues to grow shorter for doctors to spend devoting time having these conversations, unfortunately, which increases the need for navigators to step in.
Consider forming a support group, as well—go the extra step and create a separate one for the spouses/partners!

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