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American Association of Nurse Life Care Planners®
Nurse Life Care Planning
Scope and Standards of Practice
April 24, 2015
Contributors
Editor
Wendie A. Howland, MN, RN-BC, CCRN, CCM, CNLCP, LNCC
Scope and Standards Workgroup
Becky Czarnik MS, RN, CLNC, LNCP-C, CMSP
Lori Dickson, MSN, RN, MSCC, CLCP, CNLCP
Jacquelyn Godlove-Morris, RN, BSN, CRRN, CNLCP
Wendie A. Howland, MN, RN-BC, CCRN, CCM, CNLCP, LNCC
Shelly Kinney, MSN, RN, CNLCP, CCM
Victoria Powell, RN, CCM, LNCC, CNLCP, MSCC, CEAS, CBIS
Patricia Rapson, RN, CCM, CNLCP, CLCP, CBIS, MSCC
Anne Sambucini, RN, CCM, CDMS, CNLCP, MSC-C
Joan Schofield, MBA, BSN, RN, CNLCP
Nancy Zangmeister, RN, CRRN, CCM, CLCP, MSCC, CNLCP
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TABLE OF CONTENTS
Prologue …………………………………………………………………………………………….…... 3
About the AANLCP ……………………………………………………………………………….…… 4
Introduction ……………………………………………………………………………………….…..… 5
The Origins of Nurse Life Care Planning, 1997
Foundation and Framework of the Scope and Standards, 2006
Audience for Scope and Standards
Nurse Life Care Planning Scope of Practice……………………………………………………..… 9
Overview and Evolution of Nurse Life Care Planning
Nurse Life Care Planning in Context
Who Needs a Life Care Plan?
Body of Knowledge Overview
US Healthcare Cost Trends
How Nurse Life Care Planning Can Help
How Other Nursing Disciplines See Nurse Life Care Planning
Preparing for the Role and Maintaining Competence
Role Preparation: Novice to expert, background experience, education
Continuing Education
Professional Associations, Membership, Collaboration, and Certifications
Nurse Life Care Planning Functions and Roles ……………………………………………..…..… 21
Overview
AANLCP Role Delineation Study
Essential Functions
Nurse Life Care Planning Roles
Advanced Skills Applied to Nurse Life Care Planning
Nurse Life Care Planning and the Art of Nursing
Practice Settings for Nurse Life Care Planners
General Considerations for All Nurse Life Care Planner Settings
Examples of Nurse Life Care Specialty Practice Areas
Values and Principles Guiding Nurse Life Care Planning ……………………………………...… 38
Ethics in Nurse Life Care Planning Practice: The AANLCP® Code of Ethics and Conduct ...... 39
Current Issues and Trends Affecting Nurse Life Care Planning Practice …………………….… 43
Overview
Industry and Regulatory Issues Affecting the Future of the Specialty
Costing Transparency and Accountability
MSAs
Tort Reform
Elder Care
Looking Towards the Future
Nurse Life Care Planning Research ………………………………………………………………… 45
JNLCP
Research committee goals and activities
The Standards of Nurse Life Care Planning ……………………………………………………..… 47
Significance of the Standards
Nurse Life Care Planning Standards of Practice ..……………………………………………….....49
References …………………………………………………………………………………………...… 61
Appendices
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Prologue
The 2010 American Nurses Association (ANA) Nursing’s Social Policy Statement: The
Essence of the Profession defines nursing in this way: “Nursing is the protection,
promotion, and optimization of health and abilities; prevention of illness and injury;
alleviation of suffering through the diagnosis and treatment of human response; and
advocacy in the care of individuals, families, communities, and populations” (American
Nurses Association (ANA) 2010, p. 3). This definition is the foundation for
understanding the scope of practice of nurse life care planners.
The National League for Nursing (NLN) defines critical thinking in nursing practice as “a
discipline-specific, reflective reasoning process that guides a nurse in generating,
implementing, and evaluating approaches for dealing with client care and professional
concerns” (NLN, 2011). One such critical thinking process is called the nursing process.
Nurse life care planning is the protection, promotion, and optimization of health and
abilities for individuals and families affected by catastrophic injuries and chronic health
conditions. Nurse life care planners apply advocacy, judgment, and critical thinking
skills using the nursing process, to develop long-term or life time plans of care,
including the costs associated with all of a plan’s components:
•
Identified evaluations and interventions
•
Health maintenance
•
Health promotion
•
Optimization of physical and psychological abilities for the life expectancy of the
individual
Care plan development is based on nursing assessment and collaboration with the
affected individual, family, community and care providers. Members of other disciplines
prepare life care plans, though nurses are unique in their holistic approach and abilities
to promote quality health outcomes. Nurse life care planners function in the registered
nurse’s scope of practice, and, when possible and applicable, incorporate opinions
arrived by collaboration with various healthcare providers. While many registered
nurses are prepared to develop short-term care plans and provide basic care
coordination, nurse life care planners are distinguished by their advanced care
planning for complex situations over an individual’s lifetime.
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About the American Association of Nurse Life Care Planners
The American Association of Nurse Life Care Planners (AANLCP) is a professional
specialty organization founded in 1997 for registered nurses practicing life care
planning. AANLCP® promotes the professional practice that the registered nurse
delivers to the life care planning process. The goals of the AANLCP are to promote
education, collegiality, collaboration, research, and standards related to the practice of
nurse life care planning.
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Introduction
Nurse life care planning is defined as the protection, promotion, and optimization of
health and abilities for individual and families affected by catastrophic injuries, and
chronic and complex health conditions. Nurse life care planners apply advocacy,
judgment, and critical thinking skills using the nursing process to develop long-term or
lifetime plans of care. These plans include the future cost of identified interventions
and associated costs for health maintenance, health promotion, and optimization of
physical and psychological abilities for the life expectancy of the individual. Nurse Life
Care Planning: Scope and Standards of Practice addresses the scope of practice and
defines the standards of practice and professional performance for all registered nurses
identified as nurse life care planners. The Standards define, guide, and provide a
theoretical foundation for nurse life care planning in all settings. Self-regulation by a
profession assures quality of performance.
The AANLCP is a professional organization for nurse life care planners and is
responsible for developing and maintaining a scope and standard of practice for all
nurses in life care planning. Nurse life care planners use a holistic framework,
recognizing biological, psychological, social, and spiritual factors associated with and
affected by disability and chronic health conditions. Life care planning begins with a
strong nursing foundation. Nurse life care planning is enriched, strengthened, and
diversified by elements of case management, rehabilitation nursing, community health,
public health, and legal nurse consulting. Nurse life care planning requires a working
knowledge of economic trends, healthcare policy, funding sources, medical coding,
and reimbursement issues.
Nurse life care planners apply their expertise in many ways, expanding beyond
litigation-based traditional life care planning practice into the following areas:
Complex rehabilitation discharge planning
Complex utilization review
Independent nursing assessments
Lien investigations
Medical cost projections
Medicare set-aside arrangements
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Reasonableness of past medical bills
Setting insurance reserves
The Origin of Nurse Life Care Planning
In 1997, nurse life care planning began as a distinct nursing entity when Kelly Lance,
MSN, RN, CNLCP, LNCP-C, FNP-BC, recognized that a registered nurse’s
multidimensional healthcare education, combined with nursing’s native professional
standards and scope of practice, were an ideal preparatory foundation for life care
planning. She identified the nursing process as the methodology often used by registered
nurses who developed life care plans. Experienced nurses’ broad training and skills made
them particularly well-suited and sought-after to assess patients’ needs and work
collaboratively with all involved stakeholders whenever a lifetime plan of care was
needed.
Ms. Lance and a group of nurse life care planners founded the American Association of
nurse life care planners (AANLCP) as a nonprofit, professional association for nurses
who practiced life care planning. Ms. Lance developed a nurse life care planning
curriculum with the nursing process methodology at its core, to teach and disseminate
concepts and skills for nurse life care planning in the medical-legal arena. This included
formal educational content on applying the nursing process and professional nursing
scope and standards as the foundation for nurse life care planning practice. The
AANLCP continues to represent and support all nurses engaged in or interested in life
care planning.
The Association of Nurse Life Care Planners holds that the American Nurses Association
(ANA) Scope and Standards of Practice is the defining conceptual base for nurse life
care planning. Nurse life care planners use the critical thinking skills of the nursing process
to formulate a plan of care for an individual’s lifetime, often involving decades of healthcare
and other needs. The nurse life care planner then develops the plan which includes the
costs and resources necessary to meet those future medical and nonmedical needs using
the nursing process.
Foundation and Framework of the Scope and Standards
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As a professional specialty nursing organization, AANLCP has a duty to its members
and the public to develop and promulgate professional scope and standards of
practice. In 2006, the AANLCP Executive Board realized the need to define a nurse life
care planner’s scope of practice formally as a separate entity in its own right. In 2007,
AANLCP developed the initial standards of practice.
Also in 2007, the AANLCP established a preliminary work group to explore the
development of the specialty practice of nurse life care planning with the ANA. In
December 2010, this work group provided a draft outline of the Scope of Practice. A
second work group completed defining the nurse life care planner’s role and wrote the
first Scope of Practice in 2012. This updated Scope of Practice describes a nurse life
care planner’s practice framework and responsibilities.
The foundation and framework for NLCP specialty scope and standards are informed
by three ANA documents:
Nursing: Scope and Standards of Practice, Second Edition (ANA, 2010) as its
template for the specialty practice of nurse life care planning because it applies
to all registered nurses in every practice setting.
Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010)
The Code of Ethics for Nurses with Interpretive Statements (ANA, 2001)
Registered nurses developed nurse life care planning as a unique, synergistic discipline
that draws strength and diversity from existing nursing specialties, such as community
health, rehabilitation nursing, legal nurse consulting, and case management. Therefore,
it was appropriate that other specialty scopes and standards of practice were consulted
to help develop these; the AANLCP's nurse life care planning: Scope and Standards of
Practice. Definitions and competencies are expanded, enriched, and customized to
describe a competent level of nurse life care planning practice common to all nurse life
care planners. The breadth and depth to which a particular nurse life care planner may
engage in the total scope of nurse life care planning practice settings is a function of
education, experience, role, and population served.
The AANLCP placed the AANLCP Scope of Practice on the organization’s website for
public comment after informing the membership of its availability, then evaluated the
comments and made appropriate revisions. The current AANLCP Code of Professional
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Ethics and Conduct, Scope of Practice, and Position Statements are available on the
AANLCP® website at www.aanlcp.org, along with other resources. The Standards
outlined here are authoritative statements, describing obligations that nurse life care
planners are expected to meet, with the understanding that application of any
standards must be considered in context. Specific clinical and practice settings,
population served, and other factors, e.g., constraints imposed by the litigation
process or funding sources, may affect the applicability of the standards at any given
time.
The competencies accompanying each standard serve as evidence of compliance with
the corresponding standard. The list of standards is not to be regarded as exhaustive.
Application and adherence to a specific standard or competency is dependent upon
the situation. For example, collection and analysis of data may be limited by the
availability of medical records and documents, access to the healthcare consumer and
family, and scope of assignment. Implementation of the interventions outlined in the
nurse life care plan may be delegated to or executed by others as circumstances
warrant.
The primary audience of this professional resource includes:
Those who serve individuals who could benefit from life care planning
Those who want to learn about life care planning as a specialty practice
Those who want to learn about developing lifetime healthcare need and cost
projections
Registered nurses who are interested in pursuing the practice of nurse life care
planning
It is the intent of this scope and standards document to also serve as a reference
source for legislators, regulators, legal counsel, and the judicial system. Others who will
find this a valuable reference and benefit from this information include:
Persons with catastrophic injury, illness, complex care needs, and disability
Families and legal guardians
Human service agencies
Healthcare organizations
Nurse administrators
Nurses working in other specialty areas
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Other professional colleagues, including those in the rehabilitation and case
management fields
These groups are potential stakeholders who can use this document to better
understand the role and responsibilities of registered nurses who practice life care
planning and how nurse life care planners provide leadership in healthcare today and
tomorrow.
Nurse Life Care Planning Scope of Practice
Overview of Nurse Life Care Planning
The nurse’s role in coordinating care and services began in the early 1900s with the
appearance of privately funded home health nursing agencies for the poor. In the early
1900s, Lillian Wald promoted the term public health nurse, expanding nursing practice
to encompass issues of employment, recreation, health education, and sanitation.
Visiting nurses coordinated community-based resources; governmental funds for public
health nursing expanded in the 1930s. By the 1940s, the insurance industry was using
case management as a method of cost containment (CMSA, 2008), resulting in the
beginnings of occupational health nursing. Industry, during World War II used case
management nurses to help maintain a healthy workforce for the war effort.
Care planning in nursing advanced during 1961 with formal identification of the nursing
process by Ida Jean Orlando. As care planning has evolved, so has its purpose and tools.
Case management roles expanded as early as 1966, when nurses began adding budget
planning to coordinating care and services. In the mid-1970s, Paul Deutsch first identified
the term life care planning, referring to future needs, to describe a tool to project the costs
of medical care. “Case management and catastrophic disability research entered the
litigation arena as a published resource in 1981” (Deutsch, 2011).
Registered nurses in the insurance industry applied nursing expertise to project longterm healthcare needs and provide lifetime medical cost estimates. Management was
directed toward serious conditions likely to require numerous providers and involve
costly care. These early nurse life care planners assessed each case individually,
identifying the treatments and care these individuals would require for their extremely
resource-intensive conditions.
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Attorneys began engaging nurses to assist in litigation, using their nursing knowledge
to develop expanded care plans projecting the future medical needs of individuals with
complex injury or chronic illness. Nurses with an appreciation for legal issues were drawn to
this milieu. Life Care Plans were used in a variety of legal practice areas, including personal
injury, medical malpractice, product liability, and toxic tort cases, and for setting budgets for
high-cost medical claims in medical insurance and workers compensation cases. Early plans
used checklists of assumptions about what injured persons might need.
The nursing care plan has long been recognized as a product of the nursing process
based on nursing theory and evidence-based best practices identified by nursing
research. Registered nurses in all practice settings apply education and professional
experience and use the nursing process to assess immediate and ongoing care needs
for individuals and develop plans of care. As registered nurses, nurse life care planners
apply the nursing critical thinking process, knowledge, experience, and evidencebased research.
Initially, life care plans were developed by various professionals engaged in liability
litigation, working largely from a vocational rehabilitation and disability management
perspective to testify on this aspect of damages. Formal educational conferences with
necessarily broad formats met the learning needs of these ancillary providers, still
largely composed of vocational counselors with lesser numbers of nurses, educational
consultants, social workers, therapists, psychologists, and others.
Nurses who attended these early life care planning courses realized the methodology
used to train ancillary providers in life care planning was inherently different from
registered nurses’ professional framework, the nursing process. In 1997, Kelly Lance,
MSN, RN, CNLCP, LNCP-C, FNP-BC, recognized that registered nurses'
multidimensional healthcare education and nursing’s own professional standards and
scope of practice were an ideal stand-alone methodology for life care planning. Ms.
Lance led a group of like-minded nurses to establish a nonprofit professional
association for nurses who develop life care plans, the American Association of Nurse
Life Care Planners (AANLCP). She provided the first formal educational offerings on
utilizing the nursing process and professional nursing scope and standards of practice
as the methodological basis for nurse life care planning. Nurse life care planning
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emerged as a specialty practice as more nurses intuitively embraced this concept and
wholly incorporated it into life care planning practices.
Nurse life care planning today is a unique hybrid of multiple nursing disciplines. This
means it has great opportunity to expand into more healthcare spaces in the coming
decades. A nurse life care planner’s skills and knowledge are excellent long-term
planning resources for the growing elderly population and their families. As economic
and politically-driven pressures constrain care provisions in order to contain the cost of
long-term, resource intensive healthcare, advocacy and innovative approaches will be
critical to maintain safe environments for these populations. When financial constraints
are in place, the services and expertise nurse life care planners provide for these most
vulnerable is even more important. The nurse life care planner’s bundle of knowledge,
incorporating elements of many different nursing specialties, legal systems, and
healthcare economics, will be critical in changing the face of healthcare.
Applying holistic nursing concepts of nursing practice are fundamental to the nurse life
care planner’s practice. The nurse life care planner considers the mind-body-spiritemotion and environment throughout all phases of life care planning. A person who
has sustained, for instance, a brain injury or spinal cord injury, whether adult or child,
experiences both acute and chronic mind-body-spirit and environmental disruptions.
Nurse life care planners draw upon their years of rehabilitation and case management
experience. They apply nursing knowledge, expertise, and intuition to promote holistic
care in a treatment system often characterized by fragmentation. The nurse life care
planner assesses each individual on all realms affecting health, well-being, safety and
security, home and community influences, and individual and family needs to promote
optimal independence.
Nurse life care planners promote the delivery of holistic care and optimal health and
function throughout the lifespan and across the health-illness continuum. The specialty
practice considers culture, ethics, law, public policy, economics, access to individual
and community health care, and competing priorities. Nurse life care planners
advocate for social and environmental responsibility, community engagement, and
access to high-quality and equitable health care to maximize health outcomes, and
minimize health disparities between groups. Nurse life care planners advocate for the
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wellbeing, comfort, dignity, and humanity of all individuals, families, groups,
communities, and populations. Nurse life care planners focus on healthcare consumers,
interprofessional collaboration, shared knowledge, scientific discovery, and social
welfare.
Furthermore, nurse life care planners use their professional experience in case
management, community nursing, clinical settings, and rehabilitation to identify future
medical and non-medical needs, and to research dollar amounts for future care for many
different types of clients. A nurse life care planner performs a broad range of activities
applying highly-specialized skills and advanced knowledge. In a typical day, it’s quite
possible for a nurse life care planner to research changing wheelchair needs over a
person’s lifetime, determine hours of care required for a particular level of spinal cord
injury, and work with a contractor on an individual’s specific accessible housing
requirements and plans for home modification. Nurse life care plans are formulated to
smooth transitions throughout the healthcare system continuum and throughout the
stages of life. Nurse life care planners take into account the need for stewardship of
available healthcare dollars and resources, setting forth safe transitions of care while
staying focused on safety, quality of care and patient self-determination.
Nurse Life Care Planning in Context
Who Needs a Nurse Life Care Plan?
Life care plans are most often developed for individuals with injuries or chronic
conditions requiring complex long-term healthcare interventions and management.
These documents must be dynamic, organized, concise plans of care for goods and
services to meet estimated current and future, reasonable and necessary (and
reasonably certain to be necessary) medical and non-medical needs and expenses, and
include the associated costs. A plan outlines an individual’s needs throughout the
healthcare continuum, in multiple settings, and throughout life expectancy. Like any
nursing care plan, a life care plan must be flexible, with provisions for periodic
reevaluations and updates.
Body of Knowledge Overview
Nurse life care planners possess a wide body of knowledge in:
Care/case management principles
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Rehabilitation
Changing care needs across the lifespan
Epidemiology
Morbidity and mortality
Disability
Healthcare trends
Insurance and funding
Legal issues
This knowledge base forms nurse life care planners’ practice and bolsters their
credibility and authority as advocates for positive changes in healthcare.
Healthcare Costs and Trends
Five percent of the United States (U.S.) population accounts for almost half of U.S. total
expenditures for healthcare goods and services (Agency for Healthcare Research and
Quality (AHRQ), n.d.) The rapid growth of health maintenance organizations (HMOs)
and other forms of managed care from the 1970s onward was intended to control
costs. However, this change in U.S. health care delivery did not change the
concentration of health care expenses.
Moreover, studies reveal major differences in health care expenses by geographic area.
These are due not to price differences, average illness acuity, or socioeconomic status,
but rather to the overall quantity of medical services provided and to the relatively
higher proportions of internists and medical subspecialists in high-cost regions (AHRQ,
n.d.). Nurse life care planners’ services are targeted to and best serve individuals with
high-dollar, high-resource-utilization patterns. The plans of care are driven by
evidenced based principles rather than geographic factors.
How Nurse Life Care Planners Can Help
AANLCP believes that adapting nurse life care planning to a broader population would
create more informed healthcare consumers who could then change healthcare
utilization patterns via self-advocacy. Life care plans focus on nursing and medical
diagnoses, and by their nature are:
Action-oriented
Attainable
Evidence-based
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Fiscally responsible
Interdisciplinary
Time-specific
Individuals with chronic, complex, and catastrophic conditions who understand their
long-term needs as identified by a nurse life care planner are well-positioned to seek
preventive and wellness-oriented interventions as recommended in the nurse life care
plan to minimize the risk of secondary complications.
As noted in the Institute of Medicine (IOM) report, nurses have the potential to play an
influential role to ensure that the health care system provides seamless, affordable,
quality care that is accessible to all and leads to improved health outcomes. The report
recommended that nurses be full partners with physicians and other health care
professionals to redesign health care in the United States (IOM, 2010). This
collaboration is an essential component of nurse life care planning.
Nurse life care planners’ unique knowledge base in clinical conditions, healthcare
systems, regulatory, and healthcare spending makes them valuable contributors as the
United States attempts to transform its health care system. Nurse life care planners can
and should play a fundamental role in this transformation. Embedding nurse life care
planners within the healthcare system at the regulatory, insurance and care delivery
levels could be achieved within the scopes of existing nurse practice acts.
Healthcare spending pattern analyses shed important light on how best to focus efforts
to help restrain rising health care costs. Recognizing that a relatively small group of
individuals account for a large fraction of spending, regardless of payer, drives the
need for smarter cost-containment strategies. AANLCP has a long-term goal of having
a seat at the table for healthcare policy and strategy formation to design effective
consumer-directed health plans and plans of care.
Nurse life care planners are particularly well-suited to assist all stakeholders, e.g.,
government entities, policymakers, individuals, communities, and populations, to
develop and adopt strategies and tactics to address complex and chronic health issues
such as spinal cord injury, acquired brain injury, diabetes, developmental disabilities,
and chronic pain, among others.
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In litigation, the nurse life care planner may serve as testifying expert, providing
testimony on disability and function, safety, nursing care, reasonable and necessary
future care, and associated costs. In this role, the nurse life care planner educates the
trier of fact (e.g., judge, jury, mediator, arbitrator) about identified needs, and provides
evidence regarding the plan’s foundation, contents, recommendations, methodology,
and conclusions.
How Other Nursing Disciplines See Nurse Life Care Planners
Other specialties and nursing disciplines recognize the role of nurse life care planners.
Certification examinations for certified case managers (CCM) and legal nurse
consultants (LNCC) each allocate 5-7% of their examination questions to life care
planning. Basic nursing textbooks, including Stanhope and Lancaster (2012) Public
Health Nursing Population-Centered Health Care in the Community (8th ed.), now
describe the role and function of nurse life care planners; the authors are collaborating
with the Journal of Nurse Life Care Planning (JNLCP) editor on their next edition to
provide more specifics. The Association of Rehabilitation Nurses will include the role
and function of nurse life care planners in their Core Curriculum’s upcoming revised
edition.
Nurse Life Care Planning: Preparing for the Role and Maintaining
Competence
Role Preparation
The nurse life care planner role is independent, autonomous, and self-motivated. The
specialty practice requires advanced nursing assessment, critical thinking, and
communication skills. Additional qualifications include proficiency in research, literature
and medical record reviews, technical writing, financial concepts, and medical coding.
It is also critical to have a fundamental understanding of applicable laws and
regulations, including the Nurse Practice Act. Registered nurses can prepare for this
role through experience, continuing education, and other formal and informal
educational offerings.
Benner's seminal novice-to-expert work (Benner, 1982) is classically applied as a clinical
ladder model, beginning with new graduates at a basic educational level caring for
healthcare consumers with low-complexity needs who progress to expertise in higher15
complexity situations in a continuum including further experience, learning, and
mentorship. However, this cannot be wholly applied to nurse life care planning
because, unlike many nursing specialties, nurse life care planning does not include a
traditional or clinical patient care component.
In contrast to new graduate nurses working in clinical specialty areas, even novice nurse
life care planners are typically experienced in many complex aspects of patient care, as
reflected by the many contributory certifications they hold in nursing and other
specialties, e.g., rehabilitation nursing, disability management, case management,
brain injury, nursing education, utilization review, legal nursing, and others. Nurse life
care planners have experience in professional networking and research.
The AANLCP Role Delineation Study in December 2013 (Manzetti, Bate, and Pettengill,
2014) found that 89% of nurse life care planners surveyed had held RN licensure for
more than twenty years; 75% of respondents reported 30+ years of nursing experience.
The AANLCP Role Delineation Study reported that 80% of responders held a
bachelor’s degree, of whom 20% also have a master’s degree in nursing and 80% held
a master’s degree in another field. Many CNLCPs obtain other certifications and
degrees, such as Advanced Practice Registered Nurse or Master in Nursing. Some
CNLCPs are pursuing doctoral degrees (e.g., PhD, DNSc, DNP) in nursing and
performing evidence-based research in nurse life care planning.
Continuing education
As all nurses know, continuing education should never end. The AANLCP Scope and
Standards of Practice and Code of Ethics and Conduct both address nurse life care
Planners’ responsibility to advance the profession through participating in and
promoting mentorship, collegiality, education, and ongoing knowledge development
in the field. Many nurse life care planners fulfill this responsibility by attending and
presenting at professional conferences for life care planners, case managers,
rehabilitation nurses, legal nurses, and meetings of other allied professionals such as
plaintiff and defense attorneys, structured-settlement providers, insurance claims
managers, professional patient advocates, trust officers, and others.
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The commitment to lifelong learning after initial education is a nurse life care planning
core value. The nurse life care planner seeks continuing education on, for example,
regulatory issues, reimbursement, medical coding changes, adaptive technology, and
research related to supplies and equipment for specific injuries or conditions. The
AANLCP provides continuing education programs on current trends and research,
especially related to catastrophic injuries or conditions, e.g., traumatic brain injury,
spinal cord injury, amputation, burns, and chronic pain; disease states such as cancer,
chronic illnesses, Guillain-Barré syndrome, psychiatric conditions, effects of toxic
substances, and organ or other tissue transplant; and pediatric conditions such as
autism, cerebral palsy, other developmental conditions, and muscular dystrophy.
AANLCP also provides opportunities for lifelong learning through networking,
participation in small group programs, self-study, reading nursing/medical journals, the
JNLCP, other relevant literature, and collaboration with other organizations, e.g., the
American Association of Legal Nurse Consultants.
Annual AANLCP educational conferences include content on the nursing process and
nursing diagnosis which are integrated throughout conference programming.
Conference topics include both entry level and advanced practice topics and subject
matter. AANLCP also sponsors webinars on topics pertinent to the field of nurse life
care planning. Continuing education opportunities exist throughout the country on
related content such as catastrophic injury management, advances in rehabilitation,
assistive technology for persons with disability, legal aspects of life care planning, and
trends in healthcare economics.
Nurse Life Care Planning: Professional Associations, Membership, and
Certification
AANLCP
The American Association of Nurse Life Care Planners is a voluntary professional
nursing specialty association established in 1997 for registered nurses practicing or
with an interest in nurse life care planning. Members represent a multitude of
professional practice backgrounds, including orthopedic, burn, trauma and
rehabilitation nursing, case management, nursing education, insurance, physician and
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hospital administration, to name a few. Most AANLCP members practice life care
planning in the U.S., and there are an increasing number of international members.
Leaders and members in the Association are also members of the ANA, NANDA-I,
ARN, CMSA, AALNC, NAMSAP, and other nursing organizations. Activities and entities
in which they serve and provide leadership in these nursing organizations include:
Authoring, reviewing, and editing submissions for nursing periodicals
Chairing and serving on standing and special committees / work groups
Contributing to the next edition of a well-known nursing diagnosis handbook
(Ackley, 11th ed.)
Preparing a textbook of nurse life care planning exemplars for publication
Presenting continuing education topics at professional meetings and consortia
Standards validation committees for certifying entities
State Nurse Practice Advisory Panels
Teaching and precepting nursing students
Writing items for certification examinations
The AANLCP seeks to promote excellence in nurse life care planning through
education and research, and to unify the specialty practice by providing a common
foundation for nurse life care planners. It also promotes the practice of nurse life care
planning in healthcare, public, and legal communities; provides standards for quality of
practice to protect the public who uses these services; and facilitates ethical practice.
The AANLCP recognizes the expanded role of the registered nurse as separate and
distinct from the physician, therapist, or counselor, and of equal value. The nurse life
care planner assesses individuals from a holistic and comprehensive perspective in
homes, communities, and multiple care settings.
AANLCP also collaborates with life care planning colleagues from other professional
disciplines to share resources, discuss common issues, and to advance common
agendas. AANLCP is an active member of the Alliance: The Nursing Organizations
Alliance, a collaborative community of over 65 national nursing organizations. The
Association provides the opportunity for nursing organizational leaders to network,
exchange information, poll peer member organizations about association best
practices, form partnerships and alliances on initiatives of mutual interest, and lobby for
health care issues affecting member organizations.
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CNLCP Certification
As healthcare has become more complex, it is increasingly vital to assure the public
that healthcare professionals are competent. Registered nurse licensure measures
entry-level competence only; and, in so doing, provides the legal authority for an
individual to practice nursing at the minimum professional practice standard.
Certification, on the other hand, is a formal recognition of knowledge, experience,
skills, and clinical judgment within a specific nursing specialty. It validates advanced
professional practice and proficiency beyond that of basic licensure.
The CNLCP® Certification Board is a separately incorporated entity that facilitates
consumer health and safety by credentialing nurse life care planners. It ensures that
practice is consistent with established standards for developing and defending a nurse
life care plan.
Consumers seek out certification status of other professionals (e.g., pharmacists,
attorneys). The CNLCP credential indicates that a nurse life care planner is not only
licensed to practice nursing, but is qualified and competent, having met rigorous
requirements.
Since the first courses in nurse life care planning were offered, nurses seeking to
practice the specialty have taken advantage of coursework, mentors, and supplemental
materials to learn how to make best use of their nursing fundamentals of assessment,
planning, and implementation to prepare for the role. AANLCP took responsibility for
providing certification for the specialty. There are now several courses for this purpose
that meets the educational prerequisite to take the CNLCP® examination.
The AANLCP and the CNCLP Certification Board have published a joint position
statement on education and certification for nurse life care planners in 2014, available
online at the Association website. (Appendix 5)
The CNLCP Certification Board has provided oversight of the CNLCP certification
examination since 2003. Both AANLCP and the CNLCP Certification Board adhere to a
Code of Professional Ethics Mission/Vision Statement. The CNLCP Certification Board
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meets and adheres to the Accreditation Board for Specialty Nursing Certification’s
standards and organizational criteria.
The CNLCP certification examination is currently administered for the CNLCP
Certification Board by Professional Testing Corporation (PTC). Details regarding
credentialing may be found on the CNLCP website at www.cnlcp.org.
Achieving a passing score on the rigorous exam entitles the RN to use the designation
of Certified Nurse Life Care Planner (CNLCP). The current examination required for
certification in nurse life care planning evaluates the core knowledge base specific to
the specialty of nurse life care planning. This includes, but is not limited to, the nursing
process, knowledge of rehabilitation and the lifetime needs of catastrophically injured
and/or chronically ill individuals, and the ability to conduct appropriate and specific
research related to an individual's specific current and future needs. Please see the
published Role Delineation Study, attached, for details on core knowledge (Manzetti,
Bate, and Pettengill, 2014)
Certification Eligibility (effective April 1, 2015)
Candidates must meet the following eligibility criteria per the application deadline as
indicated in the CNLCP® Handbook and Website:
A. Candidate must have registered nurse licensure or its equivalent in other countries,
for at least the past three years. The license must be currently active, without any
restrictions and a copy of the current license must be submitted with the application.
B. Candidate must have a minimum of two years of full time paid professional
experience in a role (e.g., life care planning, community based case management,
medical cost projections, Medicare set-aside allocations, lifetime nurse care planning,
community based rehabilitation nursing, public health nursing, community based legal
nurse consulting) that utilizes the nursing process in assessing an individual’s long
term/lifetime treatment needs and costs across the continuum of care.
Candidates meeting criteria A and B must also meet one of the following eligibility
routes pertaining to education and relevant experience:
Route 1: Completion of a minimum of 120 continuing education units* relating to life
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care planning or equivalent areas that can be applied to the development of a life care
plan, or that pertain to service delivery applicable to life care planning, within 5 years
immediately preceding application.
*There must be a minimum of 16 hours specific to a basic orientation, methodology,
and standards of practice relevant to the nurse life care planning process contained
within the continuing education curriculum
Route 2: Verification* of two years life care planning experience or a variant thereof
(e.g., lifetime nurse care planning), that incorporates the nursing process and skill set
inherent to determination of treatment needs and their respective costs, across the
continuum of care, within the past five years immediately preceding the application.
*Verification of experience must be authenticated by an employer or a minimum of two
referral sources.
Reciprocity Eligibility (effective April 1, 2015)
Candidates must meet the following eligibility criteria per the application as indicated
in the CNLCP® Handbook and Website:
1. Candidate must be licensed as a registered nurse, or the equivalent in other
countries, for a minimum of three years. The license must be currently active and
without any restrictions. A copy of the current license must accompany the application
for reciprocity.
2. The RN candidate must have a current Certified Life Care Planner (CLCP) certificate
and letters of verification* indicative of two years full time paid professional work
experience in the field of life care planning or a variant thereof (e.g., lifetime nurse care
planning), that incorporates the nursing process and skill set inherent to determination
of treatment needs and their respective costs, across the continuum of care. A copy of
the current CLCP certificate must accompany the reciprocity application.
*Verification of experience must be authenticated by an employer or a minimum of two
referral sources.
If ambiguity exists in terms of pathway interpretation/qualification, a final decision will
be made by the CNLCP® Certification Board Application Committee, consisting of the
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Certification Board Chairman, Certification Board Co-Chairman and the Certification
Board Secretary.
Nurse Life Care Planning Functions and Roles
Overview
Nurse Life Care Planner Functions
During the life care planning process, the nurse life care planner:
Assesses and diagnoses the individual’s current response to the disability or
illness
Anticipates the effects of disability or illness and future needs as the individual
ages
Collaborates with healthcare providers when possible and applicable
Considers risk minimization and the promotion of function over the lifetime
Researches and documents the costs necessary to implement the care plan
Identifies desired outcomes of plan elements
Incorporates information and opinions from other providers
May identify available community, public, and insurance funding and how to
access those resources
May initiate aspects of the life care plan during its development, educate the
consumer and family/guardian on plan initiatives, or provide for the plan to be
implemented by a nurse case manager (choice depends on jurisdiction)
Updates the Life Care Plan based on the evaluation process
The following tables with examples are excerpts from the Role Delineation Study cited.
For further details on specific tasks related to nurse life care plan development, please
refer to the complete Role Delineation Study, attached.
Table 3
Assess need for medications (e.g., pain medications)
Rated high for
frequency of
performance >3.5
3.9
Review post morbid medical records
3.8
Assess need for medical care evaluations/services
3.8
Assess need for therapeutic evaluations/services
3.8
Assess need for therapeutic evaluations/services
Assess need for diagnostic testing
(e.g., medical labs, radiological studies, neuropsychological, etc.)
Assess need for wheelchair/mobility needs
3.8
3.8
Assess need for independent living ability
3.8
Life Care Plan Development Tasks
3.8
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Assess need for home/attendant/facility care
3.8
Assess need for adaptive equipment
3.8
Assess need for therapeutic equipment
3.8
Assess need for orthotics and prosthetics (e.g., braces, ankle/foot orthotics)
3.8
Assess need for supplies (e.g., bowel/bladder supplies, oxygen, etc.)
3.8
Review expert reports
3.7
Assess need for assistive technology
Assess need for home furnishing and accessories (e.g., specialty bed, portable
ramps, patient lifts)
Assess need for transportation (e.g., adapted/modified vehicle, etc.)
Assess the need for renovations for accessibility
(e.g., widen doorways, installing wheelchair ramp, etc.)
Document pre-existing conditions utilizing a Medical Record Summary
3.7
3.6
Assess need for health, strength maintenance
3.6
Assess need for case management services
3.6
Assess need for architectural renovations (e.g., wheel-in shower, elevator, etc.)
3.6
3.7
3.7
3.7
Table 4
Cost Research Tasks
Obtain costs for items and services in a Life Care Plan using provider/vendor
contacts
Other considerations used in determining Life Care Plan cost: Geographic
location
Obtain costs for items and services in a Life Care Plan using internet sources
Rated high for frequency
of performance >3.5
3.7
3.7
3.6
Essential Functions
In 2013, the AANLCP performed a role delineation study of nurse life care planners.
The result, A Survey of Nurse Life Care Planners: A Role Delineation Study in the
United States, was published in the Journal of Nurse Life Care Planning in September
2014 (Manzetti, Bate, & Pettengill, 2013)
The primary role of the nurse life care planner is to provide a life care plan, applying
the nursing process: assessment, diagnosis, outcome identification, planning,
implementation, and evaluation. While specific individual practice environments,
settings, and experience may differ, the nursing process methodology is common to all
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registered nurses. Respondents to the survey described the following functions for
nurse life care planner practice. The nurse life care planner:
Reviews available data, requesting additional records when needed as part of the
assessment process for the LCP.
Completes a comprehensive assessment of the injured or chronically ill person
when able, using a comprehensive assessment tool that identifies current and
probable future care needs, durable medical equipment, medical care providers,
laboratory and diagnostic tests, personal care assistance, supplies, therapies,
activity/exercise needs, educational/leisure/vocational needs, and environmental
modifications as indicated.
Collaborates as necessary with healthcare providers for current and probable
future healthcare treatment plans.
Uses critical thinking to analyze and categorize assessment data to identify the
human responses to the injury or chronic illness; makes the nursing diagnoses for
the life care plan.
Considers associated risks, benefits, costs, current scientific evidence, medical
guidelines and literature, and cultural and ethical considerations, to achieve the
identified outcomes.
Plans for identified reasonable and essential needs, including frequency of
caregiver follow-up and maintenance and replacement of equipment, including
the annual cost of each item and possible alternatives.
Considers promotion and restoration to health and injury/illness/disease
prevention to achieve the desired outcome.
Provides for implementation of the plan within an appropriate, reasonable
timeline.
Uses scientific evidence-based guidelines, nursing research, and other
guidelines.
Identifies community resources and systems; identifies and delegates the
different sections of the life care plan to an appropriate provider to coordinate
the care in the plan.
Provides for health teaching and promotion and safety and prevention strategies
from an appropriate, delegated provider.
Provides life care plan consultation using analysis, summarization, research,
evidence-based guidelines, and literature; communicates appropriate
recommendations to the injured or chronically ill person to facilitate learning.
Evaluates the life care plan to ensure a systematic approach for the completion
of the life care plan and the effectiveness of planned strategies.
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Completes an ongoing data assessment with appropriate revisions of the nursing
diagnoses, outcomes, plan and implementation as needed.
Demonstrates quality of practice, delivering life care planning consultation
services as a nurse life care planner and demonstrating the application of the
nursing process in a responsible, accountable, and ethical manner.
Testifies as an expert witness, educating the court including attorneys, jury, and
judges, concerning facts regarding the identified care needs and costs pertaining
to those needs within the life care plan.
Practices following current statutes, rules, regulations and guidelines.
Although there are areas of specialization in nurse life care planning, the specific ability
to assess the catastrophically injured or chronically ill throughout the continuum of
health care in multiple settings over the lifetime remains constant. With this
assessment, the nurse life care planner creates a plan that addresses health care, basic
protection, and safety needs for the person and caregivers. Nurse life care planners
who serve as testifying experts must be familiar and comfortable with the various rules
and procedures inherent to this role, as well as knowledgeable about their own special
knowledge, experience, skill, education, and foundations of nursing practice, and able
to communicate these clearly to triers of fact, i.e., magistrate, administrative law panel,
judge, or jury.
Each nurse life care planner maintains a current, unrestricted registered nurse license
and adheres to a professional registered nurse scope and standard of practice as
specified by a state, province, or territory nurse practice act. Individual nurse practice
acts may or may not specifically address every component of nursing process:
assessing, nursing diagnosis, outcome identification, planning, implementing, and
evaluating. Each nurse life care planner must know the applicable nurse practice act
when testifying as an expert.
Nurse Life Care Planning Roles
Nurse life care planners regard the ANA Scope and Standards of practice as the
definitive conceptual framework for care planning. Nurse life care planners use the
nursing process to develop a plan of care for the lifetime of an individual in ways that
parallel but are not equivalent to traditional nursing roles.
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Nursing is a scientific discipline as well as a profession. Registered
nurses employ critical thinking to integrate objective data with
knowledge gained during assessment of the patient. Nursing includes
diagnosis and treatment of human responses to actual or potential
health problems. We recommend healthcare interventions that are
restorative, supportive, and promotive in nature. One of nursing’s
objectives is to achieve positive patient outcomes across the entire
lifespan. All nursing practice regardless of role or setting is
fundamentally independent practice. All registered nurses are
accountable for judgments made and actions taken in the course of
their nursing practice. As nurse life care planners we regularly evaluate
safety, effectiveness, and cost in the planning and delivery of nursing
care, recognizing that resources are limited and unequally distributed.
(ANA Scope and Standards, 2010)
Nursing practice is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury, and the alleviation
of suffering. (ANA Nursing Social Policy Statement, 2010)
Many nurses are attracted to the field of life care planning because they enjoy
challenges. They want to develop advanced nursing skills to deliver safe, cost effective,
quality care, and provide related education to individuals, families, and providers in
nontraditional settings.
Unlike nurse case management, nurse life care planning is not constrained by the
economics of insurance or any contracted limits in coverage. Nurse life care planners
are free to think creatively and unconventionally to optimize patient outcomes.
Innovative thinking allows nurse life care planners to use the most important tool in
their toolboxes: themselves, with all their talents and attributes.
The Robert Wood Johnson Foundation described this in this way:
Nurse life care planners create healthcare roadmaps. These nurses help
patients who have suffered catastrophic injuries and illnesses, advocate
for them, and plan out their care. Nurse life care planners work with a
patient's family, insurance company, attorneys, and others to develop a
life care plan, determining the future needs, services, and costs of care
for the patient over their lifetime. Many nurse life care planners work
independently from the hospital system, acting as a consultant for
businesses, families, or courts of law. Because of life care plans,
patients’ caregivers know how often they need to schedule
appointments, what to expect in terms of rehabilitation, and what the
course of medical care will look like. Nurse life care planners:
Design nurse life care plans for patients
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Advocate for patients, who often cannot express their own
needs
Teach patients’ families about the illness and treatment
A nurse life care planner’s practice is:
Multifaceted
Structured
Patient-facing
Managerial
Research-oriented
Independent
(Robert Wood Johnson Foundation, 2013)
Nurse life care planners have the knowledge and skill to plan care for multiple disease
states and complicated conditions. They are well-equipped to apply their skills to
today’s healthcare challenges, e.g., the increasing awareness of autism-spectrum
conditions and developmental disability, improved survival after very premature birth
and after catastrophic trauma, and in the growing aged population with dementia.
Nurse life care plans foster patient and family engagement and partnering in the
planning process. Practice examples include:
Parents may need a life care plan for a disabled child’s changing needs as the
child grows to adulthood. The nurse life care planner will provide education
regarding choices for long term care options, e.g., remaining at home with
support services, specialized group home, or assisted living, and plan care
respecting their individual values, needs, and preferences.
An attorney or court may ask for a life care plan to address lifetime needs of the
individual with catastrophic injury, e.g., burn, spinal cord injury, traumatic brain
injury, amputation.
A trust officer may need help administering funds for an elder or disabled adult,
respecting the individual’s preferences for palliative care or hospice at end of life.
These and many other situations require thorough and comprehensive care plans that
address all needs, including safety, for a lifetime of care. Meeting such challenges by
applying one’s wealth of knowledge and previous experience as a nurse case manager
or clinician in an expanded role is invigorating.
Advanced Skills Applied in Nurse Life Care Planning
All nurses should be familiar with evidence-based practice and apply it in clinical
practice. Nursing care typically involves assessment, planning, goal identification, and
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care coordination related to data and outcomes for a discrete admission or episode of
care. The specialty practice of nurse life care planning requires the nurse to consider a
much larger picture, and apply a much broader range of resources to an individual’s
plan of care.
Nurse life care planners may review years of prior treatment, educational, vocational,
and other records to evaluate prior hospitalization causes, frequency, and resource
utilization to determine what secondary factors will most likely contribute to future
resource demands over an entire life expectancy, commonly involving decades of care
needs. Nurse life care planners apply knowledge of statistics and other research-based
findings at an advanced level to understand probable prognoses, trajectory of care,
and to project resources and associated costs.
Nurse Life Care Planning and the Art of Nursing
Nurse life care planners are nurses, first and foremost. No advanced practice would be
possible without a solid foundation in the classic art of nursing. Therefore, as a
registered nurse, the nurse life care planner applies the art of nursing and promotes
respect of human dignity.
Nurse life care planners see caring as protecting, enhancing, and preserving humanity,
human dignity, and integrity. Nurse life care planners help a person to find meaning
despite injury, illness, suffering, or pain. Nurse life care planning helps patients gain
self-knowledge, self-control, self-caring, and self-healing to restore a sense of inner
harmony regardless of the external circumstances.
Nurse life care planners typically practice nursing both in the present and
prospectively. While working with healthcare consumers in the home as with a home
assessment, nursing happens as we assess, diagnose risks, educate the consumer, and
intervene to prevent complications or reduce suffering. Prospectively we deal with
health promotion to improve functional independence while reducing complications
and improving safety. In no other specialty is nursing more holistic in partnership with
the individual, family, community and support system than in nurse life care planning.
We are intimately involved in the perception of health but also in assessing necessary
health care services.
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For example, in one case, an attorney retained a nurse life care planner to address the
needs of an elderly African-American paraplegic woman. During the home assessment,
the nurse life care planner learned the individual’s caregivers were exploiting her for
her retirement funds and not providing her with safe or adequate care. It was the duty
of the nurse life care planner to notify the appropriate authorities. She then informed
the requesting attorney that it would be inappropriate to proceed with life care
planning because the priority was assuring that the patient was moved to a safe
environment.
This vignette illustrates the nurse life care planner exemplifying the art of nursing:
embracing empathy, mutual respect, and compassion to promote health. The nurse life
care planner acted as a nurse first when she helped, listened, explored, was present,
supported, touched, intuited, served, recognized cultural influences, nurtured, and
resolved conflict.
Practical Example
The exemplar life care plan of a toddler diagnosed with severe cerebral palsy
(Appendix 4) illustrates provisions for individual and family psychological counseling
during important transitional times over the child’s lifespan. The plan identifies existing
support groups within the community, recreational and leisure opportunities for
persons with like disabilities, and support forums to help parents become educated
consumers. The needs of a person with cerebral palsy during childhood change as he
progresses through adolescence, early adulthood, middle age, and beyond. The nurse
life care planner draws upon medical literature, evidence-based practice guidelines,
and past experiences in serving like populations to address these needs.
Today’s hospital nurse case manager or episode-specific case manager may be able to
contribute to discussions about durable medical equipment and supply requirements.
However, the nurse life care planner must also be able to outline existing equipment
needs and, more importantly, project the trajectory of equipment needs over an
individual’s life span.
The exemplar life care plan anticipates changing environmental needs. Few home
modifications may be needed for young children. As the child grows into adolescence
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and adulthood, specialty systems may be needed for transfers, mobility, and
community access. The nurse life care planner is knowledgeable about anticipating
when these will be needed due to projected changes in patient size, weight, and
disability and abilities of parental caregivers, e.g.,
track ceiling transfer system
wheelchair-accessible transportation
advanced seating system
environmental controls
bathroom modification
As another example, to plan care for an individual with spinal cord injury (SCI)
(Appendix 4) or traumatic brain injury (TBI), nurse life care planners will consult US
Model Systems databases to research projected complications and likelihood of
rehospitalization. The nurse life care planner will connect these data (e.g., age of the
individual at the time of injury, years post injury, comorbidities) to individual
assessments to project outcomes and associated needs.
Durable medical equipment and associated repairs, maintenance, warranty periods and
replacement intervals for life expectancy require similar study. Planning care for life
expectancy also means looking at levels of home care, level of assistance, respite care,
counseling, assisted living, custodial care, therapies, medications, supplies, safety,
adaptive technology, and other aspects of care, all with the same level of attention to
detail and resources. Applying this level of expertise exceeds the expectations of
general nursing care planning. (See Appendix 4)
Part of long-term planning is initiating the difficult conversation of planning long-term
care options for a disabled loved one as, for example, when parents are unable to
continue in the caregiving role. This is an intimate aspect of the assessment and
planning process. The individual parent or spouse is often unaware of alternative care
settings. The nurse life care planner asks these involved persons about their wishes for
the future. Often, the nurse life care planner will broach the subject only to learn that
the stakeholders have different, conflicting ideas for the future, or perhaps have never
found it possible to think about or discuss the future.
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When asked, parents of a disabled child with cerebral palsy may hope that when the
child reaches young adulthood, they would like the child to move into a residential
living environment that affords a sense of community living. The nurse life care planner
identifies available options to accomplish this goal. The nurse life care planner
incorporates opinions expressed by neuropsychologists, therapists, and medical
providers to project the child’s likely future capacities.
Are there specialty group homes in the area?
Will the person likely be able to direct his own care with in-home caregivers?
Will an assisted living facility be sufficient?
Will a skilled nursing facility be necessary due to anticipated needs for
tracheostomy care and enteral feedings?
Will this person remain medically complex?
Will this person become more medically stable?
The nurse life care planner knows hallmark indicators that project the trajectory of
these factors. For instance, research indicates that a child who cannot ambulate by the
age of eight is unlikely to become a functional ambulator in later years. Could
therapeutic interventions lead to improvement, which in turn would lead to a different
selection of care needs?
Often, an individual’s, parents’, or spouse’s stated vision is incompatible with
evidenced-based knowledge about likely outcomes. An element of “magical thinking”
may be present. The seasoned, knowledgeable nurse life care planner performs the
delicate balancing act of crafting a lifetime plan of care which advocates for
stakeholder wishes while applying the science behind the lifetime holistic needs of the
person with the stated disability.
Other research will be necessary for comorbidities common in catastrophic conditions
(e.g., renal failure, psychiatric disability, cardiac conditions, diabetes, endocrine). The
nurse life care planner will examine the literature for current, high-quality, reliable, and
applicable studies regarding possible complications and apply current standards of
practice and cost data from Medicare and other payor sources. Applying knowledge of
rehabilitation nursing and healthcare finance, the nurse life care planners identifies
likely diagnosis codes for future care and associated Healthcare Cost and Utilization
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Project (HCUP) data from the US Government’s Agency for Healthcare Research and
Quality (AHRQ) to project those costs over life expectancy.
The nurse life care planner is often the first health care professional to introduce the
discussion about what the individual/family/community future care configuration will
look like. With few exceptions, today’s medical providers focus on today’s needs –
what new prescription should be offered for today’s symptom, what equipment is
needed today, what therapies should be ordered for the next month. Academic
programs fail to educate today’s healthcare professionals about how to help individuals
and their primary support systems plan for the future. Nurse life care planners fill this
void.
More often than not, when nurse life care planners meet with an existing treatment
team to ask about an individual’s future care needs, they are met with blank stares.
Some providers will say they don’t know or haven’t ever thought of that. Some will
provide expected needs for the next five years. And when we reiterate that we are
looking to project care needs for decades, most healthcare professionals will say that
they do not know how to do that. Most are grateful to learn that the nurse life care
planner has expertise in the statistical or epidemiological information framework
underpinning lifetime care trajectories.
