Dear Ladies,

I am wondering what the responsibility of the RN caring for the client is that recognizes a lactation need and does not make an appropriate referral.  We are responsible to assess for social work, nutrition, financial assistance, child protective services, physical therapy and so forth.  In the facilities I have worked in these referrals were initially made by the RN, after completing our admission assessment, and done without physician's orders until the initial consult was completed determining further need.  Withholding specific therapies seems negligent from my perspective and is an entirely different issue than a second physician seeing the same client - a second opinion.  Further, most often a lactation consult within a hospital facility isn't charged separately, so there is no specific cost concern here for an inappropriate referral.

As a midwifery student, I recognize the frustration with having another practitioner offer differing advice or counsel than my own, particularly when that advice is incredibly wrong.  However, my job is to build a report with my client, not only so she will trust and respect my counsel, but so that I can encourage her to be a responsible health-care consumer and do some of her own research with my guidance.  Our relationship with our client is collaborative, not ownership.  I simply need to trust that she will make the best decision for her family, even when using additional resources, and hopefully the work I put into educating her would prevent the confusion caused by others offering contradictory information.  It is so rewarding to actually witness "my client" educate staff in these situations because we have already discussed the issue and/or she has done her own research.  It may even be likely that I learn something from what my client gained from another practitioner/consultant!  So, ultimately, my placing any "hold" on my client is territorial and unprofessional - in my opinion.

As a private practice L.C., I have referred clients to cranio-sacral or chiropractics, as well as back to their primary physicians.  I also send follow-up letters to all practitioners involved with a great deal of rationale/references for my care plan.  Not too long ago I received an angry call from a physician (her secretary actually) informing me not to refer her clients to a chiropractor.  Until the physician is willing to discuss her concerns with me more professionally, one-on-one, I simply reminded her secretary that I appreciated her call but I work for the client and this is their decision.  It may have been very likely that she simply wanted to see them first or had a specific therapy or even practitioner she preferred.  I would be happy to support her if she were respectful enough to communicate with me appropriately.  Until then, my responsibility is to the client and my role is to inform her of her options, while offering her the most evidence-based approach available.

However, this was also my philosophy while working in the hospital.  I got in trouble more than once and like Marsha Glass I am no longer working "scripted" by physicians, but am poor and happy working directly for the client.  My client satisfaction rates were always bringing me bronze or silver awards from the corporation, but ironically making the care providers happy was priority over client satisfaction or any outcomes achieved.

God Bless,
Penny Lane RN, BA, IBCLC
Maternal & Child Health: Lactation Consulting
Believe - Birth & Breastfeeding Resources
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