The nurse life care planner fulfills two critical roles: advocating for the individual and
educating healthcare professionals to help plan for the future. As nurses, we are
uniquely equipped to open the conversation with the healthcare professionals on these
essential elements: individual/family goals, reasonable expectations, likely functional
outcomes, and the means to achieve them.
As nursing evolves, so does nurse life care planning. The market for nurse life care plans
has expanded to many areas outside of litigation: medical care planning, liability
insurance, special needs trusts (elders, children, disabled), and Medicare Set Aside
(MSA) allocations. Due to the value of their extensive nursing knowledge and expertise,
nurse life care planning specialists are seeing growing demand for their services. Nurse
life care planners have become sought-after consultants. The courts recognize nurse
life care planners as experts in a variety of relate fields for our unique combination of
32
experience and knowledge. The federal government specifically uses nurses for their
knowledge when responding to National Vaccine Fund cases. Some litigation calls for
expert nurse life care planners to critique plaintiff plans for defense of liability suits.
Nurse life care planning expertise is applied in Social Security Disability cases, in
medical malpractice, worker’s compensation, toxic tort liability, even in divorce cases
when a child’s or spouse’s future care needs must be considered. (See Appendix 4 for
several exemplars including a defense critique and a workers compensation case)
Practice Settings for Nurse Life Care Planners
Nurse life care planners practice in a variety of settings for diverse entities, such as
legal practices, government agencies, insurance companies, banks, private companies,
or, most commonly, in private practice as self-employed consultants (65% of
respondents in the AANLCP Role Delineation Study) (Manzetti, Bate, & Pettengill,
2014). The Appendix provides examples from both nurse life care planners working for
private corporations as well as self-employed consultants. In each of these settings,
nurse life care planners may interact with injured or chronically ill persons and their
associated support systems, legal representatives, healthcare providers, insurance
companies, employers, Centers for Medicare/Medicaid Services, other public or private
agencies, and the community at large. See also Nurse Life Care Planning Functions
and Roles for more information about the AANLCP Role Delineation Study.)
General Considerations for All Nurse Life Care Planner Settings
Nurse life care planners must follow the applicable law when handling, using,
transmitting, and communicating personal information in the process of preparing the
LCP.
The Health Insurance Portability and Accountability Act Privacy Rule (HIPAA) addresses
how private health information (PHI) must be safeguarded. While many settings in
which the nurse life care planner practices do not require HIPAA-level PHI protection,
the nurse life care planner protects all medical and confidential records to the extent
required in the individual case, and destroys these materials when the case has been
completed. These rules continue to evolve. The full text of HIPAA, summaries, and
FAQs are available at the Office of Civil Rights (OCR) website at
http://www.hhs.gov/ocr/privacy/hipaa/faq/index.html.
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The Family Educational Rights and Privacy Act (FERPA, the Buckley Amendment)
applies to access to data about student enrollment, grades, behavioral issues, and
other school information, at all levels of institutions and agencies that receive US
Department of Education funding. It also applies to states transmitting information to
federal agencies. General information on the legislation and policies can be found at
http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html
Health Information Technology for Economic and Clinical Health Act (HITECH) is
concerned with, among other provisions, information technology and the electronic
health record. It also extends the privacy and security provisions of HIPAA to business
associates of covered entities, some of which may apply to the nurse life care planner.
These rules also continue to evolve. Information on this can be obtained at
http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcementrule/hitechenforcem
entifr.html
Nurse life care planners should carry malpractice insurance. A nurse life care planner in
independent practice may also consider purchasing other business-specific insurance,
such as errors and omissions, loss of business, and premises coverage.
Examples of Nurse Life Care Planner Specialty Practice Areas
Testifying Expert Witness
Nurse life care planners who are retained as consultants by attorneys may be
considered testifying experts, expected to testify at trial or deposition in litigation.
They must clearly be able to articulate their own specialized and distinct body of
knowledge. They must also have a clear and accurate understanding of the licensed
scope of nursing practice as defined and authorized by the state, commonwealth, or
territory. The qualifications and credibility of the nurse life care planner in this role are
of great value to the triers of fact.
In other situations, nurse life care planners may be engaged by attorneys to provide
behind-the-scenes advice as a consulting expert, reviewing and offering opinions on a
testifying expert's or opposing party’s plan. In this role, opinions are considered
attorney work product and the nurse life care planner will not be disclosed as a
testifying expert. (See Appendix 4)
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Each testifying nurse life care planner must be knowledgeable about current federal
and state laws pertaining to giving testimony in the jurisdiction. If a case will require
trial or deposition testimony, the nurse life care planner should consult with the
retaining attorney for advice and specifics. However, the prudent testifying nurse life
care planner is familiar with Rule 702 in the Federal Rules of Evidence, concerning
testimony by experts, outlining the requirements for a person to be qualified as an
expert for the purposes of testimony; and Rule 703, bases of opinion testimony by
experts. These Rules may be reviewed at the Cornell Law School website,
http://www.law.cornell.edu/rules/fre/
Special Needs Trusts
A nurse life care planner may be asked to assist an attorney, financial planner, and
parent or guardian to develop a life care plan to meet the person’s needs through
adulthood to end of life. The goal is to ensure safety and protection of the disabled
person while addressing healthcare and other supplemental needs to maintain the
person’s current lifestyle as closely as possible. A trust officer may oversee the fiduciary
responsibilities of the plan, while a case manager may be engaged to implement its
components. The nurse life care planner working in this area should be knowledgeable
about types of varied trusts, Social Security programs (Supplemental and Disability),
the Association of Retarded Citizens (ARC), and CMS guidelines in addition to specialty
resource knowledge for the specific disability.
Nurse life care planners may work with children with special needs, families,
communities, and medical providers. These nurse life care planners outline current and
future medical, social, psychological, and recreational needs for the child’s growing
years. Continued planning for adulthood includes consideration of a living environment
that maximizes safety and independence. The nurse life care planner collaborates with
financial professionals regarding funding, medical insurance, and community resources
to include in the LCP. At the request of the parents, guardians, or trust officer, a nurse
life care planner may evaluate and revise the plan as the child’s needs change into
adulthood.
Worker’s Compensation Insurance
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Nurse life care planners may be company employees or independent consultants who
receive worker’s compensation cases from insurance adjusters to develop medical cost
projections, medical record reviews, or MSAs for injured workers (see below). The plans
may assist the insurance company to either settle cases and/or set financial reserves for
ongoing care of the injured worker, depending on jurisdiction. A nurse life care planner
working in this area should be knowledgeable about applicable state and federal
worker’s compensation laws, rules, and regulations and reimbursement schedules.
Medicare Set-aside Arrangements (MSA)
Some nurse life care planners have pursued specialized training in the intricacies of
MSAs.
A Workers’ Compensation Medicare Set-aside Arrangement
(WCMSA) is a financial agreement that allocates a portion of a
workers’ compensation settlement to pay for future medical
services related to the workers’ compensation injury, illness, or
disease. These funds must be depleted before Medicare will pay
for treatment related to the workers’ compensation injury, illness,
or disease (Centers for Medicare and Medicaid Services (CMS),
2014).
MSAs are completed to protect Medicare's interests when resolving cases that include
future medical expenses. These nurse life care planners must be knowledgeable about
CMS guidelines for MSAs, ICD 9 & 10 codes, and pharmaceutical and other
reimbursement structures used by CMS. The nurse life care planner must constantly
seek and apply updated information, due to the complexity of ever-changing federal
and state laws and guidelines, including those for worker’s compensation, third-party
liability, automobile, and self-employee insurance.
Federal Case/National Vaccine Fund
These complex plans are mandated by the National Childhood Vaccine Injury Act of
1986 (Public Law 99-660). This federal law protects the vaccine-injured person and
provides reasonably necessary medical care deemed related to the injury. Guidelines
are outlined and followed in developing the life care plan. These life care plans are
different from civil life care plans because the plaintiff’s insurance benefits (except
state-funded insurance plans) are considered as partial payment for future related
medical needs. The nurse life care planner must be able to interpret insurance benefit
language to identify and offset (take into consideration) these insurance benefits.
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Nurse life care planners are retained by the petitioner’s attorney and the Department
of Justice attorney. They must have expanded knowledge about applicable federal law,
receive special training, and are referred to as Petitioner Life Care Planners and
Respondent Life Care Planners. Unlike in classic adversarial litigation, the court requires
the two life care planners to collaborate to develop the final plan and determine costs.
Health and Disability Insurance
Nurse life care planners who work for health and disability insurance carriers help
claims personnel set annual reserves on high-cost members, applying the nursing
process to determine future medical care needs and costs. This information may then
be provided to an actuary, who calculates reserves to be set aside according to state or
federal requirements to pay for the following year’s healthcare needs. This position
also requires working knowledge of insurance terminology, regulations, and applicable
laws.
Senior Care
Nurse life care planners may work with senior individuals, families, and trust officers or
attorneys. This includes reviewing current and anticipated health needs, supplemental
insurance coverage options, educating about and reviewing options for care in
independent and assisted living, and planning for expected transitions through the
healthcare continuum with aging. These nurse life care plans are generally not involved
in litigation.
A nurse life care planner is the ideal professional to help develop a plan to address
health, safety and housing needs based on the individuals’ requirements, preferences,
and financial situation. What makes elder life care planning a bit different is that finding
the best solution is a bit like searching for buried treasure (See Appendix 3). There are
many financial and legal professionals who assist clients in developing retirement
portfolios, some who advertise their services (such as estate planning) and others who
have their services marketed to elders through other services.
Preparing an elder life care plan can be simple or complex. The nurse life care planner
must work with a mix of projected and current focused health care needs, and must
consider the desires and resources of the elder client in concert with the financial
expert or trust officer who will use the plan to manage the client funds to meet them.
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This is an excellent area in which to apply nurse life care planning skills for the benefit
of a vulnerable population.
advanced healthcare directives are increasingly important in today’s healthcare. Nurse
life care planners are well-positioned to expand the discussion from the familiar end-oflife terminal care directives to broader-based planning for life’s remaining years.
Case Management (CM)
Some nurse life care planners practice as nurse case managers as well as nurse life care
planners. The nurse life care planner may provide care coordination during plan
development if needed to complete the assessment process and develop opinions on
expected needs over the life expectancy. The life care plan may make provisions for
CM. Unless circumstances clearly do not present the potential for conflict of interest,
the nurse life care planner or nurse life care planning/CM company generally will not
provide nurse life care planning services on the same case. However, if the referral
source requests CM services after a life care plan has been completed and wants
continuation of services, the nurse life care planner may see no conflict of interest and
provide CM services. Legal advice may be helpful if this situation arises.
Values and Principles Guiding Nurse Life Care Planning Practice
Nurse life care planners embrace the following values and principles that are reflected
in the AANLCP Ethics Statement.
Competence: Nurse life care planners recognize that continual professional
growth, particularly in knowledge and skill, requires a commitment to lifelong
learning. Such learning includes, but is not limited to, continuing education,
networking with professional colleagues, self-study, professional reading,
certification, and seeking advanced degrees.
Integrity: For nurse life care planners, integrity is the foundation of practice
and demonstrates wholeness of character that is realized through congruence
of thoughts, words and actions. As one of the core values, integrity means
being truthful, honest, reliable, and authentic in all personal and professional
matters.
Accountability: Nurse life care planners are personally accountable for
judgments, decisions, and actions they make in their practice, regardless of
the policies or directives of others.
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Objectivity: Nurse life care planners remain impartial and approach all aspects
of the Life Care Planning process without individual bias, interpretations, or
feelings.
Respect for human dignity: In all professional relationships, nurse life care
planners practice with compassion and respect for the inherent dignity, worth,
and uniqueness of every individual, unrestricted by considerations of social or
economic status, personal attributes, or the nature of health problems.
The difficult conversation of how a disabled loved one should be cared for after
existing caregivers are no longer able to do so is an intimate part of the assessment
and planning process. The individual parent or spouse is often unaware of existing
alternative care setting options when asked about future wishes. For instance, parents
of a child with cerebral palsy may state when the child reaches young adulthood, they
would like for child to move to a residential living environment that affords a sense of
community living apart from them. The nurse life care planner knows or researches
available options to accommodate this goal.
The nurse life care planner incorporates opinions expressed by neuropsychologists,
therapists, and other medical providers to project provisions for the child’s likely future
capacities and needs. For example:
Are there specialty group homes in the area?
Will the child likely be able to direct in-home caregivers in how to give care?
Will an assisted living facility be sufficient?
Will a skilled nursing facility be necessary due to anticipated needs for
tracheostomy care and enteral feedings?
Will this child or adult remain medically complex? Is improved medical stability
developing over time? The nurse life care planner is acquainted with hallmark
indicators for future status. For instance, a child who is not able to walk by the
age of eight is not likely to become a functional ambulator in later years.
Are there therapeutic interventions that are not currently being rendered but
could likely lead to attainment of greater independence, which in turn would
lead to a different life time scenario of care needs?
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Ethics in Nurse Life Care Planning: The AANLCP Code of Ethics and
Conduct
Ethical concerns in nurse life care planning practice are often complex and
multidimensional, and may or may not be addressed in laws and professional ethics
codes. Codes of ethical practice educate and inform professionals about sound ethical
behavior, while mandating a minimal standard of practice. The ANA Code of Ethics for
Nurses with Interpretive Statements (ANA, 2001) provides the framework for ethical
nurse life care planning practice. The Code includes explanations and specific
examples are provided for each of its nine provisions.
Code of Ethics for Nurses with Interpretive Statements affirms that all nurses, including
nurse life care planners, have an ethical obligation to practice with integrity,
competence and accountability. The AANLCP Code of Ethics and Conduct was created
by a group of nurse life care planners as an additional guide to core values and
obligations of nurse life care planning.
1. The nurse life care planner does not discriminate against any person based on age,
gender, sexual orientation, ethnic background, religious beliefs or practices, social or
economic status, lifestyle choices, functional status, health status, or disability.
Nurse life care planning explanation:
An individual's differences or beliefs are respected. Personal attitudes do
not influence or interfere with professional performance.
Each individual's inherent worth, dignity and human rights are respected
by the nurse life care planner without prejudice, regardless of whether the nurse
agrees with or condones certain individual choices.
The nurse life care planner performs in a nonjudgmental and
nondiscriminatory manner.
Nurse life care planning example:
A nurse life care planner whose religious beliefs prohibit her from
accepting blood transfusions includes plans for platelet and red blood cells
transfusions for an individual with chronic malignancy.
2. The nurse life care planner maintains competency in nursing practice and nurse life
care planning practice.
Nurse life care planning explanation:
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The nurse life care planner pursues professional growth through personal
study, attendance at educational programs, national nursing conferences,
seminars, professional meetings, reading the AANLCP Journal and other
relevant professional journal articles, and collegial collaboration.
The nurse life care planner maintains an active registered nurse license in
good standing.
The nurse life care planner practices according to the Nurse Practice Act
and AANLCP scope of practice.
Nurse life care planning example:
A CNLCP earned credits towards recertification by attending the AANLCP
annual conference and a continuing education seminar on spinal cord injury, and
by presenting an offering on nurse life care planning to other nurses.
3. The nurse life care planner demonstrates high standards of professional conduct in
delivering nurse life care planning services.
Nurse life care planning explanation:
The nurse life care planner demonstrates honesty, integrity, responsibility,
accountability, timeliness, and respect for human dignity.
The nurse life care planner practices ethically and lawfully.
The nurse life care planner accurately represents professional background
and credentials.
The nurse life care planner does not promote personal interests for
personal gain.
The nurse life care planner remains objective and does not impose
individual values on others.
Nurse life care planning examples:
The nurse life care planner positively exemplifies nursing to individuals,
community, legal field, and media.
The nurse life care planner seeks consultation as necessary.
The nurse life care planner remains respectful and open in the exchange
of views with all individuals with relevant interests.
4. The nurse life care planner safeguards privacy rights.
Nurse life care planning explanation:
The nurse life care planner exercises responsibility, discretion and respect
in handling and use of all protected or sensitive information and materials.
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The nurse life care planner considers that the rights, well-being, and
safety of the individual should be the primary factors in arriving at any
professional judgment concerning the disposition of confidential information.
Nurse life care planning examples:
The nurse life care planner shares relevant data only with those with a
need to know.
The nurse life care planner is aware of and complies with local, state and
federal privacy and security regulations.
The nurse life care planner recognizes that in some circumstances private
information must be disclosed in compliance with federal or state law or
regulations.
The nurse life care planner uses appropriate technology to maintain data
security with electronic communication.
5. The nurse life care planner assumes responsibility and accountability for
professional action, opinions, recommendations, and commitments.
Nurse life care planning explanation:
The nurse life care planner assumes accountability for Life Care Plan and
actions, opinions, and decisions.
The nurse life care planner accepts, declines, or refers out cases on good
faith based upon personal competence, education, experience, and capabilities.
The nurse life care planner's professional services are delivered in a
competent, concise, and timely manner.
Nurse life care planning examples:
The nurse life care planner accepts responsibility for initiating
consultation with other health care providers when necessary.
The nurse life care planner questions incorrect or inappropriate
collaborative suggestions.
The nurse life care planner seeks opportunities for improvement based on
feedback from clients and colleagues on professional work.
6. The nurse life care planner provides professional services with objectivity.
Nurse life care planning explanation:
The nurse life care planner demonstrates critical thinking in decisions,
recommendations, and opinions.
The nurse life care planner actively seeks to eliminate personal opinion,
prejudice, conflict of interest, consideration, or appearance of any of these that
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could interfere with objectivity, performance, or outcome or tend to create the
appearance of bias.
Nurse life care planning examples:
The nurse life care planner applies standards of nursing practice (the
nursing process) consistently in all Life Care Plans, thereby not confusing bias
with advocacy.
The NCLP identifies and resolves any potential conflict of interest as soon
as possible.
7. The nurse life care planner participates in the advancement of the profession
through participating in and promoting mentorship, collegiality, education, and
ongoing knowledge development.
Nurse life care planning explanation
The nurse life care planner maintains active involvement in the
professional association's ongoing development and revisions of standards,
policies, and guidelines for nursing and nurse life care planning.
The nurse life care planner collaborates with mentors, peers, colleagues,
and others. The nurse life care planner shares materials and information
designed to advance the practice of nursing and nurse life care planning with
peers, colleagues, clients, and others.
Nurse life care planning examples:
The nurse life care planner stays current on trends and decisions
regarding healthcare delivery dynamics and expanding scopes of practice at the
local, state and national levels.
The nurse life care planner maintains an active membership in a national
nursing organization.
The nurse life care planner collaborates with members of other
professional organizations at international, national, state and community levels.
The nurse life care planner facilitates and participates in critical selfreflection and evaluation in the profession.
The nurse life care planner serves as a leader, mentor, or committee
member in the professional association.
Current Issues and Trends Affecting Nurse Life Care Planning
Overview
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AANLCP supports the policy advocacy role outlined in Role of Professional
Organizations in Advocating for the Nursing Profession (OJIN, 2012). This includes
activities such as advocating for greater nursing presence in the current Patient
Protection and Affordable Care Act (P.L. 111-148, March 2010) (ANA, 2011a;
Gallagher, 2010). The AANLCP’s goals include greater nurse involvement in providing
access to care, influencing the cost and quality of care, determining the scope and
authority of practice, and increasing and improving the healthcare workforce.
Case management was initially developed by the defense industry during World War II
to improve return-to-work rates after injury to support the war effort. After the war,
workers compensation insurance carriers continued case management as the positive
effect of such services on clinical outcomes became apparent in return-to-work data:
care coordination activities and utilization review emphasis on evidenced-based clinical
decision-making led to cost savings.
Today, case managers are an integral part of the healthcare system in all settings.
Nurse case managers are in high demand.
AANLCP foresees increased demand for nurse life care planning. Nurse life care
planning has its historical roots in the day-to-day, month-to-month, and year-to-year
nursing plans created, implemented, evaluated, and maintained by visiting nurses and
home care nurses. Case management nurses and rehabilitation nurses were likely
among the first nurse life care planners, especially those involved in litigation.
Nurse life care planning has evolved as a nursing specialty in ways these earliest
practitioners could not have imagined. Future need for nurse life care planners
probably far outweighs the number of nurses currently practicing in the specialty.
Healthcare Industry and Regulatory Issues Affecting the Future of the Specialty
Costing Accountability and Transparency
Nurse life care planners’ expertise in researching costs, applying data regarding
prognosis of medical conditions, and projecting future care needs will become more
important. Legislative calls for more statutory requirements for pricing accountability
and transparency in all aspects of healthcare grows louder with each budget year.
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Nurse life care planners will become increasingly valuable as their expertise assists
stakeholders to make meaningful use of published cost data.
Medicare Set-aside Arrangements
The Medicare Modernization Act (2003) requires that Medicare remain the secondary
payor whenever possible. As a result, nurse life care planners with an expertise in
Medicare guidelines are in high demand to assess expected care needs in worker’s
compensation and develop plans that protect Medicare’s interest, called Medicare setaside arrangements, in settlements. CMS has expanded the requirements for MSAs to
include civil litigated case settlements. This is resulting in increased demand for nurse
life care planner expertise.
Tort Reform
The potential for across-the-board tort reform could lead to damage caps in medical
malpractice, liability, and personal injury cases. Tort reform involving drug and device
product liability is another area where the need for nurse life care planners will
increase. In turn, this will increase the demand for nurse life care planner assessment
and care planning to provide direction about the injured person needs so that cases
can be resolved appropriately.
Elder Care
The baby boomer generation has created the largest population of elders in U.S.
history. This will pose a challenge for Medicare and Medicaid that can foreseeably lead
to tighter controls on healthcare funding. The nurse life care planner can assist the
Medicare system and the baby boomers plan for their healthcare needs; more nurses
are pursuing this specialty area of nurse life care planning as a result.
Looking to the Future
Nurse life care planners typically have clinical experience in settings throughout the
health care system, not only in hospitals, but in home health, public health, primary
care, and long-term care. They know what happens when the system works for patients
-- and when it doesn’t. This, combined with their rich understanding of evidencedbased care and focus on outcomes and costs, positions them for leadership roles in any
healthcare system redesign. They will be valuable contributors to transform and
improve care for persons with catastrophic and complex care needs at all stages of life.
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As we prepare this document, healthcare costs and healthcare reforms continue to
make headlines. The full effect of the Affordable Care Act on nurse life care planning
remains to be seen; speculation on this topic is becoming more common in
professional journals and meetings. As ANA states, "Registered nurses must
proactively deal with constant change and must be prepared for an evolving healthcare
environment ...” (Nursing: Scope and Standards of Practice, 2010). We believe that
nurse life care planning is, by its very nature, well-positioned for addressing the above
issues and trends in the future.
Nurse Life Care Planning and Research
Journal of Nurse Life Care Planning
The Journal of Nurse Life Care Planning (JNLCP) is recognized by nurses who practice
in the field of Life Care Planning and other specialty areas as a source for education.
Initially published in 1998, this journal began as a few articles shared by AANLCP
members to help address educational needs of their peers as determined by
AANLCP’s annual needs assessment. It is now the AANLCP’s sole journal, peerreviewed, and published quarterly. The JNLCP has been published electronically since
2009 and is indexed in the Cumulative Index of Nursing and Allied Health Literature
(CINAHL). According to annual readership surveys, readers include members of many
professions. More than 80% of all readers share individual articles or entire themed
issues with colleagues and clients more than twice a year.
Research Committee
The AANLCP collects research data from nurse life care planners to identify evolving
practice patterns. The AANLCP promotes research led by doctorally-prepared nurse
life care planners wherever possible by publicizing and supporting data collection from
members and other activities as they arise. This is congruent with AANLCP’s goal to
support evidence-based research concerning nurse life care planning.
AANLCP established the Research Committee in early 2014 to expand the body of
knowledge and theory specific to nursing practice and life care planning through
research supporting evidence based practice. The Research Committee represents the
association’s research interest, activities, and relationships to support, design, conduct,
disseminate, and integrate research specific to the specialty practice.
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The Research Committee has several activities and responsibilities including:
Initiating, facilitating, integrating and supporting nursing-focused research
projects
Developing an Institutional Review Board (IRB) process to safeguard the interests
of human subjects who participate in research projects conducted by nurse life
care planners
Carefully considering research budgets, timelines, outcomes, and usefulness for
the specialty
Developing resources for funding research projects
Developing and carrying out research plans consistent with the AANLCP
strategic plan and the objectives and budget of the committee
Mentoring novice researchers
Publishing the resulting research findings in the AANLCP Journal of Nurse Life
Care Planning and website
Standards of Nurse Life Care Planning
Significance of the Standards
The Standards of Professional Nursing Practice are authoritative statements of the
duties that all registered nurses, regardless of role, population, or specialty, are
expected to perform competently. The Standards may serve as evidence of the
standard of care, with the understanding that their application depends on context.
The Standards are subject to change with the dynamics of the nursing profession, as
new patterns of professional practice develop and are accepted by the nursing
profession and the public. Specific conditions and clinical circumstances may also affect
the application of the standards at a given time (e.g., civil unrest, natural disaster). The
Standards are subject to formal, periodic review and revision.
The competencies that accompany each standard provide evidence for compliance
with the corresponding standard. The list of competencies is not exhaustive. Whether a
particular standard or competency applies depends upon the circumstances. For
example, a nurse preparing a Life Care Plan for litigation may have limited access to
the individual due to court constraints; an in-home or in-person assessment may not be
permitted.
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The Standards of Practice recapitulate the steps of the nursing process. The
nursing process includes six singular and integrated actions of assessment:
diagnosis, outcomes identification, planning, implementation, and evaluation.
The bidirectional interactions between each component in Figure 1 convey that
the process is not linear. That is, the nursing process is cyclical and dynamic. Each
action (assessment, diagnosis, identification of outcomes planning,
implementation, and evaluation) encompasses significant actions taken by
registered nurses and forms the foundation of the nurse’s decision making.
The standards may be applied at the individual, family, community, and/or
population level.
Figure 1. The Nursing Process and Standards of Professional Nursing Practice
(ANA, 2010)
Nurse Life Care Planning Standards of Practice
The following standards of practice and performance are adapted from the American
Nurses Association 2010 Nursing: Scope and Standards of Practice, Second Edition.
Standard 1. Assessment
The nurse life care planner performs comprehensive data collection pertinent to the
healthcare consumer’s health and unique situation.
Competencies: The nurse life care planner:
Collects comprehensive data including but not limited to physical, functional,
psychosocial, emotional, cognitive, sexual, cultural, age-related, environmental,
spiritual/transpersonal, and economic assessments in a systematic and ongoing
process while honoring the uniqueness of the person.
Assesses any existing plan of care.
Analyzes current plan of care for adherence to current standards and clinical
guidelines.
Elicits the healthcare consumer’s values, preferences, expressed needs, and
knowledge of the healthcare situation when possible and as appropriate.
Includes the healthcare consumer, family, and healthcare providers in data
collection when possible and as appropriate.
Identifies barriers (e.g., psychosocial, literacy, financial, cultural) to effective
communication and makes appropriate adaptations.
Identifies unwarranted or unwanted treatment and causes of healthcare consumer
suffering in the current plan of care.
Recognizes the impact of personal attitudes, values, and beliefs.
Assesses family dynamics and impact on healthcare consumer health and
wellness.
Prioritizes data collection based on the healthcare consumer’s history, current
condition and anticipated needs or situation.
Uses appropriate evidence-based assessment techniques, instruments, and
tools.
Analyzes data and information to prescribe necessary system and community
support measures, e.g., home modifications, nursing care, counseling.
Synthesizes available data, information, and knowledge relevant to the situation
to identify patterns and variances.
Applies ethical, legal, and privacy guidelines and policies to the collection,
maintenance, use, and dissemination of data and information.
Recognizes healthcare consumers as unique sources of information on their
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own health.
Documents relevant data in a retrievable format.
Standard 2. Diagnosis
The nurse life care planner analyzes assessment data to determine diagnoses and
issues.
Competencies: The nurse life care planner:
Derives diagnoses and issues based on assessment data.
Validates the diagnoses or issues with the healthcare consumer, family, and other
healthcare providers when possible and appropriate.
Identifies actual and potential risks to the healthcare consumer’s health, safety,
and barriers to health, including but not limited to interpersonal, systematic, and
environmental circumstances.
Uses standardized classification systems and clinical decision support tools, when
available, in identifying diagnoses.
Documents diagnoses and issues in a way that makes it possible to identify
expected outcomes, establish priorities, and develop the life care plan.
Standard 3. Outcomes Identification
The nurse life care planner identifies expected outcomes for a life care plan
individualized to the healthcare consumer or situation.
Competencies: The nurse life care planner:
Involves the individual, family, healthcare providers, and others, when possible
and appropriate, in formulating expected outcomes.
Develops culturally appropriate outcomes. For example, referrals to providers
with similar language and culture whenever possible.
Considers the healthcare consumer’s age, developmental stage, values and
culture, ethical considerations, and environment when formulating expected
outcomes. For example, a child with life-long needs receives age-appropriate
occupational therapy in the home, community, or facility appropriate setting
Derives realistic outcomes for potential functional, emotional, and
developmental capabilities. For example, the plan prescribes appropriate
nursing care configuration based on functional potential over life expectancy.
Considers associated risks, benefits, costs, current scientific evidence, expected
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trajectory for the condition, and clinical expertise. For example, the
patient/family voices understanding of the plan for long-term health
maintenance needs, including follow up and treatment with specialists and
therapists.
Includes realistic timeframe estimates for attainment of expected outcomes.
Derives expected outcomes that provide direction for continuity of care. The
plan includes a long-term health maintenance plan that emphasizes continuity
of care over life expectancy.
Modifies expected outcomes according to changes in the status of the
healthcare consumer or evaluation of the situation.
Documents expected outcomes as measurable goals.
Standard 4. Planning
The nurse life care planner develops a plan that prescribes strategies, interventions,
and alternatives to attain projected outcomes.
Competencies: The nurse life care planner develops a plan that:
Provides direction to the healthcare team and consumer.
Reflects current statutes, standards, rules, and regulations.
Considers the individual’s characteristics and situation, including, but not
limited to, values, beliefs, spiritual and health practices, preferences, choices,
developmental level, coping style, culture and environment, and available
technology.
Explores suggested, potential, and alternative options and establishes the
plan’s priorities with the healthcare consumer, health care providers, and others
as possible and appropriate.
Integrates traditional and complementary health care practices as appropriate.
Includes strategies that address each identified diagnosis or issue across the
lifespan, e.g., probable future needs; strategies for health promotion and/or
restoration; illness, injury, and disease prevention; alleviation of suffering;
supportive care for end of life.
Provides for continuity.
Incorporates an implementation pathway or timeline, i.e., frequency of need.
Includes an analysis of the economic effect on the healthcare consumer, family,
caregivers, or other affected parties.
Integrates current scientific evidence, trends and research.
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Provides alternatives, associated costs, and benefits.
Can be modified according to ongoing assessment of response and other
outcome indicators as indicated.
Documents the plan that uses standardized language or recognized
terminology.
Standard 5. Implementation
The nurse life care planner provides for implementation of the plan.
Competencies: The nurse life care planner:
Recognizes and uses technology, community resources, and systems as
appropriate.
Recommends evidence-based interventions, treatments, and strategies specific
to diagnoses and issues.
Consults with others as appropriate.
Recommends implementation methods and manner.
Modifies the plan if indicated.
Provides for holistic care that addresses the needs of diverse populations across
the lifespan.
Provides for health care that is sensitive to individual needs, with particular
emphasis on the needs of diverse populations.
Applies appropriate knowledge of major health problems and cultural diversity in
providing for the plan of care.
Provides for available healthcare technologies to maximize access and optimize
outcomes for healthcare consumers.
Standard 5A. Coordination of Care
The nurse life care planner provides for coordination of the planned care and services
throughout the lifespan.
Competencies: The nurse life care planner:
Organizes the components of the plan.
Recommends a nurse case manager and/or qualified other(s) to implement the
plan, manage transitions of care delivery, and provide for dignified and humane
care by the multidisciplinary team.
Assists the healthcare consumer in identifying options for alternative care.
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Incorporates services that maximize safety, independence, and quality of life.
Advocates for the delivery of dignified and humane care by the
multidisciplinary team.
Documents decisions and actions related to coordination of care.
Standard 5B. Health Teaching and Health Promotion
The nurse life care planner employs strategies to promote health and safety.
Competencies: The nurse life care planner:
Addresses health and safety issues using data collected in the assessment,
diagnosis, and planning processes.
Provides for health teaching to address such topics as healthy lifestyles, riskreducing behaviors, developmental needs, activities of daily living, restorative
measures, intended effects and potential adverse effects of proposed
therapies, and preventive care.
Provides for health teaching methods taking into account values, beliefs, health
practices, developmental level, learning needs, readiness and ability to learn,
language preference, spirituality, culture, and socioeconomic status.
Provides for health promotion and maintenance, for example, weight loss,
smoking cessation, support group participation, or exercise programs.
Provides for education about informed decision-making related to plan options.
Standard 5C. Consultation
The nurse life care planner provides consultation to evaluate, develop, and influence
the plan of care, enhance others’ ability, and effect change.
Competencies: The nurse life care planner:
Synthesizes data, information, research, and evidence to summarize and share
with others.
Communicates recommendations in a way that facilitates understanding.
Facilitates the effectiveness of a consultation by involving the healthcare
consumers and stakeholders in decision-making.
Standard 6. Evaluation
The nurse life care planner evaluates progress toward plan outcomes.
54
Competencies: The nurse life care planner:
Incorporates a systematic and evidence-based process for outcomes evaluation
in the life care plan.
Collaborates with the healthcare consumer and other involved persons in the
evaluation process when possible and appropriate.
Uses evaluation findings to revise the nursing diagnoses, outcomes, life care
plan n, and implementation as needed.
Communicates the life care plan results to the healthcare consumer and other
involved persons as reasonable and appropriate, in accordance with state and
federal law and regulations.
Reviews the life care plan for responsible and appropriate interventions to
minimize unwarranted or unwanted treatment and healthcare consumer
suffering.
Documents the results of the evaluation.
Standard 7. Ethics
The nurse life care planner practices ethically.
Competencies: The nurse life care planner:
Uses the current ANA Code of Ethics for Nurses with Interpretive Statements
and AANLCP Code of Professional Ethics and Conduct for Nurse Life Care
Planners with Interpretive Statements to guide practice.
Practices in a manner that preserves and protects healthcare consumer
autonomy, dignity, rights, values, and beliefs
Recognizes the centrality of the healthcare consumer and family as core
members of any healthcare team.
Maintains patient confidentiality within legal and regulatory parameters.
Assists healthcare consumers in self-determination and informed decisionmaking.
Provides information on the risks, benefits, and outcomes of healthcare
regimens to allow informed decision-making by the healthcare consumer,
including informed consent and informed refusal.
Contributes to resolving ethical issues involving healthcare consumers,
colleagues, community groups, systems, and other stakeholders.
Takes appropriate action to address illegal, unethical, inappropriate behavior,
or unsafe practices that can endanger or jeopardize the best interests of the
55
healthcare consumer.
Promotes healthcare consumers’ self-determination and informed decisionmaking.
Maintains professional relationships in the healthcare, community and legal
environments.
Participates in continuing education that addresses ethical issues.
Advocates for equitable healthcare consumer care.
Standard 8. Education
The nurse life care planner attains knowledge and competence that reflects current
nursing practice.
Competencies: The nurse life care planner:
Participates as learner and teacher in formal and informal educational activities
related to appropriate knowledge and professional issues.
Demonstrates an ongoing commitment to learning through self-reflection and
inquiry to identify learning needs.
Pursues learning activities to develop and maintain skills, abilities, knowledge,
and competence.
Uses current healthcare research findings and other evidence to expand nurse
life care planning knowledge, skills, and judgment.
Consults with nursing and other healthcare professionals to develop and
maintain skills, abilities, and knowledge.
Shares educational findings, experiences, and ideas with peers.
Maintains professional records that provide evidence of competence and
lifelong learning.
Obtains and maintains professional certification in life care planning and other
applicable content areas as appropriate.
Standard 9. Evidence–Based Practice and Research
The nurse life care planner integrates research findings and evidence into practice.
Competencies: The nurse life care planner:
Uses critical thinking skills and current scientific evidence to guide nurse life
care planning practice.
Actively participates in research activities, such as:
56
- Participating in a formal research committee, program, or study.
- Critically analyzing and interpreting research for application to nurse life
care planning practice.
- Formally disseminating research findings through presentations,
publications, or consultations.
• Shares findings with peers, colleagues, individuals, families, nurses entering the
field of nurse life care planning, and others.
Standard 10. Quality of Practice
The nurse life care planner contributes to quality nursing and nurse life care planning
practice.
Competencies: The nurse life care planner:
•
Applies the nursing process responsibly, accountably, and ethically when
developing a nurse life care plan.
•
Provides leadership in the design and implementation of quality improvements.
•
Uses the results of quality improvement to initiate changes in nursing practice and
the healthcare delivery system.
•
Participates in quality improvement activities. These may include, for example:
- Identifying problems that occur in day-to-day work routines to correct
process inefficiencies.
- Seeks healthcare consumer feedback to identify opportunities for
improving practice.
- Formulating recommendations to improve practice or outcomes.
- Implementing activities to enhance the quality of practice.
- Maintaining familiarity with current standards of practice.
- Active participation in a professional organization relating to the practice of
nurse life care planning.
- Participating in and/or leading efforts to minimize costs and unnecessary
duplication.
Standard 11. Communication
The nurse life care planner communicates effectively in a variety of formats in all areas
of practice.
Competencies: The nurse life care planner:
•
Assesses communication format preferences of healthcare consumers, families,
57
and colleagues.
•
Self-assesses communication skills in formal and informal professional
interpersonal encounters.
•
Seeks continuous improvement of own communication and conflict-resolution
skills.
•
Conveys information accurately.
•
Questions the rationale supporting processes and decisions that do not appear
to be in the best interest of the healthcare consumer.
•
Discloses observations or concerns related to hazards and errors in care,
practice environment, or individual circumstances to the appropriate level.
•
Provides for communication between providers using case managers or
qualified others to minimize risks associated with transfers and transition in care
delivery.
•
Contributes professional perspective in formal and informal inter- and
intraprofessional discussions.
Standard 12. Leadership
The nurse life care planner provides demonstrates leadership in the professional
practice setting and the profession.
Competencies: The nurse life care planner:
•
Provides direction to enhance effectiveness of multidisciplinary team.
•
Educates the public about the nurse life care planning profession.
•
Fosters a supportive environment for nurses entering nurse life care planning
practice.
•
Communicates effectively.
•
Defines a clear vision, measurable associated goals, and a plan to accomplish
them.
•
Models expert practice to multidisciplinary team members and healthcare
consumers.
•
Uses best practices in the development of policies, procedures and standards
of nurse life care planning practice.
•
Demonstrates a commitment to lifelong learning and education for self and
others.
•
Promotes professional development through mentoring. Mentors colleagues for
the advancement of nursing practice, the profession, and quality health care.
•
Treats colleagues with respect, trust, and dignity.
58
•
Facilitates successful conflict resolution through effective communication.
•
Advocates for advancing nursing autonomy and accountability.
•
Participates in professional organizations.
•
Promotes the profession through writing, publishing, and formal and informal
presentations.
•
Works to influence decision-making bodies to improve healthcare services and
policies.
Standard 13. Collaboration
The nurse life care planner collaborates with healthcare consumers, healthcare
providers, and others, in the conduct of practice.
Competencies: The nurse life care planner:
•
Partners with others to effect change and produce positive outcomes through the
sharing of knowledge of the healthcare consumer and/or situation.
•
Communicates the nurse life care planner’s role to all involved parties.
•
Promotes conflict management and engagement.
•
Adheres to standards and applicable codes of conduct that govern behavior
among peers and colleagues to create a work environment that promotes
cooperation, respect, and trust.
•
Creates a work product focused on outcomes and decisions related to care and
service delivery that reflects communication with all involved parties.
•
Documents communications, rationales for plan changes, and collaborative
discussions as appropriate.
•
Cooperates in creating a documented plan focused on outcomes and decisions
related to care and delivery of services that indicates communication with
healthcare consumers, families, and others.
•
Engages in teamwork and team-building processes.
Standard 14. Professional Practice Evaluation
The nurse life care planner self-evaluates nursing practice in relation to professional
practice standards and guidelines, relevant statutes, rules, and regulations.
Competencies: The nurse life care planner:
•
Analyzes one’s life care plans for age-appropriate and developmentally
appropriate care in a culturally and ethnically sensitive manner.
59
•
Engages in self-evaluation of practice on a regular basis, identifying areas of
strength, as well as areas for professional development
•
Seeks feedback regarding one’s own practice from healthcare consumers,
peers, professional colleagues, and appropriate others.
•
Interacts with peers and colleagues to enhance her or his own professional
nursing practice or role performance.
•
Takes action to achieve goals identified as a result of self-evaluation, e.g.,
revising report format, preparing for deposition or trial, improving presentation
skills.
•
Considers new and emerging technology and tools for improving work
product.
•
Provides the evidence for practice decisions and actions as part of the informal
and formal evaluation processes.
•
Interacts with peers and colleagues to enhance her or his own professional
nursing practice or role performance.
•
Provides peers with formal or informal constructive feedback regarding their
practice or role performance.
Standard 15. Resource Utilization
The nurse life care planner recommends appropriate resources for safe, effective, and
financially-responsible healthcare services.
Competencies: The nurse life care planner:
•
Assesses the healthcare consumer’s needs and resources available to address
needs and achieve desired outcomes.
•
Recommends appropriate levels of care based on complexity and the needs of
the individual.
•
Identifies healthcare consumer needs when making resource recommendations.
•
Evaluates factors such as safety, effectiveness, availability, cost/benefits,
technology, evidence, and efficiencies when considering Life Care Plan
component options with the same expected outcome.
•
Considers new and emerging technology for inclusion in the plan.
•
Provides for delegation of elements of care in the plan to appropriate persons
and healthcare workers in accordance with applicable legal, regulatory, or
policy parameters.
•
Assists the healthcare consumer and other relevant parties to understand costs,
risks, and benefits of treatment, care, and other elements of the nurse Life Care
60
Plan.
Standard 16. Environmental Health
The nurse life care planner practices in an environmentally safe and healthy manner.
Competencies: The nurse life care planner:
•
Attains knowledge of environmental health concepts, such as implementation
of environmental health strategies.
•
Promotes practice and care environments that reduce environmental health
risks.
•
Assesses how environmental factors such as sound, odor, noise, and light affect
health.
•
Advocates for the judicious and appropriate use of products in health care.
•
Communicates environmental health risks and exposure reduction strategies to
healthcare consumers, families, colleagues, communities, and others as
appropriate.
•
Evaluates scientific evidence to determine if a product or treatment is an
environmental threat.
•
Participates in strategies to promote healthy communities.
61
References
Agency for Healthcare Research and Quality (n.d.) The High Concentration of U.S. Health Care
Expenditures: Research in Action, Issue 19. June 2006, Rockville, MD.
http://www.ahrq.gov/research/findings/factsheets/costs/expriach/index.html Retrieved
4/21/2015
American Association of nurse life care planners (AANLCP ). (2008) nurse life care planners
standards of practice with interpretive statements. Membership Guide. AANLCP. Salt Lake City
UT
. Position statement on the definition of the nurse Life Care Planning. (2008)
Membership Guide. AANLCP. Salt Lake City UT www.aanlcp.org/homepage.
. Code of professional ethics and conduct for nurse life care planners with interpretive
statements. (2008) Membership Guide. AANLCP. Salt Lake City UT
American Nurses Association (ANA). (2001) Code of ethics for nurses with interpretive
statements. Washington, DC: American Nurses Publishing.
. (2010) Nursing’s social policy statement: The essence of the profession. 2nd edition.
Silver Spring MD: Nursesbooks.org.
. (2010) Scope and standards of practice, Nursing, 2nd edition. Silver Spring MD:
Nursesbooks.org
Benner, P. (1982) From novice to expert. American Journal of Nursing 82(3), 402-407
Brock, P. From Clinical Nurse to Entrepreneur: Becoming a Life Care Planner. American Journal
of nurse life care planning. Winter 2010; X, (4): 285-291. Available at,
http://www.aanlcp.org/resources/journal.htm; 2010 December.
Centers for Medicare and Medicaid: Workers Compensation Medicare Set-aside Arrangements
(WCMSAs)
https://www.cms.gov/WorkersCompAgencyServices/04_wcsetaside.asp#TopOfPage
Deutsch. P. M. Life Care Planning. (2011) Retrieved from: http://www.paulmdeutsch.com/LCPintroduction.htm
Federal Rules of Evidence. Article VII, Opinions and Expert Testimony (Rule 701-706)
Herdman TH (2012) (Ed.). NANDA International Nursing Diagnosis: Definitions and
Classification, 2012-2014. Oxford: Wiley-Blackwell
Howland WA (2010) Nursing Diagnosis, Definitions and Classifications, NANDA I. Journal of
nurse life care planning. Winter 2010; X, (4): 292-294. Available at
http://www.aanlcp.org/resources/journal.htm; 2010 December.
Institute of Medicine (2010). The Future of Nursing: Leading Change, Advancing Health;
October 5, 2010
LaGasse, N., McDaniel, H., American Association of Legal Nurse Consulting, Legal Nurse
Consulting Practices, 3rd Edition, "The Life Care Planning Expert," Volume II, Chapter 13, (pp.
273 - 303), CRC Press, Taylor & Francis Group, Boca Raton, FL. (2010)
2
Manzetti C, Bate BT & Pettengill A, 2014. A survey of nurse life care planners: a role
delineation study in the United States. JNLCP XIV.3, Fall 2014, p.694 ff
National League of Nursing. Critical Thinking in Clinical Nursing Practice/RN Examination. June
2011. Available at http://dev.nln.org/testproducts/pdf/CTinfobulletin.pdf.
Online Journal of Issues in Nursing (2012) Role of professional organizations in advocating for
the nursing profession. Vol. 17, No. 1, Manuscript 3, January 2012.
http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tableof
Contents/Vol-17-2012/No1-Jan-2012/Professional-Organizations-and-Advocating.html Retrieved
8/24/2014
Robert Wood Johnson Foundation (2013) Discover nursing: nurse life care planning
https://www.discovernursing.com/specialty/nurse-life-care-planner#.VBioUy7CN0E Retrieved
9/16/2014
The ARC. For people with intellectual and development disabilities. (2011)
http://www.thearc.org/page.aspx?pid=2414.
Appendices:
1. Criteria for Recognition as a Nursing Specialty
2. Role Delineation Study
3. Nurse Life Care Planning in Elder Care
4. Nurse Life Care Planning Exemplars (Redacted)
Child with cerebral palsy (plaintiff)
Adult catastrophic injury (corporation)
Adult with severe burns (plaintiff)
Adult with heart transplant (workers compensation)
Defense critique of opposing life care plan – SCI (international)
5. AANLCP and Certification Board Joint Position Paper on Education and
Certification for Nurse Life Care Planners
3
AMERICAN ASSOCIATION OF NURSE LIFE CARE PLANNERS
The American Association of Nurse Life Care Planners is the only professional
organization representing registered nurses in the field of life care planning. The
Association represents nurse life care planners through its member organization,
education, work groups, publications, and website. AANLCP advances the nurse life
care planning profession by developing and promulgating standards for nurse life care
planning practice, promoting the work of nurse life care planning to many
constituencies, projecting a positive and realistic view of nurse life care planning, and
communicating with regulatory agencies on healthcare issues affecting nurses and
nursing care. In this leadership role, AANLCP must address the assurance of quality in
nurse life care planning practice.
FOUNDATIONAL RESOURCES FOR NURSE LIFE CARE PLANNERS
Three documents establish the foundation and create the framework for all nursing
practice within the global domains of practice, education, administration, and research,
as well as in more discrete areas of specialty practice. Nursing’s Social Policy
Statement: The Essence of the Profession (ANA, 2010b), describes professional
nursing’s accountability to the public and identifies the processes of self-regulation,
professional regulation, and legal regulation as mechanisms to maintain public trust.
A second resource, the Code of Ethics for Nurses With Interpretive Statements (ANA,
2001), provides significant guidance for all nurses and their nursing practice in every
setting.
The third foundational document, Nursing: Scope and Standards of Practice, Second
Edition (ANA, 2010a), presents more detail in further defining the scope and standards
of practice for all registered nurses. It describes what nursing is, what nurses do, and
those responsibilities for which nurses are accountable. The scope and standards of
nursing practice language serves also as a template for a nursing specialty when
delineating the details and complexity of that specialty.
For nurse life care planners, the most important foundational document is Nurse Life
Care Planning: Scope and Standards of Practice (AANLCP, 2015). This document
describes nurse life care planning origins, professional association, education,
certification, practice settings, methodology, ethics, research, and responsibilities as a
profession.
RECOGNITION AS A NURSING SPECIALTY
The process of recognizing an area of practice as a nursing specialty allows a
profession to formally identify subset areas of focused practice. A clear description of
the specialty nursing practice assists the larger community of nurses, healthcare
consumers, and others to gain familiarity and understanding of the nursing specialty.
Therefore, the document requesting ANA recognition must clearly and fully address
each of the fourteen specialty recognition criteria.
Because the context of specialty practice should not be separated from its standards of
practice, The Congress on Nursing Practice and Economics (CNPE) requires that a
contemporary specialty nursing scope of practice statement and standards of specialty
nursing practice also accompany the request for recognition. Other supporting
documents and references may be included to provide additional information, but are
not required.
CRITERIA FOR RECOGNITION AS A NURSING SPECIALTY
The recognition criteria were originally developed in 1998 by the American Nurses
Association Congress of Nursing Practice and its Committee on Nursing Practice
Standards and Guidelines in collaboration with members of the Nursing Organization
Liaison Forum (NOLF). The Congress on Nursing Practice and Economics regularly
reviews the adequacy of the criteria, completed minor revisions in 2004, 2008, and
2010, and continues to use the criteria during the review and decision-making
processes to recognize an area of practice as a nursing specialty.
Nurse life care planning …
1. Defines itself as nursing
Registered nurses practicing as life care planners
organized a specialty organization in the 1990s
because the methodology nurses apply to life care
planning is separate and distinct from the
methodology used by vocational rehabilitation life
care planners and others. Nurses develop and
prescribe plans of care using the conceptual
framework of the nursing process and nursing
diagnosis.
This is uniquely reserved to registered nurses
engaged in the practice of nursing.
Reference for more detailed information on the
nursing process as the conceptual framework for
nurse life care planning: AANLCP Scope of Practice
pages 7-12
2. Is clearly defined
Reference for more detailed information on nurse
life care planning and the art of nursing: AANLCP
Scope of Practice pages 28 - 29
Nurse life care planners use the nursing process to
assess, diagnose, and formulate a plan of care for the
lifetime of an individual. Following the nursing process,
the Nurse Life Care Planner develops the life care plan
that estimates the costs and resources necessary for
future medical and non-medical needs and expenses.
Reference for more detailed descriptions of nurse
life care planning processes and methodology:
AANLCP Scope of Practice pages 21-24
3. Has a well-derived
knowledge base particular to
the practice of the nursing
specialty
In 1997 Kelly Lance, BSN (now MN, FNP), RN,
recognized that registered nurses' multidimensional
healthcare education and nursing’s own professional
standards and scope of practice were an ideal
foundation for life care planning. She provided the
first formal educational offerings on using the
nursing process and professional nursing scope and
practice concepts as the basis for life care planning
and its application in health care.
A Core Curriculum for Nurse Life Care Planning
(AANLCP) was published in November 2013. The
revised and expanded second edition is in progress
and will be published in 2017.
4. Is concerned with
phenomena of the discipline of
nursing
Reference for more detailed information on “Special
Areas of Practice” for descriptions of particular
specialized knowledge necessary for Nurse Life Care
Planner subspecialty roles: AANLCP Scope of
Practice pages 32 - 37
Other disciplines and nursing disciplines recognize
the role of Nurse Life Care Planners.
Certification examinations for certified case
managers (CCM) and legal nurse consultants (LNCC)
each allocate 5-7% of their examination questions to
life care planning.
Basic nursing textbooks, including Stanhope and
Lancaster, (2012), Public Health Nursing PopulationCentered Health Care in the Community (8th ed.),
now describe the role and function of nurse life care
planners; the authors are collaborating with the
Journal of Nurse Life Care Planning editor on their
next edition to provide more specifics.
The Association of Rehabilitation Nurses include the
role and function of nurse life care planners in their
Core Curriculum’s upcoming revised edition.
The Journal of Nurse Life Care Planning includes
suggested nursing diagnoses from NANDA-I (most
current edition) in all clinical articles. The Core
Curriculum for Nurse Life Care Planning (2013)
collaborated with NANDA-I’s publisher extensively
to be able to feature NANDA-I nursing diagnoses
prominently in all clinical chapters.
The AANLCP is a member of the Alliance of Nursing
Organizations and the National Quality Forum, a
nonpartisan advisory group that works to catalyze
improvements in healthcare. AANLCP is seeking
membership in NAQC-Nursing Alliance for Quality
Care (managed by ANA). These organizations focus
on patient/family engagement; dynamic
partnerships among patients, families, and
caregivers; shared decision making; highest quality,
safety, and value of consumer centered care.
Leaders and members in the Association are also
members of the ANA, NANDA-I, CMSA, AALNC,
ARN, State Board of Nursing Practice Advisory
Panels, and other nursing organizations, including as
candidates for office. One member was tapped to
help write the case management certification
examination for the ANCC. Other members
contribute to nursing periodicals. One member has
published a textbook of nurse life care planning
exemplars. Another is contributing to the next
edition of a well-known nursing diagnosis handbook
(Ackley, 11th ed.)
The Robert Wood Johnson Foundation Initiative on
the Future of Nursing primarily addresses the future
of nursing roles in clinical settings. Although nurse
life care planning is not typically practiced in these
areas, we wholeheartedly support and see benefit to
our practice particularly in the areas of nursing
leadership in collaborative practice and in nurse-led
change to affect health. Nurse life care planners are
actively involved in these organizations’ missions in
every aspect of practice.
5. Subscribes to the overall
purposes and functions of
nursing.
Reference for more detailed information on nurse
life care planners leadership roles: AANLCP Scope
of Practice pages 18, 45
5. The AANLCP subscribes to the overall purposes
and functions of nursing. As outlined in the Scope
and Standards, the specialty practice of nurse life
care planning recognizes the power of the ANA
Scope and Standards.
Over the past twenty years, nurse life care planning
leaders and practitioners have used nursing process
and NANDA-I nursing diagnoses as the conceptual
framework for nurse life care plans.
6. Can identify a need and
demand for itself
Reference for more detailed information on
conceptual framework and roles: AANLCP Scope of
Practice pages 7 - 12
6. Nurse life care planners are in demand.
Professional conferences, e.g., local, national, and
regional Case Management Society of America,
American Association of Legal Nurse Consultants,
and conferences and seminars for attorneys and
structured settlement professionals have requested
presentations by nurse life care planners about
nurse life care planning, its conceptual framework
and methodology, and how it adds significant value
to patient care planning in litigation, trusts,
settlement planning and administration, and Federal
vaccine cases.
This has led to rapidly-increasing visibility in
medical-legal settings. Nurse life care plans and the
nurses who develop them are becoming more
valued in litigation as their strengths, backed by RN
licensure and a defined Scope and Standards,
become more respected.
7. Adheres to the overall
Reference for more detailed information: AANLCP
Scope of Practice pages 32, 34 – 37, 43 - 45
7. The AANLCP adheres to the overall licensure,
licensure, certification, and
education requirements of the
profession.
certification, and education requirements of the
profession. Certified Nurse Life Care Planners
maintain active RN licenses and adhere to the ANA
Scope and Standards of Practice.
Like other specialty credentials, the CNLCP is
renewed every five years with documented
participation in educational, research, teaching, and
other activities.
Reference for more detailed information on
certification and education requirements, and
continuing education: AANLCP Scope of Practice
pages 16 - 21
8. Defines competencies for the 8. The AANLCP defines competencies for the area
area of specialty nursing
of specialty nursing practice in the Scope and
practice.
Standards for Nurse Life Care Planners herein.
9. Has existing mechanisms for
supporting, reviewing,
and disseminating research to
support its knowledge base
and evidence - based practice
Reference for more detailed information: AANLCP
Scope of Practice page 47 - 60
9. The AANLCP has an existing mechanism for
supporting, reviewing, and disseminating research
to support its knowledge base and evidence-based
practice.
The AANLCP’s quarterly peer-reviewed journal, the
Journal of Nurse Life Care Planning, is freely
accessible to any interested party at
www.aanlcp.org. Annual readership surveys
consistently indicate that readers distribute its
contents to a wide variety of constituencies
including members of multidisciplinary care teams,
legal and financial groups, and community resources
(e.g., Brain Injury Association).
AANLCP’s research committee is chaired by a
doctorally-prepared RN. The Association hosts an
annual educational conference, periodic webinars,
and website to disseminate relevant articles,
research, and literature to all nurses.
Current projects include developing a White Paper
on Advocacy and Nurse Life Care Planning and
looking at how nurse life care planners distinguish
variables in providing for case management services
in a nurse life care plan.
While not arms of official entities, there are at least
two nurse life care planning online communities for
information sharing and communication in the field,
and nurse life care planners are well-represented in
online legal nursing fora as experts. Increasing
numbers of nurse life care planners are pursuing
doctoral degrees focusing on life care planning.
10. Has defined educational
criteria for specialty preparation
or graduate degree
Reference for more detailed information on the
Journal and the Research Committee: AANLCP
Scope of Practice pages 45 - 46
10. The AANLCP has defined educational criteria
for specialty preparation. The Association endorses
established requirements to sit for the CNLCP
examination for certification, including completion
of an educational course of study and demonstrated
competence by submitting a nurse life care plan for
review and passing the certification examination.
A recent survey showed that 80% of responders
hold a bachelors degree, of whom 20% also have a
master’s degree in nursing and 80% hold a master’s
degree in another field. 75% of members have 30+
years of nursing experience. Some CNLCPs are
pursuing doctoral degrees in nursing and beginning
evidence-based research in nurse life care planning.
Reference for the AANLCP / CNLCP Certification
Board joint position paper on education and
certification for nurse life care planners: Appendix 5
Reference for more detailed information on
certification requirements and certification board
procedure: AANLCP Scope of Practice page 19 – 21
11. Has continuing education
programs or other mechanisms
for nurses in the specialty to
Reference for more detailed information on
demographics from Role Delineation Study:
AANLCP Scope of Practice, Appendix 2.
11. The AANLCP offers continuing education
programs in many ways. These include webinars,
online interactive offerings, website fora, and blogs.
maintain competence
12. Is practiced nationally or
internationally
The Association holds an annual conference that
offers a minimum of 16 CEUs. The Journal of Nurse
Life Care Planning publishes electronically for free
access and appears quarterly.
Reference for more detailed information on
AANLCP-sponsored continuing education: AANLCP
Scope of Practice, page 17
12. The Association membership data show that
Nurse Life Care Planning is practiced nationally and
internationally. Members of the American
Association of Nurse Life Care Planners come from
all 50 states, several US territories, Canada, and
other countries. Life care planners work
internationally; our members have provided services
abroad as well as in the US.
Reference for more detailed information: AANLCP
Scope of Practice, pages 18, 44, and Appendix 4.
13. Includes a substantial
number of registered nurses
who devote most of their
professional time to the
specialty.
13. An AANLCP survey from November 2013
showed that 55% of respondents devote greater
than 20 hours per week to nurse life care planning.
Those who do not work full time as nurse life care
planners do so for a variety of personal and
professional reasons. Many perform elements of
nurse life care planning in their day-to-day work as
nurse case managers, legal nurse consultants,
researchers, or educators.
Reference for more detailed information from the
Role Delineation Study: AANLCP Scope of Practice,
Appendix 2.
14. Is organized and
represented by a national or
international specialty
association or branch of a
parent organization
14. AANLCP was formed in 1997 as a professional
association for nurses who practiced life care
planning based on the nursing process. The
founding members established Association by-laws,
policy and procedures, scope and standards of
practice and ethics statements.
Association leadership includes the Executive Board,
committee chairs, and operations manager. The
Certification Board is a legally and organizationally
separate entity.
Reference for more detailed information on the
formation of AANLCP: AANLCP Scope of Practice,
pages 6 - 7
FA L L 2 0 1 4
PEER-REVIEWED EXCELLENCE IN LIFE CARE PLANNING SINCE 1998
Vo l . X I V N o . 3
Tools of the Trade
A Survey of Nurse Life Care Planners: A
Role Delineation Study in the United States
Colleen Manzetti DNP RN CNLCP CNE
Barbara T. Bate RN-BC CCM CNLCP CRRN LNCC MSCC
April Pettengill, RN CRRN CDMS MSCC CNLCP
Life care planning is a
Certified Nurse Life Care Planner (CNLCP®)
phrase coined in the mid-
Certification Board.
1970s by an educational consultant, Paul Deutsch EdD, intended to describe a process
to project medical costs for
ligation purposes. Registered
nurses (RN) expanded their
practice to include life care
planning and in 1997 the
American Association of Nurse
Life Care Planning (AANLCP®)
was founded by Kelly Lance,
MSN, APRN, FNP-C, CNLCP,
LNCP-C (Sambucini [Chapter
1], 2013). Since then the Association and certification board
has grown considerably, and in 2008 a separate non-profit entity became known as the
Nurse life care planning is a specialty practice
in which an RN uses the nursing process as
the foundation for assessing, planning, identifying, implementing and evaluating the medical and other needs of an individual. The RN
develops a dynamic document that outlines
with reasonable certainty the future healthcare
needs of an individual along with the associated costs and frequencies of goods and services necessary to promote quality of life and a
safe environment (AANLCP®, 2008). The
CNLCP® Certification Board is responsible for
the validity of the certification examination as
well as ongoing supervision for recertification
and quality assurance of nurse life care planners.
Colleen Manzetti, Barbara Bate, and April Pettengill are
members of the Certified Nurse Life Care Planner Certification Board. Their biographical information can be found
in Contributors to this Issue on page 644.
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Background
A role delineation study is a tool used to
Klosterman, and Linda G. Dierking. Penelope
promote content validity of a certification ex-
based on her past experience in developing
amination by conducting a practice analysis.
role delineation studies.
This results define the tasks of a particular job
as well as the knowledge and skill required to
perform them competently, and is supported
by logical and empirical validity. It allows a
testing entity to base test blueprint on best
practices using psychometric standards
(ABSNC, 2014).
Caragonne, PhD was asked to participate
The role delineation study supports the mission of the Certified Nurse Life Care Planner
(CNLCP®) Certification Board by identifying
and quantifying the necessary knowledge,
tasks, and skills needed in today’s practice environment. Consistent with the Certification
Board’s mission and the requirement for ac-
In 2012, the CNLCP® Certification Board
creditation through the Accreditation Board
launched a role delineation study to ensure
for Specialty Nursing Certification (ABNSC),
that the certification examination continues to
the certification process validates nurse life
be a valid assessment of the knowledge,
care planner qualifications through profes-
tasks, and skills required by a nurse life care
sional education programs, experience in the
planner for safe and effective practice. The
specialty, and examination. This study data
role delineation study was a joint effort con-
describe current practice in several ways:
ducted by the Certified Nurse Life Care Planner (CNLCP®) Certification Board, and members of the American Association of Nurse Life
(a) Geographic areas of practice throughout the United States
Care Planners (AANLCP®) with the assistance
(b) Highest level of education, types of certification and licensure
of the Professional Testing Corporation (PTC,
(c) Age and years of experience
2013). The survey was concluded on December 13, 2012.
(d) Practice setting including frequency distribution of plans between defense and
plaintiff and venues for expert testimony
Members of the role delineation task force
(e) Patient assessment
included the following registered nurses: April
(f) Collaboration with others
Pettengill, Glenda Evans-Shaw, Mona Yudkoff,
Jan Roughan, Janice Skiljo Haris, Jacqueline
Morris, Anne Sambucini, Chris Daniel, Jan
(g) Life care plan development
(h) Cost research
(i) Life care plan report construction
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(j) Professional activities
not addressed in the survey. Professional Test-
(k) Knowledge area rating
ing Corporation (PTC) tabulated, analyzed
This study is a critical component to update
and summarized the returns and distributed
and maintain the certification examination and
the results to the CNLCP® Certification Board
educational requirement process that ensures
in April 2013.
competency for the specialty practice of nurse
Demographic Information
life care planning.
Overall, 133 respondents (n=133) completed
Methodology
This was the first time a Certified Nurse Life
the survey. Ninety-nine percent (n=132) of the
Care Planner (CNLCP®) Certification Board
tered Nurses. Using the exclusion criterion re-
had performed a role delineation study using
quiring any participant to be a Registered
a psychometrician. The role delineation task
Nurse Life Care Planner the data are from 132
force developed the survey in 2012. It con-
respondents (n=132). Not all respondents
sisted of 136 task statements, 16 knowledge
completed every item.
areas, and 15 demographic questions. The
survey was formatted and administered electronically. AANLCP® members accessed the
tool through embedded links in direct email
invitation, websites, online boards, or newsletters. To facilitate national participation, the
Certified Nurse Life Care Planner (CNLCP®)
Certification Board encouraged members to
share the link with other nurse life care planners who were not members of AANLCP®.
The survey included an introduction and instructions. The tool asked respondents to
evaluate the frequency and importance of
each task and knowledge statement using a
four-point Likert scale. Respondents had an
opportunity to enter comments including any
tasks that they normally performed that were
respondents identified themselves as Regis-
Thirty-six states were represented in the survey (n= 120) with California having the highest participation rate (n=16, 12%) (Figure 1)
Most respondents were currently performing
life care plans (n=124, 93.2%) with 36.8% (n=
49) completing fewer than 10 life care plans
per year on average (Figure 2). The pediatric
population represented less than a quarter of
all life care plans reportedly performed (PTC,
2013).
Most respondents (n=107) indicated that they
are self-employed, in private practice, with
65.4% (n=87) identifying themselves as practice owners. Thirty-nine percent reported their
highest degree of education as a baccalaureate degree (BSN) (Figure 3). Only 8.3% (n=11)
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Figure 1
Figure 2
Figure 3
Figure 4
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of the respondents reported that they held no
The Importance Rating asked the respondent
certifications. The average time practicing in
how important is this task for competent per-
the field of life care planning was identified as
formance:
six to ten years by 33.1% (n=44) of the respondents. The average age of the practitioner was between 50-59 years by 54.9% (n=73)
of the respondents. The average number of
hours required to complete a Life Care Plan
was 26-50 hours (n=66) (PTC, 2013) (Figure 4).
Task Analysis
The role delineation survey included 136 tasks
divided into six major sections:
•
Patient Assessment
•
Collaboration with Others
•
•
Life Care Plan Development
Cost Research
•
•
Life Care Plan Report Construction
Professional Activities
A four-point Likert scale was used to determine the frequency of performance and how
important the task is for competent performance. The scale was slightly modified for Frequency versus Importance.
Frequency Ratings asked the respondent how
often the task was performed as part of the
job:
•
•
•
•
4 = Regularly
3 = Frequently
2 = Occasionally
1 = Never
•
•
•
•
4 = Extremely
3 = Moderately
2 = Slightly
1 = Not
The instructions asked respondents to focus
specifically on each task as it relates to the
day-to- day performance of their jobs. In all
cases, respondents rated the importance of
the tasks the same as or higher than how often they performed the task. Tasks respondents considered equally important to the
frequency for which they are performed were
found only in the Patient Assessment category
(PTC, 2013). (Figure 5)
Most Frequently Performed Tasks
The tasks that are performed most frequently
are those that rated higher than 3.5 for frequency of performance by the respondent.
This analysis looked at how many highly-rated
tasks were found in each section of the survey
(PTC, 2013).
Eleven of 25 Patient Assessment tasks (44%)
in Patient Assessment were rated high for frequency of performance (PTC, 2013). (Table 1)
Only four of 13 Collaboration with Others
tasks (30.7%) were rated high for frequency of
performance (PTC, 2013). (Table 2)
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Figure 5
Table 1
Patient Assessment Tasks
Document date of birth
Document date of injury/loss
Document current medications
Document gender
Document functional abilities pre/post incident
Document work/education status
Document current address
Document marital/relationship status
Document daily or routine schedule
Document social/environmental profile
Document family dynamics
Rated high for frequency of performance >3.5
4
4
4
3.9
3.9
3.8
3.7
3.7
3.7
3.7
3.6
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Table 2
Collaboration with Others Tasks
Rated high for frequency of performance >3.5
In the absence of physician or medical provider input, rely upon medical records
3.9
Request information from treating physicians
3.8
In the absence of physician or medical provider input, rely upon professional education, training, and experience
In the absence of physician or medical provider input, rely upon provider and/or expert report
3.8
3.7
Table 3
Assess need for medications (e.g., pain medications)
Rated high for fre-­‐
quency of performance >3.5
3.9
Review post morbid medical records
3.8
Assess need for medical care evaluations/services
3.8
Assess need for therapeutic evaluations/services
3.8
Assess need for therapeutic evaluations/services
Assess need for diagnostic testing (e.g., medical labs, radiological studies, neuropsychological, etc.)
Assess need for wheelchair/mobility needs
3.8
Assess need for independent living ability
3.8
Assess need for home/attendant/facility care
3.8
Assess need for adaptive equipment
3.8
Assess need for therapeutic equipment
3.8
Assess need for orthotics and prosthetics (e.g., braces, ankle/foot orthotics)
3.8
Assess need for supplies (e.g., bowel/bladder supplies, oxygen, etc.)
3.8
Review expert reports
3.7
Assess need for assistive technology
Assess need for home furnishing and accessories (e.g., specialty bed, portable ramps, patient lifts)
Assess need for transportation (e.g., adapted/modified vehicle, etc.)
Assess the need for renovations for accessibility (e.g., widen doorways, installing wheelchair ramp, etc.)
Document pre-­‐existing conditions utilizing a Medical Record Summary
3.7
Assess need for health, strength maintenance
3.6
Assess need for case management services
3.6
Assess need for architectural renovations (e.g., wheel-­‐in shower, elevator, etc.)
3.6
Life Care Plan Development Tasks
3.8
3.8
3.7
3.7
3.7
3.6
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Twenty-one of 36 Life Care Plan Development
•
tasks (58%) were rated as frequently performed (PTC, 2013). (Table 3)
•
Only three of 23 Cost Research tasks were
•
rated as frequently performed (PTC, 2013).
Vo l . X I V N o . 3
Develop a rebuttal or comparison of
opposing counsel’s life care plan expert’s report
Assist in developing questions for
deposition
Assist in developing questions for cross
examination
(Table 4)
Tasks that fell between 2.5 and 3.5 are occa-
Nineteen of 34 Life Care Plan Report Con-
sionally performed. These tasks included:
•
•
•
•
•
•
•
•
•
•
•
struction tasks (56%) were rated as frequently
performed. Life Care Plan Report Construction was the second-highest-rated section for
frequency of task performance (PTC, 2013).
(Table 5)
The psychometrician determined that respondents used tasks scoring greater than 3.5
frequently in the practice of nurse life care
Architectural Renovations (3.4)
Potential complications (3.4)
Summary of total lifetime costs(3.4)
Cost resource list (3.3)
Home furnishings / accessories (3.3)
Recreational Needs (3.2)
Nursing diagnosis (3.1)
Vocational / Educational service (3.0)
Articles / literature researched (3.0)
Clinical practice guidelines (2.9)
Collateral sources (2.5)
planning. Not all professional activities tasks
Tasks rated as least frequently performed
included in the survey met this criterion (>
(<2.5) included the following:
3.5) for frequency of task performance (PTC,
•
2013). Those tasks not meeting the criterion
•
•
•
•
included:
•
•
•
•
•
Testifying at trial
Arbitration
Mediation
Settlement conference
Deposition
Physical Assessment: Day in the Life
video (1.8)
Telephone contact only (2.2)
Photographs of patient (2.2)
Photographs of home environment (2.4)
Photographs of equipment (2.4)
Collaboration with Others category rated
only one out of 13 tasks identified in the survey as low for frequency of performance: AtTable 4
Rated high for frequency of performance >3.5
Obtain costs for items and services in a Life Care Plan using provider/vendor contacts
3.7
Other considerations used in determining Life Care Plan cost: Geographic location
3.7
Obtain costs for items and services in a Life Care Plan using internet sources
3.6
Cost Research Tasks
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Table 5
Life Care Plan Report Construction Tasks
Rated high for frequency of performance >3.5
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Medications
3.9
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Future medical care (MD’s, etc.) 3.9
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Projected therapeutic modalities 3.8
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Durable medical equipment/replacement schedule 3.8
Include the following components in the Life Care Plan document/report: Narrative component regarding case data 3.8
Include the following components in the Life Care Plan document/report: List of medical providers/professionals consulted/source of recommendations
3.8
Include the following components in the Life Care Plan document/report: Medical diagnoses
3.8
Include the following components in the Life Care Plan document/report: Rationale/purpose for recommendations 3.8
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Projected evaluations 3.7
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Diagnostic/educational testing 3.7
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Mobility (wheelchair/scooter/accessories/maintenance) 3.7
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Aids for independent function 3.7
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Disposable medical supplies 3.7
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Home/facility care 3.7
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Transportation 3.7
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Orthotics/prosthetics 3.6
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Surgical intervention
3.6
Use standardized categories/tables to list the following recommendation in the Life Care Plan: Case management 3.6
Include the following components in the Life Care Plan document/report: Summary of total annual costs 3.6
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tending independent medical examinations/
evaluations (2.1) (PTC, 2013).
The Life Care Plan Development category respondents rated two of the tasks low (<2.5) in
frequency of performance, requesting a physician to review without sign-off after completing a Life Care Plan (1.8) and requesting a
physician to review with sign-off after completing a Life Care Plan (2.2) (PTC, 2013).
Vo l . X I V N o . 3
Most Important Performed Tasks
Data analysis identified the most important
tasks for competent performance whether or
not they are frequently performed. These
tasks are rated higher than 3.5 (>3.5) for
“highly important for competent performance” (PTC, 2013).
Patient Assessment
Respondents rated eleven of 25 tasks in this
section highly important (>3.5) for competent
The Cost Research category respondents
performance in the profession. Nine are the
rated four tasks low (<2.5) in frequency of per-
same they rated high for performance fre-
formance. These included:
quency. These tasks include documenting:
•
•
•
•
•
Obtaining costs for items and services
in a Life Care Plan using national databases (without geographic adjustment)
(2.2)
Using worker’s compensation fee
schedules (2.3)
Using collateral resources (2.3)
Using alternative payment sources such
as cash pay, private insurance, and
Medicaid (2.3).
Other considerations used in determining life care plan cost included referral
source request (2.3) and using Medicare
guidelines (2.4) (PTC, 2013).
In the Life Care Plan Report Construction
category only three of 34 tasks rated low
(<2.5) for frequency of performance. These
tasks included video of the patient (1.8), photographs (2.0), and Federal Rule 27 disclosure
information (2.4) (PTC, 2013).
•
•
•
•
•
•
•
•
•
•
•
Functional abilities pre/post incident
(4.0)
Current medications (4.0)
Date of birth (3.9)
Date of injury/loss (3.9)
Gender (3.7)
Daily or routine schedule (3.7)
Face to face contact (3.7)
Home/environment evaluation (3.7)
Marital/relationship status (3.6)
Work/education status (3.6)
Family dynamics (3.6)
Collaboration with Others
Respondents rated six of the tasks in this section high in importance (>3.5) for competent
performance, although only four as high for
frequency of performance. These tasks included:
•
In the absence of physician or medical
provider input, rely upon medical
records (4.0)
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Request information from treating physicians (3.9)
In the absence of physician or medical
provider input, rely upon professional
education, training, and experience
(3.9)
In the absence of physician or medical
provider input, rely upon provider and/
or expert report (3.8)
Consult with experts/specialists for a
case (3.7)
In the absence of physician or medical
provider input, rely upon clinical or published standard of care guidelines (3.7)
•
Diagnostic testing (e.g., medical labs,
radiological studies, neuropsychological, etc.) (3.8)
•
Orthotics and prosthetics (e.g., braces,
ankle/foot orthotics) (3.8)
•
Transportation (e.g., adapted/modified
vehicle, etc.) (3.8)
•
Renovations for accessibility (e.g.,
widen doorways, installing wheelchair
ramp, etc.) (3.8)
•
•
Health, strength maintenance (3.8)
Architectural renovations (e.g., wheel-in
shower, elevator, etc.) (3.8)
Life Care Plan Development
In this section, respondents rated 26 of the 36
•
Case management services (3.7)
•
Nutritional education/support (e.g.,
weight loss/weight gain) (3.6)
•
•
•
•
tasks high for importance (>3.5) for competent performance, five more than were rated
high for frequency. How to perform life care
In addition, tasks included:
•
Reviewing pre-morbid medical records
(3.6)
•
Reviewing provider and/or expert
depositions (3.6)E
Reviewing expert reports (3.8)
plan development tasks is clearly important,
regardless of frequency. These tasks included
assessing need for:
•
Medical care evaluations/services (3.9)
•
Therapeutic evaluations/services (3.9)
•
•
•
Reviewing post-morbid medical records
(3.9)
Wheelchair/mobility needs (3.9)
•
Requesting missing records (3.7)
•
•
Independent living ability (3.9)
Home/attendant/facility care (3.9)
•
Identifying pre-existing conditions utilizing a Medical Record Summary (3.6)
•
Adaptive equipment (3.9)
•
•
Therapeutic equipment (3.9)
•
Assistive technology (3.9)
Using medical experts and/or provider’s
opinion for input regarding the content
of a life care plan (3.6)
•
Home furnishings and accessories (e.g.,
specialty bed, portable ramps, patient
lifts) (3.9)
Cost Research
Respondents rated only four of the tasks in
•
Medications (3.9)
tent performance (3.5>). These tasks in-
•
Supplies (e.g., bowel/bladder supplies,
oxygen, etc.) (3.9)
cluded:
this section high for importance for compe-
•
Provider/vendor contact (3.8)
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•
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Geographic location (3.7)
Internet sources (3.6)
Recent billing (3.6)
Vo l . X I V N o . 3
•
List of medical providers/professionals
consulted/source of recommendations
(3.8)
All but recent billing were rated high for per-
•
Medical diagnoses (3.8)
formance frequency.The survey suggests that
•
•
Rationale/purpose for recommendations (3.8)
Architectural renovations (3.7)
•
Transportation (3.7)
•
Acute medical intervention (3.7)
•
Case management (3.6)
•
Summary of total annual costs (3.6)
other tasks represented in this section are
only moderately necessary for a competent
life care planner to know how to perform
(PTC, 2013).
Life Care Plan Report Construction
Respondents rated performing twenty-one of
the tasks in this section competently as highly
Knowledge Analysis
The role delineation task force identified six-
important (>3.5). These included using stan-
teen knowledge areas that a Certified Nurse
dardized categories/tables to list the follow-
Life Care Planner should understand. Re-
ing recommendations in the Life Care Plan:
spondents rated their importance to competent performance. Respondents identified all
•
•
Orthotics/prosthetics (3.9)
Durable medical equipment/
replacement schedule (3.9)
•
Aids for independent function (3.9)
•
Disposable medical supplies (3.9)
•
Medications (3.9)
•
•
Future medical care (MDs, etc.) (3.9)
Projected evaluations (3.8)
the survey. Table 6 shows the average impor-
•
Projected therapeutic modalities (3.8)
scending order.
•
Ddiagnostic/educational testing (3.8)
•
•
Mobility (wheelchair/scooter/
accessories/maintenance) (3.8)
Home/facility care (3.8)
•
Surgical intervention (3.8)
comprehensive description of the tasks and
•
Narrative component regarding case
data (3.8)
knowledge used by experienced nurse life
as essential for the majority of this category.
Knowledge of anatomy and physiology was
also required for most of the tasks listed in the
Life Care Plan Report Construction section of
tance rating of each knowledge area, in de-
Summary
The 2012 role delineation study of Nurse Life
Care Planners in the United States reflects a
care planners. The CNLCP® Certification
Board will use these data to maintain the certification examination, including updating the
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Table 6 Knowledge Areas Ranked by Number of Tasks Which Require It
Knowledge Area
Importance Rating
Life care planning process/methodology 4.0
Brain 4.0
Nursing process 3.9
Nursing scope of practice 3.9
Spine 3.9
Normal physiology of aging 3.9
Limb function 3.9
Integumentary (skin) systems 3.9
Body organs 3.9
Pain 3.9
Mental health 3.8
Growth and development
3.8
Expert witness qualifications 3.8
Venues in which life care planning is applicable 3.7
Expert witness rules/regulations 3.7
Nursing diagnoses
3.5
test blueprint to reflect current practice and
While the role delineation survey results con-
expanding the question data bank. The data
firmed the importance of each of these com-
will also guide educational preparation for
ponents to underlying individual assessment
entry into nurse life care planning practice.
and the resulting Life Care Plan, the survey
The study identifies the need to include other
also identified that documentation develop-
weighted components in the certification ex-
ment are the nurse life care planner’s most
amination besides the basic six areas of:
frequently performed tasks. Hence, we rec-
•
•
Life Care Planning (35%)
Spinal Cord Injuries (15%)
ommend adding a Life Care Plan Construction
•
Burns and Amputations (10%)
certification examination.
•
Acquired and Traumatic Brain Injuries
(15%)
This study supports the mission of AANLCP®,
•
Neonatal and Pediatric Injuries/Illnesses
(15%)
assesses the individual, identifies problems,
•
Chronic Pain (10%)
category to the test blueprint for the CNLCP®
which states the RN Nurse Life Care Planner
plans for appropriate interventions, provides
for plan implementation, and evaluates the
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plan using the nursing process (AANLCP®,
Certified Nurse Life Care Planner (CNLCP®) Certifica-
Mission Statement, 2014).
tion Board (2014). Mission Statement. Retrieved from:
http://cnlcp.org/mission-statement.htm
References
Professional Testing Corporation (2013).Role Delinea-
AANLCP® Mission Statement (2014). Retrieved from
tion Survey Results.
http://www.aanlcp.org/?page=MissionStatement
Sambucini, A. (2013). History and Evolution of the
Accreditation Board for Specialty Nursing Certification
Nurse Life Care Planning Specialty. In: D.Apuna- Grummer & W.A.Howland (Eds.), A Core Curriculum for Nurse
(2014).Accreditation Standards. Retrieved from:
http://www.nursingcertification.org/accreditation-standa
rds.html
Life Care Planners (pp 1-20). Bloomington: iUniverse.
Ꮬ
Show Them The Evidence
Evidenced-based practice begins with research.
"
"
"
If you write life care plans you already do research.
" "
"
"
"
No fear!
Lighten the load!
.
"
"
"
"
Strengthen the practice!
Together we can learn the scoop
share knowledge
build a body of evidence
by life care planners
for nurse life care planners
Participate:
email [email protected]
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING
ISSN 1942-4469
707
Elder Life Care Planning
submi&ed by
Becky Czarnik RN, MS, CLNC, LNCP-­‐C, CMSP
Here are two representa,ve examples where an elder care plans were beneficial.
Acute Illness in Both Spouses
The nurse life care planner received an urgent call asking for help sor,ng through a medical crisis to provide some direc,on about John V., a 73-­‐year-­‐old male with a permanent tracheostomy and mul,ple thoracic and lumbar compression fractures. John was admiHed to the hospital for an acute myocardial infarc,on, conges,ve heart failure and pacemaker inser,on. His 70-­‐year-­‐old wife, CharloHe V., is his primary caregiver and in generally good health. CharloHe regularly visited John during his hospitaliza,on un,l one day she did not arrive at her usual ,me. John became concerned and no,fied his neighbors, who went looking for her. She was found unresponsive in her car in the grocery store parking lot. CharloHe was admiHed to the same hospital with an acute leL thalamic intracranial hemorrhage, right sided hemiplegia, and aphasia. John and CharloHe have a long term care policy, some savings, and a Medicare Advantage policy. In collabora,on with the hospital case managers, the Nurse Life Care Planner iden,fied a skilled nursing facility where John and CharloHe could receive the appropriate level of care needed for rehabilita,on while remaining together. The long term care policy required no prior authoriza,on and would pay a maximum benefit of $300,000 per person. The Medicare Advantage policy dictated which skilled nursing facility was within their network and covered 10 days of skilled nursing with a 20% copay. Knowing this informa,on, we were able to plan for at least 10 days of skilled nursing care, skilled home health care upon discharge, and paid caregivers for four hours a day. A “lady from the church” moved in with them to provide onsite oversight. The Nurse Life Care Planner es,mated that this plan would be effec,ve and affordable for the next 6 months. As a result of the couple’s financial and physical fragility, she also made a referral to the area’s Elder Protec,ve Services. The Nurse Life Care Planner determined that the couple could afford 13 months of homemaking/
aHendant care ($2250/month) or sell their home and move into a group home (for about $2500/month) and have some residual income and qualify for Medicaid assistance. The second choice was more secure, and has worked out well for them.
A “Healthy” Older Couple A trust officer asked the Nurse Life Care Planner to review a case regarding a “healthy older” couple, Jan and Clare E. They were doing their annual review and wanted to make sure their finances would support their current needs. Armed with a file of medical bills and a brief health history from the couple, the Nurse Life Care Planner prepared a medical cost projec,on.
Jan was an 80-­‐year-­‐old white female whose primary medical concern was pulmonary hypertension status post pulmonary emboli in 2010. She saw a pulmonologist twice a year and had her an,coagula,on status monitored monthly by the community hospital Coumadin Clinic. She used supplemental oxygen, performed ac,vi,es of daily living independently, and par,cipated in outpa,ent pulmonary rehabilita,on three ,mes a week. Clare was an 86-­‐year-­‐old white male whose primary medical concern, wet macular degenera,on, was diagnosed in 2013. He received intraocular injec,ons every 4-­‐8 weeks monthly as indicated by examina,on findings. He could perform most ac,vi,es of daily living independently, requiring assistance only for detailed work, such as bookkeeping ac,vi,es like wri,ng checks and reviewing financial statements.
Jan and Clare owned their one-­‐story home in a small town in Ohio. Jan was a re,red RN and Clare a re,red physician; they were ac,ve in their church and community. They had five adult children, one living two hours away and the rest scaHered across the country. They obtained their health care from their community hospital and the metropolitan hospital located one hour away. They hired help for home repair, lawn mowing, and snow removal, and did the general housekeeping themselves. They needed frequent rest periods for housekeeping and ac,vi,es of daily living. Jan drove locally and had help from neighbors for addi,onal transporta,on. To cover their medical expenses they both had Medicare coverage (Part A, B and D), a Medi-­‐gap supplemental insurance policy, and some private funds.
Based upon the interview and review of current expenses the following services were warranted:
• Transporta,on for physician appointments and therapy (Jan and Clare)
• Housekeeping services (Jan and Clare)
• Referral to a low vision therapy team (OT, low vision therapist, Vision Rehabilita,on therapist) (Clare)
• Self-­‐help ADL vision related devices (Clare)
As with tradi,onal medical cost projec,ons, the Nurse Life Care Planner reviewed the couple’s insurance expense coverage and then iden,fied current and an,cipated life ,me needs. Insurance expenses:
Insurance Cost
Jan
Care
Medicare
A & B
Re,rement benefit
Re,rement benefit
Medicare D
$ 847.20
Medi-­‐Gap Annual Total Expected life Expected cost
,me *
Life,me cost
$ 4,189
$ 5,036.20 10 years
$ 50,362.00
$ 847.20
$ 4,382
$ 5,229.20
5 years
$ 26,146.00
Combined total cost es,mate
$ 10,265.40
$ 76,508.00
* Life expectancy and costs are based on the US Life Table, Na,onal Vital Sta,s,cs Reports, Volume 61, Number 3 dated 9/24/2012 the “US Life Tables, 2008” published by the US Department of Health and Human Services, Center for Disease Control, current at the ,me of the plan. These were not rated ages.
LifeAme Medical Cost projecAons:
Costs were not adjusted for infla,on or growth. * Dura,on (Years) is life expectancy.
Jan E
ITEM
Dura,on Avg # # per (Years)* per year life,me
Physician
Pulmonologist
10
2
20
Avg. unit Rou,ne Rou,ne $ cost
Annual $ for life,me
per year
$ 106
$ 212
$ 4,240
Coumadin Clinic
10
12
120
$ 80
Subtotal
Current Medica,on
Warfarin 7.5 mg #30 10
Oxygen
365
10
3650
$ 00.70
3.5
$465 every 36 months
Subtotal
Therapy
$ 9,600
$ 96,000
$ 9,812
$ 10,240
$ 248
$ 2,480
$ 1,627.50
$ 248
Pulmonary Rehab
10
156
1560
$ 180
Subtotal
$4107.50
$ 28,080 $280,800
$ 28,080 $ 280,800
Transporta,on Taxi for in town appointments
Subtotal
10
Housekeeping General cleaning, services
grocery shopping, errands Subtotal
10
2
6
20
60
$ 40
$ 100
Totals
$ 80
$ 800
$ 80
$ 800
$ 600
$6, 000
$ 600
$ 6,000
$ 38,820 $ 388,200
Clare E
ITEM
Dura,on (Years)*
Avg # per # per year
life,me
Physician
Ophthalmologist 5
7
35
Avg. unit Rou,ne Rou,ne $ cost
Annual $ for life,me
per year
$ 120
$ 840
$ 4,200
Procedure
Ocular injec,on
5
7
35
$ 260
$ 1,820
$ 9,100
Diagnos,c studies
Re,nal imaging
5
7
35
$ 62
$ 434
$ 2,170
Medica,on
Aflibercept 1mg
Low Vision Devices
Magnifica,on systems: portable and sta,onary
Annual Total
LifeAme Total
5
7
35
$2,750
$ 19,250
$ 96,250
1
1
$ 4000
$ 4,000
$ 4,000
$ 26,344
$ 115,720
As a result of expert financial planning and foresight, this couple required approximately $10,000 to pay for their annual insurance premiums. Their out-­‐of-­‐pocket expense were an,cipated to be less than 1% of projected costs. Therefore, their trust officer made the recommenda,on to set aside $1000 for medical expenses with an annual 1.5% buffer for the cost of infla,on. MEDVIEW
MED-LEGAL & CASE MANAGEMENT SPECIALISTS
404 Solano Drive S.E.
Albuquerque, NM 87108
505-254-2121
Fax: 505-217-9162
[email protected]
Roger Lee, Attorney-at-Law
Law Offices, PC
888 Rio Grande Blvd NW
Albuquerque, NM 87106
Re:
John Smith
DOB:
March 29, 2002
Primary Diagnosis: Spastic diplegic cerebral palsy
Secondary Diagnosis: Developmental delay
This Life Care Plan has been prepared at the request of John Smith’s attorney, Roger Lee. John is a
now four year boy with cerebral palsy and developmental delay. A Life Care Plan is a clinical analysis
of the projected lifetime care needs of John and the associated costs of such care. The actual cost of
care will depend on maturational changes, choice of healthcare providers and vendors, and geographic
location. The scope of this report is not intended to cover all economic and non-economic damages to
John and his family. The information and opinions contained within this report are subject to revision
and amendment contingent upon receipt of additional information which may become available.
John displays cognitive, developmental and physical delays. Attending physician pediatric neurologist
John Phillips, MD believes a neuropsychological evaluation can be performed once John is five years old
and he has made the referral for such testing. Once the study has been completed, a better prognosis can
be made of John’s adulthood. John's private physical therapist Corey Mane believes John has unrealized
potential and that with more intensive therapy services in his early childhood years, he may be an
independent household ambulator with assistive devices and could possibly live on his own with supportive
services. Taking both opinions into account, this consultant has structured the Life Care Plan to include
more non-school based therapy services in the earlier years of life and budget for the lowest level of
supportive care during adulthood.
Joan Schofield, RN, BSN, MBA
Certified Nurse Life Care Planner
1
Basis for recommendations:
1.
Review of medical records and medical bills
2.
Assessment interviews with John's parents on June 30, 2006 and July 18, 2006
3.
Discussion with attending physician pediatric neurologist John Phillips, MD and attendance at
appointment on July 18, 2006
4.
Correspondence with Dr. Phillips re: future needs
5.
Telephonic conference with physical therapist Corey Mane on November 21, 2006
6.
Medical and rehabilitation literature review
7.
My education, training, knowledge and experience as a Life Care Planner, Catastrophic Injury and
Rehabilitation Case Manager, and twenty-five years experience as Registered Nurse, including
work with children and adults with disabilities.
2
Medical Summary
John was born prematurely via normal spontaneous vaginal delivery after artificial rupture of membrane with
clear fluids in the Sierra Lista Emergency Room at twenty eight weeks of age by ultrasound according to
contemporaneous birth records. His mother’s course of pregnancy was healthy with the exception of an upper
respiratory infection. His Apgar scores were 7 at one minute and 9 at five minutes. Birth weight was 3lbs. 2oz.
He was transferred to Providence Memorial Hospital in El Paso, Texas for definitive care, staying in their
neonatal ICU from May 29, 2002 until September 21, 2002 when he was discharged home to the care of his
parents on room air and Caffeine to manage apnea and bradycardia spells. He was intubated for a total of two
days and required nasal C-PAP on two additional episodes. He developed several complications associated
with prematurity: necrotizing enterocolitis, gastroesophageal reflex, apnea and bradycardia, possible sepsis at
least three times, and a small patent ductus arteriosis which was treated with Indocin. He received
phototherapy for hyperbilirubinemia. Intracranial ultrasounds were normal. Retinopathy of prematurity was
resolved by the time of discharge.
John initially was evaluated for developmental delay in Wyoming where the family was living at the time. In
October of 2003, he was subsequently evaluated by and qualified to receive Early Intervention services from
Tresco, Inc. in Las Cruces. At that time he was sixteen months old with an adjusted age of thirteen and a half
months. Gross and fine motor, speech and language, cognitive and self-help skills developmental delays,
greater than 25%, were present.
John underwent an initial evaluation in the Carrie Tingley Pediatric Multidisciplinary Spenser Cerebral Palsy
Clinic on May 18, 2004. Examination by John P. Phillips, MD of the cerebral palsy clinic was significant for the
following abnormal findings, intermittent bilateral estropia, slightly decreased tone in the upper extremities, and
mild spasticity of the of the lower extremities, especially the hamstrings. Dr. Phillips concluded that John, then
two years of age had a history and physical examine consistent with mild spastic diplegic cerebral palsy with
developmental delay. Initiation of therapy services was recommended. At that time, the spasticity was not
limiting him and it was recommended that he engage in ongoing physical therapy before making decisions
about focal spasticity treatment such as stretching, strengthening, bracing, or medication management with oral
or focal Botox injections. It was Dr. Phillips opinion that the etiology was most like related to his prematurity
although a brain MRI scan was suggested to insure that no other developmental abnormality was present.
Pediatric neurologist Margaret Armstrong, MD also evaluated John, noting additional problems of chronic
constipation treated with herbal laxatives, occasional choking on solid foods, and immature development of
communication. At two years of age he was unable to sit independently unassisted although he was able to
communicate simple words but primarily used whining to communicate. He was a well developed well
nourished child.
When he was seen 3 months later in the Cerebral Palsy Clinic on September 21, 2004, it was observed that he
had made gains in language development and communication since receiving therapy services through Tresco.
Equipment concerns were raised. It was thought that he may be a candidate for a gait trainer walker and that
a formal equipment evaluation would be the best way to approach this. Upon examination, his hamstrings were
quite tight and his ankles were even tighter with dorsal flexion. When upright with assist, he was able to take
steps with support showing some scissoring and toe walking. Dr. Phillips noted that the MRI scan was
suggestive of periventricular leukomalacia which is typically seen in children born between 24 and 34 weeks
gestation which Dr. Phillips offered would explain John’s spastic diplegia. Also, as expected with the condition,
his spasticity was getting worse and various treatment options were discussed with the family. In addition to
ongoing therapy, it was agreed that Botox injections into the lower extremity muscles would be done. Medical
records review show this was accomplished on November 16, 2004 with Botox injections in to both the left and
right gastrocnemius by Dr. Phillips with a plan to initiate serial stretch casting to improve range of motion
3
afterward. The Botox injections were done for equinus contracture due to his spastic diplegic cerebral palsy.
On November 23, 2004 bilateral serial stretch casting was initiated through Carrie Tingley in an effort to
improve his ankle range of motion, which is needed for a more normalized gait pattern and progress toward
physical therapy goal accomplishment. He was then moved into an Ankle-Foot-Orthosis (AFO) orthothic
appliance on December 15, 2004. On January 13, 2005, he was issued a gait trainer for home use for
ambulation training. It was recommended that the AFO be used primarily at night to provide prolonged stretch
as the device did not assist well with ambulation. In 2004 and 2005, John has several upper respiratory
infections and right lower lobe pneumonia, typically treated with nebulizer treatments and antibiotics.
On July 8, 2010, John underwent bilateral tendon lengthening of his tibial tendons by Carrie Tingley surgeon
Dr. Coronado per referral of Dr. Phillips after the Botox injections not longer had sufficient beneficial effect. As
of the November 9 2010 onsite evlaution, John was ambulating short distances with bilateral AFO brace and a
gait trainer walker and his mother pushed him in a large size specialty stroller the majority of the time.
REVIEW OF SYSTEMS:
• INTEGUMENT (SKIN) STATUS
No skin breakdown events to date. John should be at minimal risk for skin breakdown in later years unless he
is confined to a wheelchair for a major portion of the day.
• NEUROLOGIC STATUS
Mrs. Smith recalls noting signs of developmental delay when John was about nine months old. He was formally
evaluated and enrolled in an Early Intervention Program, Tresco Tots, for comprehensive multidisciplinary
treatment. He then transitioned to the public school system’s early childhood program, receiving eight hours a
week of therapy services and specialized pre-school. The May 2007 IEP report indicates John continues to
have significant delays in receptive and expressive language skills, and gross and fine motor skills. The report
cites cognitive delays as a concern which may impact his ability to access the general curriculum. A detailed
plan was been developed to support John as he enters kindergarten in the fall of 2008. In addition, he receives
private therapy twice a week. John has spastic diplegic cerebral palsy. His physical therapist and mother report
that lower extremity muscle tone can rapidly fluctuate. Pediatric neurologist Dr. John Phillips wrote in his
evaluation report of July 18, 2006 that the most recent brain MRI of June 23, 2004 may represent occipital lobe
periventricular leukomalcia. He has not experienced seizures nor is he on antiseizure medication.
• CARDIOVASCULAR/HEMODYNAMIC STATUS
No active problems or risks at this time. In later life, risk for developing claim related cardiovascular problems in
later life should be no greater than the general population unless John is immobile a great portion of the day
and leads a very sedentary lifestyle.
• RESPIRATORY STATUS
John had respiratory distress syndrome and pulmonary insufficiency of prematurity after his premature birth at
30 weeks of age. He was on mechanical ventilation during part of his initial hospitalization in the NICU. He
was discharged to home on room air at two months of age. Caffeine was prescribed for management of apnea
and bradycardia spells for the first six months of life. During the first year, he had repeat bouts of bronchitis,
several resulting in hospitalization. Nebulizer treatments are still occasionally necessary during wintertime to
maintain adequate aeration but otherwise John is usually healthy from a pulmonary standpoint. The May 1,
2007 speech and language evaluation showed John to have functional breath support at an age-appropriate
level.
4
• GASTRIOINTESTINAL (GI) AND ABDOMINAL STATUS
Chronic constipation was an active problem in John’s earlier years but is now well managed.
• GENITOUROLOGIC (GU) STATUS
No active problems or risks.
• MUSCUOSKELETAL STATUS
Mrs. Smith notes her son’s muscle tone varies during the day and other than cold temperatures, there does not
seem to be any particular inciting factors.
Trunk: Fair trunk control was exhibited during the most recent examination by Dr. Phillips. Postural trunk
stability was achieved only by proper positioning and propping by his mother. His shoulders were rounded and
he hunched forward but did not fall over when placed into a cross-legged position. His physical therapist is
working with him on positioning, balance and developing his core muscle groups to minimize the risk the risk of
secondary injury due to falls.
Lower extremities: Spastic diplegia present with tightness of the hamstrings limiting popliteal motion to 140
degrees bilaterally and also ankle tightness. He will most likely be a candidate for tendon lengthening surgery
while in early elementary school. Botox injections followed by serial casting done in 2004 was fairly effective
in managing spasticity and preventing further contracture for about eighteen months. The treatment course was
to be repeated this summer, however, according to physical therapist Corey Mane, a decision was made to put
it on hold as John began to rapidly progress in his ambulation and standing skills.
Upper extremities: John has right greater than left spasticity of the upper extremities. His grip and pinch
strength are adequate for age appropriate activities but impaired fine motor skills continue to be addressed in
therapy.
Dr. Phillips believes lifetime rehabilitation services will be needed on an episodic basis to maximize
independence and optimal functional status, both physical, emotionally, and vocationally. According to Dr.
Phillips, increased muscle tone can be expected as John ages and will most likely require oral antispasmodic
medication(s) such as Baclofen or a Baclofen pump. Remaining active throughout his lifetime, regardless of
his method of mobility, will be important to minimize the risk of arthritis due to inactivity.
•
NUTRITIONAL/METABOLIC STATUS
John is within ideal body weight for his height. He is at the 50th percentile for four year old boys in terms of head
circumference and weight. Prior problems with swallowing coordination and choking with eating and delayed
diet advancement (around the age of two) have resolved. No current nutritional or metabolic problems have
been identified.
• INFECTIOUS DISEASE STATUS
Non-contributory
• PSYCHIATRIC/BEHAVIORAL
Behavioral problems have not been identified by John’s therapists and physicians, nor reported by the parents.
He is a likeable child, albeit on the shy side. His physical therapist describes him as motivated to succeed.
5
• PREMORBID/INTERCURRENT CONDITIONS
None
•
HEARING AND VISION
Hearing has been tested as normal (June 23, 2004; UNM Audiology Evaluation by Florence Peterson M.A.)
Left eye strabismus is diagnosed by UNM pediatric ophthalmologist Dr. Woods. No visual deficits have
been identified and there is no plan for routine follow up.
FAMILY SUPPORT
John’s parents are highly supportive. Mrs. Smith has undergone training in “Conductive Education” to better help
support her son and facilitate his development.
There are extended family members locally in Truth or
Consequences to provide emotional and hands-on assistive support.
Physical Therapist Corey Mannan
emphasizes the excellent follow through with recommendations by John’s parents and grandparents.
MARITAL STATUS/FAMILY COMPOSITION
John has one sister who is two years old.
EDUCATION
The May 2006 Preschool Individualized Assessment and plan concluded that “John’s fine and gross motor delays
have significantly impacted his ability to be independent with age-appropriate skills, to safely negotiate throughout
the preschool environment, utilize school resources (bathroom, playground equipment, cafeteria), and access
general education curriculum unless modifications and accommodations are given to him”. Continued 100%
segregated Early Childhood Education preschool classroom augmented by 0.5 – 1.5 hours per week of physical,
occupational and speech therapy.
FUNCTIONAL STATUS ASSESSMENT
SELF-CARE – eating, grooming, bathing, and dressing upper and lower body
John is delayed compared to his peers in his ability to initiate and perform self-care activities. He has
learned to eat independently using regular utensils and a cup.
COGNITION – problem solving, memory, orientation, and attention
Dr. Phillips has referred John for a neuropsychological evaluation within the next year to more accurately
assess where John stands in relationship to his peers in the various realms of neuropsychological
functioning and cognitive skills. According to the May 2006 Preschool Individualized Education Assessment
and Plan, Johns demonstrates delays in learning readiness skills. Problems with attention have not
identified.
COMMUNICATION – comprehension, expression, reading, writing, speech intelligibility, and swallowing
As of July 2006, John could speak in short sentences and communicate his needs. His speech was
clear. He is behind his peers in language development. He demonstrates delays with functional
communication skills, including difficulty expressing his needs and wants most of the time, although his
receptive language appears to be within normal range for age. Dysphagia (problems with swallowing)
from earlier years have resolved.
6
BEHAVIOR – social interaction, emotional status, and adjustment to limitations
John reportedly interacts appropriately at home, in the community and in his pre-school environment.
MOBILITY
John learned to crawl at the age of three and can do so independently for mobility within the home. He
requires hands-on assistance or a specialized walker/gait trainer to stand and ambulate, walking on his tip
toes with short steps, for short distances. Eighteen months prior to the July 2006 evaluation by Dr. Phillips
and before the Botox injections with serial casting, John could only take a few short steps with assistance.
He can now use his walker for short-distance ambulation, evidence of some progress. He has a Rifton gait
trainer type walker which provides extra trunk stability and support. Ms. Mane believes John has the
potential to learn to use a manual wheelchair for community mobility. He has used an AFO (ankle-foot
orthosis) intermittently over time. New ones would need to be fabricated repeatedly over time as John
grows. Based on the conversation with Dr. Phillips at the time of the July 2006 evaluation and
accompanying report, more likely than not, John will not progress to independent ambulation, although there
is a possibility of such advancement. Ms. Mane is more optimistic about the prospect of John becoming
an independent household ambulator with an assistive device.
ELIMINATION – bowel management and bladder management
Bowel, bladder and toilet training is delayed and had not been fully achieved as of May 2006.
HOUSEHOLD MANAGEMENT – Money management, housekeeping
It should be anticipated that John will need assistance with money management, housekeeping, home
maintenance, transportation and community access. Once the neuropsychological evaluation is completed,
a better projection can be made of these needs. The public school will most likely provide basic money
training skills as part of his special education curriculum; however, his ability to safely implement such skills
or advance towards independent financial management of his monies is uncertain at this point in time.
7
John Smith
PROJECTED FUTURE COSTS
A.
PROFESSIONAL SERVICES AND THERAPIES
DESCRIPTION
YEAR
COST
TOTAL NUMBER OF
VISITS
ANNUAL
COST
Outpatient P.T.
Twice a week
Ages 8 - 10
$175
100
$17500
Weekly
Ages 11- 14
$175
50
8750
Episodically, averaging 16 sessions per year.
Ages 12 – 18
$175
16
2800
Ages 19 – Life
Expectancy
$175
2
350
Ages 4 – 10
$175
50
8750
Ages 11 - 18
$175
16
2800
2007, 2013, 2017,
2027, 2047
$1500
n/a
Episodically in adult, 2 sessions per year
Outpatient S.L.T.
One hour per week through age 10 for the next three
years to prepare him for kindergarten through early
school years.
Episodically thereafter for an average of 16 sessions
annually.
Neuropsychological Evaluation
Evaluation upon entering kindergarten, mid school, and
high school, once in his mid twenties, and last one in
mid-life.
8
John Smith
PROJECTED FUTURE COSTS
B.
MEDICAL CARE
DESCRIPTION
YEARS
Rehabilitation physician: Physiatrist, neurologist or other
qualified physician to manage conditions related to
cerebral palsy
Lifetime
$70
2 visits
$210
Episodically over
Lifetime
$120
Every 3 years
$40
Orthopedist to evaluate, monitor and surgically treat joint
contractures
E.R. Visits- none budgeted although at risk for secondary
injury due to falls secondary to impaired mobility
Hospitalizations- none budgeted other than tendon
lengthening although at risk for secondary injury due to
falls secondary to impaired mobility
Surgeries
Repeat tendon lengthening after growth maturity
COST
FREQUENCY
ANNUAL
COST
Once age 20
9
John Smith
PROJECTED FUTURE COSTS
C.
DIAGNOSTIC STUDIES
DESCRIPTION
Upper/Lower Extremity and Spine X-Rays to
evaluate possible bony changes and joint
changes due to increased stress associated
with impaired mobility and gait
YEARS
Lifetime
COST
FREQUENCY
$140
Intermittently –
budget for average of
1 joint/limb per year,
frequency increasing
with age
ANNUAL
COSTS
$140
10
John Smith
PROJECTED FUTURE COSTS
D.
MEDICATIONS
DESCRIPTION
YEARS
Baclofen or other oral antispasmotic – Dr. Phillips hopes this will not be
needed. He particularly lacks to avoid its use in childhood due to the
medication’s sedating effect
Over the counter or mild prescription strength analgesics for expected
joint pain with aging sue to increased stress on the joints due to
impaired mobility and altered gait pattern
uncertain
Ages 20 –
lifetime
COST PER
UNIT
$10
UNITS PER
YEAR
12
CURRENT
ANNUAL
COSTS
$120
11
John Smith
PROJECFTED FUTURE COSTS
E. DURABLE MEDICAL AND ADAPTIVE EQUIPMENT, MOBILITY AIDS
DESCRIPTION
Shower Chair for safe bathing due to impaired ability to
stand independently for prolonged periods & hand held
shower hose
Gait trainer walker1 for moderate distance walking as
youth
Front wheeled walker – replacement every 2-3 years
until age 18, the every 5 years. PT Corey Mane believes
John possesses the capacity to advance to a walker in
later youth
Manual wheelchair for community mobility (currently
parents use a stroller, which is quite embarrassing for 8
year old John). PT Corey Mannan believes John has
capacity to learn to use a manual self propelled
wheelchair. This consultant recommends one with
power assist wheels ($6000/set) in adulthood for easier
propulsion and to limit damage to shoulder joints)
YEARS
COST
REPLACEMENT
ANNUAL
COST
Ages 16 Lifetime
$150
Every 5 years
$30
Age 11
$750
None
Ages 12 – 18
$209
Every other year
105
19 - Lifetime
$209
Every 5 years
42
Ages 7 –
Lifetime
$10,000
Obtain initial one at age
9 and replace at age
16, exact ages
depending on growth
maturation rate.
Replace every 10 years
as an adult (less often
than typical
replacement schedule
as it will not be the
1 The Rifton Gait Trainer is a type of walker, which provides considerable postural support for the user. It comes in a range of sizes that caters for tiny children through to adults.
Each size has a range of adjustable features that can be adjusted to meet individual needs. This walker has been superseded by the Pacer Gait Trainer, which is a redesign of the
Rifton Gait Trainer. It is suitable for children and adults who require moderate to maximum support for walking. The fame is made of aluminum. The large castors offer a range of
functions -- gradual brake/drag, brake lock, swivel, swivel lock and one-way ratchet control. This gives a wide range of control in speed, direction and maneuverability. Three sizes
are available - user elbow heights from 44.5 to 119.5 cm.
12
Wheelchair Maintenance/Repairs and Power assist
battery ($780) replacement every 3 years
Wheelchair cushion, basic type due to minimal amount
of time expected to need wheelchair
Exercise table matt for home stretching and exercise
program needed to maintain
Standing frame for stretching, similar to one used in
school
Ages 7 Lifetime
$360
primary means of
mobility)
Annually
Ages 7 –
Lifetime
Ages 12 –
Lifetime
Age 16
$100
Every other year
$50
$570
Every 10 years
$57
$5000
Replace once at age 35
$100
13
John Smith
PROJECTED FUTURE COSTS
F.
HOME CARE BASED CARE OPTIONS
DESCRIPTION
At this time, based on available data and opinions, this consultant is
recommending budgeting for the minimal level of “Supportive Living”
support services as defined by the State of New Mexico. This assumes
John will be able to live in a house or apartment with intermittent
support services such as those described below. Should the
neuropsychological evaluation test findings indicate John has cognitive
impairments of a severity to, more likely than not, warrant a need for
more extensive residential supportive care, the cost per month would
increase to $2458/month ($29,496 annually2).
COST
$1693/month
3
DAYS
Year round
starting at
age 20
through
lifetime
ANNUAL
COST
$20,316
“These services are intended to provide the support needed to live a satisfying life in the community and may include assistance with money
management, meal planning and preparation, health monitoring and maintenance, personal care, household care, planning and participation in
recreation and leisure activities, medication administration and/or assistance and nursing support, and developing effective self-advocacy skills.
Individuals may receive these services in their family home or in their own home. In all environments, these services focus on increasing,
maintaining, or promoting independent functioning, social and relationship skill development, and full participation in the community.
A 24-hour on-call system provides emergency backup support for all individuals receiving Supported or Assisted Living services in order to assure
the health safety of the individual.
These services are designed around each individual’s unique needs and desires and promote the individual’s capacity to live independently and as a
full member of the community. “
Tresco, Inc.; Las Cruces based provider of Assisted Living Services
2 Vendor payment rate 2006; NM Long Term Care Services
14
G. TRANSPORTATION
Transportation needs are unknown at present. It is the opinion of this consultant that more likely than not, John will not be able to operate a
vehicle and drive. He will most likely be dependent on others and public transportation.
Wheelchair accessible transportation will be needed. The cost to convert a van is typically $27,000 - $32,000.
H. ARCHTITECTURAL/HOME MODIFICATIONS
John will need to live in a home or apartment with universal design and easy accessibility. The front door of the existing home will need a ramp
and to be widened once John learns to use a wheelchair.
Ceiling track systems for transfers may be needed as John grows in size.
Cost projections for this expense category may be offered at a later time as the current home is rented.
15
Life Care Plan
For
Paula Brown
12/20/2011
Prepared by:
Patricia Rapson, RN, CCM, CNLCP, CLCP, CBIS, MSCC
Table of Contents
Demographic Information ......................................................................................3
Introduction ............................................................................................................3
Methodology ..........................................................................................................4
Medical Records Reviewed ...................................................................................5
Description of Injury/Summary of Medical Care ....................................................5
Phone Conference with Dr. Paul Revere .............................................................12
Current Treatment Regimen ................................................................................13
Medications ......................................................................................................13
Treating Physicians ..........................................................................................14
Current Functional Status ....................................................................................14
Equipment ............................................................................................................14
Supplies ...............................................................................................................15
Attendant Care .....................................................................................................15
Pre-Injury Status ..................................................................................................16
Pre-Injury Medical History/Co-Morbid Conditions ................................................16
Psychosocial Considerations ...............................................................................17
Reaction to Illness/Injury ..................................................................................17
Social / Community Activities / Hobbies ...........................................................17
Available Resources ........................................................................................17
Home Environment / Accessibility .......................................................................17
Nursing Diagnoses ..............................................................................................18
Education / Vocational Issues ..............................................................................19
Education .........................................................................................................19
Work History .....................................................................................................19
Life Expectancy ...................................................................................................19
Potential Care Needs ...........................................................................................20
Discussion............................................................................................................21
Ankle Anatomy .................................................................................................21
Bi-Malleolar Ankle Fracture and Posttraumatic Arthritis ...................................22
Ankle Fusion ....................................................................................................23
Complex Regional Pain Syndrome ..................................................................25
Spinal Cord Stimulation (SCS) for Chronic Pain ..............................................28
Comments / Conclusions .....................................................................................30
References ..........................................................................................................31
Life Care Plan
RE: Paula Brown
Demographic Information
DOB: 1/19/19xx
Case #:
DOI: 3/3/20xx
SS#
Address:
Jurisdiction/State:
Medical Diagnoses
ICD-9
824.4
716.17
718.47
719.47
998.78
733.81
845.00
727.06
724.2
338.4
300.4
337.22
Description
Left Ankle Bimalleolar Fracture, closed
Traumatic Arthritis, Left Ankle
Contracture of Ankle and Foot Joint
Pain in Joint, Ankle and Foot not otherwise specified
Other Complications due to Internal Orthopedic Device Implant and Graft
Nonunion of Fracture
Ankle Sprain, Left
Tenosynovitis of Foot and Ankle
Lumbago
Chronic Pain Syndrome
Depression with Anxiety,
Chronic Regional Pain Syndrome (CRPS)
Introduction
The following Life Care Plan was developed at the request of Ms. Brown’s attorney, to address
Ms. Brown’s current medical status and project her anticipated future medical care with
associated costs related to injuries she sustained in the 3/3/20xx motor vehicle accident.
3 of 32
Methodology
This Life Care Plan report and its attachments represent a dynamic document based upon
review of the records, data analysis and research. This review also considered past patterns of
utilization, responses to prior treatment regimens, review of the current medical status,
availability of resources in the community and the impact of aging and/or progression of disease
or disability. Past medical, social, psychological, vocational, educational and rehabilitation data
was considered to the extent that it was available and applicable. A logical and systematic
methodology was utilized to create an organized concise plan which projects anticipated
medically appropriate care and services. The goal of this plan is to promote prompt access to
medical care and supportive services to promote health, maximize overall functioning and
prevent, or significantly reduce, known complications and/or co-morbidity over one’s life time.
The Life Care Plan serves as a guide for family members, case managers and health care
providers. It represents a blueprint for anticipated health care and other related needs based on
reasonable medical and rehabilitation probability and current concepts of patient care
management.
The information can also be used by those given fiduciary responsibility to
monitor and allocate funds and/or select appropriate investment strategies designed to preserve
funding so that remains available over ones life time. Illustrations within this report are provided
to facilitate and enhance the readers overall understanding and not meant to be an exact
representation of Ms. Brown’s injuries and/or conditions.
The pricing for each item on the attached spreadsheet has been researched, verified and
represents costs for goods and services relative to the geographic domain where the majority of
care is anticipated. The Life Care Plan pricing was based on both actual costs/expenses for
services and/or the appropriate state usual and customary reimbursement rates for the
corresponding codes (CPT, HCPCS etc).
Calculations utilize the mean costs and frequencies
of the items listed, thus providing for fluctuations in both the level and intensity of services
received over life expectancy. Costs contained within this Life Care Plan reflect the “Current
Value” of items and services, or what it would cost if provided today. Should “Total Present
Value” calculations be required, a qualified economic expert should be consulted.
4 of 32
Medical Records Reviewed
1. City Fire Department, 3/3/20xx
2. State Peace Officer’s Crash Report, 3/3/20xx
3. Memorial Hermann Northwest Hospital, 3/3/20xx, 3/12/20xx - 3/15/20xx
4. Barton Kendrick, MD, 3/3/20xx, 3/9/20xx, 3/19/20xx, 3/24/20xx, 4/7/09, 5/21/20xx,
6/4/20xx, 7/7/20xx, 8/25/09, 8/31/20xx, 9/23/20xx, 9/24/20xx, 10/14/20xx
5. Memorial Hermann Home Health, 4/22/09, 4/23/09, 4/27/20xx, 5/1/20xx, 5/4/20xx,
5/6/20xx, 5/7/20xx, 5/8/20xx
6. Davidson Physical Therapy, 5/21/20xx – 6/8/2008, 6/29/20xx
7. Tomiko Jefferson, MD, 10/6/20xx, 10/15/20xx, 11/18/20xx, 12/14/20xx, 1/26/2010,
8/10/2010, 11/12/2010, 11/23/2010, 12/16/2010, 3/3/2011, 5/10/2011, 5/26/2011,
6/7/2011, 6/9/2011, 7/6/2011, 9/8/2011, 10/11/2011, 10/12/2011
8. Sharasra Multi-Specialty, 2/9/2010, 2/11/2010, 2/16/2010, 2/23/2010, 2/25/2010,
3/2/2010, 3/4/2010, 3/9/2010, 3/11/2010, 3/23/2010, 3/25/2010, 4/1/2010, 4/6/2010,
4/8/2010, 4/13/2010, 4/15/2010, 4/21/2010, 4/27/2010, 4/29/2010, 5/4/2010, 5/6/2010,
5/11/2010, 5/13/2010, 5/18/2010, 5/23/2010, 5/25/2010, 6/1/2010, 6/8/2010, 6/15/2010,
6/22/2010, 6/29/2010, 7/6/2010, 7/13/2010, 7/20/2010, 7/27/2010, 8/4/2010, 8/11/2010,
8/18/2010, 8/25/2010, 9/1/2010, 9/8/2010, 9/15/2010, 9/22/2010, 9/29/2010, 10/6/2010,
10/13/2010, 10/20/2010, 10/27/2010
9. Diagnostic Clinic of State, 12/5/2011
10. Deposition: Tomiko Jefferson, MD, 10/25/2011
11. Deposition: Paula Brown, 3/9/2011
12. Bills and Payments
Description of Injury/Summary of Medical Care
On 3/3/20xx, Ms. Brown was the restrained driver of a vehicle and was involved in a motor
vehicle accident (MVA) as she approached an exit. Records described a side impact at an
estimated speed of 40 mph. Ms. Brown’s vehicle then proceeded to hit the cement barriers on
either side of the exit ramp. Per the City Fire Department report, her vehicle sustained severe
damage. In her 3/9/2011 deposition, Ms. Brown testified that her vehicle bounced between the
two concrete barriers like a “ping pong ball” from one side to the other. She reported hitting her
head on the windshield as well as other body parts which hit the car’s interior.
She was
assisted out of the vehicle by others who had stopped at the scene and was found sitting on the
ground when the City Fire Department arrived.
5 of 32
Ms. Brown was alert and orientated at the scene with a Glasgow Come Scale score of 151.
She complained of bilateral wrist, left ankle, right knee, neck and back pain and was noted to
have left ankle swelling and multiple abrasions to the left ankle, right knee and left wrist.
Ms.
Brown was placed in a cervical collar, back board and transported to Memorial Hermann
Northwest Hospital’s emergency room.
In the emergency room, she complained of pain as a 10/10 on a numeric pain scale2. She was
provided with intravenous morphine and a Toradol injection for her acute pain3. She received
clearance from her spinal precautions and the cervical collar and backboard were discontinued.
Left ankle x-rays confirmed a severely comminuted bi-malleolar fracture with associated soft
tissue swelling4. A splint was applied to Ms. Brown left ankle and she was provided with a
walker, oral pain medications and instructions to follow up with Barton Kendrick, MD, an
orthopedic surgeon.
At the time of his 3/9/20xx evaluation, Dr. Kendrick noted severe edema, bruising and the
development of a large anterior-medial fracture blister5. Ms. Brown was non ambulatory and
complained of constant burning, stabbing, shooting, sharp and achy pain at a level of 10/10.
Surgery was scheduled and she was admitted to Memorial Hermann Northwest Hospital two
days later. On 3/13/20xx, Dr. Kendrick performed an Open Reduction with Internal Fixation
(ORIF) of the left ankle fracture.
In his operative report, he noted the fracture was highly
comminuted (with many fragments). Plate and screw fixation was provided after which a short
1
The Glasgow Come Scale (GCS) is based on a 15 point scale for estimating and categorizing the
outcomes of brain injury. The number helps medical practitioners categorize four possible levels for
survival, with a lower number indicating a more severe injury and a poorer prognosis.
2
Although there are different types of pain rating scales (numeric and visual), on a scale with numeric
rating of 0 to 10, 0 typically refers to no pain and 10 refers to severe pain. Although these scales are
highly subjective, the individual is able to compare their ratings so that if pain was considered a 6 one
week and a 3 the next, it shows an improvement of their symptoms and vice versa.
3
Morphine is a pure opioid analgesic which was used to manage Ms. Brown’s acute pain. When
administered intravenously, rapid onset of analgesia occurs. Toradol is a nonsteroidal anti-inflammatory
medication used to treat pain and decrease inflammation.
4
Please see the Discussion section of this report for additional information on Bi-Malleolar ankle
fractures
5
Fracture blisters are most commonly associated with fractures of the leg, ankle, forearm and wrist.
They are caused by the combination of excessive swelling and a torsional type injury to the tissues which
overly the fractured bone. The “blister” represents an area of damaged and/or necrotic epidermis.
6 of 32
leg splint was applied. During her hospital stay, occupational and physical therapy were
initiated. Problem areas included balance deficits, decreased activity tolerance and deficits in
her functional mobility (including bed mobility and transfers). Prior to her admission, Ms. Brown
reported she had tried to use a rolling walker at home, but had fallen and therefore was relying
on a wheelchair for mobility. However, because the bathroom at her condo was not wheelchair
accessible, the rolling walker was utilized for toileting activities. Physical therapy reported that
she was fearful of ambulating with the rolling walker and would likely rely on the wheelchair as
her primary means of mobility, using the walker only for very short distances.
Her therapists
noted several safety concerns as Ms. Brown demonstrated impulsiveness, trying to get up
without assistance and tended to sit down without assuring her wheelchair, bed or chair was
behind her. Multiple verbal cues were also required for safe ambulation. By the time of her
discharge, Ms. Brown continued to require moderate physical assistance with mobility including
lying to sitting, scooting, and bed to chair transfers.
She required moderate to maximum
physical assistance for sit to stand activities. She was able to ambulate short distances (0 – 45
feet) using her rolling walker but required at least one seated rest break to accomplish this.
Home health services were recommended to include physical therapy, a home health aide and
a social work consult.
Additional equipment included an elevated toilet seat, grab bars, a tub
transfer bench and a rolling walker with a seat.
Her left ankle remained too swollen to be casted at her post operative office visit with Dr.
Kendrick (3/19/20xx) so the posterior splint was maintained for an additional week after which a
short leg cast was applied. Ms. Brown continued strict non weight bearing on the left lower
extremity and continued to report significant pain. She gradually improved and by her 4/7/20xx
office visit reported her pain at a 4/10 level. X-ray’s confirmed some interval healing with an
acceptable alignment of the bones. Ms. Brown had reportedly removed her own cast due to
wetness the previous day. Dr. Kendrick placed her in a walking fracture boot with instructions to
initiate weight bearing as tolerated on the left leg.
Home physical therapy was not initiated until 4/23/20xx as they had difficulty reaching Ms.
Brown for scheduling.
She reported increased pain with physical therapy and when she
returned to see Dr. Kendrick on 5/5/20xx, she reported panic attacks and nightmares regarding
the accident. Records described her mood as alert, anxious and depressed. Moderate left
ankle swelling persisted and marked joint stiffness was noted as Mr. Kendrick was unable to
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passively dorsiflex her ankle to a neutral position6. Dr. Kendrick reviewed and encouraged her
to perform stretching exercises several times a day and out patient physical therapy was
prescribed.
Ms. Brandon attended four out patient therapy sessions at Davidson Physical Therapy and
discharge was recommended due to her failure to complete treatments. Left ankle pain and
swelling persisted. On 7/7/20xx, Dr. Kendrick noted that while the distal fibular fracture had
healed (lateral malleolus); the medial malleolus fracture exhibited a progressive fragmentation.
By 8/25/20xx, Ms. Brown left ankle remained moderately swollen and could not be brought to a
neutral position. She reported persistent pain of 6/10 and was unable to put any weight on her
left lower extremity. Dr. Kendrick prescribed Celebrex7, Norco8 and added a Medrol dosepak9 to
her medication regimen.
A CT scan of her left ankle revealed the development of significant
posttraumatic arthritis with global narrowing of the joint space as well as marked irregularity and
erosion of the articular surfaces of the tibia and talus10 and bony debris in the joint space. Dr.
Kendrick opined Ms. Brown would continue to do poorly in light of the extensive joint damage
and referred her to the Fondren Orthopedic Group for further assessment and treatment.
On 10/6/20xx, Dr. Tomiko Jefferson evaluated Ms. Brown. Although she continued to utilize a
walker to ambulate, she had stopped wearing the boot due to ankle swelling.
Ms. Brown
complained of moderate, intermittent shooting and achy pain which worsened with activity. She
continued to take five to six Norco per day and had developed a patchy rash on the anterior
6
Dorsiflexion refers to pulling your foot up towards the leg, while a neutral position would represent the
foot as flat on the floor while standing or at a 90 degree angle to the leg. So in this case Dr. Kendrick was
not able to push Ms. Brown’s foot upward to reach the neutral position.
7
Celebrex (Celecoxib) is a COX-2 inhibitor NSAID which works by blocking certain substances in the
body that cause inflammation. Celebrex is used to treat pain and symptoms of inflammation, arthritis and
acute pain in adults
8
Norco (Hydrocodone) (also known as Vicodin, Lortab, Lorcet) is a tablet containing a combination of
Tylenol (acetaminophen) and hydrocodone. The hydrocodone is a narcotic pain reliever. The Tylenol
works with hydrocodone to increase its effectiveness. Norco is indicated for relief of moderate to
moderately severe pain
9
Medrol Dosepak contains the steroid Methylprednisolone which prevents the released of substance in
the body that cause inflammation.
10
Please see the Discussion section of this report for additional information on posttraumatic arthritis.
8 of 32
aspect of both her shins.
On examination of the left ankle, Dr. Jefferson noted 2+ pitting
edema11 and a relatively vertical left hind foot. In addition to the post traumatic arthritic changes
noted above, diagnostics also confirmed a nonunion of the medial malleolus, fragmentation of
the distal fibula and migration of the fixation screws (backing out). She diagnosed traumatic left
ankle arthritis and an equinus contracture of the left ankle and foot joint12.
Dr. Jefferson
discussed both conservative and surgical options with Ms. Brown and ultimately surgical fusion
of the ankle with hardware removal and correction of the contracture deformity was planned.
Ms. Brown received surgical clearance, however decided to postpone the procedure to a time
when she could be off work during her recovery. She was provided with a steroid joint injection
in late January, 2010, but only received transient relief with this.
Two weeks later, Ms. Brown was evaluated by Iesha Grant, a nurse practitioner at Sharasra
Multi-Specialty. Ms. Brown reported persistent low back and left ankle pain since the 3/3/20xx
MVA. She reported feeling anxious, depressed and unable to work or sleep more than four
hours a night, often waking up crying due to the pain.
Ms. Grant diagnosed back pain
(lumbago), chronic pain syndrome and depression with anxiety.
She recommended
psychotherapy and prescribed physical therapy and medications to include Soma, Lorcet and
Zoloft.
Between 2/9/2010 and 10/27/2010, Ms. Brown presented to the Sharasra clinic on
approximately 48 occasions13.
Ms. Brown reported that Ms. Grant provided medical
11
Edema is the noticeable swelling which results from fluid accumulation in body tissues. If an
indentation is left after pressure is applied (i.e. pressing a finger into the swollen area) it is referred to as
Pitting Edema.
12
Equinus or “foot drop” is a condition in which the upward bending motion of the ankle joint is limited.
Someone with equinus lacks the flexibility to bring the top of the foot toward the front of the leg. In Ms.
Brown’s case, shortening of the Achilles tendon was felt to be the cause. Although people with equinus
develop ways to “compensate” for their limited ankle motion, this often leads to other foot, leg or back
problems. Conservative treatment can include splints, heel lifts, custom shoe orthotics and physical
therapy. In Ms. Brown’s case, Dr. Jefferson ultimately performed a tendon lengthening procedure to
correct this.
13
This consultant reviewed records from approximately 48 different dates in which Ms. Brown was seen
at the Sharasra clinic. On some days, multiple services were provided (medical evaluation, counseling,
physical therapy). Bills & Payments noted a Physical Medicine Superbill for services from 2/9/2010 –
9 of 32
evaluations,
psychotherapy,
and
she
prescribed
and
provided
physical
therapy
services/modalities (to include application of heat/cold, electrical stimulation, therapeutic
exercises, and massage). As Ms. Grant’s therapy records consist primarily of check lists, it is
not clear if formal evaluations of Ms. Brown’s functional status, range of motion or progress
were provided or reported to Dr. Jefferson. Ms. Brown’s mood was frequently noted to be sad,
depressed and anxious and her antidepressant was changed to Effexor, although there was no
report of improvement in her mood after this change.
On 11/12/2010, Dr. Jefferson performed a left ankle arthrodesis (fusion), removal of the old
hardware, lengthening of the left Achilles tendon and removal of degenerative bone spurs. Her
initial postoperative course went well with improvement of her pain to 3/10.
For approximately
four weeks, Ms. Brown remained non-weight bearing on the left leg and used her walker to
ambulate. After which her cast was removed and she was placed in a tall Bledsoe Boot14. By
mid January, 2011, Ms. Brown’s ankle had minimal tenderness and she was eager to transition
from the boot to shoes. X-rays revealed consolidation of the joint with callous and plans were
discussed to wean her from the Bledsoe Boot to Rocker Soled shoes15.
When she returned to see Dr. Jefferson in early March, 2011, Ms. Brown continued to use the
walker for ambulation and reported intermittent ongoing use of the Bledsoe Boot as she
continued to experience difficulty with her balance, causing her to roll her left ankle.
Dr.
Jefferson ordered physical therapy to begin with pool therapy (aquatic therapy) and focus on
proprioception. At her next follow up office visit, Ms. Brown reported increased ankle pain and
swelling since rolling her left foot.
Although she was participating in physical therapy, her
participation was being limited by the pain. In addition, she reported burning in the lateral ankle
which was interfering with her sleep.
Dr. Jefferson diagnosed a left ankle sprain and
16
tenosynovitis of the left foot and ankle . Ms. Brown tried using a supported ankle brace but did
not find this comfortable. Two weeks later, she reported multiple instances of rolling her foot
and had also fallen. A CT scan was ordered to assess for nonunion of the ankle joint. Results
noted the presence of bridging callus with healing of at least 30% of the joint surface area. Mild
10/27/2010 which noted 54 visits billed at $85.00 each (Bills & Payments2, pg2). Services listed include
Paraffin Bath, TENS applications and Therapeutic Procedure/Exercises. It does not appear that
treatment with Ms. Grant has continued.
14
See description in the “Equipment” section of this report
15
See description in the “Discussion” section of this report
16
Tenosynovitis is the inflammation of the fluid filled sheath (synovium) that surrounds the tendon.
Symptoms can include pain, swelling and difficulty moving the involved joint.
10 of 32
subtalar degenerative changes were also noted.
loosening of the hardware.
There was no evidence of bone loss or
Ms. Brown was provided with a Bone Growth Stimulator17 and
gradual consolidation of the joint was monitored. Use of the Bone Stimulator continued through
October 2011, when the records concluded.
Ms. Brown was gradually able to tolerate full
weight bearing and weaned out of the boot. Compression stockings were recommended as she
continued to experience ankle pain, swelling and stiffness. A 10/12/2011 CT scan noted a solid
fusion of the ankle joint and some advancement of the subtalar degenerative changes (from
mild to moderate).
In her 10/25/2011 deposition, Dr. Jefferson noted Ms. Brown’s recovery has been more difficult
than is typical.
She opined Ms. Brown would undergo additional surgery to remove the
hardware in an attempt to reduce the persistent pain and increase function; however, she did
not have a high degree of confidence that this would make a major difference in her symptoms.
Depending on her life expectancy, other anticipated procedures include surgical fusion of the
subtalar joint and/or transtarsal joints (talonavicular joint and the calcaneocuboid joint).
On 12/5/2011, Ms. Brown was evaluated by Paul Revere, MD, a physiatrist. She reported
chronic left ankle and back pain with weakness, numbness, tingling, and burning in her feet,
toes and hands.
She reported loss of appetite with weight gain, nervousness, and sleep
difficulties, loss of balance and persistent pain which limited her day to day functioning. On
examination, Dr. Revere noted left ankle edema with areas of excoriation18. He diagnosed left
ankle Chronic Regional Pain Syndrome and prescribed a topical compounded cream19 for pain
relief. Future consideration of spinal cord stimulation (SCS) was recommended should she fail
to obtain relief of her pain.
17
Bone Growth Stimulator’s use a pulsed electromagnetic field to facilitate bone healing. The device is
worn on the outside of the body for several hours a day as prescribed. Most individuals wear the device
between four and eight months.
18
Excoriation describes a raw irritated lesion or skin abrasion
19
Topical pain relieving drugs include preparations applied to the skin as a cream, ointment, gel, spray
or patch. These drugs seek to reduce inflammation below the skin surface and sooth nerve pain.
Formulations diffuse through the skin and enter the bloodstream initially bypassing the digestive system.
Many systemic side effects such as stomach irritation can be lessened or eliminated.
11 of 32
Phone Conference with Dr. Paul Revere
This consultant spoke with Paul Revere, MD on 12/16/2011 and discussed Ms. Brown’s current
status and future care. He noted that pain was her main complaint at the 12/5/2011 office visit.
We discussed the fact that Ms. Brown had some pre-accident history of back pain. Dr. Revere
explained that individuals with a history of pain are more likely to develop a chronic pain
syndrome if a second type of pain occurs. Currently, Ms. Brown is prescribed antidepressants
and appears quite focused on her pain.
Dr. Revere recommends aggressive psychiatric
intervention to incorporate Cognitive Behavioral Therapy (CBT)20 (at least three to four years
two to four times per month) along with routine psychiatric monitoring over her lifetime.
In
addition several months of aggressive physical therapy is anticipated.
Dr. Revere prescribed a transdermal cream in an effort to relieve her persistent nerve pain. He
anticipates a phone call from Ms. Brown in the next week as he wanted to give her sufficient
time using the cream to determine its effectiveness. If her pain is not adequately relieved, Dr.
Revere indicated he would obtain a psychiatric evaluation to determine her appropriateness for
SCS.
Ms. Brown will be referred to a specialist for SCS trial, implantation and programming.
Dr. Revere anticipated he would continue to follow Ms. Brown monthly for approximately six
months as she transitioned from oral pain medications to SCS; after which his visits would
decrease to every two to three months for several months and then finally to three to four times
annually once stabilized.
As the SCS functions by interfering with the pain signals, it is not anticipated that this will result
in a significant decrease in her ankle swelling. Overall ongoing use of oral pain medications will
be dependent on the effectiveness of her pain relief with the SCS.
Dr. Revere noted that due to the changes in body mechanics with weight bearing, overuse
syndrome and early degenerative changes can occur in the joints of the opposing leg, hip and
back, ultimately leading to gait destabilization. Dr. Revere is aware that several equipment
items are provided within this Life Care Plan to promote independent functioning both at home
and in the community. Currently Ms. Brown has no restrictions on her activity as he encourages
her to do as much as she can. Dr. Revere anticipates follow up with Ms. Brown in the next few
20
Cognitive Behavioral Therapy (CBT) focuses on patterns of thinking that are maladaptive and the
beliefs that underlie such thinking. CBT sessions are often active, problem-focused and goal directed.
CBT has been shown to be as useful as antidepressant medication for individuals with depression and is
superior in preventing relapse.
12 of 32
weeks. Although he agreed that her chronic ankle pain would likely contribute to a poorer
quality of life, he did not feel her current life expectancy would be altered by this or in lieu of her
current co-morbid conditions.
Current Treatment Regimen
It is noted that Ms. Brown’s pain medications may be significantly reduced if she achieves
adequate pain relief using the SCS.
Medications
Medication / Dosage
Effexor XL (Venlafaxine) 37.5mg
Once daily
Lorcet (Hydrocodone) 10/650 mg
tablets
As needed for pain
(As Ms. Brown was previously
prescribed 120 tablets/ month, only the
additional quantities (#90/mo) are
reflected on the attached spread sheet.
Valium (Diazepam) 10 mg tablets
As needed for anxiety and/or back
spasms
(As Valium was previously utilized for
anxiety, only #30 tablets / 4 times/year
are provided on the attached
spreadsheet)
Comments
Effexor is an antidepressant medication used in
treatment of depressive disorders, anxiety and panic
disorders.
Lorcet (also known as Vicodin, Lortab, Norco) is a
tablet containing a combination of Tylenol
(acetaminophen) and hydrocodone. The hydrocodone
is a narcotic pain reliever. The Tylenol works with
hydrocodone to increase its effectiveness. Norco is
indicated for relief of moderate to moderately severe
pain. Ms. Brown reports currently using up to 7 tablets
per day for pain.
Valium belongs to a group of drugs called
benzodiazepines which affects chemicals in the brain
that can become unbalanced and cause anxiety. Ms.
Brown reports intermittent prior use of Valium.
Ambien (Zolpidem )
10 mg tablet
As needed for sleep
Ambien is used to treat insomnia (difficulty falling
asleep or staying asleep). Ambien works by slowing
activity in the brain to allow sleep.
Motrin (Ibuprofen) 800mg tablets
As needed for mild to moderate pain
and inflammation
Motrin is a nonsteroidal anti-inflammatory drug
(NSAID) which works by reducing hormones that
cause inflammation and pain in the body
Lidocaine 2%, Prilocaine 2%,
Topirmate (Topamax) 2.5%,
Meloxicam (Mobic) 0.09%
Transdermal Cream
Compounding creams are made in a special
pharmacy. Medications are blended and applied to the
skin where they slowly absorb. The combination of
medications can be tailored to meet an individuals
needs.
Lidocaine and Prilocaine are anesthetic or numbing
medications which block pain impulses and prevent
them from reaching the brain.
Topiramate is an anticonvulsant medication which is
also sometimes used in the treatment of pain
Apply up to 4 Grams 4 times per
day (16 Gm/day) for treatment of
pain and/or muscle spasms
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conditions involving nerve mediated pain
Meloxicam is a non steroidal anti-inflammatory drug
(NSAID) used in the treatment of arthritis.
Treating Physicians
Thomas Jefferson, MD (Orthopedic Surgery)
Town, ST zip
telephone
Paul Revere, MD, (Physical Medicine & Rehabilitation)
Diagnostic Clinic of City
City, ST 77004
telephone
Current Functional Status
Ms. Brown remains independent driving and completing her basic and advanced activities of
daily living, however, pain continues to limit her activities.
She continues to use adaptive
equipment intermittently for support and balance with her mobility. Provisions for various items
have been included to promote independent functioning and reduce her risk of falling. As she
ages, it is anticipated that Ms. Brown’s reliance on these items may increase.
Equipment
Item
Roll-A-Bout
Compression Stockings
Tall Bledsoe Walking Boot
Rocker soled shoes
Rationale
The Roll-A-Bout is a walker / crutch substitute. The user
places the knee of their injured leg on a padded seat. There
are 4 wheels for stability and a hand break. This item was
recommended by Dr. Jefferson.
This item is designed to increase blood circulation and provide
graduated pressure on the lower leg/foot to alleviate
circulatory problems such as edema. By compressing the
surface veins, arteries and muscles, the blood is forced
through narrower circulatory channels. As a result, the arterial
pressure is increased which causes more blood to return to
the heart and less to pool in the feet.
Used previously during post op recovery, these boots provide
ongoing postoperative support to the ankle joint after cast
removal. It is anticipated that this will also be used
subsequent to future ankle fusions.
The bottom of Rocker soled shoes are thick and curved,
creating the rocking ability that is lacking in traditional flat
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shoes. After ankle fusion, these can improve walking
mechanics. Rocker soles shoes were recommended by Dr.
Jefferson
Custom Left Shoe Orthotic
Motorized Scooter
Scooter vehicle lift
Stair lift
Shower Seat
Hand Held Showerhead with
anti-scald protection
Grab Bars
Orthotics can facilitate appropriate foot positioning during
walking and help prevent the tendency to roll the ankle.
This item is provided to facilitate independent mobility in the
community as Ms. Brown has difficulty walking distances
This item allows Ms. Brown to access the community with her
scooter. The specific lift style of lift will be dependent on the
type of scooter and Ms. Brown’s vehicle.
This is provided as a safety measure as Ms. Brown has
reported multiple falls and has altered mobility making stair
climbing more difficult. As she ages, this will be more of a
concern. Please note that this item would be removed should
she decide not to remain in her 2-story condo.
Promotes safe independent bathing activities. Depending on
the design of the tub/shower and Ms. Brown’s ability to step
over the side of a tub, a tub transfer bench might be indicated.
Promotes safe independent bathing activities
Permanently placed in the showers and by the toilet in the
bathrooms at both her home and condo. This item should be
removed if grab bars are currently installed
Supplies
Item
Pill organizer
AAA Batteries
(12 pk/year)
Rationale
Facilitates compliance by organizing medications
Used to power the hand held SCS programmer
Attendant Care
Although Ms. Brown currently does not require attendant care assistance, it is noted that she
does live alone. Previously, friends and family have assisted, however many of these individuals
also worked. As it is not always possible to predict when and who would be available to assist
in the future, provisions for limited home health aide assistance during her postoperative
recovery has been included as follows:
After surgery to remove hardware
● 12 hours/day x 3 days, then
● 6 hours/day x 4 days, then
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●
4 hours/day x 7 days
After surgical joint fusions
● 24 hours/day x 7 days, then
● 12 hours/day x 4 days, then
● 6 hours/day x 3 days, then
● 4 hours/day x 14 days
After SCS implantation and replacement
● 12 hours/day x 3 days, then
● 6 hours/day x 4 days, then
● 4 hours/day x 7 days
Pre-Injury Status
Prior to the 3/3/20xx MVA, Ms Brown was independent with all basic and advanced ADL
activities. In her 3/9/2011 deposition, she reported a prior workers compensation injury in the
late 1990s when she stepped into a hole, twisting her back and left ankle. In 2008, she received
additional treatment for unspecified back complaints, which were conservative per her report
and included medications. No physical therapy or chiropractic intervention was provided. Ms.
Brown testified that she had continued to take Norco and Soma as needed once or twice a
month when her back bothered her.
Ms. Brown also reported prior treatment for anxiety, panic attacks and depression subsequent
to the deaths of multiple immediate family members (two of her children, a granddaughter and
her husband). Although she noted intermittent ongoing use of anti-anxiety medications (Xanax)
for panic attacks, after 2005, she was not prescribed antidepressant medications.
Pre-Injury Medical History/Co-Morbid Conditions
●
Allergies: Compazine
●
Anxiety
●
Eye surgery, 2003
●
Liposuction, 2002
●
Left ankle sprain, 1995-1996
●
Back strain, 1995-1996
●
Breast surgery, unspecified1980s
●
Abdominoplasty (Tummy Tuck), 1980s
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●
Height 5’5”; weight 176.2 lbs 12/5/2011
Psychosocial Considerations
Reaction to Illness/Injury
Ms. Brown testified that this accident has changed her whole life.
She reported feeling
depressed and is no longer able to be active like she was before the accident. Medical records
noted feelings of frustration with her prolonged recovery and persistent pain.
Ms. Grant
prescribed antidepressant medications, however it is not clear how effective these have been in
managing her mood.
Since the 3/3/20xx MVA, Ms. Brown attended approximately seven counseling sessions with
Ms. Grant in 2010. She reported anxiety with a sleep disturbance and periodically cried during
her sessions. It does not appear that she is currently involved in counseling.
This Life Care
Plan does provide for psychiatric intervention per Dr. Revere’s recommendations.
Social / Community Activities / Hobbies
Prior the 3/3/20xx MVA, Ms. Brown enjoyed dancing with girlfriends, jogging at Memorial Park,
and taking long walks in her neighborhood. She reports feeling that she’s now “stuck” in front of
the TV. Although her friend, Tina, comes over two to three times a week, they don’t go out.
Instead they spend their time watching TV.
No other current social / leisure activities were
reported.
Available Resources
Ms Brown is a Medicare beneficiary; however no information was available regarding other
available resources.
Home Environment / Accessibility
Ms. Brown owns two homes which are briefly described below.
In her deposition, Ms. Brown
explained that she usually stays in her condo in City during the week, traveling to her home in
Village on weekends.
A third address was noted on her driver’s license and also provided in
the records from Dr. Revere. No information was available regarding her address.
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Street address
City, ST
This is a 2-story condominium with the master bedroom/bathroom located on the second
floor. The master bathroom has a tub/shower combination. A half bath is located on the
first floor. There are no steps to enter the home and records noted three accessible exits.
Street address
Village, ST
This is a ranch style home. No specifics were available regarding accessibility.
Nursing Diagnoses
A Nursing Diagnosis is defined as a clinical judgment about individual, family or community
responses to actual or potential health problems or life processes which provide the basis for
selection of nursing interventions to achieve outcomes for which the nurse is accountable.
The following Nursing Diagnoses were developed by this consultant subsequent to review of the
available information, phone conversations and research and reflects approved diagnoses’ per
NANDA-I (North American Nursing Diagnosis Association International).
●
Chronic pain
●
Anxiety related to chronic condition and altered body image
●
Impaired physical mobility related to left ankle joint fusion
●
Potential activity intolerance related to pain and deconditioning
●
Risk for injury related to poor balance and altered lower extremity sensation
●
Disturbed sleep pattern related to persistent lower extremity pain
●
Social Isolation related to altered state of wellness and deficient diversional activity
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Education / Vocational Issues
Education
Ms Brown was born in Town, State and graduated from Dana High School in 1955 after which
she attended classes at Capitol Community College in California. Additional training included
certification as an Acupuncture Detoxification Specialist, 1996; Substance Abuse and
Counseling internship at New Direction Counseling Center, 1989-1990; certification as a
Trauma Resolution Therapist; and in 2010, she obtained certification to perform DNA and drug
testing.
Work History
Year
2010 - present
I-10 West Medical
Business Owner
Position
Analyses DNA and Drug samples
Hours: 8 am to 11:30 five days per week
Ms. Brown testified that, while at work, she sits on the couch and
watches TV while her associate does the testing.
2008-2010
2007-2008
Unemployed
Trauma Resolution Therapist
E & A Associates
2005-2007
Trauma Resolution Therapist
Thomas Medical Clinic
2000 – 2005
Dr. Steve Smith
1995-1996
Trauma Therapist: Duties included working with individuals who
have had severe trauma such as death, accidents, abuse.
Office administrative duties
Counselor
Left this position after being injured at work
Criminal Justice
Department
Life Expectancy
The average remaining life expectancy for 69 year old females living in the United States is 16.8
years (rounded to 17 years). This represents the average number of remaining years one is
expected to live and is based on data published in the September 28, 2011 National Vital
Statistics Reports United States Life Tables, 2007; Volume 59, Number 9, Table 3 for females.
This Life Care Plan was prepared utilizing the average life expectancy for individuals of the
same / similar age, race and gender living in the United States. Dr. Revere noted that, although
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Ms. Brown’s ankle condition may affect her overall quality of life he did not feel it, or any of her
other co-morbid conditions would affect her life expectancy.
Potential Care Needs
In addition to the goods and services which can be projected within a reasonable degree of
probability, there are other conditions and/or complications which are possible and do not meet
this threshold.
These are therefore listed separately for informational purposes and the
associated costs are not reflected within the projected total costs of this Life Care Plan.
Potential Needs
Nonunion
Chronic Regional Pain
Syndrome (CRPS)
Comments
Delayed healing and nonunion occurred both after the initial surgery
(medial malleolus fracture) and the ankle fusion. Ms. Brown
required use of a bone growth stimulator for greater than three
months after her ankle fusion after which the bones eventually
healed. In light of this, it is possible that she would be at a higher
risk of experiencing nonunion and/or delayed healing after future
surgeries which would impact her care. Per Dr. Revere
concomitant use of the SCS and bone stimulator may be possible, if
the SCS unit is turned off while the bone stimulator is in use and
vice versa.
Diminished Motor Function
Non-use of a limb can lead to tissue wasting (atrophy) and tightness
of the muscles, tendons and ligaments (contracture) leaving the
affected area in a fixed position. Ms. Brown developed contractures
in her left foot/ankle due to non-use prior to her fusion. In addition
moderate to severe muscle spasms can occur in the affected limb
and associated musculature. Spasms may become debilitating and
can increase pain levels. Together, these can result in a severe
loss of the joint range of motion. Although Ms. Brown underwent
left ankle fusion (tibial/talar joint), the remaining joints and soft
tissues in her lower extremity remain at risk.
Bone Changes
Like other tissues in the body (i.e. skin) we constantly produce bone
cells. In normal bones there is a balance between bone cells being
produced (osteoblastic activity) and resorbed (osteoclastic activity)
thereby renewing and maintaining our bone strength and structure.
In early stages of CRPS, increased vascularity and osteoclastic
activity can be identified. In latter stages, significant diffuse
osteoporosis can develop. Periodic diagnostics have been included
on the attached spreadsheet to monitor for these changes. Should
this occur, medications such as Boniva, Fosamax and supplements
of vitamin D, calcium can help to restore and maintain bone
strength.
Spreading Symptoms
Although symptoms of CRPS are initially localized to the site of
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injury, as time progresses, pain and symptoms tend to become
more diffuse. Spreading of symptoms can impact functional
mobility, independents, coping and overall treatment. There are
three patterns of spreading that have been described.
1. “Continuity type” – spreads upward from the initial site i.e.
from the foot to the upper leg
2. “Mirror-Image” – symptoms spread is to the opposite limb
3. “Independent type” – symptoms tend to occur in other
distant areas of the body
Injuries related to Falls
Ms. Brown reports poor balance and coordination, which has
resulted in multiple previous falls. In addition, sensory changes
(pain) and altered mobility due to weakness and ankle fusion place
her at greater risk for injuries. Prior injuries have been reported as
relatively minor (bruises and cut lip), however post fusion; she
sustained additional injury to the soft tissues of the left ankle
(sprain) after “rolling” her foot. Falls can result in more serious
injury and/or fractures. Equipment aimed at minimizing this risk has
been included in the attached spread sheets
Discussion
This section is included to provide additional educational information that may facilitate the
reader’s general understanding of terms and concepts noted within the body to this report.
Ankle Anatomy
The ankle joint is composed of three bones (see front view below). The tibia, forms the inside
(medial) portion of the ankle, the fibula forms the outside (lateral) portion of the ankle; and the
talus is underneath. This is considered the “true ankle joint” and allows us to move our foot up
and down. The edges of the tibia and fibula which hang down around the talus are considered
malleolus and together with supporting ligaments and tendons, help to maintain the position of
the leg bones over the foot. The subtalar joint lies below the talus where the calcaneus (heel
bone) and talus come together and allows side-to-side motion of the foot. The transverse tarsal
joints allow rotational movement of the forefoot while the heel remains relatively still.
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Bi-Malleolar Ankle Fracture and Posttraumatic Arthritis
The vast majority of ankle fractures are malleolar fractures with 15 to 20 percent being
bimalleolar (involving both the medial and lateral malleolus). Because the medial malleolus is
shorter than the lateral malleolus, there is a greater tendency to “roll” the ankle outward. The
range of injury severity depends on the forces associated with the injury mechanism.
Associated injuries can include damage to the many tendons and ligaments that support the
ankle joint as well as injury to the articular cartilage and joint surface.
Unlike bone, damaged cartilage is not replaced. Development of posttraumatic arthritis
complicates 20-40% of ankle fractures. Generally the more severe the fracture, the greater the
likelihood posttraumatic arthritis will develop. Other risk factors include residual joint instability,
malalignment, obesity, high levels of activity and advancing age. As arthritic changes progress
the smooth cartilage in the joint deteriorates, causing friction between the bones. Pieces of
cartilage break off and the bone surface becomes thick and broad to compensate. Bone spurs
or osteophytes form around the joint causing deformities and can further impair joint motion.
Arthritic changes cause pain, stiffness, thickening of the joint fluid, inflammation and swelling.
Pain can originate from the structures within the joint or include surrounding ligaments, muscles
and bone.
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Conservative treatment for posttraumatic arthritis can include medications and topical creams
for pain and inflammation, physical therapy to regain and/or maintain functional mobility, bracing
for added support and comfort and Cortisone (steroid) joint injections to reduce local
inflammation.
Ankle Fusion
Surgical fusion of a joint is called arthrodesis (arthro-joint and desis-to bind). Ankle fusion for
treatment of end-stage ankle arthritis is considered a salvage procedure. When the bones have
healed together, no movement remains in the joint. This causes permanent alterations in one’s
gait pattern as they are not able to move their foot up and down as they walk. Running is very
difficult as one has lost the ability to “push off” with the toes during the gait cycle. Because the
“true ankle joint” no longer moves, additional stress can be placed on the subtalar and
transtarsal joints (noted above) as foot mechanics compensate.
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After ankle fusion, individuals often have difficulty climbing stairs and walking on uneven
surfaces. Physiologically, there is a decreased gait velocity or speed (16%), increased oxygen
consumption (3%), and an overall decrease in gait efficiency (10%). This increased physiologic
demand is not well tolerated by elderly pts who, because of their other medical conditions often
have a diminished ability to compensate for this higher demand (6, 7).
Some individuals can improve their gait by using custom orthotics21 and/or special shoes with
rocker bottoms. Because of the ankle positioning required to wear and walk in high-heeled
shoes, most women are unable to wear them after ankle fusion.
21
An orthotic is an externally applied device used to support / control a body part. There are multiple
types of braces and supports used to support the ankle. Braces and orthotics can reduce side to side
motion
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Complex Regional Pain Syndrome
Complex Regional Pain Syndrome (CRPS) describes an array of painful conditions that are
characterized by continuing (spontaneous and/or evoked) regional pain that is seemingly
disproportionate in time or degree to the usual course of any known trauma or other lesion. The
pain is regional (not in a specific nerve territory or dermatome) and usually has a distal
predominance of abnormal sensory, motor, sudomotor22, vasomotor23 and/or trophic24 findings.
Typical features include changes in the color and temperature of the skin of the affected body
part, accompanied by intense burning pain, skin sensitivity, sweating and swelling.
The
syndrome shows variable progression over time.
There are two types of CRPS. Type I is frequently triggered by tissue injury and is used to
describe individuals with the above symptoms who do not have an obvious underlying nerve
injury. When an injury to the nerve(s) is evident, the condition is generally considered Type II
CRPS (previously known as Causalgia)
Although the cause of CRPS is not clear, it is thought that the sympathetic nervous system is
involved with sustaining the pain and suggests that pain receptors in the affected part of the
body
become
responsive
to
a
family
of
nervous
system
messengers
known
as
catecholamine’s25 which acquire the capacity to activate pain pathways after tissue or nerve
injury.
In addition, although the exact triggering mechanism is not clear, the resulting
neurogenic inflammation appears to involve axonal (nerve cell) damage to the small distal nerve
fibers.
The key symptom of CRPS is continuous, intense pain, which is out of proportion to the severity
of the injury. This pain tends to worsen over time and can spread to include an entire extremity
and/or travel to the opposite or other extremities.
22
Sudomotor relates to nerves that stimulate the sweat glands.
Vasomotor pertains to the nerves and muscles that control the diameter of the blood vessels causing
constriction and/or contraction of blood vessels
24
Trophic refers to a nutritive effect on or quality of cellular activity
25
Catecholamines are naturally occurring hormones, which are released into the blood during times of
physical or emotional stress. Examples include epinephrine (adrenaline), norepinephrine (noradrenaline)
and dopamine. When released, these hormones cause the general physiological changes that prepare
us for physical activity; also known as the “fight-or-flight response”.
23
25 of 32
Although still under study, some researchers believe CRPS has three stages marked by
progressive alterations in the skin, muscles, joints, ligaments and bones of the affected area.
●
Stage I: Thought to last from 1 to 3 months and is characterized by severe, burning
pain along with muscle spasm, joint stiffness, rapid hair growth, and alterations in the
blood vessels that cause the skin to change color and temperature
●
Stage II: lasts from 3 to 6 months and is characterized by intensifying pain, swelling,
decreased hair growth, cracked, brittle grooved or spotty nails, softened bones, joint
stiffness and weak muscle tone.
●
Stage III: notes progression of skin and bone changes, which are not reversible. Pain
becomes unyielding and may involve the entire limb. There may be marked muscle
atrophy, severely limited mobility and flexion contractures.
Treatment:
CRPS can be very difficult to treat.
Not only is the syndrome biomedically multifaceted,
comprising both central and peripheral pathophysiology, it also frequently contains psychosocial
components. The goals of treatment include 1) management of pain and 2) restoration of
function.
Psychological Interventions
Although there is currently no solid evidence that psychological factors are necessarily involved
with the onset of chronic CRPS, there are theoretically plausible pathways through which
psychological factors could affect its development. It is important to determine the presence of
comorbid psychiatric disorders (Major Depression, Generalized Anxiety, and Post Traumatic
Stress Disorder); consider cognitive, behavioral and emotional responses to the CRPS; note
any ongoing life stressors as well as responses by significant others to the condition.
Approaches such as relaxation training, biofeedback, and cognitive / behaviorally focused
interventions are recommended and can be beneficial especially to individuals in which the
pervasive learned (or centrally mediated) disuse is perpetuated. Training in cognitive pain
coping skills and behavioral intervention to address disuse and activity avoidance issues, as
well as family reinforcement issues should be included as interventions focus on pain
management.
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Pain, one of the central features of CRPS, is a subjective experience, which can be influenced
by culture, memory of past pain experiences, personality type, affective state and other
functional variables. To address these complexities, an orderly interdisciplinary approach is
consistently recommended in the literature.
The CPRS Treatment Guidelines note that
treatment must simultaneously address the medical, psychological and social aspects of the
syndrome.
Functional Restoration
Functional restoration has historically been considered a critical and necessary component of
interdisciplinary pain management for CRPS. Functional restoration emphasizes physical
activity, desensitization and normalization of sympathetic tone. This involves progression from
the most gentle, least invasive interventions to the ideal of complete rehabilitation in all aspects
of the patients’ life. Many patients experience movement phobia (kinesiophobia). This fear of
pain can lead to avoidance of any and all activities, which can ultimately result in increased
disability.
Physical Therapy:
The physical therapist can help patients increase their range of motion, flexibility, and later
strength, through the use of gentle progressive exercise.
Gait training can also improve
functional abilities. PT activities should be done within the bounds of the patients’ tolerance as
aggressive therapy can trigger extreme pain, edema, distress and fatigue. Likewise, prolonged
periods of inactivity can also aggravate CRPS. The goal is to find and maintain a “happy
medium” which will promote steady functional gains and minimize setbacks due to pain.
Aqua therapy:
Pool therapy has been shown to be very beneficial in treating CRPS. The hydrostatic pressures
realized under water provide a mild compressive force around the affected extremity and may
help to reduce edema. The effect of buoyancy allows for weight bearing and facilitates early
restoration of functional activities such as walking. The water environment also adds resistance
without adding full stress/weight to the joints. Temperature extremes should be avoided as
water that is excessively cold or hot can exacerbate symptoms.
Because nearly all land
exercises can be adapted to the water, aqua therapy can lay the groundwork for ultimate
transition to full weight bearing activities.
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Recreational Therapy:
The recreational therapist is frequently the first clinician to succeed in getting the patient with
CRPS to increase their movement, a primary goal of successful treatment. Overcoming fear of
movement (kinesiophobia) to again participate in prior and/or new recreational activities can
help to reestablish the individuals’ sense of freedom to determine their own leisure lifestyle
choices. In addition, the increased social contact can increase their chance of remaining active
in the community after treatment concludes.
Optimally, the therapy team members should communicate and coordinate their treatment goals
so that they reinforce and compliment each of the involved disciplines.
Pharmacotherapy and other treatments
Pharmacotherapy, as with most chronic pain syndromes, achieves the greatest results when
prescribed in conjunction with functional restoration and an interdisciplinary treatment approach.
Various opioids and adjuvant medications have been used in the treatment of CRPS. Adjuvant
medications include anticonvulsants, antidepressants, NSAIDs, corticosteroids and topical
compound creams. Intrathecal delivery of medications may also be effective in certain cases
where intolerable side effects occur with high doses of opioids.
Sympathetic nerve blocks
performed under fluoroscopic guidance can also be beneficial in reducing pain associated with
CRPS. Surgical sympathectomy (interruption of the affected portion of the nervous system)
remains a procedure of last resort and as results can be varied, some controversy remains with
regards to its overall effectiveness.
Spinal Cord Stimulation (SCS) for Chronic Pain
Neuromodulation refers to modifying or adjusting functions of the nervous system. This can be
accomplished by using pharmacological agents (medications), introducing electrical stimulation
(SCS) or both to interrupt normal nerve pathways and alter our perception of pain. According to
the North American Neuromodulation Society (NANS), neuromodulation provides a reversible
alteration of the nervous system as the therapeutic effects cease when the unit is turned off.
Other procedures such as those that cut, destroy or resect create permanent changes to
structures (13)
The Gate Control Theory of Pain considers the entire pain experience (including psychological
factors) and explains it on a physiological level. Normally, pain messages flow along peripheral
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nerve fibers to the spinal cord and proceed to the brain. In the spinal cord there are “nerve
gates” that can inhibit (close) or facilitate (open) nerve impulses traveling from the body to the
brain. When the brain receives pain messages, it associates the message with an emotional
experience and then processes it. The emotional aspect of pain is a person’s response to
thoughts about the pain. If you believe the pain is a serious threat (thoughts), then emotional
responses may include fear, depression, or anxiety. Conversely, if you believe the pain is not a
threat, then the emotional response is more negligible. Consider how we feel after a vigorous
workout. The day afterword, we may be grimacing, moaning, moving slowly, and demonstrating
other pain behaviors, but our thoughts about the pain are positive (“Boy, what a great workout”).
Even though pain behaviors may be similar, the emotional response can be quite different with
chronic pain.
Our perception of the resulting sensation therefore, has both physical and
emotional components. Thus, the nerve gates are influenced by a number of factors including
the size of the fibers carrying the message and information or “instructions” traveling down from
the brain about our pain experience. (10-16)
The dorsal column runs the entire length of the spinal cord and is the portion of the cord
responsible for transporting sensory input from the body to the brain. A mass of gelatinous grey
matter (Substantia gelatinosa) sits posterior along the outer surface of the dorsal column and
specializes in the transmission of painful sensory information. In 1967, Shealy theorized that
sustained electrical stimulation of the nerve fibers in the dorsal columns (dorsal column
stimulation) would keep the gate closed at the point where the message entered the cord; thus
preventing the message from reaching the brain and allowing continuous pain relief. When a
spinal cord stimulator is turned on, instead of feeling pain, the patient feels a sensation of
numbness or mild tingling referred to as paresthesia. (10, 11)
Future Care Considerations with SCS include adjustments in the parameters of electrical
stimulation. Device reprogramming is necessary at regular intervals, as is periodic monitoring to
maintain and maximize pain relief.
An ongoing multidisciplinary treatment approach is
recommended and provides effective tools for long-term management. Although device battery
life has greatly improved with the addition of rechargeable units, they do not last forever.
Replacement frequency is dependent on the type of device implanted.
The interaction with sources of strong electromagnetic interference (e.g., MRI, Radio Frequency
Ablation, defibrillation, therapeutic ultrasound) cannot only damage an implanted device, it can
29 of 32
cause tissue injury. Patients are given an ID card as implanted devices are likely to set off
airport metal detectors. Contact with anti-theft devices (such as those in retail stores) may
temporarily alter function, increasing or decreasing stimulation. These devices are considered
safe around normal household equipment, such as cell or portable phones, computers, TV’s,
microwaves and other appliances and typically do not pose problems.
Ms. Brown has
experienced delayed healing and nonunion after the initial injury and also after her ankle fusion.
Her ability to use both a spinal cord stimulator along with a lower extremity bone growth
stimulator (should she require it after a future fusion) will be dependent on the compatibility of
the specific devices and physician clearance. Per Dr. Revere, concomitant use of these devices
may require one of the devices to be turned off while the other is in use and vice versa.
Comments / Conclusions
Ms Brown is a 69-year-old woman who sustained a left ankle fracture subsequent to a 3/3/20xx
motor vehicle accident. She has experienced delayed healing and developed advanced
degenerative changes in the left ankle joint. This necessitated a tibial-talar joint fusion that also
noted delayed healing. Ms. Brown has experienced chronic edema in the left ankle region and
persistent pain that continues to limit her activities. Ms. Brown reports a tendency for her left
ankle to “roll” outward and appears to have caused a left ankle sprain post fusion. In addition,
poor balance has contributed to several falls resulting in minor injuries to date.
Dr. Jefferson testified that she anticipates additional surgery to remove the existing left ankle
hardware.
She also indicated that ultimately, additional joint fusions would be required to
manage chronic pain associated with traumatic arthritis. Dr. Revere has recently diagnosed Ms.
Brown with CRPS in her left lower extremity. If transdermal creams do not adequately control
her pain, he has recommended a SCS along with aggressive physical therapy for functional
restoration and psychological care. Recommendations for Ms. Brown’s anticipated future care
are provided on the attached spreadsheets. These recommendations as well as the opinions
provided within this report are made with a reasonable degree of Life Care Planning certainty.
Patricia Rapson, RN, CCM, CNLCP, CLCP, CBIS, MSCC
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References
1. Duetsch, Paul M. A Guide to Rehabilitation. Ahab Press. White Plains, NY, 2002.
2. Weed, R., Berens, D. Life Care Planning and Case Management Handbook, Third Edition.
CRC Press, Boca Raton, FL, 2010
3. North American Nursing Diagnosis Association. Nursing Diagnoses 20xx-2011: Definitions
and Classification
4. Sparks S, Taylor C. Nursing Diagnosis Reference Manual: Eighth Edition. Wolters Kluwer
Health / Lippincott Williams & Wilkins 2011.
5. Nanda R, Scott S, Rangan A. Bi-Malleolar Ankle Fractures: Functional Outcome at Seven
Years (Mean) Following Operative Fixation. J Bone Joint Surg – British Volume, Vol 88-B,
Issue SUPP_1, 165
6. Thomas R, Daniels TR, Parker K. Gait analysis and functional outcomes following ankle
arthrodesis for isolated ankle arthritis. J Bone Joint Surg Am 2006 Mar; 88(3):526-35.
7. Raikin S, Myerson M. Complications of Total Ankle Replacement. The Institute for Foot
and Ankle Reconstruction at Mercy – Research and Publications. Jan, 2003. Retrieved
December 2011 http://footandankle.mdmercy.com/research_pubs/pressItem81.html
8. Equinus. American College of Foot and Ankle Surgeons. www.foothealthfacts.org.
Retrieved December 2011.
9. Prager J., RSD Advisory – Where Chronic Pain & Depression Collide: New Rechargeable
SCS Systems Offer Advantages in CRPS Treatment.
www.rsdadvisory.wordpress.com/new-rechargeable-scs-systems-offer-advantages-in-crpstreatment/ . Retrieved September 2011.
10. Pinzon E, Spinal Cord Stimulation: An overview and case study of spinal cord (dorsal
column) stimulation in a spine-centered/orthopaedic clinical practice setting. Practical PAIN
MANAGEMENT, May/June 2005
http://gsm.utmck.edu/surg_rehab/documents/pinzon6_PPM_MayJune05.pdf
11. Deardorff W, Psychological Management of Chronic Pain. ContinuingEdCourses.Net,Inc.
2004-2011 http://www.continuingedcourses.net/active/courses/course016.php
12. Saranita J, Childs D, Saranita A., Spinal Cord Stimulation in the Treatment of Complex
Regional Pain Syndrome (CRPS) of the Lower Extremity: A Case Report. The Journal of
Foot & Ankle Surgery, 48(1):52-55, 20xx
13. International Neuromodulation Society (INS). www.neuromodulation.com
14. Davies P, Spinal Cord Stimulation – The “Pain Pacemaker”
(http://mypainspecialist.com/wordpress/?p=41 )
15. North American Neuromodulation Society (NANS) (www.neuromodulation.org)
16. Gildenberg P, History of Electrical neuromodulation for Chronic Pain. Pain Medicine, Vol. 7
(S1) 2006 (http://www.sld.cu/galerias/pdf/sitios/rehabilitacionfis/history_of_electrical_neuromodulation_for_chronic_pain.pdf)
17. Pain Intensity Instruments. National Institutes of Health Warren Grant Magnuson Clinical
Center. 2003. Retrieved December 2011
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18. Osteoarthritis of the Ankle. Skill Builders Rehabilitation Center, 20xx.
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19. Iskyan K, Ankle Fracture in Emergency Medicine. Medscape updated Feb 2, 2010.
www.medscape.com Retrieved December 2011.
20. Truumees E. How do Topical Drugs Reduce Back and Neck Pain? Spine Universe
Updated 3/2/2010. www.spineuniverse.com. Retrieved December 2011.
21. Hyatt, K. (2010). Overview of complex regional pain syndrome and recent management
using spinal cord stimulation. AANA Journal, 78(3), 208-212. Retrieved from EBSCOhost.
22. Crepitation. (2011). Merriam-Webster Dictionary. www.merriam-webster.com/medical
Retrieved September 2011.
23. Allodynia. (2011). Merriam-Webster Dictionary. www.merriam-webster.com/medical
Retrieved September 2011.
24. Hyperpathia. (2011). Merriam-Webster Dictionary. www.merriam-webster.com/medical
Retrieved September 2011.
25. Cognitive Behavioral Therapy (CBT). (2011). Mayo Clinic.
www.mayoclinic.com/health/cognitive-behavioral-therapy/MY00194 Retrieved September
2011.
26. Wallace, M., & Backonja, M. (2011). Neuropathic pain syndromes: New localized
therapeutic options. American Academy Of Pain Management.
www.aapainmanage.org/education/EducationLit/neuropathic%20monograph.pdf Retrieved
September 2011.
27. Ackley, B., & Ladwig, G. (2011). Nursing Diagnosis Handbook: An Evidence-based Guide to
Planning Care. (9th ed.). Mosby. ISBN: 978-0-0323-07150-5
28. Complex Regional Pain Syndrome Fact Sheet. National Institute of Neurological Disorders
and Stroke. National Institutes of Health. NIH Publication No. 04-4173. Updated April 12,
2011
29. Complex Regional Pain Syndrome: Treatment Guidelines. Reflex Sympathetic Dystrophy
Syndrome Association June 2006
30. Hooshmand H, Hashmi M. Complex Regional Pain Syndrome, Reflex Sympathetic
Dystrophy Syndrome Diagnosis and Therapy – A Review of 824 Patients. Pain Digest 1999
9:1-24
31. Prager J., RSD Advisory – Where Chronic Pain & Depression Collide: New Rechargeable
SCS Systems Offer Advantages in CRPS Treatment.
www.rsdadvisory.wordpress.com/new-rechargeable-scs-systems-offer-advantages-in-crpstreatment/ . Retrieved September 2011.
32. Physio-Stim: Questions & Answers. Orthofix 2005. www.orthofix.com. Retrieved
December 2011.
32 of 32
Paula Brown
Report Date: 12/21/11
Life Care Plan- Financial
Recommendation
PHYSICIAN
EVALUATIONS
Orthopedic Surgeon
Pain Management
Pain Management
(Additional)
Purpose
Frequency
Ongoing monitoring
8-16 x over
and management of
LE
left ankle condition
Monitors and adjusts
2x/year
SCS settings
Periodic additional
visits for
12-20x over
exacerbation and
LE
during initial SCS
stabilization
Physical Medicine &
Rehabilitation
Ongoing monitoring
and management of
left ankle condition
relative to functional
rehabilitation and
pain management
2-4x/year
Physical Medicine &
Rehabilitation
(Additional)
Additional visits to
accommodate
increased visit
frequency during
initial stabilization
with SCS and for
exacerbations
6-8x over LE
Provided as part of
Psychiatrist Evaluation assessment for SCS 1x over LE
appropriateness
For ongoing
medication
Psychiatrist
1-4x/year
management and
assessment
For medication
Psychiatrist
12-18x over
management and
(Additional)
LE
assessment
Provides
Psychologist
(CBT,
psychotherapy for
biofeedback, relaxation
72-192x over
management and
24-48 visits annually for
LE
coping of chronic
3-4 years)
pain and depression
THERAPY
DIAGNOSTICS
Physical Therapy
Functional restoration
to increase ROM,
12-24x over
flexibility, strength,
LE
endurance
Aquatic Therapy
Functional restoration
to increase ROM,
12-24x over
flexibility, strength,
LE
endurance
Recreational Therapy
Provides education
and assistance
4-6x over LE
regarding community
and leisure activities
Standard Bloodwork
(CBC, Chem Panel)
CT Scan
(Left Ankle/Foot)
Bone Scan
Ankle)
Bone Density
X-Ray
(Left Ankle)
(Left
Routine monitoring
due to ongoing
medication usage
Annual Cost
(Low End)
# of Yrs
Annual Cost
(High End)
Annual Cost
(Mean)
Annual
Recurring
Intermittent or
Expenses Over One-Time Costs
Lifetime
$161-$203
1
$
1,288.00
$
3,248.00
$
-
$
$111-$161
17
$
222.00
$
322.00
$
272.00
$
-
$111-$161
1
$
1,332.00
$
3,220.00
$
-
$
$111-$161
17
$
222.00
$
644.00
$
433.00
$
$111-$161
1
$
666.00
$
1,288.00
$
-
$
$258
1
$
258.00
$
258.00
$
-
$
$140-$179
17
$
140.00
$
716.00
$
428.00
$
$140-$179
1
$
1,680.00
$
3,222.00
$
-
$
-
$
2,451.00
$121-$155
1
$
8,712.00
$
29,760.00
$
-
$
-
$
19,236.00
$118-$129
1
$
1,416.00
$
3,096.00
$
-
$
-
$
2,256.00
$158-$236
1
$
1,896.00
$
5,664.00
$
-
$
-
$
3,780.00
$40-$80
1
$
160.00
$
480.00
$
-
$
-
$
320.00
$125
17
$
125.00
$
250.00
$
187.50
$
$
-
$1,129$1,578
1
$
2,258.00
$
4,734.00
$
-
$
-
$
3,496.00
$661-$934
1
$
661.00
$
2,802.00
$
-
$
-
$
1,731.50
$163
1
$
163.00
$
489.00
$
-
$
-
$
326.00
1
$
198.00
$
448.00
$
-
$
-
$
323.00
1
$
46.00
$
165.00
$
-
$
-
$
105.50
1
$
1,099.00
$
5,548.00
$
-
$
-
$
3,323.50
1
$
1,155.00
$
3,104.00
$
-
$
-
$
2,129.50
1
$
2,399.00
$
3,499.00
$
-
$
-
$
1 2,949.00
4,624.00
-
7,361.00
$
$
$
2,268.00
-
2,276.00
$
-
-
$
977.00
-
$
258.00
$
-
7,276.00
1-2x/year
Ongoing assessment
and monitoring of left 2-3x over LE
foot/ankle
To monitor for
changes related to
CRPS
To monitor for
changes related to
CRPS
Cost/Unit
(Range)
3,187.50
1-3x over LE
1-3x over LE
Periodic reevaluation
of left ankle fracture / 2-4x over LE
fusion
$99-$112
Facilitates safe
independent mobility
EQUIPMENT
2-3x over LE
at home and in the
community
$23-$55
Facilitates
independent
Scooter
1-2x over LE
community mobility
$1,099with aging
$2,774
To maintain function 15-16x over
Scooter Maintenance
of scooter
LE
$77-$194
Facilitates
independent
EQUIPMENT
Scooter vehicle Lift
1x over LE
community mobility
$2,399with
aging
$3,499
Costs based upon actual expenses & TX U&C general liability pricing guidelines for specific geographical region.
Cane
(Single Tip)
Paula Brown
Report Date: 12/21/11
Life Care Plan- Financial
Recommendation
Purpose
Frequency
Scooter Vehicle Lift
Maintenance
to maintain function
of scooter vehicle lift
16x over LE
Compression Stocking Worn daily to control
(2 pairs)
/ minimize swelling
Custom Left Shoe
Orthotic
Roll-A-Bout
Roll-A-Bout Personal
Bag
EQUIPMENT
MEDICAL
PROCEDURES
SURGERY
SURGERY
facilitates safe
ambulation with
annually
impaired ankle ROM
Facilitates
appropriate foot
Every 2-3
positioning and
years over LE
reduces ankle rolling
Allows community
mobility without the
1-2x over LE
need for left ankle
weight bearing
To carry personal
every 2-3
items during use with
years
Roll-A-Bout
Stair Lift
(If
Ms. Brannon is no
Facilitates safe stair
longer in her 2-story
mobility with aging
condo, this item would
be removed)
Used to power the
AAA Batteries
handheld SCS
(12/pack per year)
programmer
Facilitates
compliance by
Pill Organizer
organizing daily
medications
Promotes safe
Shower Seat
independent bathing
Hand held showerhead
Promotes safe
with Anti-Scald
independent bathing
protection
4-8 Grab Bars
(price includes
Permanent
installation - This item
placement in
should be removed if
showers and toilets
permanent grab bars
to promote safety
currently exist)
Routine
reprogramming to
Spinal Cord Stimulator
monitor response
Reprogramming
and maintain optimal
pain relief
Provides relief of
Sympathetic Nerve
chronic pain and aids
Block
in confirming CRPS
diagnosis
Spinal Cord Stimulator
Provided initially to
Trial
determine
(Includes Facility Fee,
effectiveness of
Surgeon Fee,
implanted SCS
Anesthesia)
Spinal Cord Stimulator
Recommended by
Permanent Placement
Dr. Paily for long(Includes Facility Fee, term management of
Surgeon Fee,
pain associated with
Anesthesia, Hardware)
CRPS
to assist with
Post-Surgical Support
activities of daily
Care
living after surgery
to assist with
Post-Surgical Support
activities of daily
Care
living after surgery
to assist with
Post-Surgical Support
activities of daily
Care
living after surgery
Spinal Cord Stimulator
Recommended by
Replacement
Dr. Paily for long(Includes Facility Fee, term management of
Surgeon Fee,
pain associated with
Anesthesia, Hardware)
CRPS
to assist with
Post-Surgical Support
activities of daily
Care
living after surgery
to assist with
Post-Surgical Support
activities of daily
Care
living after surgery
# of Yrs
Annual Cost
(High End)
Annual Cost
(Mean)
$168-$245
1
$
2,688.00
$
3,920.00
$
-
$
$62-$105
17
$
186.00
$
420.00
$
303.00
$
$102-$270
1
$
102.00
$
540.00
$
-
$
$115-$120
17
$
115.00
$
120.00
$
117.50
$
$90-$439
17
$
30.00
$
220.00
$
125.00
$
$499-$650
1
$
449.00
$
1,300.00
$
-
$
$13-$20
17
$
4.00
$
10.00
$
$1,895$3,049
1
$
1,895.00
$
3,049.00
$
$4-$13
17
$
4.00
$
13.00
$
$2-$6
17
$
1.00
$
6.00
$43-$50
17
$
9.00
$
$42-$62
17
$
8.00
$143-$359
1
$
$155
17
$1,655
-
$
3,304.00
3-4x/year
Provided as part of
High Top Walking Boot
post-surgical
1-2x over LE
(Tall Bledsoe Boot)
recovery to stabilize
ankle joint post fusion
Rocker Soled Shoes
Annual Cost
(Low End)
Annual
Recurring
Intermittent or
Expenses Over One-Time Costs
Lifetime
Cost/Unit
(Range)
$
-
$
321.00
1,997.50
$
-
2,125.00
$
-
-
$
874.50
$
119.00
$
-
$
-
$
8.50
$
144.50
$
-
$
3.50
$
59.50
$
-
13.00
$
11.00
$
187.00
$
-
$
16.00
$
12.00
$
204.00
$
-
143.00
$
359.00
$
-
$
-
$
251.00
$
310.00
$
310.00
$
310.00
$
$
-
1
$
1,655.00
$
4,965.00
$
-
$
-
$
3,310.00
$9,283
1
$
9,283.00
$
9,283.00
$
-
$
-
$
9,283.00
$38,515
1
$
38,515.00
$
38,515.00
$
-
$
-
$
38,515.00
$720
1
$
720.00
$
720.00
$
-
$
-
$
720.00
$480
1
$
480.00
$
480.00
$
-
$
-
$
480.00
$560
1
$
560.00
$
560.00
$
-
$
-
$
560.00
$35,505
1
$
-
$
35,505.00
$
-
$
-
$
17,752.50
$0-$720
1
$
-
$
720.00
$
-
$
-
$
360.00
$0-$480
1
$
-
$
480.00
$
-
$
-
$
7.00
5,151.00
-
1x over LE
-
2,472.00
annually
every 1-2
years
every 4-5
years
every 4-5
years
1x over LE
2x/year
5,270.00
1-3x over LE
1x over LE
1x over LE
12 hours/day
for 3 days
6 hours/day
for 4 days
4 hours/day
for 7 days
0-1x over LE
12 hours/day
for 3 days
6 hours/day
for 4 days
Costs based upon actual expenses & TX U&C general liability pricing guidelines for specific geographical region.
2
240.00
Paula Brown
Report Date: 12/21/11
Life Care Plan- Financial
Recommendation
Purpose
Frequency
Post-Surgical Support
Care
to assist with
activities of daily
living after surgery
4 hours/day
for 7 days
Hardware Removal
Recommended by
(Includes Facility Fee,
Dr. Fukuda to
Surgeon Fee, Assistant
improve functional
Fee, Anesthesia,
status and decrease
Hardware, Equipments,
pain
Pre-Op & Post-Op Care)
Post-Surgical Physical
Therapy
Post-Surgical Support
Care
Post-Surgical Support
Care
Post-Surgical Support
Care
SURGERY
Post-Surgical Support
Care
Post-Surgical Aquatic
Therapy
Post-Surgical Physical
Therapy
to assist with
activities of daily
living after surgery
to assist with
activities of daily
living after surgery
to assist with
activities of daily
living after surgery
to assist with
activities of daily
living after surgery
Facilitates functional
restoration
Facilitates functional
restoration
Transtarsal Fusion
Recommended by
(Includes Facility Fee,
Dr. Fukuda to
Surgeon Fee, Assistant improve functional
Fee, Anesthesia,
status and decrease
Hardware, Equipments, ongoing pain related
Pre-Op & Post-Op Care) to traumatic arthritis
Post-Surgical Support
Care
Post-Surgical Support
Care
Post-Surgical Support
Care
Post-Surgical Support
Care
Post-Surgical Aquatic
Therapy
Post-Surgical Physical
Therapy
MEDICATION
MEDICATION
Ibuprofen 800mg
(Motrin) Tablets
to assist with
activities of daily
living after surgery
to assist with
activities of daily
living after surgery
to assist with
activities of daily
living after surgery
to assist with
activities of daily
living after surgery
Facilitates functional
restoration
Facilitates functional
restoration
Treatment of
depression and
anxiety
Treatment of
moderate to severe
pain
Diazepam 10mg
(Valium) Tablets
Periodic use to
manage anxiety
Lidocaine 2%, Prilocaine
2%, Topirmate 2.5%,
Transdermal cream
Meloxicam 0.09%
applied locally for
Transdermal cream
neuropathic pain
apply up to 4 grams, 4x
daily (16grams/day)
Zolpidem 10mg
(Ambien) Tablets
Periodic use to
facilitate effective
sleep
Annual Cost
(Low End)
$0-$560
1
$
$7,575
1
$
$138
1
$14,188
-
Annual Cost
(High End)
Annual Cost
(Mean)
Annual
Recurring
Intermittent or
Expenses Over One-Time Costs
Lifetime
$
560.00
$
-
$
-
$
280.00
7,575.00
$
7,575.00
$
-
$
-
$
7,575.00
$
1,104.00
$
2,484.00
$
-
$
-
$
1,794.00
1
$
14,188.00
$
14,188.00
$
-
$
-
$
14,188.00
$3,360
1
$
3,360.00
$
3,360.00
$
-
$
-
$
3,360.00
$960
1
$
960.00
$
960.00
$
-
$
-
$
960.00
$360
1
$
360.00
$
360.00
$
-
$
-
$
360.00
1x over LE
24 hours/day
for 7 days
12 hours/day
for 4 days
6 hours/day
for 3 days
4 hours/day
for 14 days
8-18x over LE
8-18x over LE
$1,120
1
$
1,120.00
$
1,120.00
$
-
$
-
$
1,120.00
$158-$236
1
$
1,264.00
$
4,248.00
$
-
$
-
$
2,756.00
$134-$205
1
$
1,072.00
$
3,690.00
$
-
$
-
$
2,381.00
$15,047
1
$
15,047.00
$
15,047.00
$
-
$
-
$
15,047.00
$3,360
1
$
3,360.00
$
3,360.00
$
-
$
-
$
3,360.00
$960
1
$
960.00
$
960.00
$
-
$
-
$
960.00
$360
1
$
360.00
$
360.00
$
-
$
-
$
360.00
$1,120
1
$
1,120.00
$
1,120.00
$
-
$
-
$
1,120.00
$158-$236
1
$
1,264.00
$
4,248.00
$
-
$
-
$
2,756.00
$134-$205
1
$
1,072.00
$
3,690.00
$
-
$
-
$
2,381.00
$17
17
$
68.00
$
68.00
$
68.00
$
1,156.00
$
-
$95
17
$
1,140.00
$
1,140.00
$
1,140.00
$
19,380.00
$
-
$25
17
$
300.00
$
300.00
$
300.00
$
5,100.00
$
-
$9
17
$
36.00
$
36.00
$
36.00
$
612.00
$
-
$508
17
$
6,060.00
$
6,060.00
$
6,060.00
$
103,020.00
$
-
$216
17
$
864.00
$
864.00
$
864.00
$
14,688.00
$
-
$
145,907.00
$
250,279.00
$
10,686.00
$
181,662.00
$
1x over LE
24 hours/day
for 7 days
12 hours/day
for 4 days
6 hours/day
for 3 days
4 hours/day
for 14 days
8-18x over LE
8-18x over LE
Anti-inflammatory for
PRN
mild to moderate pain 90, 4x/year
Venlafaxine 37.5mg
(Effexor)
Tablets
Hydrocodone/APAP
10-650mg
(Lorcet) Tablets
# of Yrs
1x over LE
Facilitates functional
8-18x over LE
restoration
Subtalar Fusion
Recommended by
(Includes Facility Fee,
Dr. Fukuda to
Surgeon Fee, Assistant improve functional
Fee, Anesthesia,
status and decrease
Hardware, Equipments, ongoing pain related
Pre-Op & Post-Op Care) to traumatic arthritis
Cost/Unit
(Range)
QD
30/month
TID
90/month
PRN
30, 4x/year
PRN
408gm/
month
PRN
30, 4x/year
Total Projected Costs
Costs based upon actual expenses & TX U&C general liability pricing guidelines for specific geographical region.
187,407.00
3
Paula Brown
Report Date: 12/21/11
Life Care Plan- Financial
Recommendation
Purpose
Frequency
Cost/Unit
(Range)
# of Yrs
Annual Cost
(Low End)
Annual Cost
(High End)
Annual Cost
(Mean)
Total Annual
Cost (mean)
Total Projected
Lifetime Expenses
Costs based upon actual expenses & TX U&C general liability pricing guidelines for specific geographical region.
$
Annual
Recurring
Intermittent or
Expenses Over One-Time Costs
Lifetime
Estimated
Estimated
Annual
Intermittent
Recurring
or One-Time
Expenses
Expenses
Over Lifetime Over Lifetime
369,069.00
4
µ
Howland Health Consulting, Inc.
Wendie A. Howland RN MN CRRN CCM CNLCP
Life Care Planning
Case Management Services
Life Care Plan
Report Date:
Name:
Date of Birth:
Date of Referral:
Customer Name:
Medical Diagnoses:
Date of Injury:
Mary Doe
, 1983
Jones Law Firm
42% total body surface area burns
• Face and ears: superficial, partial-thickness,
and deep partial-thickness
• Posterior thighs and buttocks: deep partialthickness and full-thickness
• Anterior thighs, superficial, partialthickness, and deep partial-thickness
• Chest: superficial and partial-thickness
• Hands: deep partial-thickness and fullthickness
, 2008
866-604-9055  fax 915-990-1367  www.howlandhealthconsulting.com
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Mary Doe
, 2010
INTRODUCTION
A Life Care Plan is a tool for estimating medical and non-medical needs of a person with a catastrophic injury or chronic illness over an estimated life span. It is a dynamic document based
upon published standards of practice, comprehensive assessment, data analysis and research. A
Plan may include medical needs and costs, future projections, and a vocational assessment. The
contents may be comprehensive or modified, based on the needs of the party making the request.
This Life Care Plan is not generalized for burns; it addresses the author’s best nursing assessment of Ms. Doe’s specific health status and needs. The assessment includes collecting subjective and objective data from observations, examinations, interviews, and written records. The
Plan follows the nursing process to develop a goal-oriented plan of care as defined in the Nurse
Practice Act.
All prices included in the Plan are based on today’s dollars and are obtained from suppliers, facilities, pharmacies, vendors, and providers. Shipping is included in costs if the product is unavailable in the local area. Equipment maintenance varies with individual needs and frequency of
equipment use. Costs do not reflect inflationary trends of the health care industry. Allowances
for inflation and any medical care cost trends should be determined by a qualified Economist.
This Plan cannot guarantee absence of errors and omissions, nor can it guarantee optimal outcomes with suggested interventions. The plan provides a guideline for optimizing the client’s rehabilitation to prevent possible complications. Implementation of this plan cannot guarantee the
absence of complications, predict with certainty the client’s future needs, or guarantee all costs
related to the client’s future medical and care needs. The author reserves the right to modify it if
new information is received.
The Life Care Plan should be reviewed and updated by the author every 6 to 12 months. It does
not include a vocational assessment to address loss of income. A qualified vocational counselor
should be consulted for this purpose. Finally, the Plan includes recommendations for continuing
medical case management services to coordinate cost-effective medical care and address recommended equipment needs.
3
Mary Doe
, 2010
RECORDS REVIEWED
Approximately 4500 pages of medical records, medical billing, photographs, and other reports
were received. All records received were reviewed.
Past Medical History and Summary of Care
Ms. Doe was 25 years old when she sustained extensive burns on April 12, 2008 in an explosion
and fire at a house in Town, ST. She and her friend, who was also burned, were thrown to the
ground outside the back door, landing in a yard described as containing a large amount of dog
feces from pets in the home. They drove to the nearest emergency room, County Memorial Hospital.
Ms. Doe had partial- and full-thickness burns on her face, head, ears, hands, back, buttocks, and
thighs, totaling 45% total body surface area (TBSA), a major burn injury. Her chest, abdomen
and lower legs were spared. She was sedated and paralyzed for long-term respiratory support
since she had signs of being at high risk for pulmonary injury, e.g., facial burns, scorched hairs in
her nostrils, and soot in her mouth. She had initial fluid resuscitation and sedation, and was then
4
Mary Doe
, 2010
transported by helicopter to the Burn Intensive Care Unit at Mercy Hospital in City ST under the
care of Dr. Adams.
She underwent immediate flexible bronchoscopy, at which time no carbon, erythema, or edema
were found in her airways. The endotracheal tube was left in place for respiratory control, supplemental oxygen, and pulmonary toilet (to suction secretions).
Burns are a particularly devastating injury. Unlike many other tissue wounds, burns will not heal
if left alone. In all but the most superficial wounds, all burned tissue must be debrided (cut away)
down to healthy tissue below, often repeatedly; wounds are then covered with biological dressings (various preparations of pig or synthetic skin) until they are stabilized; grafting with more
permanent covering follows. Sometimes this is accomplished with a temporary synthetic material
that acts as a scaffold for normal tissue; the burn surgeon removes this and applies skin grafts to
the area. As scar tissue develops, parts of it too must be cut away, to allow function of the part
below it. New skin and grafted areas may be delicate, tear easily, become infected, and heal
poorly or not at all. This process can take many years to complete. Burn care involves excruciating pain for years; the psychological effects of the pain, helplessness, and disfigurement are devastating. Many burn patients say that they wish they had died rather than endure it. PTSD is
common.
At arrival at Mercy Ms. Doe had immediate wide
debridement of approximately 168 cm² of facial burn
wounds, with porcine (pig skin) graft placement, and
approximately 5200 cm² on her torso and legs, with
more porcine grafts placed. Three days later, on April
15, she had more burn wounds cut away and grafting on
both hands and elbows. On April 19, she developed a
high fever, suspicious for infection. She therefore underwent more excision of her burn wounds, on buttocks,
upper thighs, back of neck, both ears, cheek, face, and
chin. On April 23, she underwent bronchoscopy and tracheostomy, as long-term airway control would be necessary.
5
Mary Doe
, 2010
Over the next several weeks she underwent multiple excisions and grafting of the burns on her
face, neck, arms, hands, buttocks, and posterior
thighs. In mid-May, there was graft disruption and
fecal contamination of a large grafted area on her
buttocks (above) which required more excision and
new grafts. Grafts on both of her hands failed, resulting in open wounds and severe pain. These,
too, were excised, with damaged tissue cut away,
and new grafts applied.
On May 27, more than six weeks after the explosion, her face and ears were deemed ready for
grafting. Donor skin was harvested from her back and posterior scalp. This involves shaving a
thin layer of the donor skin away using a surgical plane, and placing it on the burned area. Graft
donor sites are extremely painful since the nerve endings in the skin are sliced and exposed to the
air when the plane removes the upper layer of skin, leaving an oozing open wound of extensive
size.
Burn scars hypertrophy (grow and grow) especially on areas which are normally mobile, like
face and joints; rigid hypertrophic scars distort the area and prevent normal function. Pressure
must be exerted on scars with garments or other appliances 23 out of every 24 hours for months
to years. Garments are hot and painful and can be frightening to wear. Scarring around the mouth
causes the mouth opening to shrink and become rigid (microstomia); a mouth appliance to
stretch the mouth may be included in the mask. Scarring under the chin pulls the cheeks and chin
down, distorting the appearance further. Pressure was applied to all Ms. Doe’s grafted areas with
a tight face and neck mask; this was not removed for about two weeks.
She was kept paralyzed, sedated with medication, and on a ventilator for three days to allow the
grafts to take hold. Sedation and paralysis was decreased on May 31. Plans were made for further excision and grafting to the burned areas on her legs.
On June 2, 2008, she had an initial evaluation by physical therapy and was found to have foot
drop. Foot drop can be caused by allowing the foot to relax passively, pointing the toes, while on
bed rest. This results in shortening in the Achilles tendons at the back of the leg, causing the foot
6
Mary Doe
, 2010
to point downwards in a rigid position. It is usually prevented by regular range of motion exercises to stretch the tendon and maintain normal ankle movement in conjunction with splinting in
the normal position of function. Unless this is done, standing and walking will be difficult or impossible due to pain and lack of ankle motion. Although she had had no burns on her feet and
lower legs, she was found to have foot drop so severe that she was unable to stand unassisted.
On June 2 a neuropsychologist, illegible signature, spoke with her family for the first time. It was
noted that he or she would see Ms. Doe “in the next few days” to “address deep issues of adjustment and acceptance.”
On June 4, the burn surgeon removed the temporary material from a very large area of her buttocks and thighs and applied split thickness skin grafts (STSG). The donor sites were from the
unburned skin on her legs. On the same day her physical therapist working with her hands noted
that she cried throughout her entire treatment period.
On June 5, the psychologist (signature illegible) noted that Ms. Doe was very fearful and had
poor coping skills. Plan was to “continue to address anxiety and fears and monitor progress.” No
specifics were mentioned in this note. No other psychology notes are found during the time Ms.
Doe spent in St. Elizabeth’s except one note on June 13 stating, “seen in chart review,” no
changes planned.
Over the next two weeks multiple therapy notes mention Ms. Doe’s high level or fear, resistance
to treatment, and increased scar tightness. A burn surgery team member wrote that progress was
limited by decreased willingness to participate in therapies. The therapist noted that she would
need extensive physical, occupational, and psychotherapy in a rehabilitation setting (June 11
note). No further psychological notes of assessment or supportive treatment are found in the
records available for review.
Throughout this entire admission she received nutrition by feeding tube to support the massive
caloric and protein demands needed for burn healing. This was necessary even after she was able
to take food orally, as she had difficulty in opening her mouth well enough to eat, and because
caloric requirements were greater than she could consume.
In summary, for almost ten weeks in the acute burn care unit she underwent repeated surgery to
cut away injured tissue and, later, scar tissue; place temporary biologic and other specialized
7
Mary Doe
, 2010
burn wound dressings; and apply skin grafts, some of which were complicated by infection and
had to be replaced. She wore extensive and painful pressure garments, learned that she had extensive facial and other disfigurement, limited use of her hands, was unable to speak due to her
tracheostomy, and was unable to walk normally due to foot drop. She had extensive painful occupational and physical therapy, and little psychological support.
Her physical therapist dis-
charge note documented her capabilities and needs as:
•
able to turn in bed, sit up, and stand with moderate amount of assistance
•
able to walk 10 feet of the walker and moderate assistance
•
passive range of motion in arms within normal limits except wrists and fingers, limited
•
able to oppose index, long, and ring fingers actively
•
pressure garments and wraps his arms and fingers, face mask to face and neck
•
microstomia prevention appliance to mouth as tolerated
•
flexion gloves on two hours/off two hours during the day, on at night as tolerated; when
off, splints should be on at night
•
ankle flexion about 15°
•
will require intensive inpatient rehabilitation OT, PT, and psych
Ms. Doe was discharged from Mercy on June 19, 2008 to the acute rehabilitation unit at ABC
Rehabilitation Hospital in City ST. Admission diagnoses were noted as the following:
•
extensive burn injury, status post multiple procedures and prolonged hospitalization
•
deficits in mobility and self-care
•
deconditioning
•
anxiety and adjustment issues
•
“diagnosed with posttraumatic stress disorder by psychiatrist at Mercy”
No specific mention was made of her foot drop, although this would have been considered under
mobility deficits. Plan was for physical therapy, occupational therapy, recreational therapy,
weaning off tracheostomy, psychology, dietitian consult. Note was made that she had had all her
teeth extracted three or four years previously. She has no dentures; her facial changes would
make it necessary for her to have new ones in any case.
8
Mary Doe
, 2010
Case management admission note states that Ms. Doe’s goal was to go home with her mother
and her daughters, then aged six and seven.
There is no documentation of any kind of neuropsychological evaluation, but the plan is given
as individual therapy once or twice a week for 20 to 30 minutes, estimated length of stay, six
weeks. Outcome goal, was given as “patient will report satisfactory adjustment to rehab and
medical condition.” No note is made of the patient’s own outcome goals. This note is signed by
a PhD, but the name is illegible.
Initial team conference after admission determined the following goals:
•
independent with directing self-care and burn care
•
completing self-care with moderate assistance
•
feed self with standby assistance
•
attaining neutral ankles to attain normal gait
•
independent transfers from bed to chair
•
independent walking 150 feet
•
standby assistance with handrail on steps
•
satisfactory adjustment to rehab and medical condition
Concerns noted by the team included some respiratory distress, some swallowing difficulties,
risk for infection, and contractures. Education/training needs: “Package of information related to
burns was provided to the patient for her and her family.” No mention is made of any specific
teaching related to the above concerns. No input from the patient herself is documented.
Dr. Adams notes at outpatient burn clinic visit that Ms. Doe did not wish to wear compression
garments. He wrote that she was “marginally cooperative” and “squawked” when areas that the
physician felt were well-healed were palpated. He noted that she had limited mobility in her
hands, was barely able to support herself standing, and needed aggressive therapy. Although Ms.
Doe was diagnosed with PTSD at Mercy according to records received, and it is generally accepted that PTSD will have an impact on a person’s ability to cope with stressful situations, there
is no note by this physician on any psychological concern, allowances made for the possibility,
or any consult recommendation for psychological care.
9
Mary Doe
, 2010
On June 30, 79 days post injury, it was first noted that Ms. Doe had a contact lens in her left eye.
There was concern about long-term injury to the cornea if this were not removed, and ophthalmology consult was recommended. No note was found in Mercy’s documentation regarding the
presence of the contact lens; as Ms. Doe had limited use of her hands, it is unlikely that she had
obtained and inserted it without staff knowledge. As facial burns are a known risk for ophthalmic
injury, eye examination is standard of care for any person with facial burns.
On this day also, the first note from a psychologist was found. Dr. Jefferson’s note indicates a
consult with the charge nurse, who was concerned about Ms. Doe’s resistance to removal of the
contact lens. The psychologist’s plan was to meet with the patient early the next day, before the
ophthalmology appointment, to help her process information and make an informed choice about
vision based upon physician recommendation. Ophthalmologic consult noted very poor, limited
vision in the right eye and distorted scarred cornea underneath the contact lens in the left eye.
The ophthalmologist documented that he explained that leaving the contact lens in place put her
at severe risk for blindness from infection in that eye. She stated that she understood the risk of
going blind her left eye. The ophthalmologist recommend consult with eyeglass vendors, but Ms.
Doe stated that she was afraid she would not be able to see without the contact lens and didn’t
think glasses would fit the burns on her ears, nose, and face. The psychologist did not come to
see her until late in the afternoon, after this appointment. She did not change her mind.
Subsequent case management status report on care plan indicated estimate estimated discharge
date of July 31. These notes also discuss that Ms. Doe was eager to get home. Barriers noted included need for large amount of pain medication, but that patient frequently refused this. Ms.
Doe was described as not always compliant with instructions to where compression gloves; refuses contact approval and being fitted for glasses. She was walking with a platform walker,
transferred with minimal assistance, and fed herself with some cuing. This progress note addresses no psych issues, no psychological support issues, and no behavioral issues. However,
physician note mentions weaning Seroquel (quetiapine, commonly prescribed for depression),
Klonopin (clonazepam, benzodiazepine, for anxiety and panic disorder), methadone (synthetic
opioid for pain) and Lyrica (pregabalin, for neuropathic pain),
10
Mary Doe
, 2010
The next team conference was on July 8. Goals were unchanged, with discharge planned for
July 31. Team was concerned about her ongoing resistance to some of her range of motion needs,
resistance to wearing compression garments, resistance taking out her contact lens, so they
documented that they were developing a new plan of therapy to begin the next day. This plan
was to have a neuropsychologist assess her for depression and gain insight into her rationale for
not being “completely compliant with all orders from physicians.” Spiritual care was to be involved to assess coping skills. They were to ask her if she would like a family meeting. They
also noted that she was resistant about taking pain medication, which affected her ability to take
part in all activities. Team concerns: she appeared depressed, was resistant to care and “orders,”
did not appear to understand possible long-term effects of burns, was eager to be discharged
home, and missed her family. Education and training needs were documented as addressed by the
same boilerplate of a “packet of information given to her for her family.”
It is notable that not one of these team meeting records indicate Ms. Doe’s participation, and
there is no documentation of any new insight into her rationales for her not being willing to participate in care as recommended by her team or strategies to work with this. There are no regular
notes found or referred to for any kind of psychological care, much less 20 to 30 minutes several
times a week as planned at admission. There is no note of any change in approach to assess or
address her psychological status. There are few notes from any discipline that indicate anyone
took any time to sit and listen to her fears, concerns, or goals. At this point she been in the facility for almost 4 weeks without documentation of any meaningful psychological evaluation or
support. It was clear to staff that her coping style was inadequate; this was noted often. Daily
nursing checklists consistently noted that her speech, behavior, affect, and mood and thought
processes were within normal limits; however, written nursing notes indicate significant difficulties with all of them. The tone of notes from nursing and burn clinic indicates that staff felt frustration and impatience with her.
The next psychologist note is dated July 10. It states that she had “some compliance issues
emerging lately–have added to behavior rounds as well.” She was discussed in behavioral rounds
that day, and the psychologist discussed her independently with therapists. There is mention of a
“new schedule” that was to begin the next day, “hopefully patient will increase compliance with
11
Mary Doe
, 2010
activities and schedule.” However, there is no note that the psychologist ever spoke to Ms. Doe
herself.
Over the next several days there were increasing indications that Ms. Doe was angrier, more
guarded, and upset. There was no note of implementation of any “new schedule.” She delayed or
refused several aspects of her burn care. She stated she wanted to go home and leave the hospital
without medical approval. She was “given several talks” regarding the possibilities of further
health complications including infection and contractures. They also mentioned the insurance
ramifications of leaving against medical advice, implying that insurance would deny her bill if
she left against advice. Her attending physician discontinued all her pain medication.
Discharge note dated July 14 by Dr. Washington indicates that she refused pain medications
methadone, Lyrica, and Norco (hydrocodone, synthetic opioid); however, at the end of this dictation it indicates increased doses for all of these. It appears that this is part of the admission dictation and was included in the dictation for discharge for unknown reasons. It was noted that her
ex-husband had been educated on burn care, and the team felt he was doing an adequate job. She
was being discharged home at her own insistence, and the team felt it was fairly safe without
imminent danger. It was recommended that she continue with the Lexapro (escitalopram, selective serotonin reuptake inhibitor [SSRI] for major anxiety disorder) long-term for PTSD. This
appears to be the only mention of any care specifically for PTSD. List of discharge diagnoses
included:
•
burns
•
urinary tract infection
•
tracheostomy
•
pain
•
adjustment disorder with anxiety
•
PTSD
•
corneal ulcer
•
hand and ankle contractures
The nursing discharge note indicates that the ex-husband assisted with shower and burn care effectively. Outpatient care was to begin the next day at Community Hospital in Town, ST. Ms.
12
Mary Doe
, 2010
Doe was issued size medium pressure gloves. Her ex-husband demonstrated independence with
donning gloves and splints, range of motion program, and skin care. Therapist felt she needed a
tub transfer bench at home, although there is no note of anyone obtaining one for her, and she did
not have one when I visited her in October 2010. A primary care physician is identified in Town,
ST, a Dr. Wilson. There are no records from this office. Follow-up appointment in burn clinic
was with Dr. Adams two days later. There appears to be no psychological input into this nursing
summary.
Team discharge note indicates patient met only 2 of 9 long-term goals, as she insisted on discharge home “earlier than the team recommended or anticipated.” The team “pulled together a
discharge plan,” and she went home with her ex-husband’s support. The therapist notes recommends wound and skin care supplies to go home with her. She also notes that hand range of motion significantly reduced and there is decreased balance due to foot drop requiring Ms. Doe to
walk on tiptoes. There is a note here to document medical necessity for a walker or wheelchair,
but it is not clear whether these were obtained for discharge. There are three pages of the discharge plan instructions, but they are not signed by the patient, any clinician, or dated. These
included information about Community Hospital outpatient services, names of speech, occupational and physical therapists, and date and time of OT and PT appointments. No records are
available from this facility.
There are three more notes from Mr. Burr, physician’s assistant in the burn clinic, dated July 23,
September 10, and October 15, 2008. They indicate that he had received calls from physical
therapy staff saying that Ms. Doe missed a number of appointments, which she denied. He notes
increasing contractures in her hands, notably right second and fifth fingers, and left fifth finger.
She said that they were not splinting it in therapy, and she is not aggressively exercising them.
There is no note about any deficits in her lower legs, difficulty walking, balance, or other related
problems which were noted a week before discharge. There is note that she would be referred to
plastic surgery for scar tissue in her cheek around her mouth, but no notes are found to indicate
that this referral was ever completed. This note uses the word “sternly” and “told her that unless
she was willing to comply with treatment plans in all aspects, care could be refused.” Witnesses
to this conversation are mentioned. Follow-up scheduled for two months later, but it appears that
she never returned.
13
Mary Doe
, 2010
On January 13, 2009, there is what appears to be a physician’s note, but it is not on letterhead
and has no signature. It states that she came in for preoperative history and physical, needing a
right little finger contraction release. Plan was to call directly into Mercy Hospital, surgery
should be done on by Dr. Jay on January 15. There are no records to reflect whether this was ever
done.
Three months later, April 2009, there is a note from Dr. Harrison, orthopedics, after she fell and
sprained her wrist; no fractures found on x-ray, no follow-up needed.
In March 2010, she visited a physician, no name given, dictation noted by JP. Seen for cough,
congestion, and runny nose. In June 2010, an unsigned note mentions that Dr. Truman could not
see her unless she was seen in the emergency room first in their office was on call. No appointment was made. This note is also signed by JB. Another note of the same day signed by JJS
(possibly J….. S…., MD, a primary care physician) indicates that she has had some surgical repair of contractures in her fingers in the past (in 2009?), but they have been unsuccessful in
maintaining position of function. Notes that she had pain in heel and foot with dorsal flexion of
the feet against resistance (consistent with Achilles tendon shortening). Plan was to refer to Dr.
Truman, who does upper extremity surgery. There are no further medical notes to review.
Health Care Providers
The health care providers involved in Ms. Doe’s care according to available medical records are
outlined below. At the time of discharge from ABC Rehabilitation Hospital, ongoing care was
scheduled with Dr. Adams in Mercy’s burn clinic, and with a physical therapy facility in Corning, Iowa for what was anticipated to be many years of ongoing therapies for burn scarring, contractures, and pain. It appears from records received that these were not fully realized. At the
time of our meeting at her home in Village ST on October 14, she had had no followup care of
any kind for at least 18 months.
Health Care Providers from Records
Provider
Address
County Memorial
Hospital
Town ST
Contact
Numbers
Specialty
Hospital, acute care
14
Mary Doe
, 2010
Mercy Medical
Center
D.W. Adams MD
City ST
Hospital, acute care
Mercy Medical Center, City
ST
R.N. Burr, PA
Mercy Medical Center, City
ST
M.A. Tyler MD
Mercy Medical Center, City
ST
E.T. Washington MD ABC Rehabilitation
Hospital
P. Wilson MD
City ST
M.C. Kennedy MD
M. Jackson PhD
City ST
City ST
General surgeon
Physician assistant
Colorectal surgeon
Physiatrist
Internal medicine,
family practice,
infectious disease
Ophthalmology
Clinical psychology
Help from an expert case manager, Andrew Monroe RN of the Expert CM Group, was obtained
to assist Ms. Doe in identifying and accessing continuing care for her burns and their complications. When I interviewed her Ms. Doe reported that she had no current healthcare providers because she had no money and no insurance. Mr. Monroe reported that he had been unsuccessful in
getting her seen by providers due to financial constraints, i.e., she had no insurance except Medicaid and they would not accept Medicaid patients.
Ms. Doe’s past medical history included two difficult pregnancies with premature labor, total
hysterectomy during a third pregnancy due to uterine perforation
during surgery for endometriosis, multiple urinary tract infections, chronic constipation with diarrhea, and extraction of all her
teeth. She says she was diagnosed with a blood clotting disorder
at the time of her last pregnancy and was told she should wear
support hose to decrease the risk of clots in her legs; she does not
have any. She has a family history of lupus erythematosus and is
concerned that she has some of those symptoms as well, specifically hair loss and rashes.
Ms. Doe smokes constantly, up to four or five packs per day by her estimate, depending on how
stressed she feels. She says she has had no alcohol for four or five months, and before that, it was
rarely. She eats one meal per day. She describes inability to sleep more than an hour or two at
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Mary Doe
, 2010
night due to pain, intrusive thoughts and horrible nightmares, some of which are so terrifying
that she loses control of her bladder and is afraid to try to go back to sleep. She is hypervigilant,
startling at the least sudden sound. Flames are terrifying; even the smell of burning food causes
flashbacks to the explosion and fire. She says she doesn’t think anyone can help her with her
problems; indeed, she never asked me about what I or anyone could do to help her.
When asked about pain, she said she can stand the constant pain from the burns and surgeries,
but then said, “But, oh, my feet!” She is unable to walk, sit, or stand without severe pain in her
feet and lower legs, indicating the area of the Achilles tendon. She is unable to walk normally
with the severe limits on her ankle
range of motion, so she has to turn her
feet sideways to make forward progress. This is an unstable stance. It has
caused her to develop severe pain in
both hips. It makes stairs almost impossible, so she is unable to go downstairs to the basement where the laundry is and where her children sleep.
She and her housemate note that she
has fallen several times; there is one orthopedics visit for wrist sprain after a fall. She cannot
climb into the bathtub independently or shower safely alone.
Her hands are obviously deformed and
disabled from normal use. She says she
has tried to develop workarounds for
most of what she has to do with them,
like household tasks, but is always
bumping them or getting the fingers
caught in things, producing a nearpermanent series of skin tears and shear-
16
Mary Doe
, 2010
ing injury. She cannot wash her own hair because the contracted fingers get caught in it. It is difficult or impossible to open containers and do other fine motor skills. She says she had surgery to
straighten them but they went right back to the way they were, and now she has been told she
should have them amputated because they cannot be repaired. She does not want this done.
Her eyesight is very poor. She has near-total vision loss in the right eye and sees very poorly with
the left with a contact lens. Her last eye examination was about a year and a half ago; she was
prescribed new contact lenses but never returned for them due to financial constraints. It is hard
to tell how much of her vision impairment is related to corneal damage from the fire and subsequent lack of care and how much is related to what she says is severe astigmatism. She says she
drives by fixating on the center line as it passes under the hood of her truck, but her passengers
have to describe things for her and alert her to slow or stop if needed. She says she only drives at
night “if I have to,” and does drive her children.
She is devoted to her children and bitterly regrets being unable to do things with them, such as
coach them in gymnastics (she says she was a gymnast when she was younger), play outside, or
keep up with them, as at the store or walking outside. She also regrets being unable to keep
house for them as she used to, due to pain, balance issues, and inability to use her hands well.
She describes behavior problems and outbursts from them such as “I hate you, I wish you were
never hurt!” and anger that she cannot physically do what they want her to do. She said they used
to like her to come to school to have lunch with them and participate in their activities, but now
they don’t want her to come because the other children stare at her. This is very painful for her.
She says they have had no counseling. When asked, she says that they “have someone to talk to,”
but could not tell me who that was.
CURRENT MEDICAL ISSUES
•
Severe contractures, bilateral 5th fingers and right index finger
•
PTSD, anxiety, depression, sleep deficit
•
Disturbed balance, falls
•
Chronic low blood pressure
•
Pain in hips, feet, and ankles; post-burn pain
17
Mary Doe
, 2010
•
Recurrent urinary tract infection
•
Anorexia and recurrent vomiting attributed to stress
•
Tobacco abuse, bronchitis/COPD
•
Vision loss not corrected by lenses
•
Edentulous
•
Surgical menopause
•
Chronic constipation/diarrhea
•
Thermoregulation abnormality
CURRENT MEDICATIONS
•
None
CURRENT TREATMENT PLAN
•
None. She does some range of motion exercises and her roommate “works out her back.”
VOCATIONAL
Ms. Doe earned a GED at 17. Prior to her injury, she worked in a number of unskilled jobs, as a
babysitter and at a truck stop. She says she was mostly at stay-at-home mom. Before her injury,
Ms. Doe enjoyed bowling and outdoor activities with her children. Now she is limited to reading
and sedentary video games indoors.
LIVING ARRANGEMENTS
Ms. Doe lives in a rental home with her two daughters aged 8 and 9. There are three bedrooms
on the main floor; the cellar has three beds in it for children (right), plus the laundry, water
18
Mary Doe
, 2010
heater, and furnace. Other residents
include her sister-in-law and her
children, and her friend Jamie who
was injured in the explosion with
her and was present for our interview. Ms. Doe’s former fiance is
there off and on, but she says she
has called off the engagement
pending some problems he has to
work out. He was present for part of our interview.
There are also five cats and two dogs in the household, all calm and apparently in good health. It
is noted that the care and affection given them is probably beneficial; there are many resources
citing positive stress-relief of petting a companion animal.
At the time of my visit the house was in extreme disarray, with clothes piled up on every floor,
unwashed pots, dishes and old food, full of flies, overflowing ashtrays and soda cans pressed into
service for this, broken curtain rods, and general litter and toys everywhere. She gestures to it
helplessly and says, “It never used to look like this; I used to be able to clean this up in two
hours.” She cannot descend into the cellar to do laundry; there are three stairs to the side yard
extending down to the cellar (left above) which pose a hazard to her. There is a single bathroom
with a tub-shower and a small kitchen.
19
Mary Doe
, 2010
CURRENT FUNDING AND INCOME
Ms. Doe receives $593 per month from Social Security Disability. She has no other source of
income. She is on Medicaid for her medical expenses; however, she has been unable to identify a
local physician who will see her for primary care who accepts Medicaid patients, and therefore
has no referral source for other services.
LIFE EXPECTANCY
Normal life expectancy for a 27-year-old white female is 55.4 more years, to age 81. 1 Ms. Doe
will turn 81 on 8/13/2064. Lifetime costs are projected for 55 years, although this may be optimistic given her stress, smoking and pulmonary insufficiency, risk of falls, and risky behavior
(driving). This should be revisited as her condition changes with age.
SUMMARY
Recommended Evaluations While it is understandable that addressing needs for survival is
paramount during acute hospitalization, this leaves psychological assessment and support needs
unmet. Persons with burns can be expected to exhibit signs of post-traumatic stress disorder; up
to 45% of patients with burns develop PTSD in the months and early years after injury. They are
characteristically hypervigilant, anxious, have serious sleep disturbance, and constantly relive
intrusive memories of surgeries, painful procedures, hopelessness, or other painful or frightening
events of their injury and treatment. Psychological factors are the main limiting factor above all
others in rehabilitation from this condition. Rehabilitation cannot proceed without psychiatric
care and support. Ms. Doe has been diagnosed with PTSD, but had minimal treatment in the
hospital and has none now. This is long overdue.
Ms. Doe describes a life that was hard even before her burns, with little help from anyone and
many daunting barriers and traumas. She doesn’t seem to expect much of life so hopelessness
probably feels familiar. She puts up a tough front, wary, and uncommunicative to start, but did
warm up over a few hours. She appears to find it hard to trust people. She gives the impression
that she is doing the best she can to put one foot in front of the other to do what has to be done,
especially where her children are concerned. She is very caring about making sure Jamie takes
1 National Vital Statistics Reports, Vol. 58, No. 21, June 28, 2010, http://www.cdc.gov/nchs/fastats/lifexpec.htm, table 6, retrieved
7/26/2010
20
Mary Doe
, 2010
care of herself, too. However, she explosively admits to being very stressed and looks like she’s
on the edge. Her memories of her time in the hospital are filled with pain, fear, frustrations,
hopelessness, feeling that no one was listening to her, and that nobody was interested in what she
thought or felt. We discussed that sometimes when people are in awful circumstances with little
control over what happens to them, the only control they have is to say, “No,” even if they know
they would be adversely affected by it. People with severe burns are more likely to have psychological problems if they had any before their injury. This describes her experience.
Although it is understandable that some of her behaviors may be off-putting to caregivers, seen
in context they are probably the only defenses she has. Her toughness can be her biggest asset.
While she would probably describe herself as unwilling to take help, the right providers could
help her and her children to cope with this terrible period in their lives. Therefore the plan includes provisions for psychological evaluations and counseling for her and her children to deal
with role changes, grieving, body image, disability, effective coping with ongoing and future
care, parenting skills, problem-solving, and family dynamics. Psychological care is not an optional frill in major burns; burns affect everyone in a family.
At this point it is not clear whether the burn clinic would have anything to offer Ms. Doe in term
of wound or scar care. It has been 18 months since she has seen them. One visit to determine
whether they do would be reasonable, then annual follow-up, as many burn-injured persons are
seen annually for follow up on scar maturation, contractures, and other long-term effects of burn
injury. Wound contracture may continue for some time and can become disabling due to decreased range of motion and function. This is usually treated with physical medicine techniques:
massage, therapy, splints, and so forth. Surgery may be a last resort. Again, many patients with
PTSD cannot tolerate return to inpatient care or even outpatient surgery without considerable
psychotherapy.
Painful scarring is a difficult management challenge, but can often be helped with medications
for neuropathic pain. Ms. Doe is wary of pain medication. However, consultation with a good
pain management specialist who could integrate supportive services could result in a plan of care
for some pain relief without unwanted side effects or fear of addiction.
21
Mary Doe
, 2010
Evaluation by a good physiatrist with experience in burns would be beneficial to guide further
evaluations and care for her foot and ankle pain, gait disturbance, range of motion, and physical/
occupational therapy issues.
An occupational therapist should do a home visit to determine if any modified home equipment
would be beneficial for safety and independence.
Referral to a foot and ankle specialist for evaluation of her foot and ankle pain would be appropriate. It is possible that surgical release might be necessary to restore normal mobility.
Ms. Doe has already had surgical release of the deformities in her fingers. Unfortunately, postoperative care for this requires frequent and aggressive therapy, and it was not successful. If the
damaged fingers become infected from repeated trauma, they may need to be amputated to save
the rest of the hands. A good hand plastics surgeon with experience in burns and prosthetics, not
a general orthopedist, should make this evaluation and perform the surgery if indicated, to
maximize the condition of the residual digit to help avoid wound breakdown and facilitate prosthetic fitting. If this becomes necessary or desirable, there are excellent finger prostheses available which would be cosmetically and functionally acceptable; these services are provided by an
anaplastologist and a prosthetist. This would also be helpful with body image.
Burned people may experience long-standing dermatological complications, such as ingrown
hairs and impacted (clogged) sebaceous cysts. Dermatological consultation can be helpful with
management; surgery may be needed for severe cases.
Ms. Doe has never had a complete neuropsychological examination. Most burn centers do this at
about 6 months post injury, because occult head injury consistent with the mechanism of injury
and periods of hypoxia commonly seen with burns can have long-lasting cognitive sequelae. Her
problems with balance may be partially related to inner ear damage in the explosion, for example.
Ms. Doe has never had comprehensive pulmonary function testing. This should be done to establish a baseline as accelerated pulmonary insufficiency can be expected due to her smoking his-
22
Mary Doe
, 2010
tory overlaid upon her pulmonary injury at the time of the explosion and fire. These effects often
can reveal themselves years after the initial burn.
Ms. Doe would benefit from a comprehensive ophthalmology exam to see if corneal surgery
(transplant, implant, or other) would improve her vision. If it is possible for surgery to improve
her vision, this would make her safer and more independent in many ways. A concurrent optometric examination will evaluate general vision and make recommendation for corrective
lenses if needed for safe vision. It is possible that the thought of anesthesia and surgery would be
very frightening to her and trigger serious PTSD symptoms.
Ms. Doe eats only one meal per day by her account. I was unable to tell whether that was entirely
due to anorexia, lack of teeth, financial constraints, or a combination of all, though she says one
of her housemates is a very good cook. She could benefit from a dietician consult to help with
food selection to optimize her nutrition. She also needs a dental consult to fit her with either
good dentures or evaluate her for dental implants and bridges to make eating easier. Had she had
dentures before her burn, she would need new ones now due to changes in her facial structure
from scarring.
Projected Therapeutic Modalities Ms. Doe would benefit from having regular physical and occupational therapy as prescribed by the physiatrist. Customized splints or other equipment for
home use may be indicated.
Because smoking can increase pain, especially orthopedic pain, and retard healing, a good smoking cessation plan would be appropriate. This would also benefit her children’s health and decrease the chances of fire in her home, both of obvious immediate benefit. This would likely
need to follow (i.e., not be concurrent with) care for PTSD, too.
Accelerated pulmonary insufficiency may lead to the need for supplemental oxygen, increased
levels of home care, and institutional care in later years.
Corrective lenses, either contacts or glasses, are needed now.
23
Mary Doe
, 2010
Orthotics/Prosthetics As noted, this depends on evaluation by the physiatrist and therapists. Orthotics could help relieve some of her foot and ankle symptom and improve her ability to walk
safely.
Medical Equipment A tub transfer bench is needed immediately to decrease risk of falls in the
bathroom. Modified kitchen and household tools are available for easier use by persons with
dexterity, strength, or pain in hands. A modified steering wheel, e.g., rim knobs, and a pushbutton
starter retrofit would make driving easier.
Home Furnishings Persons with burns are more susceptible to thermal injury. Any hot water
heater in the home should be set for 120 degrees F or less to prevent burns. Smoke detectors
should be present on both floors of the house. Since burn scars are painful and contribute to
sleeplessness, and are also more susceptible to pressure, a pressure-relieving surface mattress
overlay would be beneficial; a “Sleep Number” bed is included in the plan because it would not
need maintenance or replacement for 20 years and is thus more cost-effective than mattress overlays. Because she has difficulty in rising from a chair now and will have more difficulty as she
ages, a lift chair would be helpful.
Aids for Independent Function Modified kitchen and household tools are available for easier
use by persons with dexterity, strength, or pain in hands. A decorative cane to help with balance
and mobility might be more acceptable. A wheelchair has been recommended for her, at least for
community distances, but she refuses to consider this. However, a scooter might be more acceptable and would give her more freedom to be independent. Meanwhile, a keyless ignition retrofit
for her vehicle would be easier for her hands to use; adaptive handgrips for the steering wheel
will improve her grip. Accessible design switches, faucets, and door handles will be easier for
her to use. A tub transfer bench will improve bathroom safety and independence; a long-handled
bath sponge will be safer than reaching to wash her feet and legs given her balance problems and
can also be used to apply moisturizers to her grafted areas. As her mobility decreases, a raised
toilet seat would be safer; padded seat is necessary to protect the grafted areas on her buttocks.
Drug/Supply Needs
Burned skin will be always dry, prone to cracking and itching, and at risk
for secondary infection as a result. It needs frequent moisturizing because it has lost sebaceous
24
Mary Doe
, 2010
glands that make natural lubrication; this will be required life-long.2 Sunscreen is essential for
burned skin; UV-blocking clothing is available. Other medications, e.g., vitamin supplements,
vitamin D, anti-anxiety medications for PTSD, bronchodilators, or pain medications, may be indicated depending on future evaluations. Medication and supply costs are based on local suppliers when possible. Generics are used where available.
Future Routine Medical Care Routine monitoring and care from ophthalmology, orthopedics
(hand, foot and ankle), dermatology, physiatry, pulmonology, dietician, and psychology/
psychiatry/pain management are likely to be needed for many years, if not for lifetime. Dentures
are not included in this plan, although she needs them, because she was edentulous before her
injury. Routine primary care should include general health screening panels as noted; pulmonary
function testing and chest x-ray to monitor progression of lung effects of injury; bone density
examination due to decreased ability to absorb vitamin D; and annual influenza immunization
because she is at increased risk for complications. Her history suggests that four visits annually
for bronchitis exacerbation can be expected. The cost of future medical care and anticipated
complications could be decreased through continued expert coordination of medical care; case
management services by a registered nurse with expertise in burn rehabilitation are included to
coordinate care and facilitate communication between disciplines.
Potential Complications
It is quite likely that Ms. Doe will experience accelerated progression
of her pulmonary dysfunction related to her injury and smoking. As normal skin is needed to absorb Vitamin D, which is needed for bone health, she will be at increased risk for osteoporosis.
Because normal sensation is lost in burn areas, and because her hands are disabled from normal
function, Ms. Doe is at risk for injury especially in exposed areas.
Future Medical Care, Surgical Intervention, or Aggressive Treatment Based on past history, it
is reasonable to expect orthopedic surgery for hands, feet and ankles, and possibly hips. If Ms.
Doe does have one or several fingers amputated, she will need prosthetics for cosmesis and function. Pulmonary rehabilitation will be appropriate when her lung function decreases.
2
Holavanahalli RK et al, Long-term outcomes in patients surviving large burns: the skin, JBurnCareRes 31:631-639, 2010
25
Mary Doe
, 2010
Transportation Ms. Doe’s eyesight has not been tested recently but she describes considerable
limitations in vision. This plan includes costs for transportation to medical appointments and
other normal needs. If her vision cannot be corrected, this need will be life-long.
Health & Strength Maintenance The cost of future medical care and anticipated complications
could be decreased through continued expert coordination of medical care by a registered nurse
case manager with expertise in burns. Gym membership for self-directed exercise would be good
for general conditioning and stress relief. Referral to a recreational therapy program to determine
options for physical activities she can do would also benefit Ms. Doe’s mental and physical
health.
Architectural Renovations
Ms. Doe lives in a rental house now so permanent renovations are
not possible. They have not been in the house long enough to know whether heating and cooling
are adequate for safety; burned scar tissue cannot compensate for changes in environmental temperature to maintain body temperature. Adequate heating and cooling will be essential. Any
home in the future should include features of universal design, e.g., single floor layout, accessible bathroom and kitchen for safety, lever handles on doors, rocker electrical switches, no
thresholds between rooms, safe flooring surfaces, wide doors and halls to accommodate mobility
aids, access ramps, and access under cover from weather. These will all become increasingly
necessary as she ages and can be useful now due to her mobility, balance, and manipulation disabilities. Her home should also have hardwired smoke detectors with battery backup and a controlled hot-water thermostat to avoid burns. A washer/dryer that does not require outside venting
could be placed in her rental to avoid the need to go to the cellar, and could be moved with the
family.
Vocational/Educational Plan Ms. Doe formerly enjoyed being outside and active with her children and others, and worked to support them. She has depression that is made worse by her inability to participate in work and recreational activities. A vocational assessment could be helpful
to facilitate meaningful paying work for her. Educational opportunities could open some doors
for work commensurate with her physical condition.
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Mary Doe
, 2010
Note on Projected Costs
When exact costs are not available and a range given, the number used in the total is the average
within the range. Costs noted are for 90th percentile of usual and customary rates 3; contracted
rates or actual billed amounts may vary by payor.
Life Care Plan
Table of Contents
! Tables
Page
Future Routine Medical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i - iii
Recommended Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv - v
Projected Therapeutic Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
v - vi
Mobility / Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
vii
Scooter Accessories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii - viii
Orthotics / Prosthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
viii
Home Furnishings and Accessories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ix
Aids for Independent Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix - x
3
Drug/Supply Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xi
Home Care/Facility Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xii
Future Medical Care, Surgical Intervention, or Aggressive Treatment . . . . .
xii
Potential Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xiii
Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xiv
Health & Strength Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xiv
Architectural Renovations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xv
Lifetime Cost Projection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xvi
Medical Fees in the United States 2010, PMIC, Los Angeles CA. Copyright 2009, American Medical Association. ISBN: 978-
157066-612-4
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i
Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Future Medical Care: Routine / Scheduled
Routine Medical Care
Description
Primary care:
• Cardiovascular and general
medical assessment with EKG,
general health panel, urinalysis,
immunizations, bone density
exam
Burn/Plastics followup
Frequency
Nursing diagnosis:
Purpose
Cost Per Visit
Office visits:
CPT 99215 $260
CPT 99213 $115 x 4
=$460
Ineffective self-health
General health panel
management: General
CPT 80050 $207
medical followup is indicated
Urinalysis CPT 81000
Annual for life
to monitor systems that may
$30
expectancy plus four
be at higher risk for
Immunizations
episodes of care for
complications post serious
CPT 90471 $80
respiratory problems
burn, especially renal,
EKG CPT 93000 $111
pulmonary, and
Bone density evaluation
cardiovascular
CPT 77080 $463
Chest x-ray, AP & lateral
CPT 71020 $149
Pulmonary function
CPT 94010 $144
Annual for life
expectancy
Ineffective self-health
management: Evaluation
for potential surgical or
other interventions in
ensuing year; referrals to
other specialties
Office visits CPT 99215
$260
Cost Per Year
Lifetime Cost
Recommended by
$1,904
$104,720
Wendie Howland RN
MN CRRN CCM
CNLCP
$260
$14,300
Burn center
(cont.)
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ii
Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Physiatry:
• Eval for complications,
strength/ motor/
musculoskeletal &
integumentary changes,
adherence to plan, MD & case
manager, pain management,
referral to other services as
indicated
Annual for life
expectancy
Impaired physical mobility
Dermatology
Annual for life
expectancy
Impaired skin integrity,
Ineffective
thermoregulation
Dietician, for weight and
general nutritional assessment
and recommendations
Optometry / ophthalmology***
Counseling, psychiatric, 45-50
minutes, with medical
evaluation and management
services
$260
$14,300
Wendie Howland RN
MN CRRN CCM
CNLCP
CPT 99215 $251
$251
$13,805
Wendie Howland RN
MN CRRN CCM
CNLCP
Twice yearly
Risk of imbalanced
nutrition: Assessment for
adequate nutrition to
support healing, energy
requirements for ongoing
therapy, optimize weight
CPT 97802
One hour $188
$376
$20,680
Wendie Howland RN
MN CRRN CCM
CNLCP
Annual for life
expectancy
Risk for injury: Corneal
injuries with burns,
increased risk of long-term
sequelae, corrective lenses
Screening
CPT 99172 $61
Glaucoma test
CPT 92140 $133
Refractive check
CPT 92015 $99
$293
$16,115
Wendie Howland RN
MN CRRN CCM
CNLCP
Stress overload,
Compromised family
coping, Post-trauma
syndrome; risk-prone health
Depends on
behavior: Assess for
assessment
depression, PTSD,
Assume monthly for
substance abuse, body
three years, then four
image, life changes with
times yearly*
aging, parenting role
(total 244 visits)
challenges, smoking
cessation
CPT 90807 $241
$58,804
Wendie Howland RN
MN CRRN CCM
CNLCP
CPT 99215 $260
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iii
Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Counseling, psychiatric, 45-50
minutes, using play equipment,
physical devices, for 2 children
Stress overload,
Compromised family
coping, Post-trauma
syndrome; risk-prone health
Depends on
behavior: Assess for
assessment
depression, PTSD,
Assume monthly for
substance abuse, body
three years*
image, life changes with
(total 72 visits)
aging, parenting role
challenges, smoking
cessation
CPT 90814 $420
$30,240
Wendie Howland RN
MN CRRN CCM
CNLCP
Pain management
Depends on
assessment
Assume four times a
year for one year and
then twice annually
(total 112 visits)
Chronic pain, Sleep
deprivation
CPT 99215 $251
$28,112
Wendie Howland RN
MN CRRN CCM
CNLCP
8-12 hours per
month**
Ineffective self-health
management: Coordination of
care, interspecialty
communication, patient
teaching, support
10 hours @ $80 =
$800
$528,000
Wendie Howland RN
MN CRRN CCM
CNLCP
Nurse case management
$9,600
Total
$829,076
* Wiechman SA, Patterson DR, BMJ 2004, 329(7462):391–3; Fauerbach JA et al, Psychosomatic Medicine 2007 69:473-482
** Caragonne and Associates. Assessment Protocol: Case Management Support Needs, JNLCP X.3 Sept 2010
*** Medical Disability Advisor, Burns of the Eye, accessed 10/12/2010
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iv
Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Recommended Evaluations
Evaluation
Nursing Diagnosis
Neuropsychiatric evaluation, Post-trauma syndrome; Risk
four hours
for injury d/t tissue hypoxia*
Burn/plastics initial
evaluation
Base Cost
CPT 96118
$1452
Frequency
Lifetime Cost
Recommended By:
Once
$1,452
Wendie Howland RN MN CRRN
CCM CNLCP
Impaired healing
CPT 99215 $251
Once, then annual f/u
as above
$251
Wendie Howland RN MN CRRN
CCM CNLCP
Chronic pain, Sleep
deprivation
CPT 99215 $251
Once, then f/u as
indicated
$251
Wendie Howland RN MN CRRN
CCM CNLCP
Physiatry, initial evaluation
Self-care deficit
CPT 99215 $251
Once, then f/u as
above
$119
Wendie Howland RN MN CRRN
CCM CNLCP
Physical therapy/orthotics:
• Assess scar and
contracture progression,
equipment needs and
modifications (orthotics),
technology, home exercise
program, adherence to plan,
functional capacity, range of
motion
Impaired mobility
CPT 97110
One hour $112
Once, then f/u as
above
$112
Wendie Howland RN MN CRRN
CCM CNLCP
Once, then annual f/u
as above
$165
Wendie Howland RN MN CRRN
CCM CNLCP
Once, then f/u as
above
$251
Wendie Howland RN MN CRRN
CCM CNLCP
Pain management initial
evaluation
Occupational therapy:
• Evaluation for current
and future adaptive
technology for home and
work, protective hand
splints, hand therapy range
of motion if possible
Orthopedist / hand plastics
specialist
CPT 97762 $33
Self-care deficit
Self-care deficit, Impaired
tissue integrity
CPT 97755
one hour
$132
CPT 99215 $251
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v
Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Driving evaluation (visual
screen and counseling first,
then driving simulation if
vision is acceptable)
Impaired visual
perception, Impaired
mobility
Visual screening,
CPT 99172 $69
Counseling and risk
factor reduction
CPT 99402 $165
Once
$234
Wendie Howland RN MN CRRN
CCM CNLCP
Impaired skin integrity,
Ineffective
thermoregulation
CPT 99215 $251
Once, then f/u as
above
$251
Wendie Howland RN MN CRRN
CCM CNLCP
Ineffective breathing pattern
related to hypoventilation
Pulmonary function
CPT 94010 $144
Once, then annual f/u
by PCP
$144
Wendie Howland RN MN CRRN
CCM CNLCP
Optometry /
ophthalmology**
Risk for injury: Corneal
injuries with burns,
increased risk of longterm sequelae, corrective
lenses
Screening
CPT 99172 $61
Glaucoma test
CPT 92140 $133
Refractive check
CPT 92015 $99
Once, then annual f/u
as above
$293
Wendie Howland RN MN CRRN
CCM CNLCP
Dietician, for weight,
general nutritional
assessment, and
recommendations
Imbalanced nutrition, less
than body requirements
Once, then f/u as
above
$216
Wendie Howland RN MN CRRN
CCM CNLCP
Dermatology consultation
Pulmonary function test
CPT 97802
One hour $216
Total
$3,739
* Wiechman SA, Patterson DR, BMJ 2004, 329(7462):391–3; Fauerbach JA et al, Psychosomatic Medicine 2007 69:473-482
** Medical Disability Advisor, Burns of the Eye, accessed 10/12/2010
Note that results of evaluations may result in ongoing care, to be added to Routine / Scheduled care.
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vi
Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Projected Therapeutic Modalities
Therapy
Nursing
Diagnosis
Treatment
Frequency
Base Cost
Lifetime cost
To be prescribed by
Corrective lenses, annual until
age 50, then every 2 years
Impaired vision
Annual
Est. $150
$9750
Ophthalmology/optometry
Impaired mobility
CPT 97110
One half hour $56
Weekly $140 x 12 = $1680
2x/week for
x13 weeks = $21,840
three months,
then twice yearly Annual $22,064 first year
then
followup
$224 / year
$34,160
Physiatry
Self-care deficit
CPT 97110
One half hour $56
2x/week for three
Weekly $140 x 12 = $1680
months,
x13 weeks = $21,840
then 1 hour
twice yearly for Annual $22,064 first year
then
followup
$224 / year
$34,160
Physiatry
Physical therapy/orthotics:
• Monitor for scar and
contracture progression,
equipment needs and
modifications (orthotics),
technology, home exercise
program, adherence to plan,
functional capacity, range of
motion, treat as indicated
Occupational therapy:
• Monitor for changes in hand
splints; hand and arm therapy,
range of motion, treat as
indicated
Smoking cessation
Home oxygen
Total
Ineffective breathing pattern
TBD, assume
weekly for six
months
CPT 99407 $64
$1,664
PCP or pulmonology
Ineffective breathing pattern
Assume for
last ten years
of life
expectancy
$175/month for
concentrator and all
supplies
(Lincare, Lincoln NE)
= $2100 / yr
$21,000
PCP or pulmonology
$100,734
(cont.)
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Mobility/Maintenance Note: Any mobility aid should be fitted by a professional seating expert, not a vendor
Wheelchair Type
Age/Year Purchased
Replacement
Schedule
Nursing Diagnosis
Base Cost
Lifetime Cost
Catalog or Supplier
Go-Go Elite Traveller
3-wheel scooter
28 / 2011
Every 5 years
Impaired mobility
$899
$11,988
• Amazon / EasyMed (1)
$2970
• Invacare (2)
• Health Products for
You (3)
• Enhancing Life Home
Medical (4)
$10,400
Various
Wheelchair cushion
InTouch Flovair
Gentle or equivalent,
fit for scooter seat
Replacement wheels
and tires
28 / 2011
Every two years
Impaired skin integrity
• $360
• $252
• $200.06
average $270
28 / 2011
Annually
Impaired mobility
Estimated $200
Total
$25,358
(1) http://tinyurl.com/29jdspx; (2) www.invacare.com; (3) www.healthproductsforyou.com; (4) www.enhancinglife.org
Scooter Accessories
Wheelchair
Accessory
Wheelchair backpack
28 / 2011
Replacement
Schedule
Annual
Battery x2 (one for
back up)
28 / 2011
Annual
Impaired mobility
Estimated $150
$8,100
Various
Battery charger
28 / 2011
Every two years
Impaired mobility
$25
$1,375
multiple
Annual maintenance
29 / 2012
Annual
Impaired mobility
$100
$5,500
Wheelchair clinic or
vendor
Age/Year Purchased
Nursing Diagnosis
Annual Cost
Lifetime Cost
Catalog or Supplier
Impaired mobility
40.00
$2,160
Various
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Scooter carrier to
attach to vehicle:
EZ-1 carrier and
ramp $445 and hitch,
plus installation;
INCLUDES tie-down
and security rail
Econo Wheelchair and
Scooter Lift + Class 2
hitch + installation
Spinlife (1)
$445
ScooterLink (2)
$605
28 / 2011
Every 7 years
$451
Brophy carrier with
ramp + Class 2 hitch
+ installation
$3,728
Ameriglide (3)
$361
Hitchesonline.com (4)
(average $466)
Total
$20,863
(1) http://tinyurl.com/35onq2u ; (2) http://tinyurl.com/2wbtgnx ; (3) http://www.ameriglide.com/item/AmeriGlide-AG001.html
(4) http://www.hitchesonline.com/transporter.htm
Orthotics/Prosthetics
Equipment
Description
Hand splints
Prosthetist
Total
Age/Year Purchased
Replacement
Schedule
Equipment Purpose
Annual Cost
Lifetime Cost
Catalog or Supplier
27 / 2010
1-2 x/ year
Maintain position of
function, protective
Estimated $175
$14,437
occupational therapy
provider
depends on whether
amputation is indicated,
see Potential
Complications, below
$14,437
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Home Furnishings and Accessories
Item
Lift chair, Pride specialty
LC-205, 2-position,
battery backup
Vent-free washer/dryer,
e.g.,
LG WM3431
QuietLine WD-9900
Age/Year Purchased
Replacement
Schedule
Nursing Diagnosis
Base Cost
Lifetime Cost
Catalog or Supplier
27 / 2010
lifetime
Impaired mobility
$699
$699
Spinlife
www.spinlife.com
27 / 2010
15 years
Impaired mobility
$1400
$7200
multiple
• $4319
• $2455
• $3099
average $3291
$9873
• Select Comfort Retail
• QVC (4)
• Sleep Better Store (5)
$47
$423
Wal-Mart.com,
includes free shipping to
local store
Sleep Number Bed
model 9000 or equivalent
27 / 2010
Every 20 years
Risk for impaired skin
integrity
Kidde smoke & CO
detectors
27 / 2010
Every seven years
Risk for injury / tissue
hypoxia
Total
$18,195
(1) 800-367-9444; (2) 877-753-3770
Aids for Independent Function
Equipment
Age/Year Purchased
Replacement Schedule
Equipment Purpose
Base Cost
Lifetime Cost
Catalog or Supplier
Modified kitchen tools,
household tools
27 / 2010
lifetime
Independence
$500 est.
$500
local hardware and
homegoods store
Keyless ignition for
vehicle (average length
of vehicle ownership in
US = 5.5 years, NADA,
2010)
StartSmart SSD-215
$450
27 / 2010
6 years
Operate and lock vehicle
Keytroller (1)
$4,245
2Go Keyless DGD-PBS
$399
DigitalGuardDawg (2)
(cont.)
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Adaptive handgrips for
steering wheel:
MPS Tri-pin
Spinner Knob
27 / 2010
10 years
Operate steering wheel
$103
$515.00
Adaptive Equipment
Specialists (3)
Light switches,
accessible
27 / 2010
When moves from home,
assume 2 moves
Independence
$100 est.
$300
local hardware store
Faucets, accessible
27 / 2010
When moves from home,
assume 2 moves
Independence
$125
$375
local hardware store
Lever door handles
27 / 2010
When moves from home,
Open and close doors
assume 2 moves
$150 est.
$4,650
local hardware store
$168
• Enhancing Life Home
Medical (4)
• Health Products For
You (5)
• WalMart
$1,110
• Enhancing Life Home
Medical (4)
• Health Products For
You (5)
• WalMart
• $22.36
Long-handled bath
sponge
• $36.50
27 / 2010
Annual
Independence in hygiene
• $3.88
Average $21
Tub transfer bench
Raised toilet seat with
drop sides and padded
seat
27 / 2010
Five years
Independence in hygiene
Average $110
• $219
• $96
40 / 2023
Every 7 years
Impaired mobility
$834
• $101
Average $139
Total
• DMETree (6)
• Enhancing Life
Home Medical (4)
• Health Products For
You (5)
$12,697
1) 813-877-4500; 2) 916-337-1040; 3) 888-707-0456; 4) www.enhancinglife.org; 5) www.healthproductsforyou.com; 6) www.dmetree.com
(cont.)
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Drug/Supply Needs
Supply/ Equipment
Description
Drug (Prescription)
Nursing Diagnosis
Lexapro (escitalopram)
10 mg
If resumed after
psychology/psychiatry
consult, assume 2011
Cost
Cost Per Year
Lifetime Cost
Source
$ 1160/ 365 doses
$62,640
Average national retail
price, Drugstore.com
Cocoa butter bar soap
Impaired skin integrity
$1.50 / bar, assume 1
bar/week
$78
$4,290
Average national retail
price, Drugstore.com
Cocoa butter lotion,
Vaseline Intensive
Care Hydrating
Lotion
Impaired skin integrity
$4.50 / 10oz tube,
assume 1 tube per week
$234
$12,870
Average national retail
price, Drugstore.com
Pain medication, cannot
specify
Total
As indicated after pain Commonly $1000-5000 /
management
year for chronic pain Assume ½ range =$2500
consultation
syndromes
$142,500
$222,300
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Home Care/Facility Care*
Agency
Home Care/ Service
Recommendation
Nursing Diagnosis
Cost
Length of Service
Annual Cost
Lifetime Cost
Homemaking service
Homemaking
2 hours per week
Impaired physical
mobility
$40
Life expectancy until in
facility (last 15 years of life
expectancy)
$2,080
$83,200
Assisted living or skilled
facility care may be
needed at a younger age
than usual due to
complications, unable to
quantify at this time.
Assisted living
Self-care deficit
$2719 / month
Assume ten years
$32,628
$326,280
Skilled nursing facility
Self-care deficit
$153 / day
Assume last five years of
life expectancy
$55,845
$279,225
Total
$688,705
*The 2010 MetLife Market Survey of Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs, October 2010
Future medical care, surgical intervention, or aggressive treatment
Condition / Treatment
Corneal blindness requiring corneal transplant or implants
Estimated Costs
Corneal transplant CPT 65710, $4751, plus
associated evaluation, hospital, medications,
anesthesia, lab, and related costs, estimated
total $20,000 per eye
Lifetime Cost
$40,000
xii
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Potential Complications
Complication
Estimated Costs
Dermatological: impacted cysts, ingrown hairs,
deformed nails
Lifetime Cost
Lifetime costs not calculated as there is no objective
basis or history for basis
Pulmonary insufficiency; pulmonary
rehabilitation, supplemental oxygen
Home oxygen noted above, assume 10 years
Pulmonary rehabilitation program, est. $1500
Home oxygen, 10 years, as noted above, $21,000
Pulmonary fibrosis with ventilatory failure;
pulmonologist
$80,000 per episode
If she becomes ventilator-dependent, lifetime costs can
easily exceed $500,000 per year for in-hospital care
Ongoing chronic wounds, multiple; pressure
ulcers; plastic surgeon, WOCN, pain management
$70,000 per ulcer
Lifetime costs not calculated as there is no objective
basis or history for basis
Osteoporosis risk: fall, fracture, posttraumatic
intracerebral bleed, hospital care with skilled
nursing care facility to follow
Amputation, prosthetics
Average cost of hip fracture care is $26,912 per patient,
exclusive of post-acute care. (National Center for Health
Statistics; Centers for Disease Control and Prevention; 2003
National Hospital Discharge Survey)
Average annual cost of intracerebral bleed is $125,000 (Hsieh
PC, Awad IA, Getch CC, Bendok BR, Rosenblatt SS, Batjer HH.
Current updates in perioperative management of intracerebral
hemorrhage. Neurol Clin. 2006;24:745-64.)
$50,000+ for fingers/hand depending on extent of loss
Not possible to specify but can be assumed to be
considerable.
Lifetime costs not calculated as there is no objective
basis or history for basis
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Transportation
Mode of
Transportation
Taxi transport to
appointments and
grocery shopping if
driver safety
evaluation precludes
driving
Age/Year Purchased
27 / 2010
Replacement Schedule
Equipment Purpose
Estimate 30 trips to
appts, 26 trips to grocery
shopping, weekly other
medical appointments,
outing, annually; assume
recreation, child care,
less travel related to
and grocery shopping
children and more travel
related to medical care in
future years
Base Cost
$1.32 / mile:
•approx $15 round
trip local = $780
•approx $143 round
trip to St. Elizabeth’s,
Lincoln NE (54 miles
each way per
Mapquest), est. 30
trips = $4276
Lifetime cost
Catalog or Supplier
$277,750
Driving service
City ST
phone
Fully licensed, insured,
certified, and authorized with
the State Public Service
Commission (SPSC),
Department of Transportation
(DOT), and the Department
of Motor Vehicles (DMV).
= $5050 per year
Total
$277,750
Health & Strength Maintenance
Description
Frequency
Base cost
Gym membership for
self-directed exercise
plan, recreation with
children, Y of Lincoln
(4 locations),
www.ymcalincoln.org
$65 / month, family
membership, until
Annual membership to
youngest child turns 18 =
age 70
10 years, then individual
membership $45 / month
Recreational Therapy,
estimated, program in
formation
Monthly, until age 70
Total
$150 / month
Annual cost
Lifetime Cost
10 years, $7800
33 years, $17,820
$25,620
Wendie Howland RN
MN CRRN CCM
CNLCP
$1800
$77,400
Amy Brown MA CTRS
ATRIC, Town ST
phone
$103,020
Recommended /
provided by
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Architectural Renovations
Renovation
Nursing Diagnosis
Replacement
Schedule
Base Cost
Lifetime Cost
Home inspection for safety and code
Risk for injury
immediate
$320
$320
Ramp for home access with scooter
Impaired mobility
ten years
$1800
$10,800
Catalog or Supplier
Structural changes:
None possible in current rental
AmRamps (1)
The following features should be
present in the home for safe access:
Bathroom access- remove thresholds,
widen doors, open space for scooter
turn-around, grab bars, roll-in shower or
tub transfer device
Kitchen access— remove thresholds,
widen doors, roll-up counters,
cupboards, drawers, and outlets
reachable, stovetop controls in front
Entrance/egress, ramps, thresholds
removed, covered entrance
General safety- light switches reachable,
halls wide enough to turn scooter, fire /
smoke/CO alarms with lights
Total
$11,120
Note: This home is generally unsuitable for anyone with a mobility deficit and may not be compliant with local building codes for safety.
Consult a certified home modification specialist if modifications are needed for an existing home, and expect costs to be approximately
$75-120,000. New construction or home in existing adapted living buildings can also be considered.
1) National distributor, 888-715-7598
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Mary Doe
Date of Birth: 1983
Date of Injury: 2008
Date Submitted: 2010
Cost Summary:
Recommendation
Lifetime Cost
Future Routine Medical Care
$829,076
Recommended Evaluations
$3,739
Projected Therapeutic Modalities
$100,734
Mobility/Maintenance
$25,358
Mobility Accessories
$20,863
Orthotics/Prosthetics
$14,437
Home Furnishings & Accessories
$18,195
Aids for Independent Function
$12,697
Drug/Supply Needs
$222,300
Home Care/Facility Care
$688,705
Future Medical Care, Surgical Intervention, or Aggressive Treatment
$40,000
Transportation
$277,750
Health & Strength Maintenance
$103,020
Total
$2,356,874
Please note that costs for potential complications, new medications and therapies pending medical evaluation, and replacement
housing (purchase) or modifications to an existing home over the life expectancy are not included in this calculation and can be
assumed to be considerable. Accessible housing options should be investigated by a qualified real estate agent and adaptive housing
professional.
Thank you for the opportunity to assist you with Ms. Doe’s Life Care needs. Please contact me with any questions.
Cordially,
Wendie Howland RN MN CRRN CCM CNLCP
Principal, Howland Health Consulting, Inc., Certified Nurse Life Care Planner
NURSE LIFE CARE PLAN Timothy Smith APRIL 7, 2015 Nancy Zangmeister RN, CRRRN, CCM, CLCP, MSCC, CNLCP, CBIS Quality Rehabilitation & Consulting Services, LLC Nurse Life Care Plan for Timothy Smith – Table of Contents
Section One – Client Summary 3-34
Methodology
Diagnosis
Introduction
Medical Timeline
Records Reviewed
Past Medical History
Surgeries Related to Incident
Current Medications
Current Symptoms/Limitations
Psychosocial Information
Educational/Vocational Information
Life Expectancy
Nursing Diagnosis
Summary
Potential Complications
LVAD
Heart Transplant Wait List
Clinic Heart Transplant Clinic
Resources
3-4
5
5-8
8-24
24-25
25
25
26
26
27
27
27-28
28
28-29
29-30
30-31
31-32
33-34
Section Two - Nurse Life Care Plan without Transplant
Usual & Customary Costs – Tables 35-44
Projected Evaluations
35
Supplies
36
Medications
37-39
Future Medical Care – Routine
40-42
Transportation
43
Lifetime Cost Projection
44
Section Three- Nurse Life Care Plan with Transplant
Usual & Customary Costs - Tables 45-60
Projected Evaluations
45
Projected Therapeutic Modalities
46
Medications
47-48
Future Medical Care – Routine
49-56
Acute Surgical Interventions
57
Transportation
58
Housing/Child Care
59
Lifetime Cost Projection
60
2 Timothy Smith
Methodology
The American Nurses Association (ANA) defines nursing as the protection,
promotion, and optimization of health and abilities, prevention of illness and
injury, alleviation of suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families, communities, and
populations. The human response includes the reaction of the individual and
family to actual or potential health problems. ANA notes “…Nurses are educated
to be attuned to the whole person, not just the unique presenting health
problem. While a medical diagnosis of an illness may be fairly circumscribed,
the human response to a health problem may be much more fluid and variable
and may have a great effect on the individual’s ability to overcome the initial
medical problem. In what some describe as a blend of physiology and
psychology, nurses build on their understanding of the disease and illness
process to promote the restoration and maintenance of health in their
clients…Nursing is a key element in patient survival as well as in the
maintenance, rehabilitation, and preventive aspects of healthcare.." (ANA
Nursing's Social Policy Statement, Second Edition, 2003).
The American Association of Nurse Life Care Planners (AANLCP) defines nurse
life care planning as the specialty in which the nurse life care planner utilizes
the nursing process in the collection and analysis of comprehensive client data
to prepare a dynamic document. This document provides an organized concise
plan of estimated reasonable and necessary, current and future healthcare
needs with the associated costs and frequencies of goods and services. The
Nurse Life Care Plan (NCLP) is developed for individuals who have experienced
an injury or have chronic healthcare issues. Nurse life care planners function
within their individual professional scope of practice and, when applicable,
incorporate opinions arrived at collaboratively with various health care
providers. The Nurse Life Care Plan is considered a flexible document and is
evaluated and updated as needed. The Nurse Life Care Plan is based on
assessing health status, establishing goals, and planning care as defined in the
Nurse Practice Act specific to the state of RN licensure. (AANLCP Membership
Guide, 2008).
The nursing process is the foundation of developing the nursing care plan. The
nursing process includes an assessment, nursing diagnosis, plan of care, and
implementation and evaluation of the plan of care. Nurse Life Care Planners
also use the nursing process as the foundation to formulate a plan of care called
a Nurse Life Care Plan. The Nurse Life Care Planner initiates the nursing
process by reviewing medical records to understand the course of medical
treatment, complications, and outcomes. The NLCP also conducts a nursing
assessment with the client, family or caregiver to discuss present symptoms,
limitations, and activities. In addition, daily living issues, psychosocial
considerations, and family dynamics are examined. 3 Timothy Smith
The Nurse Life Care Planner then identifies an appropriate nursing diagnosis
to describe the client’s individual needs. When applicable, a collaborative
approach is used with other health care providers to determine these needs.
Research is also performed to determine long term outcomes, complications,
costs, and maintenance and replacement frequency of recommended necessary
medical and non-medical products. Nurse life care planning is an extension of
case management where the nurse has learned to 1) perform an assessment, 2)
formulate a plan of care in collaboration with the health care team members, 3)
facilitate care for medical needs, and 4) negotiate costs related to care. A Nurse
Case Manager can be introduced by the referral source to implement the Nurse
Life Care Plan recommendations and evaluate the response to complete the
nursing process.
The Nurse Life Care Plan is specific to the individual and is intended to follow
the client throughout her lifetime to ensure funds will be available to properly
care for the client. Costs for medical care are acquired through actual and
potential healthcare providers and national databases with a geographical zip
code modifier. Other costs are secured through research with suppliers,
facilities, pharmacies, and other resources. Where applicable, costs are obtained
from various vendors and the median cost is listed in the Nurse Life Care Plan.
The costs included in the Nurse Life Care Plan are based on today's dollars. No
provision has been made for future inflation, therefore an economist should be
considered. Costs have been rounded to the nearest dollar. The Nurse Life Care
Plan should be reviewed and updated when there are significant changes to the
medical condition.
4 Timothy Smith
391 Saddle Path Lane N.
Pataskala, Ohio 43062-8028
Ph: (740) 964.9366 Fax: (740) 927.2766
Nurse Life Care Plan Report
Referral:
Client: Timothy Smith
Address:
Address:
Phone:
Fax:
Email:
Referral:
Interview:
Report:
Phone:
DOB:
March 17, 1976
SSN:
DOI:
October 18, 2011
January 21, 2015
Not completed
April 7, 2015
Medical Diagnoses
Substantial acceleration of a pre-existing cardiovascular disease (Marfan
syndrome), cerebral vascular accident (stroke), dysphagia (difficulty swallowing),
deep venous thrombosis (arterial blood clot), protein S deficiency (most often
inherited disorder that predisposes a person to venous blood clots), Lupus
anticoagulant disorder (causes an increase in both arterial and venous blood
clotting), epilepsia partialis continua (prolonged focal seizure [limited to one area
of the brain]), bilateral pulmonary embolism (blood clots in both lungs), chronic
anticoagulation (inability for the blood to clot), foot pain related to pressure
ulcer, anemia, chronic heart failure hypertension, hemoptysis (bloody sputum),
end-stage cardiomyopathy (abnormal heart muscle), and aortic root dilatation
(enlargement of the root of one of the major blood vessels).
Introduction
Mr. Timothy Smith was referred by Mr. Mark Thomas, Esq. for the development
of a Nurse Life Care Plan in an effort to address current and future medical and
non-medical needs related to injuries sustained on October 18, 2011.
Mr. Smith, thirty-four (34) years-old at the time of the accident, was involved in
an incident at the deaerator storage tank where he was working. As a result of the
incident, Mr. Smith developed substantial acceleration of a pre-existing
5 Timothy Smith
cardiovascular disease (Marfan syndrome1). He had a history of decreased
ejection fraction (35%) one year prior to incident2). He also experienced a
cerebral vascular accident (stroke), and coronary thrombosis (blood clot) as a
result of his incident.
On October 18, 2011, Mr. Smith arrived for work around 5:30 pm to work inside
the Unit 5 deaerator storage tank. Mr. Smith’s responsibility was to wire-wheel
weld lines (cleaning welds with a wire wheel). Mr. Smith wore a respirator, steel
toe shoes and safety glasses while working in the tank. Mr. Smith and the crew
entered the tank through a manhole at approximately 6:30 pm and were
instructed on the welds to wire-wheel. Before Mr. Smith could start his work,
water began to flow into the tank followed by steam as a result of a valve
malfunction. Mr. Smith and the crew immediately evacuated the tank back
through the manhole. Mr. Smith and the crew did not return to the tank that
night. Mr. Smith returned to work at Sun Petroleum the following day. Mr.
Smith continued to work at Sun Petroleum for another week before being laid off
and has not worked since that time.
Figure 1 - Deaerator tank
Figure 2 - Inside the tank
Mr. Smith reportedly coughed up blood, (hemoptysis) and had a low grade fever
with chills a day or two following the incident. He was examined by his family
physician, Dr. Michael Norman, and treated with amoxicillin without
improvement. In November 2011, Mr. Smith began experiencing a lack of
appetite, and on December 5, 2011, Mr. Smith was admitted to the Clinic with
1
Marfan syndrome is a genetic disorder that affects the body’s connective tissue. Marfan
syndrome can affect different parts of the body. Features of the disorder are most often
found in the heart, blood vessels, bones, joints, and eyes. Some Marfan features – for
example, aortic enlargement (expansion of the main blood vessel that carries blood away
from the heart to the rest of the body) – can be life threatening. The lungs, skin and
nervous system may also be affected.
1
The left ventricle is the heart's main pumping chamber, so ejection fraction is usually
measured only in the left ventricle (LV). An ejection fraction of 55 percent or higher is
considered normal.
6 Timothy Smith
expressive aphasia (loss of the ability to produce spoken or written language),
facial droop, and weakness of his right side. He was diagnosed with an acute left
middle cerebral artery (MCA) infarct or stroke thought to be caused from an
embolic event from his dilated cardiomyopathy.
Mr. Smith experienced focal motor seizures (twitches) of his face during his
hospitalization, and demonstrated bilateral hand tremors. He was started on
Levetiracetam 500 mg twice a day and the medication resolved the facial
twitches. At the time of discharge, Mr. Smith’s speech had returned to normal,
and he regained full use of his right hand. His hospital course was complicated
by gastrointestinal bleed (GIB) due to erosive duodenitis. On January 9, 2011,
Mr. Smith was readmitted to the clinic with congestive heart failure (CHF) due to
severe left ventricular dysfunction. He also suffered from weight loss and
abdominal pain. On January 14, 2012, he experienced hypotension and cardiac
arrest during the first Azithromycin infusion (as treatment for a respiratory
infection), requiring cardio pulmonary resuscitation (CPR), dopamine and
dobutamine. A thoracentesis was performed on January 23, 2013 with removal
of two liters of fluid. Mr. Smith continued to deteriorate and developed
cardiogenic shock. A left ventricular assist device (LVAD) was implanted on
January 30, 2012 for treatment of non-ischemic cardiomyopathy and cardiogenic
shock heart failure as a bridge to heart transplantation (the LVAD was inserted to
enable Mr. Smith to survive until a heart transplant could be performed. At the
time of the implantation, an eight centimeter (8 cm) RA/SVC (right
atrial/superior vena cava) thrombus was removed. On February 15, 2012, Mr.
Smith returned to surgery for a right atrial thrombectomy and bilateral
pulmonary embolectomy. Mr. Smith ’s hospital course was further complicated by respiratory failure
leading to a tracheostomy (a surgical procedure to create an opening through the
neck into the trachea), candida albicans (caused by an over growth of yeast called
candida) infection of the lungs, pseudomonas (a common bacterium that can
cause disease) urinary tract infection, hypercoaguable state (a condition in which
there is a tendency toward blood clotting) secondary to new finding of lupus
anticoagulant antibody, multiple deep venous thrombosis, heparin resistance,
hyper and hyponatremia (low and elevated sodium level in the blood), postoperative cardiac insufficiency(insufficiency occurs when the heart muscle
doesn’t pump blood as well as it should and the patient goes into congestive heart
failure), atrial flutter (a common abnormal heart rhythm), hospital acquired
pressure ulcers, malnutrition, dysphagia (difficulty swallowing), and physical
deconditioning (a decline in function). Mr. Smith was transferred to a
rehabilitation nursing facility on February 27, 2012. The rehabilitation stay was
complicated by bleeding hemorrhoids and also by epilepsy secondary to his
history of cerebral vascular accident (CVA). Mr. Smith’s tracheostomy was
removed on March 5, 2012, and he was discharged to home on March 26, 2012.
This Nurse Life Care Plan report will comment on Mr. Smith’s past surgeries and
procedures, current medical status, and future medical treatment
7 Timothy Smith
recommendations with associated costs as related to the incident which occurred
on October 18, 2011.
Recommendations included in this Nurse Life Care Plan report are based on a
reasonable degree of certainty in an effort to manage symptoms, reduce
complications and secondary diagnosis, maintain functioning, and optimize
independence throughout Mr. Smith’s lifespan. The recommendations are
gathered from information provided by medical records, as well as knowledge
and experience of this Nurse Life Care Planner. The Nurse Life Care Plan report
and tables were completed following a review of the provided medical records.
This Nurse Life Care Plan report is being submitted with the understanding
additional medical information may be received from the medical providers. The
Nurse Life Care Plan recommendations are subject to change if additional
medical information is received from the medical providers. Prior to court
appearance, consideration will be given to any changes in Mr. Smith’s medical
condition and this Nurse Life Care Plan will be revised as needed.
Please refer to the following Medical Timeline on pages 9-25 for details
sequenced by date of Mr. Smith’s medical conditions, treatment, and outcomes.
Medical Timeline:
Date
Facility/Physician
May 24,
2011
Dr. Kenneth G.
Zuber, Pediatric
Cardiologist
8 Timothy Smith
Summary
Mr. Smith attended follow-up for his Marfan
Syndrome and dilated cardiomyopathy with
Dr. Zuber (Dr. Zuber had been treating Mr.
Smith since childhood). Mr. Smith had
presented with stable aortic sinus
dimensions in the forty-two to forty-four (4244) millimeter range from 1994 to 2004,
however, he experienced a gradual increase
in his left ventricular diastolic dimensions
from sixty-three (63) in June 2004 to sixtyfive (65) and seventy-four (74) in May 2011
(normal is forty-two to fifty-nine [42-59],
sixty to sixty-three (60-63) is mildly dilated,
sixty-four to sixty-eight (64-68) is
moderately dilated and greater than sixtynine (69) is severely dilated). Dr. Zuber had
prescribed atenolol and Lisinopril but Mr.
Smith had not been taking the medications
regularly. A nuclear stress test completed in
2006 showed an ejection fraction of fortyone percent (41%). Mr. Smith remained
asymptomatic with preserved exercise
capacity and no dizziness or palpitation.
May 24,
2011
(cont’d)
October 18,
2011
November
30, 2011
December
1, 2011
Dr. Kenneth G.
Zuber, Pediatric
Cardiologist
Dr. Kenneth G.
Zuber, Pediatric
Cardiologist
Dr. Susan Thomas,
Cardiovascular
Medicine
9 Timothy Smith
Mr. Smith was instructed to avoid weight
training, and dangerous activities where
dizziness might cause injury.
The incident inside deaerator storage tank
occurred.
Mr. Smith reported chronic diarrhea over the
past year. He informed Dr. Zuber of the
incident that occurred at work when steam
entered the tank where he was working. Mr.
Smith presented with cough, sweating,
fatigue, epigastric pain and a ten (10) pound
weight loss.
He also complained of
abdominal pain when walking. Mr. Smith
was given antibiotics by his primary care
physician. Dr. Zuber noted that Mr. Smith’s
clinical cardiac examination was at baseline
with no mitral valve prolapse (MVP), gallop
or hepatic congestion, however Dr. Zuber
noted lung crackles suggesting intercurrent
infection (An infection that intervenes during
the course of another disease with which it
has no connection). Laboratory studies and
echocardiogram did not reveal endocarditis
or serious systemic infection. Mr. Smith’s
aortic root size appeared to be larger by
magnetic resonance imaging (MRI). Dr.
Zuber felt that Mr. Smith’s clinical problem
was dilated cardiomyopathy related to
Marfan Syndrome. Dr. Zuber further noted
that the chronic diarrhea could represent
impaired cardiac output.
Mr. Smith
presented with an increased risk of sudden
death
based
on
the
MRI
and
echocardiogram. Mr. Smith was referred to
the heart failure center to assess the need for
further therapy.
Mr. Smith attended an initial evaluation with
Dr. Susan Thomas for symptoms of
congestive heart failure (CHF) and
obstructive pulmonary disease (OPD). Mr.
Smith reported resolution of previous
symptoms of dyspnea (shortness of breath or
breathlessness), and upper respiratory
infection, but continued to experience mild
fatigue. He was able to work and perform
light yard work.
December
1, 2011
(cont’d)
Dr. Susan Thomas,
Cardiovascular
Medicine
December
1, 2011
Dr. Paul Howard,
Cardiologist
December
5, 2011
Clinic Emergency
Department
December
7, 2011 –
December
11, 2011
Clinic
10 Timothy Smith
Dr.
Thomas noted superficial phlebitis
(inflammation of a vein) following the
cardiac MRI.
She advised Mr. Smith to use warm
compresses to the right upper extremity. Dr.
Thomas recommended increasing the
Lisinopril to 10 mg daily, continue the
atenolol and add carvedilol 125 mg twice a
day. Dr. Thomas did not feel that Mr. Smith
required anticoagulants.
Mr. Smith was referred to Dr. Paul Howard
for a Holter monitor (a continuous tape
recording of a patient’s EKG for twenty-four
(24) hours) for evaluation of premature
ventricular contractions (PVCs).
Dr.
Howard noted that Mr. Smith was not
compliant with his medication regimen and
was only occasionally taking the medications
on a weekly basis. Dr. Howard prescribed
Coreg and ACE-I titration as tolerated and
recommended a repeat echocardiogram in
three (3) months. If Mr. Smith continued to
have depressed left ventricular function, he
would be a candidate for an implantable
cardioverter defibrillator (ICD).
Mr. Smith presented to the Clinic Emergency
Department for complaints of intermittent
epigastric abdominal pain with watery dark
colored stool over the past ten (10) days. Mr.
Smith rated the pain at six out of ten (6/10)
and often experienced shortness of breath
with the pain. Mr. Smith underwent testing
and was administered Zofran with relief of
the symptoms. He was discharged home.
Mr. Smith presented to the Clinic Emergency
Department with expressive aphasia and a
facial droop that began the evening before.
Mr. Smith noted that at 8:40 pm, he was
unable to speak, write or hold a pen. He was
transported by ambulance to Ashtabula
Emergency Department where he underwent
computerized axial tomography (CAT scan)
of his head. The scan was negative for
bleeding and received a tissue plasminogen
activator (TPA).
Mr. Smith was transported to the Clinic for
further management.
December
7, 2011 –
December
11, 2011
(cont’d)
Clinic
Mr. Smith showed improvement later that
day.
Mr. Smith was diagnosed with acute ischemic
stroke syndrome, and non-flowing limiting
dissection of the left common carotid artery,
(this condition is not unusual with Marfan
Syndrome) and possible intra-arterial
emboli. Mr. Smith underwent testing for
epigastric pain and diarrhea which indicated
gastritis so a proton pump inhibitor
(Protonix) was prescribed. Mr. Smith was
instructed to follow-up with his primary care
physician, cardiologist and stroke neurologist
after discharge. He was prescribed daily
aspirin and monitoring of his INR
(international normalized ratio measures
coagulation) level.
December
12, 2011 –
December
14, 2011
Clinic
Dr. Randy Young,
Cardiologist
Mr. Smith was evaluated by Dr. Randy Young
for follow-up of his heart failure. Mr. Smith
was discharged from Clinic on December 11,
2012 and that evening developed shortness
of breath (SOB) at rest, edema and pallor.
He was instructed to take Lasix 60 mg. After
taking the Lasix, he slept with no further
episodes of shortness of breath. Mr. Smith
informed Dr. Young that his breathing and
energy level were unchanged. He was able to
climb one flight of stairs without problem.
Dr. Young noted mild edema of Mr. Smith’s
lower extremities.
Mr. Smith was readmitted on December 12, 2012 to Clinic’s
heart failure unit for intravenous fluids and
medication adjustment. An echocardiogram
completed on December 12, 2011 showed a
moderately dilated left ventricle with
decreased systolic function and ejection
fraction of fifteen plus or minus five percent
(15 + 5%). The scan also showed a dilated
right ventricle with moderate to severe
decreased systolic function, moderately
severe mitral valve regurgitation caused by
left ventricular enlargement. Chest x-ray
showed small bilateral pleural effusions and
patchy retrocardiac opacity.
11 Timothy Smith
December
12, 2011 –
December
14, 2011
(cont’d)
Clinic
Dr. Randy Young,
Cardiologist
December
22, 2011
Dr. Randy Young,
Cardiologist
Mr. Smith was discharged on December 14,
2012.He was instructed to incorporate a low
salt, low fat diet, daily weights, daily aspirin,
Lisinopril 5 mg daily, Lasix 20 mg as needed,
and Coumadin 5 mg daily.
Figure 2 – Heart
12 Timothy Smith
Mr. Smith returned for follow-up with Dr.
Randy Young for evaluation of ongoing heart
failure
and
reported
intermittent
palpitations. Dr. Young noted that Mr. Smith
had not been compliant with his restrictions,
and was eating foods with high sodium
content and ignored fluid restrictions. Dr.
Young recommended that Mr. Smith
increase his dosage of Carvedilol to 6.25 mg
twice a day, start epierenone 25 mg daily,
continue Lisinopril 5 mg daily, recheck blood
levels on January 3, 2012, schedule a
metabolic stress test and repeat his
echocardiogram in one (1) month. He also
recommended dietary and nutritional
counseling, a continuation of Coumadin and
aspirin and a follow-up INR level. Mr. Smith
was instructed on dietary and medication
compliance, specifically salt restriction,
monitoring of daily weights and blood
pressure, and exercise through walking. Dr.
Young noted that Mr. Smith presented with
advanced cardiomyopathy, and advised that
he not work as a laborer. Dr. Young felt that
Mr. Smith would need an implantable
cardioverter
defibrillator
(ICD)
for
prevention and was not optimistic that Mr.
Smith would successfully reverse with
medications.
December
22, 2011
(cont’d)
Dr. Randy Young,
Cardiologist
December
22, 2011
Katherine M.
Patton, Registered
Dietician
January 3,
2012
Dr. Thomas E. Lai,
Interventional
Cardiology
Specialist3
January 4,
2012
Jamie Cummings,
Registered Nurse
January 9,
2012
Dr. Randy Young,
Cardiologist
Figure 3 -Implantable Cardiac Defibrillator
3
Mr. Smith attended a dietary and nutritional
consultation with Katherine M. Patton for
instruction on a cardiac diet.
He was
instructed to limit sodium intake to 15002000 mg per day, with 600 mg with meals,
and 200 mg with snacks, eat breakfast of
cereal with less than 140 mg per serving of
sodium, choose whole foods for snacks such
as fruit or unsalted nuts, research nutrition
facts in restaurants to make low sodium
choices, and purchase more meals at grocery
store when traveling instead of eating out.
Mr. Smith reported mild loss of appetite and
nausea for several days duration to Dr.
Thomas E. Lai. Mr. Smith had undergone a
right upper quadrant ultrasound the day
before that was normal. Dr. Lai instructed
him to discontinue the Inspra and aspirin
because of rising creatine and potassium
levels.
Ms. Jamie Cummings contacted Mr. Smith to
inform him of the appointment on February
1, 2012 for placement of his ICD. Mr. Smith
informed Ms. Thourot that he and Dr. Young
decided to wait on placement of the ICD.
Mr. Smith informed Dr. Randy Young of
increased difficulty with breathing and lower
energy along with abdominal pain and
nausea when he walked after eating. Mr.
Smith complained of a poor appetite and the
ability to only eat soft foods such as yogurt.
An Interventional Cardiology Specialist deals specifically with the catheter based treatment of structural
heart diseases, such as angioplasty and heart catheterization.
13 Timothy Smith
January 9,
2012
(cont’d)
Dr. Randy Young,
Cardiologist
Mr. Smith was diagnosed with stage C heart
failure4. Dr. Young felt that the abdominal
symptoms were related to Mr. Smith’s
underlying duodenitis and erosive gastritis.
Mr. Smith’s blood pressure was low at sixtyseven millimeters of mercury (67 mm Hg),
and he was admitted to the hospital
overnight for observation.
January 9,
2012 –
February
27, 2012
Clinic
Mr. Smith was hospitalized for a low cardiac
output state, weight loss, abdominal pain and
right lower lobe pneumonia.
Nipride,
dobutamine, and azithromycin were started.
On January 14, 2012, Mr. Smith experienced
a cardiac arrest during the first Azithromycin
infusion. He required CPR, Dopamine and
Dobutamine.
Following the arrest, Mr.
Smith continued to deteriorate and
eventually developed cardiogenic shock (a
condition in which the heart can’t pump
enough blood to meet the body’s needs).
Mr. Smith underwent an emergency
implantation of a left ventricular assist device
(LVAD) on January 30, 2012 with Dr.
Edward Soltesz. Mr. Smith was diagnosed
with a thromboembolism (formation in a
blood vessel of a clot or thrombus that breaks
loose, is carried by the blood stream and
plugs another vessel) An eight (8) centimeter
thrombus was removed at the time of the
LVAD implantation.
Mr. Smith’s hospital course was further
complicated by respiratory failure leading to
a tracheostomy (a surgical procedure to
create an opening through the neck into the
trachea).
Heart failure is rated by stages A through D. Stage C includes structural heart disease
with prior or current symptoms of heart failure. Patients with Stage C heart disease
experience shortness of breath, fatigue and reduced exercise tolerance. Goals for
treatment include mitigation of hypertension and lipid disorders, smoking cessation, and
regular exercise, reduction of alcohol intake and illicit drug use, and control of metabolic
syndrome. Additional goals include dietary salt restriction. Patients in this stage may
undergo biventricular pacing and implantable defibrillators. 4
14 Timothy Smith
January 9,
2012 –
February
27, 2012
(cont’d)
Clinic
Figure 4 – LVAD5
He was also diagnosed with candida albicans
infection of the lungs (caused by an over
growth
of
yeast
called
candida),
pseudomonas urinary tract infection (a
common bacterium that can cause disease),
hypercoaguable state secondary to new
finding of lupus anticoagulant antibody
(hypercoaguable means that there is a
tendency toward blood clotting), multiple
deep venous thrombosis, heparin resistance,
hyponatremia and hypernatremia (low and
elevated sodium level in the blood), postoperative cardiac insufficiency (Insufficiency
occurs when the heart muscle doesn’t pump
blood as well as it should and the patient
goes into congestive heart failure), atrial
flutter (a common abnormal heart rhythm),
hospital
acquired
pressure
ulcers,
malnutrition,
dysphagia
(difficulty
swallowing), and physical deconditioning (a
decline in function).
Mr. Smith was
transferred to a rehabilitation nursing home
on February 27, 2012.
5
A ventricular assist device (VAD) is a mechanical pump that's used to support heart
function and blood flow in people who have weakened hearts. The device takes blood
from a lower chamber of the heart and helps pump it to the body and vital organs, just as
a healthy heart would.
15 Timothy Smith
February
28, 2012 March 6,
2012
Rehabilitation
Nursing Facility
April 6,
2012
Dr. Kevin Brandon,
Cardiovascular
Medicine
April 13,
2012
Kathy Houser,
Certified Nurse
Practitioner
LVAD Clinic
April 20,
2012
Susan Sunshine
16 Timothy Smith
Mr. Smith’s rehabilitation stay was
complicated by epilepsy secondary to his
history of cerebral vascular accident (stroke)
requiring Keppra for one (1) year to prevent
seizures. Mr. Smith underwent tracheostomy
decannulation (removal of tracheostomy
tube) on March 5, 2012. A Corpak (feeding
tube) remained in place, and he underwent a
barium
swallow
test
(a
radiologic
examination of swallowing function that uses
a special video-type x-ray where the patient
is observed swallowing various types of
substances).
Mr. Smith underwent implantation of an ICD
(see figure 3 in the 12/22/2011 entry). He
was discharged from the nursing facility on
March 26, 2013.
Mr. Smith presented for follow-up with Dr.
Brandon for follow-up of his left ventricular
assist device (LVAD).
He voiced no
complaints and remained active.
Dr.
Brandon felt that Mr. Smith was doing well;
however, his blood pressure was eighty (80)
and not within the preferred limits. Dr.
Brandon increased the Coreg to 6.25 mg
twice a day (used for treatment of heart
failure and for stabilization of blood
pressure). Dr. Brandon instructed Mr. Smith
to continue the Keppra for one (1) year to
prevent seizures (epilepsia partialis).
Mr. Smith presented for an initial evaluation
with Ms. Kathy Houser. Mr. Smith noted
fatigue with walking but continued to
increase the amount he walked daily. Mrs.
Young was performing daily dressing
changes of his LVAD without problem. Mr.
Smith remained on aspirin and Coumadin for
treatment of a prior thrombus.
He
demonstrated pressure ulcers on the right
foot and fifth toe.
Mr. Smith had experienced swallowing
difficulty at the time of his stroke and
underwent a repeat modified barium swallow
with Ms. Susan Sunshine.
April 20,
2012
(cont’d)
Susan Sunshine
Ms. Sunshine assessed Mr. Smith’s
oropharyngeal swallow function and risk of
aspiration. Mr. Smith had a history of
oropharyngeal dysphagia, however, at this
time he denied swallowing problems and
tolerated a regular diet without difficulty.
The
study
demonstrated
moderate
pharyngeal dysphagia with pharyngeal
residue and incomplete airway protection.
Mr. Smith benefited from tucking his chin
during swallowing to reduce the depth and
frequency of laryngeal penetration with thin
liquids.
Figure 5 - Chin Tuck
April 20,
2012
Dr. Paul Howard,
Cardiologist
May 9,
2012
Dr. Brandon,
Cardiovascular
Medicine
17 Timothy Smith
Mr. Smith presented for follow-up with Dr.
Paul Howard for evaluation of his LVAD.
Mr. Smith had been attending follow-up
every two to four (2-4) weeks and was not
enrolled in remote monitoring. He was
instructed to return to the clinic in six (6)
months for follow-up.
Mr. Smith attended follow-up with Dr.
Brandon for evaluation. Mr. Smith reported
an episode of lightheadedness while out over
the weekend. Dr. Brandon felt that the
episode was due to dehydration and he
increased the dose of Coreg to 25 mg twice a
day. Mr. Smith was instructed to return in
one (1) month for a heart catheterization to
assess hemodynamics, and a repeat
computerized axial tomography (CAT) scan
for updated measurements of his aorta.
May 9,
2012
(cont’d)
June 1,
2012
June 28,
2012
June 28,
2012
June 28,
2012
June 28,
2012
Dr. Brandon,
Cardiovascular
Medicine
Dr. Brandon felt that at the time of his
transplant, Mr. Smith’s aorta would require
replacement due to the effects of his Marfan
Syndrome.
Dr. Carl Jones, Mr. Smith presented for a heart
Cardiologist
catheterization with Dr. Carl Jones (No
report was available for review).
Clinic
Mr. Smith’s CAT scan of the chest was
completed on June 28, 2012 and revealed a
dilated aortic root with complete effacement
of the sinotubular junction, consistent with a
history of Marfan Syndrome. The CAT scan
also showed a mildly and diffusely ectatic
(dilated) abdominal aorta, and severe
biventricular
and
moderate
biatrial
enlargement.
Dr. Jeff Wilds,
Mr. Smith visited Dr. Jeff Wilds for follow-up
Epileptologist
of his seizures. Mr. Smith’s symptoms of
facial twitches and right hand tremors had
not returned.
Dr. Wilds recommended
continuing
the
same
medication,
Levetiracetam for one (1) year. Dr. Norman
also recommended gradually discontinuing
the
Neurontin
for
lower
extremity
neuropathy. Mr. Smith was instructed to
return in one (1) year.
Kathy Houser,
Mr. Young presented for routine follow-up
Certified Nurse
of his LVAD with Kathy Houser with
Practitioner LVAD
complaints of fatigue. Mr. Smith reported
Clinic
poor sleep and anxiety thinking about
transplant testing. Mr. Smith was able to
work in the yard and spend time with his
family.
Dr. Jeff Wilds,
Mr. Smith attended a consultation with Dr.
Neurologist
Jeff Wilds for evaluation of seizures. Mr.
Smith had not experienced seizures since his
hospitalization in December 2011. Dr. Wilds
recommended continuing treatment with
Levetiracetam for one (1) year then reevaluate if necessary. Mr. Smith’s lower
extremity neuropathy had resolved and Dr.
Wilds recommended tapering the gabapentin
to 300 mg twice daily for two (2) weeks, then
daily for two (2) weeks. If the foot pain did
not recur, Mr. Smith could discontinue the
medication.
18 Timothy Smith
July 5,
2012
Bradley Little,
Registered Nurse
Dermatology Clinic
July 5,
2012
Patty Colon,
Physician Assistant
Center for
Osteoporosis and
Metabolic Bone
Disease
July 6,
2012
Mary Lamb
Loannou, Certified
Nurse Practitioner
Infectious Disease
July 24,
2012
Cathy Snow,
Registered Nurse
August 1,
2012
Kathy Houser,
Certified Nurse
Practitioner
LVAD Clinic
August 1,
2012
Dr. Brandon,
Cardiovascular
Medicine
19 Timothy Smith
Mr. Smith presented to Bradley Little for pretransplant evaluation. Mr. Smith’s skin was
clear of chronic disease and skin cancer. He
was instructed to return in one (1) year and
as needed following transplantation.
Mr. Smith underwent a bone density scan to
monitor for osteoporosis per transplant
protocol. He had not been exercising and
had experienced three (3) falls over the past
year. Mr. Smith was taking vitamin D and a
multivitamin supplement. Mr. Smith’s scan
was within the expected range for his age.
Ms.
Paozos
recommended
calcium
supplementation and annual scans if Mr.
Smith was prescribed corticosteroids.
Mr. Smith attended a pre-transplant
evaluation with Mary Lamb Loannou. Mr.
Smith received a twinrix vaccine (a vaccine
that helps prevent hepatitis A and B) series
with a second dose to be given in one (1)
month, and a third dose in January 2013. He
underwent a battery of tests including testing
for fungus and Staph aureus.
Mr. Smith was not approved for a heart
transplant when his case was presented at
the Heart Transplant Selection meeting. The
team felt that Mr. Smith was doing well on
the LVAD and medical therapy and would be
reassessed at a later date. He was diagnosed
with irremediable (incurable) terminal
cardiac disease with severely compromised
survival of less than seventy (70) years.
Mr. Smith returned for routine follow-up of
his LVAD with Kathy Houser. He denied
problems, had been able to help with a home
remodeling project, and was weaning off the
gabapentin.
Mr. Smith returned for follow-up with Dr.
Brandon, and reported no problems with the
LVAD. Mr. Smith’s blood pressure was
stable and he demonstrated adequate platelet
inhibition on Coumadin. Mr. Smith asked
Dr. Brandon to present his case to the
transplant committee in six (6) months as he
wanted to travel and return to work as a
welder.
August 2,
2012
September
7, 2012
October 3,
2012
Kathy Houser,
Certified Nurse
Practitioner
LVAD Clinic
Kathy Houser,
Certified Nurse
Practitioner
LVAD Clinic
Beckey Long
Hopper, Registered
Nurse
LVAD Clinic
October 23, Kathy Houser,
2012
Certified Nurse
Practitioner
LVAD Clinic
December
27, 2012
Kathy Houser,
Certified Nurse
Practitioner
LVAD Clinic
January 18, Dr. Robert
2013
Sampson,
Cardiologist
20 Timothy Smith
Mr. Young presented for routine follow-up
with Kathy Houser. He reported that he was
doing well and was helping with a home
remodeling project.
Mr. Young presented for routine follow-up
with Kathy Houser and reported that he was
doing well, but reported one (1) or two (2)
episodes of lightheadedness with standing.
Beckey Long Hopper received a phone call
from Mr. Smith’s wife stating that he had a
cough and fever and was lethargic. Ms.
Young was instructed to contact his primary
care physician. Mr. Smith contacted his
family physician who prescribed antibiotics.
Mr. Smith presented routine follow-up with
Ms. Kathy Houser. Mr. Smith reported an
episode of fever and chills for which he was
evaluated by his local primary care physician
(PCP). The PCP prescribed antibiotics and
symptoms resolved. Mr. Smith was not
experiencing any difficulties with swallowing
or the LVAD. Mr. Smith’s INR measured 1.5
so he was instructed to increase the
Coumadin to 9.5 mg daily.
Mr. Smith presented for routine follow-up at
the VAD clinic with Ms. Kathy Houser. Mr.
Smith reported infrequent lightheadedness
when standing that resolved quickly. He
remained active around the house and
reported a good appetite. Ms. Williams
decreased Mr. Smith’s Lisinopril from 10 mg
to 5 mg daily and instructed him to continue
the warfarin at 8.5 mg.
Mr. Smith attended an independent medical
evaluation (IME) with Dr. Robert Sampson.
The purpose of the evaluation was to
determine if Mr. Smith’s work related injury
caused or worsened his cardiomyopathy and
other related heart conditions. Dr. Sampson
opined that Mr. Smith had severe dilated and
congestive cardiomyopathy related to his
Marfan Syndrome that worsened throughout
his life and was not related to the incident of
October 18, 2011.
January 18, Dr. Robert
2013
Sampson,
(cont’d)
Cardiologist
January
29, 2013
Clinic
Dr. Sampson also felt that the stress suffered
during the incident was not cause for the
worsening of the underlying cardiomyopathy
that had existed for many years.
Dr.
Sampson further believed that the deep
venous thrombosis (DVT) and pulmonary
complications were not related to the
incident.
An electrocardiogram was performed on Mr.
Smith at the Clinic that showed an ejection
fraction of 20%, severely dilated left and
right ventricles, and decreased systolic
function.
The pulmonary veins showed blunted systolic
flow, and the right atrial cavity was mildly
dilated. The scan revealed aortic, tricuspid
and mitral valve regurgitation. The aortic
root remained dilated.
Figure 6 – aorta
January
29, 2013
Dr. Brandon,
Cardiovascular
Medicine
21 Timothy Smith
Mr. Smith returned for evaluation with Dr.
Brandon. Mr. Smith’s blood pressure was
elevated so Dr. Brandon increased the
Lisinopril to 10 mg twice a day. He remained
on full dose Coreg and aspirin. Mr. Smith
was instructed to return to the clinic in eight
(8) weeks.
March 8,
2013
Dr. Brandon,
Cardiovascular
Medicine
Mr. Smith presented for follow-up with Dr.
Brandon for evaluation of the LVAD. Mr.
Smith reported feeling well without
complaints.
He remained active and
exhibited no difficulties. He had no signs of
paroxysmal nocturnal dyspnea, orthopnea,
palpitations, presyncope, syncope, and chest
pain, dyspnea on exertion or ankle edema.
Dr. Brandon noted that the last assessment
of Mr. Smith’s aorta was December 2012
where the maximal diameter measured 4.4
cm at the sinus of Valsalva (a common
cardiac anomaly that can be congenital or
acquired). Dr. Young planned to reimage the
aorta in December 2013.
April 11,
2013
Dr. Brandon,
Cardiovascular
Medicine
June 5,
2013
Kathy Houser,
Certified Nurse
Practitioner
September
3, 2013
Dr. David Castro,
Occupational
Health
Mr. Smith returned for follow-up with Dr.
Brandon for evaluation of the LVAD. Mr.
Smith reported feeling well without
complaints and an “excellent quality of life”.
He remained active with few limitations and
exhibited no difficulties. He had no signs of
paroxysmal nocturnal dyspnea, orthopnea,
palpitations, presyncope, syncope, and chest
pain, dyspnea on exertion or ankle edema.
Mr. Smith reported an excellent quality of
life. Dr. Brandon planned to contact the preheart transplant team regarding outstanding
consultations or testing needed to proceed
with registration on the transplant list. Mr.
Smith continued to take anticoagulant
therapy and medication (full dose aspirin)
and undergo regular PTL inhibition studies
(posterior tricuspid leaflet).
Mr. Smith presented for routine follow-up at
the VAD clinic with Ms. Kathy Houser and
reported new onset of shortness of breath
with exertion.
Mr. Smith was evaluated by Dr. David Castro
for determination of maximum medical
improvement (MMI). Dr. Castro felt that Mr.
Young was relatively stable on the left
ventricular assist device, and medications.
Dr. Castro determined that without a heart
transplant, Mr. Smith had reached MMI and
was not expected to further improve.
22 Timothy Smith
September
3, 2013
(cont’d)
January 15,
2014
Dr. David Castro,
Occupational
Health
Dr. Bruce D. Long,
Center for
Osteoporosis and
Metabolic Bone
Disease
March 17,
2014
Dr. Brandon,
Cardiovascular
Medicine
March 17,
2014
Dr. Thomas Caper,
Dermatologist
May 28,
2014
Dr. Brandon,
Cardiovascular
Medicine
6
Dr. Castro recommended proceeding with
the heart transplantation.
Mr. Smith presented for a pre-heart
transplant metabolic bone disease follow-up
with Dr. Bruce D. Long.
The scan
demonstrated normal bone mass with a
mildly elevated PTH (parathyroid which
regulates calcium-phosphate metabolism and
increases in response to low serum calcium
levels and can lead to bone resorption) due to
past low calcium and vitamin D intake. Dr.
Long instructed Mr. Smith to increase his
calcium intake and repeat the PTH level in
two (2) months. Mr. Smith would undergo a
repeat bone scan after transplantation or in
two (2) years.
Mr. Smith returned for follow-up with Dr.
Brandon for evaluation of the LVAD. Mr.
Smith denied complaints and remained
active with an “excellent quality of life”. Mr.
Smith was listed on the United Network for
Organ Sharing (UNOS) as a status 1B6 on the
heart transplant waiting list. Dr. Brandon
increased the dose of Coreg to 37.5 mg to
decrease the stress on Mr. Smith’s aorta as it
related to the Marfan Syndrome.
Mr. Smith presented to the Clinic
Dermatology Clinic for a pre-transplant
evaluation by Dr. Thomas Caper. Mr. Smith
was diagnosed with folliculitis (infection in
the hair follicles) of his back, and instructed
to use BPO wash (benzoyl peroxide) 4% OTC
each morning.
Mr. Smith was instructed to return to the
clinic following transplant unless problems
occurred.
Mr. Smith returned for follow-up with Dr.
Brandon for evaluation of the LVAD. Mr.
Smith denied complaints and remained
active with an “excellent quality of life”.
The United Network for Organ Sharing (UNOS) manages the heart transplant waiting list. In order to
determine the order for receipt of a donor heart, individuals are classified by degrees of severity for a donor
heart, blood type, body weight, and geographic location. Individuals classified as a Status 1A have the
highest priority on the heart transplant waiting list. Individuals classified as a Status 1B have the second
highest priority on the wait list.
23 Timothy Smith
May 28,
2014
(cont’d)
Dr. Brandon,
Cardiovascular
Medicine
June 6,
2014
Mona Hot,
Physician Assistant
Clinic Neurological
Institute Epilepsy
Center
July 10,
2014
Kathy Houser,
Certified Nurse
Practitioner
July 10,
2014
Dr. Randy Young,
Cardiologist
Records Reviewed
• Randy Young, MD
• Kenneth Zuber, MD
• David Brandon, MD
• Susan Thomas MD
• Paul Howard MD
• Clinic
•
Dr. Randy Young MD
•
•
Jamie Cummings
Kevin Brandon MD
•
Kathy Houser CNP
24 Timothy Smith
Dr. Brandon discussed the possibility of
invoking 30-day 1A status to change his risk
stratification, however, Mr. Smith preferred
to wait.
Mr. Smith presented to Clinic Neurological
Institute Epilepsy Center for medical
management of epilepsia partialis.
Mr.
Smith was taking Keppra 500 mg twice a day
without side effects.
His last seizure
occurred in February 2012.
Ms. Hot
recommended continuing the Keppra until
he receives his transplant and instructed Mr.
Smith to return for follow-up in six (6)
months.
Mr. Smith presented for routine follow-up at
the VAD clinic with Ms. Kathy Houser. Mr.
Smith informed Ms. Williams that he was
feeling well.
Mr. Smith attended follow-up with Dr. Randy
Young. Dr. Young diagnosed Mr. Smith with
advanced heart failure and recommended
upgrading Mr. Smith’s status to 1A for
transplantation. Mr. Smith was instructed in
smoking and alcohol abstinence, dietary and
medication compliance, particularly salt
intake, monitoring of daily weights and blood
pressures and an exercise regimen of
walking.
1/22/15
5/20/10, 5/24/11, 11/30/11
2/10/15
12/1/11
12/1/11, 4/20/12
12/5/11, 12/7/11-12/11/11, 1/9/122/27/12, 6/28/12, 1/29/13
12/12/11-12/14/11, 12/22/11
1/9/12, 7/10/14
1/4/12
5/6/12, 5/9/12, 8/1/12, 1/29/13,
3/8/13, 4/11/13, 3/17/14,
3/17/14, 5/28/14
4/13/12, 6/28/12, 8/1/12, 8/2/12
10/23/12, 6/5/13, 7/10/14
•
•
•
•
•
•
•
•
•
•
•
•
Susan Sunshine
Paul Howard MD
Jeff Wilds MD
Bradley Little
Patty Colon
Cathy Snow
Beckey Long Hopper
Oliver W. Caminos MD
Robert Sampson MD
Bruce D. Long MD
Thomas Caper MD
Mona Hot PA
4/20/12
6/1/12
6/28/12, 6/28/12
7/5/12
7/5/12
7/24/12
10/3/12
1/18/13
9/3/13
1/15/14
3/17/14
6/6/14
Past Medical History
Marfan syndrome
Rhinoplasty
Hiatal hernia
Erosive duodenitis
Smoking history
Surgeries Related to Incident
Date
Procedure
1/30/2012
Median Sternotomy, open
heart surgery, removal of
right atrial thrombus,
implantation of HeartMate II
left ventricular assist device
(LVAD), and preperitoneal
pump pocket dissection
2/04/2012
IVC Filter Placement
2/13/2012
Open tracheostomy
2/15/2012
Redo Median sternotomy,
open-heart surgery, right
atrial thrombectomy and
bilateral pulmonary
embolectomy
March 5, 2012 Tracheostomy decannulation
March 16,
ICD placement
2012
25 Timothy Smith
Physician
Dr. Thomas Hardy
Dr. Daniel Roadway
Dr. Edward Sun
Dr. David Jones
Current Medications
Coreg (Carvedilol) 25 mg 2 tablets daily
Digoxin 250 mcg 1 tablet daily
Warfarin (Coumadin) 5 mg 1 tablet per day (dose dependent on INR results)
Warfarin (Coumadin) 1 mg 1 tablet per day (dose dependent on INR results)
Ferrous Sulfate 325 mg 2 tablets daily
Pantoprazole 20 mg 1 tablet daily
Clindamycin 1% gel topically as needed
Spironolactone 20 mg 1 tablet daily
Lisinopril 30 mg 1 tablet daily
Multivitamin 1 tablet daily
Aspirin 325 mg 1 tablet daily
Vitamin D3 1,000 IU 1 tablet twice daily
Calcium Citrate/Vitamin D 315/200 IU 1 tablet twice daily
The following information was ascertained from review of the medical records,
Ms. Cummings’ life care plan, and the depositions of Mr. and Ms. Smith.
Although requested, this Nurse Life Care Planner did not have the opportunity
to assess or speak to Mr. Smith or his physicians.
Current Symptoms/Limitations
Mr. Smith underwent placement of a left ventricular assist device (LVAD) on
January 20, 2012. He is currently evaluated every two (2) months by the LVAD
physicians at the Clinic. He and his wife were trained on the care and safety of
the LVAD regarding daily dressing changes, battery changes, and night time
power source (see page 29 for more information on the LVAD). Mr. Smith was
placed on the heart transplant list in October 2013 and is status 1B. Mr. Smith’s
wife and father are very involved in his care.
According to Ms. Boeing’s life care plan, Mr. Smith is restricted from lifting over
twenty (20) pounds and experiences shortness of breath carrying items weighing
less than twenty (20) pounds. He becomes fatigued and requires rest after
standing longer than fifteen (15) minutes, and feels short of breath when walking
short distances and climbing stairs.
Mr. Smith is independent in self-care; however, his wife performs the daily
dressing changes to his LVAD site. He is able to perform light housekeeping
chores but is not allowed to operate a vacuum cleaner due to the LVAD and risk
of shock. Mr. Smith completes lawn work with the use of a riding lawn mower
but was advised to avoid excessive exposure to the sun.
26 Timothy Smith
Psychosocial Information
Mr. Smith , a thirty-nine (39) year-old married man lives with his wife of eleven
(11) years, Cathleen, and his two daughters, Emily, nine (9), and Jocelyn, seven
(7) in a two-story home. Mr. Smith stands 6’ 11” tall and weighs approximately
190 pounds. His mother passed away from complications of Marfan syndrome
when he was a child, his daughters and two (2) brothers, David and Raymond,
also have the condition. Both brothers have undergone aortic root replacement
(the first segment that exits the heart) and Raymond had a Type B dissection (an
arterial tear).
Mrs. Young has become the family supporter since Mr. Smith is no longer
working. Mrs. Young must also perform outside chores, such as mowing the
lawn. If she did not do the work, they would have to hire it done. The home has
an outdoor wood burning stove for which Mrs. Young splits wood in order to have
heat. They do not have a furnace in the home.
Prior to the incident Mr. Smith enjoyed woodworking, hunting, bowling, hiking,
fishing and swimming. The Young family has two (2) horses on their property for
the girls. Mr. Smith helps to care for the girls but is unable to care for the horses.
Educational/Vocational Information
Mr. Smith graduated from high school and attended Holly Carsen earning an
associate degree in 1996 in electrical maintenance. Mr. Smith earned a welding
certification and is currently enrolled in an apprenticeship program to become a
Journeyman7. Mr. Smith began his apprenticeship in 2012 and still plans to
complete the process in January 2016.
Mr. Smith is a member of Boilermaker’s. Just prior to his employment at Sun
Petroleum, he worked at Flo’s, and construction companies, as a welder. He
worked at Doors from 1998 to 2000, as an electrical maintenance worker, and
from 2000 to 2007 he worked at Corporation as a welder. Mr. Smith returned to
work at Doors in 2007 through 2008. In 2008, he joined the Union, and worked
at a number of companies, including Earth Ware. Mr. Smith began working
periodically at Sun Petroleum between 2008 and 2009, and again in 2010 and
2011. Mr. Smith was laid off a week after the incident and has not returned to
work. Life Expectancy
A rated age was obtained from KP Underwriting, LLC yielding a median rated age
of seventy-eight (78) years without a heart transplant and a life expectancy of
10.3 (rounded to 10) years.
7
A journeyman is an individual who has completed an apprenticeship and is fully educated in a trade or
craft, but not yet a master. To become a master a journeyman has to submit a master work piece to a guild
for evaluation and be admitted to the guild as a master. Sometimes a journeyman is required to accomplish
a three-year working trip which may be called the journeyman years.
27 Timothy Smith
A rated age was obtained from KP Underwriting, LLC yielding a median rated
age of sixty-four (64) years with a heart transplant and a life expectancy of 19.9
(rounded to 20) years.
Nursing Diagnosis
• Risk for imbalanced fluid volume (Domain 2. Nutrition, Class 5.
Hydration) –Vulnerable to a decrease, increase, or rapid shift from one to
the other of intravascular, interstitial, and/or intracellular fluid, which
may compromise health. This refers to body fluid loss, gain or both.
• Impaired gas exchange (Domain 3. Elimination and Exchange, Class
4. Respiratory function) – Excess or deficit in oxygenation and/or carbon
dioxide elimination at the alveolar-capillary membrane.
• Disturbed sleep pattern (Domain 4. Activity/Rest. Class 1. Sleep/rest)
time-limited interruptions of sleep amount and quality due to external
factors.
• Fatigue (Domain 4. Activity/Rest. Class 3. Energy Balance) – An
overwhelming sustained sense of exhaustion and decreased capacity for
physical and mental work at the usual level.
• Activity intolerance (Domain 4. Activity/Rest, Class 4.
Cardiovascular/Pulmonary Responses) – Insufficient physiological or
psychological energy to endure or complete required or desired daily
activities.
• Decreased cardiac output (Domain 4. Activity/Rest, Class 4.
Cardiovascular/Pulmonary Responses) – Inadequate blood pumped by
the heart to meet the metabolic demands of the body.
• Risk for impaired cardiovascular function (Domain 4.
Activity/Rest, Class 4. Cardiovascular/Pulmonary Responses) –
Vulnerable to internal or external causes that can damage one or more
vital organs and the circulatory system itself.
• Risk for decreased cardiac tissue perfusion (Domain 4.
Activity/Rest, Class 4. Cardiovascular/Pulmonary Responses) –
Vulnerable to a decrease in cardiac (coronary) circulation, which may
compromise health.
• Risk for ineffective peripheral tissue perfusion ((Domain 4.
Activity/Rest, Class 4. Cardiovascular/Pulmonary Responses) –
Decrease in blood circulation to the periphery that may compromise
health.
• Death anxiety (Domain 9. Coping/Stress Tolerance, Class 2. Coping
Responses) – Vague, uneasy feeling of discomfort or dread generated by
perceptions of a real or imagined threat to one’s existence.
Summary
Mr. Timothy Smith has a pre-existing history of Marfan syndrome, a genetic
disorder that affects the body’s connective tissue. The connective tissue provides
strength, support, and elasticity to tendons, cartilage, heart valves, and other vital
28 Timothy Smith
parts of the body. Connective tissue is made up of proteins. The protein that
plays a role in Marfan syndrome is called fibrillin-1. Marfan syndrome is caused
by a defect (or mutation) in the gene that tells the body how to make fibrillin-1.
This mutation results in an increase in a protein called transforming growth
factor beta, or TGF-β. The increase in TGF-β causes problems in connective
tissues throughout the body, which in turn creates the features and medical
problems associated with Marfan syndrome. Among these medical problems is
aortic enlargement which can lead to dissection or rupture of the inner layers of
the aorta. Aortic dissection can be deadly and surgery is required to replace the
affected part of the aorta.
Physical characteristics of a person with Marfan syndrome may include:
• Long arms, legs and fingers
• Tall and thin body type
• Curved spine
• Chest sinks in or out
• Flexible joints
• Flat feet
• Crowded teeth
• Stretch marks on the skin not related to weight gain or loss.
A person with Marfan syndrome may also have a leaky aortic or mitral valve (the
valve that controls the flow of blood between the two left chambers of the heart).
This problem can damage the left ventricle (the lower chamber of the heart that is
the main pumping chamber) or cause heart failure. Mr. Smith has suffered heart failure and now requires a heart transplant.
Potential Complications
Left Ventricular Assist Device
The left ventricular assist device (LVAD) is used in patients with heart failure as
bridge therapy when the person is waiting for a heart transplant, destination
therapy for someone who is not going to have a transplant, or for temporary
measure for some reversible issue such as endocarditis. The device includes the
pump, external cable, external controller, and batteries. This device is necessary
because the left ventricle is not pumping adequately. Blood flows through the
device into the left ventricle of the heart and is sent as a continuous flow into the
right side of the heart, then out from the aorta to the body.
Possible complications of the device include: drive line infection or sepsis,
bleeding (cerebral or gastrointestinal), pump thrombosis (blood clot), pulmonary
emboli, left ventricular suction event (pump pressure too high and collapses the
left ventricle), aortic insufficiency (the blood flows down the aorta not out to the
body), and problems with the right side of the heart such as ventricular
fibrillation, or myocardial infarction (heart attack).
29 Timothy Smith
The patient with a LVAD will not have a pulse. The hum of the pump can be
heard to determine if the pump is working. The patient will not have a blood
pressure but will have a mean arterial pressure when a blood pressure cuff is
applied. Cardio pulmonary resuscitation should never be performed due to
possible damage to the pump at the insertion site to the heart resulting in
bleeding.
Heart Transplant Wait List
Heart Transplant is a lifesaving surgical procedure to replace a person’s diseased
heart with a healthy heart from a deceased person (donor). Heart transplantation
is considered when there are no other medical or surgical options available to the
patient. Ninety percent of heart transplantations are done on persons who have
end-stage heart failure. End-stage means that the condition has become so severe
that all treatments other than heart transplant have failed. Donor hearts are in
short supply, so individuals who need a heart transplant go through a careful
selection process at a heart transplant center. Persons who are eligible for a heart
transplant are placed on a waiting list.
The United Network for Organ Sharing (UNOS) manages the heart transplant
waiting list. In order to determine priority for receipt of a donor heart, the UNOS
eventually ranks potential recipients. Factors affecting ranking may include
tissue match, blood type, length of time on the waiting list, immune status and
the distance between the potential recipient and the donor.
(http://www.unos.org/donation/index.php?topic=fact_sheet)
Individuals classified as Status 1A have the highest priority on the heart
transplant waiting list. Status 1A are individuals who must stay in the hospital as
in-patients and require high doses of intravenous drugs, OR require a VAD
30 Timothy Smith
(ventricular assist device) for survival, OR are dependent on a ventilator OR have
a life expectancy of a week or less without a transplant.
Individuals classified as Status 1B are generally not required to stay in the
hospital as in-patients. These individuals may also require a VAD (ventricular
assist device) or low doses of continuous intravenous medications; however they
are stable enough to remain at home with regular follow-up. Individuals
classified as Status 1B have the second highest priority on the heart transplant,
wait list.
Requirements include a medical report of physical findings including a statement
that the person has been placed on the heart transplant waiting list, chest x-ray,
electrocardiogram, echocardiogram, cardiac catherization, and cardiac magnetic
resonance imaging.
There is currently a shortage of donor hearts available for the approximately
3,000 people on the waiting list for a heart transplant in the United States.
Organs are matched for blood type and size of donor and recipient. A person can
be taken off the waiting list if a serious medical event such as a stroke, infection,
or kidney failure develops. Time spent on the heart transplant waiting list is a key
factor in determining who receives a donor heart. Another factor that is taken
into consideration is the urgency of need. Some individuals die while waiting for
a suitable donor heart due to the current shortage of available donor hearts.
Persons on the waiting list for a donor heart receive ongoing treatment for heart
failure and other medical conditions such as irregular heartbeats (arrhythmias).
These conditions can cause sudden cardiac death. Depending on the severity of
their condition, some persons receive mechanical assist devices such as
implantable cardioverter defibrillators (ICDs) to control the irregular heartbeat
or a VAD to help the heart pump blood. These devices serve as bridges to the
heart transplant surgery, to enable the patient to survive until the transplant can
be performed. Heart transplant surgery carries many risks including rejection of
the donor heart. Signs of rejection include shortness of breath, fever, fatigue,
weight gain, and reduced amounts of urine resulting from kidney problems.
Other complications include medication reaction, infection, and cancer. Cardiac
Allograft Vasculopathy (CAV), a blood vessel disease, may develop. (The official
website of the U.S. Social Security Administration, Program Operations Manual
System (POMS) 7/29/2011).
Clinic Heart Transplant Clinic
The Clinic heart transplant clinic is registered with the Scientific Registry of
Transplant Recipients. The center currently has one hundred (100) patients
registered for transplant and the majority are in the 1B class. Clinic completed
sixty-five (65) transplants in 2014. The length of wait time is dependent on the
availability of a donor heart, the recipient’s age, blood type, and clinical status.
According to the SRTR registry, one quarter (1/4) of the patients in the program
31 Timothy Smith
received a transplant thirty-six (36) months after being placed on the waiting list.
The other three quarters (3/4) were either still waiting or removed from the
waiting list. At the Clinic, 66.7% of adult patients were alive one year after
transplant.
While it is not possible to predict with absolute certainty all future medical and
technological advances or associated complications pertaining to Mr. Smith’s
case, the Nurse Life Care Plan tables reflect what can be reasonably anticipated
for Mr. Smith’s future medical and non-medical needs based on the information
provided. The Nurse Life Care Plan is a projection of Mr. Smith’s current and
future medical and non-medical needs. I reserve the right to amend the plan
should Mr. Smith’s condition change or updated medical information becomes
available.
Thank you for the opportunity to assist with Mr. Smith’s case.
Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP, CBIS
Certified Nurse Life Care Planner
32 Timothy Smith
Resources:
Nolan, S., Ionescu, A. Accidental Cold Water Immersion: an Unusual Cause of
Stress Cardiomyopathy in a Patient with Marfan syndrome and Aortic Exostent.
Int. J. Cardiology 151 (3): e98-9, 2011
Schofield, P. M., & Corris, P. A. (Eds.). (1998). Management of heart and lung
transplant patients. Travistock Square, London: BMJ Books, BMA House.
Hricik, D. (Ed.). (2011). Primer on transplantation (3rd Ed.). West Sussex, UK:
Wiley-Blackwell.
Gray, H. (1977). Anatomy descriptive and surgical. New York, NY: Crown
Publishers.
Weed, R. O., & Berens, D. E. (2010). Life care planning and case management
handbook (3rd Ed.). Boca Raton, FL: CRC Press.
Wallach, J. (1996). Interpretation of diagnostic tests (6th Ed.). Boston, MA:
Little, Brown and Company.
Hunt, S. A., Abraham, W. T., Chin, M. H., & Feldman, A. M. (2005). Stages of
heart failure (new classification). In The clinician's ultimate reference (pp. 154235). Retrieved from http://circ.ahajournals.org/cgi/content
National Institutes of Health. (2011, November 9). What is an implantable
cardioverter defibrillator [Fact sheet]. Retrieved January, 2015, from National
Heart, Lung, and Blood Institute website:
http://www.nhlbi.nih.gov/health/health-topics/topics/icd
Mayo Clinic Staff. (2013, February 1). Heart disease and Marfan syndrome [Fact
sheet].
Retrieved
January,
2015,
from
WebMD
website:
http://www.webmd.com/heart-disease/guide/marfan-syndrome
The Clinic Heart and Vascular Institute. (2015, January 28). Left ventricular
assist device (LVAD) for heart failure [Fact sheet]. Retrieved February, 2015,
from WebMD website:
http://www.webmd.com/heart-disease-failure/left ventricular-assist-device
Heart health center [Fact sheet]. (2014). Retrieved January, 2015, from
www.WebMD.com website: http://www.webmd.com/heart/picute-of-the-heart
JNLCP XV. Transplantation ….. Kathie Allison, PT, MS, CLCP (“Organ
Transplant Overview”)
http:/my.clevelandclinic.org/services/transplant-center/transplantprograms/heart-transplant-program
33 Timothy Smith
http://hearttransplant.com/biopsies.html
ww.goodrx.com
Pinney, S. P. (2012). Timing isn't everything: donor heart allocation in the
present LVAD era. Journal of the American College of Cardiology, 60(1), 52-53.
Yamani, M. H., & Taylor, D. O. (n.d.). Heart Transplantation. Retrieved March
30, 2015, from http://www.clevelandclinicmeded.com
Slaughter, M. S. (2011). UNOS status of heart transplant patients supported with
a left ventricular assist device. Texas Heart Institute Journal, 38(5), 549-551.
The official website of the U.S. Social Security Administration, Program
Operations Manual System (POMS) 7/29/2011
http://www.unos.org/donation/index.php?topic=fact_sheet
Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). Nursing diagnoses definitions
and classification (10th Ed.). Chicester, West Sussex: Wiley Blackwell.
The following Nurse Life Care Plan Tables outline the recommendations for Mr.
Smith’s current and future needs based on the review of the medical records and
on the experience and knowledge of this Nurse Life Care Planner.
The life care plan tables represent recommendations based on Mr. Smith’s life
expectancy:
1) Without a heart transplant using the Ohio Bureau of Workers’
Compensation fee schedule
2) With a heart transplant using the Ohio Bureau of Workers’ Compensation
fee schedule
3) Without a heart transplant using usual and customary costs
4) With a heart transplant using usual and customary costs
34 Timothy Smith
35 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Projected Evaluations Recommendations Indication Dietician Evaluation Monitor (97803) Nutrition Duration Frequency/Replacement Begin/End 2015-­‐2021 Annually to LE Mr. Smith is on a low salt cardiac diet. Cost obtained from Medical Fees 15 for Mr. Smith’s geographical area (75%) Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP UCR Per Visit $53.98 Per Year $53.98 Life Time Cost $323.88 Comment 36 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Supplies Recommendations Indication Duration Frequency/Replacement Begin/End Used to Clean LVAD Chlorhexidine 4 oz. 2015-­‐2021 Tubing Insertion Site Used at LVAD Dressing Kits LVAD Tubing 2015-­‐2021 Insertion Site HeartMate II Left Ventricular Assist Device (LVAD) (33979 ) (ICD9 37.65) HeartMate II Left Ventricular Assist Device (LVAD) Batteries (Q0506) Maintain Heart Function Maintain Equipment 2015-­‐2021 2015-­‐2021 1 Bottle/Month Monthly Every 8 – 10 years UCR Per Unit $4.48 Per Year $53.76 Per Unit $20.45 Per Year $245.40 Per Unit $250,000.00 Per Unit $2,500.00 4 batteries every 2 years Per Year $1,250.00 Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP Life Time Cost $322.56 $1,472.40 Comment $7,500.00 Mr. Smith received his LVAD in 2012. (Q0478-­‐0505) For informational purpose only (2) Lithium Ion Batteries 37 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Medications Recommendations Indication Duration Begin/End Frequency/Replacement UCR Life Time Cost $261.36 Comment Per Unit OTC $3.63 Osteoporosis 2015-­‐2021 Monthly Prevention Per Year $43.56 Per Unit OTC $9.39 365-­‐count (2 Aspirin 325 mg Heart Health 2015-­‐2021 Monthly $56.34 bottles) 1 tablet/day Per Year $9.39 Per Unit CVS $34.00 Digoxin (Lanoxin) 2015-­‐2021 $56.25 Walgreens $39.00 250 mcg Heart Health Monthly $4,050.00 Rite-­‐Aid $73.00 1 tablet/day Per Year Kmart $79.00 (generic) $675.00 Per Unit OTC Ferrous Sulfate 2015-­‐2021 $11.98 325 mg Iron Monthly $862.56 2 tablets/day Supplement Per Year (OTC) $143.76 Per Unit OTC $1.33 $95.76 Multivitamins Maintain Health Monthly 2015-­‐2021 1 tablet/day (OTC) Per Year $15.96 Unit cost equals monthly cost of medication. Costs obtained from www.goodrx.com for Mr. Smith’s zip code. Calcium Citrate/Vitamin D 315/200 mg) 2 tablets/day Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP 38 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Medications (cont’d) Recommendations Indication Duration Begin/End Frequency/Replacement spironolactone 2015-­‐2021 (Aldactazide) Prevent Edema 25 mg 1 tablet/day (generic) pantoprazole (Protonix) 20 mg Treatment of 2015-­‐2021 1 tablet/day Acid Reflux (generic) 2015-­‐2021 Clindamycin 1% Topical Gel Antibiotic Pneumonia Vaccine Coreg (carvedilol) 25 mg 2 tablets/day (generic) Prevent Pneumonia Maintain Blood Pressure 2015-­‐2021 Monthly Monthly Monthly One Every 5 years to LE (2 to LE) 2015-­‐2021 Monthly Unit cost represents monthly cost of medication. Costs obtained from www.goodrx.com Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP UCR Per Unit $15.67 Per Year $188.04 Per Unit $129.50 Per Year $1,554.00 Per Unit $145.00 Per Year $1,740.00 Per Unit $90.10 Per Year $18.02 Per Unit $76.50 Per Year $918.00 Life Time Cost $1,128.24 $9,324.00 $10,440.00 $180.20 $5,508.00 Comment Kmart $16.00 Rite-­‐Aid $17.00 Walgreens $17.00 CVS $14.00 Kmart $166.00 Walgreens $119.00 CVS $103.00 Rite-­‐Aid $130.00 Walgreens $145.00 Kmart $148.00 Rite-­‐Aid $74.00 Walgreens $43.00 CVS $41.00 39 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Medications (cont’d) Recommendations warfarin (Coumadin) 5 mg 1 tablet/day (generic) warfarin (Coumadin) 1 mg 1 tablet/day (generic) Vitamin D3 1,000 IU 2x/day (OTC) Indication Prevent Blood Clots Duration Frequency/Replacement UCR Begin/End Per Unit 2015-­‐2021 $24.75 Per Year Monthly $297.00 Life Time Cost $1,782.00 Prevent Blood Clots Per Unit $22.00 Per Year $264.00 $1,584.00 Per Unit $5.98 Per Year $71.76 $430.56 Supplementation 2015-­‐2021 2015-­‐2021 Monthly Monthly Unit is equal to monthly cost. Costs obtained from www.goodrx.com Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP Comment Dose is dependent on INR level Rite-­‐Aid $36.00 Walgreens $21.00 CVS $19.00 Kmart $23.00 Dose is dependent on INR level Kmart $20.00 Rite-­‐Aid $30.00 Walgreens $20.00 CVS $16.00 OTC 40 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Future Medical Care Routine Recommendations Indication Duration Begin/End Frequency/Replacement UCR Per Unit $135.92 Cardiologist 2015-­‐2021 Every 3 months Follow-­‐up (99213) Per Year $543.68 Per Unit Adjust $25.06 INR Blood Draw Coumadin 2015-­‐2021 Monthly (85610) Per Year Level $300.72 Per Unit Blood Draw 2015-­‐2021 Monthly $19.28 Venipuncture (36415) Per Year $231.36 Per Unit Complete Monitor 2015-­‐2021 Every 3 months $71.34 Metabolic Panel Health Per Year (CMP) (80053) $285.36 Per Unit Complete Blood Monitor 2015-­‐2021 Every 3 months $40.49 Count (CBC) Health Per Year (85025) $161.96 Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%). Monitor LVAD, Assess Cardiac Health Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP Life Time Cost $3,262.08 Comment $1,804.32 $1,388.16 $1,712.16 $971.76 41 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Indication Duration Begin/End Frequency/Replacement UCR Per Unit $156.17 2015-­‐2021 Every 3 months Per Year $624.68 Per Unit $135.92 Dermatologist Monitor Skin 2015-­‐2021 Annually to LE (99213) Per Year $135.92 Per Unit Monitor $927.37 Bone Density Every 2 years to LE Bone 2015-­‐2021 (78320) (3 to LE) Per Year Integrity $ Per Unit Monitor $135.92 Epileptologist Annually for 2 years Seizure 2015-­‐2021 (99213) (2 to LE) Per Year Disorder $ Per Unit Monitor $45.31 Electrocardiogram Heart 2015-­‐2021 Every 3 months to LE (93010) Per Year Function $181.24 Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%). B-­‐Type Natriuretic Peptide (BNP) (83880) Monitor Heart Function Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP Life Time Cost Comment $3,748.08 $815.52 $2,782.11 $271.84 $1,087.44 42 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Echocardiogram (93306) Indication Duration Begin/End Monitor Heart 2015-­‐2021 Function Frequency/Replacement Every 3 Months to LE Chest X-­‐ray (71010) Monitor 2015-­‐2021 Every 3 Months to LE Pulmonary Health Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%). Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP UCR Per Unit $944.72 Per Year $3,778.88 Per Unit $72.30 Per Year $289.20 Life Time Cost Comment $22,673.28 $1,735.20 43 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Transportation Recommendations Mileage Reimbursement (154.80 miles round trip) (0.56/mile) Parking Garage Fee Handicap Parking Permit (Placard) Indication Duration Frequency/Replacement Begin/End Reimbursement to 2015-­‐2021 appointments Parking to attend appointments Disability Parking 2015-­‐2021 2015-­‐2021 Every 3 months to LE Every 3 months to LE Every 5 years (2 to LE) Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP UCR Life Time Cost Comment Per Unit $86.69 Per Year $346.76 $2,080.56 Per Unit $6.00 Per Year $24.00 Per Unit $0.00 Per Yer $0.00 $144.00 $0.00 Travel from Linesville, Pennsylvania to Cleveland, Ohio 44 Nurse Life Care Plan Recommendations without Heart Transplant Cl Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 10 years (2021) Date Prepared: April 7, 2015 Annual & Lifetime Costs UCR Category Annual Costs Projected Evaluations Supplies Medications Future Medical Care Routine Transportation Totals Prepared by Nancy Zangmeister RN, CRRN, CCM, CLCP, MSCC, CNLCP $53.98 $1,549.16 $5,938.49 $6,533.00 $370.76 $14,445.39 Life Time Costs $323.88 $9,294.96 $35,703.02 $42,251.95 $2,224.56 $89,798.37 45 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Projected Evaluations Recommendations Indication Pre-­‐Transplant Team Evaluation* Evaluate Readiness for Transplant Physical Therapy Evaluation and Re-­‐evaluation (97001, 97002) Determine Need for Therapy Duration Begin/End 2016 2016-­‐2031 Frequency/Replacement UCR Life Time Cost $30,539.00 Once Per Unit $30,539.00 Per Year $ Per Unit $98.33 Per Year $98.33 $1,650.40 97001 $175.45 97002 $98.33 One Evaluation and Re-­‐evaluation Annually to LE Comment *Pre-­‐transplant evaluation includes: Surgeons, transplant nurse, nurse practitioner, cardiologists, transplant coordinator, psychologist, social worker, dietician, pharmacist, financial coordinator, physical therapist, and other physicians. Cost obtained from Cleveland Clinic financial office (basic charge) Wait time for transplant at Cleveland Clinic is typically 36 months Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%) 46 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Projected Therapeutic Modalities Recommendations Physical Therapy (97110) Indication Maintain Strength and Endurance post-­‐
transplant Duration Begin/End 2016-­‐2031 Frequency/Replacement Allow for 60 sessions over LE UCR Per Unit $193.77 Per Year $ Life Time Cost $11,626.20 Comment Cost is for 45 minute session. Additional therapy to be determined at annual re-­‐evaluation Cardiac rehabilitation for a minimum of 3 months is recommended after heart transplant. Periodic physical therapy sessions are recommended for increased strengthening, endurance, and physical mobility. Cost obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%) 47 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Medications Recommendations Indication Duration Frequency/Replacement Begin/End Prevent Immunosuppressant Rejection of 2016-­‐2031 Medications Heart Calcium Carbonate/Vitamin D 500 mg Magnesium Oxide 400 mg Clindamycin 300 mg Monthly Supplement 2016-­‐2031 Monthly Supplement 2016-­‐2031 Antibiotic prior to Dental Work 2016-­‐2031 Monthly 2-­‐4 tablets 2x/year to LE Costs obtained from www.goodrx.com for Mr. Smith’s zip code. UCR Per Unit $4,982.00 Per Year $59,784.00 Per Unit $3.00 Per Year $36.00 Per Unit $8.39 Per Year $25.17 Per Unit $0.22 Per Year $0.88 Life Time Cost $896,760.00 Comment See below for list of medications $540.00 $377.55 $26.40 OTC Cost is for 120 tablets 48 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 According to Cleveland Clinic Heart Transplantation guidelines, the following immunosuppressant medications can be used post-­‐
transplantation: Immunosuppressant Medication Cyclosporine Dose Administration Route Possible Complications 3-­‐6 mg/kg/day Oral or intravenous Tacrolimus 0.05-­‐0.15 mg/kg/day Oral or intravenous Azathioprine 1-­‐2 mg/kg/day Oral or intravenous Mycophenolate mofetil 2000-­‐6000 mg/day Oral or intravenous Sirolimus 6 mg, then 2 mg/day Oral Corticosteroids (methylprednisolone maintenance dose of prednisone) 0.0-­‐0.1 mg/kg/day Oral or intravenous Renal effects, hypertension, gingival hyperplasia, hirsutism, tremor, headache, paresthesia, flushing Renal effects, hypertension, tremor, headache, tremor, paresthesia, glucose intolerance. Macrocytic anemia, leukopenia, pancreatitis, cholestatic jaundice, hepatitis Gastrointestinal distress, leukopenia Hypertriglyceridemia, thrombocytopenia, leukopenia Cushingoid habitus, glucose intolerance, hyperlipidemia, hypertension, cataracts, myopathy, osteoporosis 49 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Future Medical Care Routine Recommendations Indication Duration Begin/End Frequency/Replacement UCR Per Unit $71.34 1st Year Allow 13 for year 1 $927.42 Complete Allow 4 year 2 Monitor 2nd Year Metabolic Panel 2016-­‐2026 Allow 3 year 3 Health $285.36 (CPM 80053) Allow 2 years 4-­‐10 3rd year $214.02 Years 4-­‐10 $856.08 Per Unit $40.49 1st Year Allow 13 for year 1 $526.37 Allow 4 year 2 Complete Blood Monitor 2nd Year 2016-­‐2026 Allow 3 year 3 Count (CBC 85025) Health $161.96 Allow 2 years 4-­‐10 3rd year $121.47 Years 4-­‐10 $485.88 Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%) Life Time Cost Comment $2,282.88 $1,295.68 50 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Indication Monitor Health Duration Begin/End 2016-­‐2026 Frequency/Replacement Allow 13 for year 1 Allow 4 year 2 Allow 3 year 3 Allow 2 years 4-­‐10 UCR Per Unit $88.69 1st Year $1,152.97 2nd Year Lipid Panel (80061) $354.76 3rd year $266.07 Years 4-­‐10 $1,064.28 Per Unit $37.60 1st Year Allow 13 for year 1 $488.80 Monitor Allow 4
y
ear 2
Magnesium 2nd Year Health 2016-­‐2026 Allow 3
y
ear 3
(83735) $150.40 Allow 2 years 4-­‐10 3rd year $112.80 Years 4-­‐10 $451.20 Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%) Life Time Cost Comment $2,838.08 $1,203.20 51 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Indication Duration Begin/End Frequency/Replacement UCR Per Unit $871.46 1st Year $11,328.98 Immunosuppressant Allow 13 for year 1 Drug Levels (80158, Monitor Allow 4 year 2 2nd Year 80197, 83789, Safe 2016-­‐2026 Allow 3 year 3 $3,485.84 80180, 80195) Levels Allow 2 years 4-­‐10 3rd Year $2,614.38 Years 4-­‐10 $10,457.52 Per Unit $19.28 1st Year Allow 13 for year 1 $250.64 Allow 4 year 2 Monitor 2nd Year Urinalysis (81015) 2016-­‐2026 Allow 3 year 3 Health $77.12 Allow 2 years 4-­‐10 3rd Year $57.84 Years 4-­‐10 $231.36 Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%) Life Time Cost Comment $27,886.72 $616.96 52 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Indication Duration Begin/End Frequency/Replacement UCR Per Unit $45.31 1st Year Allow 13 for year 1 $589.03 Electrocardiogram Monitor Allow 4 year 2 2nd Year (EKG) Heart 2016-­‐2026 Allow 3 year 3 $181.24 (93010) Function Allow 2 years 4-­‐10 3rd Year $135.93 Years 4-­‐10 $543.72 Per Unit $72.30 1st Year Allow 13 for year 1 $939.90 Monitor Allow 4 year 2 Chest X-­‐ray 2nd Year Lung 2016-­‐2026 Allow 3 year 3 (71010) $289.20 Health Allow 2 years 4-­‐10 3rd Year $216.90 Years 4-­‐10 $867.60 Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%) Life Time Cost Comment $1,449.92 $2,313.60 53 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Indication Post-­‐Transplant Laboratory Studies Monitor Health Duration Begin/End 2027-­‐2031 Frequency/Replacement Annually to LE UCR Per Unit $553.34 Per Year $553.34 Per Unit $135.92 1st Year $1,766.96 Allow 13 for year 1 2nd Year Allow 4 year 2 $543.68 Cardiologist Monitor Allow 3 year 3 2016-­‐2031 (99213) Health Allow 2 years 4-­‐10 3rd Year Annually years 11-­‐15 $407.76 Years 4-­‐10 $1,631.04 Years 11-­‐15 $679.60 Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%) Life Time Cost Comment $2,213.36 Lipids (80061) AgbA1C (83036) CRP (86140) BNP (83880) Troponin (84484) EKG (93010) $5,029.04 54 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Indication Endomyocardial Biopsy (93505, 88307) Monitor for Rejection of Heart Endomyocardial Biopsy (93505, 88307) Monitor for Rejection of Heart Duration Begin/End 2016 2017-­‐2031 Frequency/Replacement UCR Per Unit Allow 16 for year 1 $2,825.98 (1st month weekly, 2nd Per Year month every 2 weeks, 3-­‐ $45,215.68 12 every 3-­‐4 weeks. Per Unit $3,470.00 As needed Per Unit $5,371.41 2016 Allow 1 post-­‐transplant Per Year $5,371.41 Per Unit Right & Left Heart Monitor $5,371.41 Catheterizations Cardiac 2017-­‐2031 Annually Per Year (93461) Function $5,371.41 Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75% Right & Left Heart Catheterizations (93461) Monitor Cardiac Function Life Time Cost $45,215.68 Comment After the first year, the frequency of the biopsies is determined by the rejection history Cost not calculated. For information purpose only $5,371.41 $7,999.74 55 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Indication Duration Begin/End Frequency/Replacement Venipuncture (36415) Laboratory Allow 13 for year 1 Allow 4 year 2 Allow 3 year 3 Allow 2 years 4-­‐10 Annually years 11-­‐15 UCR Per Unit $19.28 1st Year 2016-­‐2031 $250.64 2nd Year $77.12 3rd Year $57.84 Years 4 -­‐10 $231.36 Years 11-­‐15 $96.40 Per Unit Echocardiogram Monitor Heart 2016-­‐2031 Allow 1 after transplant, $1,236.81 (93306) Function then yearly as needed Per Year Costs obtained from Medical Fees 2015 for Mr. Smith’s geographical area (75%) Life Time Cost Comment $713.36 $1,236.81 56 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Future Medical Care Routine (cont’d) Recommendations Indication Duration Begin/End Frequency/Replacement Coronary Angiogram (75574) Monitor Coronary Artery Disease 2016-­‐2031 Annually Intravascular Ultrasound (75945) Monitor Heart Vessels 2016-­‐2031 As needed UCR Time Cost Comment Per Unit $1,884.62 Per Year $1,884.62 Per Unit $707.58 $28,269.30 One 6-­‐8 weeks post-­‐transplant and then annually Not included in totals. For informational purposes only Mr. Smith may or may not undergo this test 57 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Acute Surgical Interventions Recommendations Indication Duration Begin/End Frequency/Replacement Heart Transplant (Surgery, Treatment for 2016 Anesthesia, Heart Failure Hospital Stay, etc.) Estimated cost obtained from financial coordinator at Clinic. Once UCR Per Unit $775,000.00 Per Year $ Time Cost Comment $775,000.00 58 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Transportation Recommendations Mileage Reimbursement (154.80 miles round trip) (0.56/mile) Parking Garage Fee Handicap Parking Permit (Placard) Indication Duration Frequency/Replacement Begin/End Reimbursement to 2016-­‐2031 appointments Parking to attend appointments Disability Parking 2016-­‐2031 2016-­‐2031 Allow 13 for year 1 Allow 4 year 2 Allow 3 year 3 Allow 2 years 4-­‐10 Annually years 11-­‐15 Allow 13 for year 1 Allow 4 year 2 Allow 3 year 3 Allow 2 years 4-­‐10 Annually years 11-­‐20 Every 5 years (2 to LE) UCR Life Time Cost Per Unit $86.69 1st Year $1,126.97 2nd Year $346.76 3rd Year $260.07 Years 4 -­‐10 $1,040.28 Years 11-­‐15 $433.48 Per Unit $10.00 Per Year $ Per Unit $0.00 Per Yer $0.00 Comment Travel from Home $3,207.53 to Clinic $280.00 $0.00 $130.00 $40.00 $30.00 $120.00 $50.00 59 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Housing/Child Care Recommendations Indication Hotel Stay Housing Daily Meals Food Hotel Stay Post-­‐Transplant Housing Duration Frequency/Replacement UCR Begin/End Per Unit 2016 7-­‐14 days $185.00 Per Year $2,590.00 Per Unit 2016 7-­‐14 days $71.00 Per Year $994.00 Per Unit 2016 4 – 6 weeks $185.00 Per Year $7,770.00 Daily Meals Food 2016 4-­‐6 weeks Child Care Attend to Children 2016 8 weeks Per Unit $142.00 Per Year $5,964.00 Per Unit $13.00 Per Year $13,312.00 Life Time Comment Cost Intercontinental Hotel 877.707.8999 $2,590.00 While Mr. Smith is in the hospital Government per $994.00 diem rate Mr. Smith will need to live near the $7,770.00 hospital for 4-­‐6 weeks after transplant $5,964.00 Unit Cost is equal to hourly rate $13,312.00 16 hours/day during school days, 48 hours on weekend 60 Nurse Life Care Plan Recommendations with Heart Transplant Client: Timothy Smith Diagnosis: Heart Failure Life Expectancy: 20 years (2031) Date Prepared: April 7, 2015 Lifetime Cost Projection URC Category Projected Evaluations Therapeutic Modalities Medications Future Medical Care Routine Future Surgical Intervention Transportation Housing/Child Care Totals Annual Totals $98.33 $59,846.05 $104,025.90 $3,577.56 $167,547.84 Life Time Totals $32,189.40 $11,626.20 $897,703.95 $135,935.74 $775,000.00 $3,577.56 $30,630.00 $1,866,662.85 Review of the Life Care Plan for Lucy Adams
November 9, 2010
This report has been prepared as a response to the Life Care Plan submitted for Ms. Lucy Adams,
a 58-year-old woman who sustained an incomplete spinal cord injury at C5-6 on January 10,
2002, at age 50, resulting in quadriplegia.
To simplify comparison, the sections in this report follow the outline given in the Life Care
Plans prepared by Anna M. Monroe SCM OT(C) dated November 18, 2004 and August 28,
2008, presented by the plaintiff’s attorney, Ms. Mary P. Jefferson.
It is noted that Dr. Madison, Ms. Monroe, and Ms. Lincoln are treating Ms. Adams and that Ms.
Monroe is the owner of a medical supply concern with billing to this patient’s account.
The following records were used and referenced in the preparation of this report:
Ms. Monroe
Life Care Plans
11/18/2004, 8/28/2008
Ms. Monroe
Occupational Therapy Report
2/13/2009
Dr. M. George Washington Expedited Medical Report Addendum
1/10/2005
Mary Lincoln
Physiotherapy Report
6/7/2006
Assorted 2002-2005
Receipts for drugs and supplies, unlabeled
Ms. Lincoln
Physical Therapy Evaluation
2/26/2009
Ms. Lincoln
Addendum letter to Atty Jefferson
6/19/2009
Dr. Madison
Record review and examination
4/15/2010
Ms. Jefferson
Initial Filing
AA Johnson Ltd.
Quotation Ref# AA4350/RR
10/21/2010
ABC Rehab
Quotation for selected items
11/9/2010
THIS REPORT IS ATTORNEY INTERNAL WORK PRODUCT AND NOT TO BE
PRODUCED IN EVIDENCE.
Lucy Adams
November 9, 2010
Re: Life Expectancy
According to statistics compiled from the UN and other sources, Island life expectancy is
comparable to 95% of US life expectancy 1; in Ms. Jefferson’s Initial Filing, Dr. George Madison,
therein identified as a psychiatrist but actually a physiatrist with a specialty in pain management,
opined that Island citizens enjoy a level of health that brings them to high levels of life
expectancy. The most recent US National Vital Statistics Reports indicate that the life expectancy
for a black woman of age 57-58 is 24.2 more years,2 to age 82. Ninety-five per cent of this figure
is 77.9 years, 19.9 more years from now.
The Island Statistical Service reports that life expectancy for a 58-year-old female is 27.8 more
years, 3 to age 86.8.
In the Initial Filing, Dr. Washington is quoted in 2004 as estimating Ms. Adams’ life expectancy
to be decreased by 13 years, although his source is not quoted and normal life expectancy is not
given. Applying Dr. Washington’s estimate of a decrease of thirteen years to the above statistics,
life expectancy would be between 6.9 and 14.7 more years, an average of 10.8 years from now.
The Initial Filing cites Dr. Madison in 2010 variously opining that life expectancy is 20-25 years,
to age 78-83. He cites Ms. Adams’ general good condition, attitude, and lack of ongoing
complications, and references statistics from the National Spinal Cord Injury Statistical Center
(NSCISC). However, according to the NSCISC, for persons with a C5-8 SCI without ventilator
dependence and who survive at least one year post injury sustained at age 50, life expectancy is
15.7 years after injury, i.e., to age 65.7, 7.7 years from now.4 A second table notes that for a
person with this level injury who has attained the age of 55-60 regardless of age at injury, life
expectancy is between 13.1 and 10.1 years, respectively.5 These tables are appended on page
16 of this report. Therefore an estimate of 20-25 more years is not supported by this source.
This range is also congruent with Dr. Washington’ estimate of a decrease of 13 years.
1 Wolfram Alpha database, 2010
2 National Vital Statistics Reports, Vol. 58, No. 10, March 3, 2010, http://www.cdc.gov/nchs/fastats/lifexpec.htm, table 9, retrieved
3/26/2010
3 Personal communication from Smith J, statistician, Socio-Economic Statistics Division, Island Statistical Service, 10/13/2010
4 National Spinal Cord Injury Statistical Center, Birmingham Alabama, Table 12, February 2010
5 NSCISC, ibid., Table 13
2
Lucy Adams
November 9, 2010
The use of the life expectancies in the tables in this report are for comparison only and is not
meant to imply agreement with a particular life expectancy.
On costs:
Each item is listed in the order given in the Monroe life care plans submitted, with subsequent
columns giving discussion on the appropriateness or other features of each item. The next
columns give the annual cost proposed by Monroe and the actual appropriate cost supported by
standards of care, research into current costs, and other factors as given in the discussion. The
final columns give one-time costs. While there are many duplicated items or items that are
completely inappropriate, note that this plan prepared by a non-nurse ignores some required
items for care, such as pain medications, and adds several which are not in use and have not been
for some years. Refer to the discussions as noted in the tables to clarify these discrepancies.
When costing out large items with known replacement intervals, it is often not appropriate to
give an “annual” cost when working with life expectancy. For example, an item which costs
$1000 and must be replaced every five years for a person with a life expectancy of 13 years from
now must be costed thus:
•
•
First purchase, year 0 (now)
Second purchase, end of year 5
•
•
Third purchase, end of year 10 (last purchase, will outlast life expectancy)
Total cost for life expectancy, $3000
If one were to calculate this item at $200/year and multiply that times 13 years, the total of
$2600 would not cover the required time period.
However, if the item were already in use, having been bought two years before today, (year -2)
costing hence is properly done thus:
•
First purchase, end of year 3
•
•
Second purchase, end of year 8 (last purchase, as life expectancy ends at end of year 13)
Total cost for life expectancy, $2000
In this example, if one were to calculate this item at $200/year and multiply that times 13 years,
the total of $2600 would be excessive for the required time period.
3
Lucy Adams
November 9, 2010
Durable medical equipment comes all of a piece. One cannot purchase one half of a year of a bed
and it is meaningless to budget for it in that manner. If the above replacement comes due at one
year before life expectancy, the replacement in full is indicated.
Therefore only annual amounts for goods or services which are provided truly annually, e.g.,
medications, disposable supplies, medical office visits, and nursing hours, should be costed on an
annual basis. For comparison, the summary table below gives an annual total from the tables
using the methodology used by Monroe for all items, but these should properly be recalculated in
their entirety for all durable goods taking into account what is already in use.
Costs noted here are from suppliers as given. If Monroe’s costs are lower, they are used. If other
supplier’ costs are lower, they are used as noted. Occasionally one-time costs are given instead of
an annual cost; in all cases these are less than annual replacement over many years.
Re suppliers:
Re Mrs. Anna Monroe, Occupational Therapist, research reveals that Mrs. Monroe is the
Managing Director of Island Rehab, “ … leading supplier of rehabilitation and home care
products in Island,” (according to their Website at www.xxxxxxxx.com/.htm). They are
representatives for Invacare, a well-known line of rehabilitation products, and won the Growth
Award for Latin America and South America from Invacare Corporation in 20xx. As noted in
individual line items in the charts, some prices were obtained from another Invacare dealer, AA
Johnson Ltd., Christ Church, Island; ABC Rehab; and from Clinton Medical Supply, XYZ
Medical Centre, St. Anselm.
All prices included in the Review are based on today’s Island dollars (ID) and are obtained from
suppliers, facilities, pharmacies, vendors, and providers as available. Prices should be assumed
to be negotiable. Equipment maintenance varies with individual needs and frequency of
equipment use. Costs do not reflect inflationary trends of the health care industry. Allowances
for inflation and any medical care cost trends should be determined by a qualified Economist.
This report may be amended or supplemented upon receipt of additional medical records or
evaluations. Opinions expressed are held to a reasonable degree of professional certainty.
4
Lucy Adams
November 9, 2010
This Review cannot guarantee absence of errors and omissions, nor can it guarantee particular
outcomes with suggested interventions. The author reserves the right to amend or supplement it
upon receipt of additional medical records, evaluations, or billings.
Summary of Total Annual Costs by Modality
Annual Costs
One-Time Costs
Monroe
Howland
Monroe
Howland
MD specialty care
$20,598
$2,906
PT/OT
$20,800
$400
Medications
$4,570
$175
$45,968
$3,481
$800
Wheelchair
$4,790
$2,029
$1,272
Supplies
$26,085
$1,640
Medical Care
TOTAL
$800
Medical Equipment
Therapeutic
exercise equipment
TOTAL
$11,979
$18
$10,609
$150
$42,854
$3,687
$10,609
$1,422
Diagnostic Testing
$3,100
$972
$96,000
$39,805
$26,000
$0
$13,000
$0
$135,000
$39,805
$226,922
$47,945
$10,609
$2,222
Future Domestic
and Nursing Care
and Assistance
Home nursing
Housekeeping
Driving
TOTAL
GRAND TOTAL
Note that Ms. Adams is likely receiving medications which Monroe did not include in her plan. If desired,
refer to previous draft of 11/9/2010 for gabapentin and NSAID costs to include.
5
Lucy Adams
November 9, 2010
Cost Projections by Modality
Future Domestic and Nursing Care and Assistance
Note: The NSCISC gives hours of care for a C6 level of injury living alone thus: personal care, 6 hours per day and
homemaking (including meals and home management), 4 hours per day. Interquartile range is 8-24 hours with a
median of 17 hours; note that this would be for a complete (ASIA A) SCI and Ms. Adams has an incomplete (ASIA
D) injury. Assumption is that patient is appropriately able to direct her own care if needed, which is reasonable
given Dr. Madison’ description. Twelve hours per day of unlicensed care, plus family involvement, is generous.
Consortium for Spinal Cord Medicine, Outcomes Following Traumatic SCI: Clinical Practice Guidelines for
Health-Care Professionals, pp 13-20, Washington DC, Paralyzed Veterans of America, 1999, in Life Care Planning
and Case Management Handbook, 3rd ed., Weed RO and Berens DE, CRC Press, Boca Raton FL, 2010
NSCISC = National SCI Statistical Center, University of Alabama Birmingham Department of Physical Medicine
and Rehabilitation
Annual
Item (Monroe)
Practical nurse, 24
hrs/day, $8000/
month
Housekeeper, 7
days/week, $500/
week
Driver, 3 days/
week, $250/week
TOTAL
Costs
One-Time Costs
Monroe
Howland
Monroe
According to Dr. Washington, 24-hour
care is not indicated at this point. Many
more severely-affected persons with SCI
do not need 24-hour licensed care. 8-12
hours per day of care from a certified
nursing aide would be appropriate, with
family assistance, and supervision from
an RN monthly. According to Clinton
Medical Supply in St. Anselm, average
wages for home nursing in Island are:
• RN, $25 - 40/hour ID (av. $32)
• nursing aide, $8-10/hour ID (av.
$9)
Therefore, 12 hours per day of personal
care would cost $108 x 365 days =
$39,420, plus 12 hours per year RN
supervision = $385
$96,000
$39,805
I am not familiar with Island law in this
respect; however, if there are adults living
in a home, it is reasonable to expect that
they would perform these duties as need
for them is not dependent on presence or
absence of her injury. See Note above, in
which four homemaker hours is included
in the total home care hours; this assumes
patient is living alone without family
members.
$26,000
$0
I am not familiar with Island law in this
respect; however, if there are adults living
in a home, it is reasonable to expect that
they would perform these duties using the
family vehicle. No indication that Ms.
Adams would need transportation in this
range.
$13,000
$0
$135,000
$39,805
Discussion (Howland)
Howland
6
Lucy Adams
November 9, 2010
Home Care Equipment
Wheelchair Needs/Mobility/Maintenance Chair model is not specified by Monroe. Unknown when present
chair was purchased so replacement date cannot be used. Fitting changes may be indicated with weight change, can
be evaluated annually. The wheels will likely need to be replaced every 2 years (not noted by Monroe). A specialty
wheelchair cushion lasts approximately one year when used daily, not two years as noted by Monroe. The chair will
require repairs every 1-2 years and replacement every 5-7 years.
Note that it would have been appropriate for Monroe to include vehicle modifications, e.g., a carrier installed on a
tow-ball, to carry the power chair after Ms. Adams is seated in the vehicle (she is noted to be able to do transfers), or
modifications to a van to allow her to roll in and tie down. It is not appropriate to include the full cost of a van;
average cost of a vehicle should be subtracted from any vendor estimate, since it is assumed that everyone has a car.
Van replacement is estimated at ten years; modifications, e.g., lift and tie-downs, can be moved to a new vehicle
without replacement.
Annual
Item
(Monroe)
Costs
One-Time Costs
Monroe
Discussion (Howland)
Monroe
Howland
Power chair
Brand and features not specified. However, a
representative power chair is the Invacare
51LXP, $10,117 ID with battery and charger
from AA Johnson; an unspecified model from
ABC is $7893 (without charger). A chair
should be replaced every five to seven years
(average 6). Wheelchair should be fitted by a
seating specialist, not a vendor or caregiver.
Has a chair now; document date of purchase
and do not count costs against annual sum
until this one needs replacement. Charger does
not need annual replacement.
$2,400
$1,686
Extra battery
(First year cost $0) Battery = $799 from AA
Johnson, $753 from ABC, does not need
replacement annually. One time cost. See also
comment above.
$325
$0
Maintenance
Should be included in wheelchair clinic annual
eval by certified seating therapist, not vendor
$450
$0
Roho cushion
and rigidizer
Roho DuroGel-Foam cushion, $111 ID, should
be replaced annually. Rigidizer is part of
wheelchair options and is a one-time cost, $52
per AA Johnson; cushion is $447 from ABC.
$500
$111
Incontinence
cushion covers
(2)
Not indicated; diapers, disposable pads will
serve this function, cover is impervious
$100
$0
Wheelchair
fleece liners (2)
Two liners is reasonable for skin protection,
replacement every two years as they will not
be in constant use. ABC price, $85
$400
$85
Acrylic lapboard
With wheelchair, lap tray, $162 USD / $324
ID, seven years. ABC price, $430/7 = $61
$115
$47
Manual transport
chair
Inexpensive manual chair for emergency
transport only, no replacement anticipated due
to low use, $421 per AA Johnson
$200
$0
Howland
$799
$52
$421
7
Lucy Adams
November 9, 2010
Annual
Item
(Monroe)
Maintenance
Discussion (Howland)
Minimal maintenance beyond normal
household capabilities (lubricating bearings,
tightening bolts, etc.)
TOTAL
Costs
One-Time Costs
Monroe
Howland
Monroe
$300
$100
$4,790
$2,029
Howland
$1,272
Supplies
Note also that Ms. Lincoln, in her addendum letter to Atty. Jefferson, opines that since Ms. Adams will not be able to
be independent in the kitchen or bath, the long list of items for independent function given in the plan are not
appropriate. Objects falling under this category, or objects found in any home and/or not related to injury include:
shower grab bars, pull-down toilet safety bars, shampoo assist, toenail scissors, button hook and scissors pull, rocker
knife, T-handle knife and carry case, can opener, jar opener, pan handle stabilizer, cooking utensils, cutting board,
spreading board, electric chopper, and roller knife. As these were not included in the summary from Atty Jefferson I
do not include them here. Home modifications for kitchen accessibility and independence are likewise not
indicated according to Ms. Lincoln’s addendum.
Annual
Item (Monroe)
Costs
One-Time Costs
Monroe
Discussion (Howland)
Monroe
Howland
“Routine
supplies:
incontinence
pads, lotions,
disinfectants”
Billing documentation for current use needed,
otherwise not substantiated. Also subtract
Nizoral cream, $840, seen under Medication,
not related to injury. Incontinence pads at
$370 for box of 150 at AA Johnson, assume
3 /day, 8 boxes per year, $2900. Disinfectants
in addition to normal household cleaning
supplies already in use are not needed for
home care.
$2,400
accept
“Disposables
(diapers, urinary
condom
catheters, urine
bags, tubing)”
According to reports received, Ms. Adams
does not have an indwelling catheter and is
successfully managing her bowels using a
commode chair (supra). Condom catheters are
not used by females.
Four adult diapers per day, on average, is
reasonable, cost $3080 ID per Monroe LCP
2004 (Monroe gives cost of $1540 ID / yr for
2 a day, total amounts unchanged in 2008
plan)
$5,000
$1,540
Wound care
supplies
No documentation of any wounds found.
Several mentions that skin is without wounds.
$6,000
$0
Antibiotics
Billing to establish history is not presented.
Duplicate in Medications
$2,000
$0
Howland
8
Lucy Adams
November 9, 2010
Annual
Item (Monroe)
Discussion (Howland)
Costs
One-Time Costs
Monroe
Howland
Monroe
Medication
related to head
injury
Billing to establish history is not presented.
According to Madison MD 2009 evaluation,
none in use. No current head injury sequelae
documented.
$5,000
$0
Therapeutic
pressure gradient
support hose
Should have two pair per year. AA Johnson
has these for $57 / pair; ABC, for $99 / pair
$40
accept
Indwelling
urinary catheters
No indwelling catheter by documentation
$350
$0
Catheterization
kits
No indwelling catheter by documentation, no
cath kits needed (also no RN to change caths
every 3 weeks, see Domestic Care)
$610
$0
Leg bags
No indwelling catheter by documentation, so
no need for drainage bag
$780
$0
Bedside urine
bags
No indwelling catheter by documentation, so
no need for drainage bag
$260
$0
Knee-high
therapeutic
pressure gradient
support hose
Duplication of hose above
$1,080
$0
Ball-style right
finger wrist
splint
Not indicated by Madison MD evaluation
$140
$0
Functional right
wrist splint
Not indicated by Madison MD evaluation
$140
$0
Serial splinting
right wrist and
fingers
Duplication of splints above
$450
$0
Bilateral anklefoot orthoses
(AFO)/bed use
Madison MD evaluation indicates these are
not necessary as no weightbearing is expected.
$80
$0
Bilateral anklefoot orthoses
(AFO)/custom
Duplication of item above, not indicated
$480
$0
Supportive
footwear (laced
trainers)
Since Ms. Adams will not be bearing weight
and walking, shoes will not wear out rapidly,
so replacing shoes more often than annually is
not indicated. Shoes are cosmetic only, no
support required for non-weightbearing. Soft
slippers would be more appropriate and
decrease the risk of pressure injury.
$975
$100
Howland
9
Lucy Adams
November 9, 2010
Annual
Item (Monroe)
Bilateral back
slabs
Costs
One-Time Costs
Monroe
Discussion (Howland)
Monroe
Howland
Duplication, because power chair includes
seating support and cushion rigidizer. Madison
MD evaluation notes neurological
preservation of trunk stability for upright
seated posture.
$300
$0
$26,085
$1,640
TOTAL
Howland
Medical Care/Follow up
Annual
Item
(Monroe)
Urology, 2/yr
Discussion (Howland)
Annual urological exam is reasonable. Check
cost for office visit with MD office. Receipts
indicate cost in the $150 range for MD office
visits.
Costs
Monroe
Howland
$300
$150
Neurology,
2/yr
Not indicated. Neurological status is stable.
Neurological monitoring is part of primary care.
$1,000
$0
Physiatry, 4/yr
Twice annual is reasonable to oversee condition
and suggest changes in plan, if any. Check cost
for office visit with MD office. Receipts indicate
cost in the $150 range.
$800
$300
Home care
physician/
primary care,
6/yr
Office visit twice yearly is appropriate; allow
two extra visits every two years, yielding three
visits per year on average. Check cost for office
visit with MD office. Receipts indicate cost in
the $150 range.
$900
$450
Ophthalmology
Annual ophthalmological exam is a normal
expense for someone who needs glasses, not
related to injury.
$650
$0
Gynaecology
Every woman should have routine
gynaecological screens. Not related to injury.
$300
$0
Psychiatry,
12/yr
Ms. Adams has never been described as
depressed; is noted as “wear(ing) a constant
smile” in Initial Filing. Dr. Madison notes no
depression history or present condition.
Allowance for periodic counseling might be
appropriate, but there is no evidence at all that
ongoing counseling is indicated at this point.
$1,800
$100
One-Time Costs
Monroe
Howland
10
Lucy Adams
November 9, 2010
Annual
Item
(Monroe)
Discussion (Howland)
Costs
Monroe
Howland
$173
$0
Registered
Nurse, once per
3 wks “Change
catheter and
catheter kit”
Ms. Adams has not had an indwelling catheter
for several years. RN monthly to supervise
unlicensed personnel in home is reasonable.
Cost listed above under Domestic Nursing.
Podiatrist every
6 weeks
SCI patients can experience foot problems. Feet
can be monitored for lesions daily during
bathing by unlicensed personnel and by RN at
monthly visit. Twice-annual visit is reasonable
for nail care. Assuming $675 is accurate for
eight visits per year, each visit is $78.
$675
$156
No history to support this much hospital
admission. It might be reasonable to assume one
admission every two years for infection
according to Dr. Washington; he also felt costs
of $2000 per day were excessive. Allowed for
five inpatient days every two years at $700/day.
$14,000
$1,750
$20,598
$2,906
Acute Hospital
Care
TOTAL
One-Time Costs
Monroe
Howland
$0
$0
Physical and Occupational Therapy
Annual
Item
(Monroe)
Physical
therapy
Occupational
therapy
TOTAL
Costs
One-Time Costs
Monroe
Discussion (Howland)
Monroe
Howland
Howland
No frequency given. At eight years post injury,
Ms. Adams should be completely transitioned
to home care with maintenance range of
motion and stretching directed by patient and
performed by unlicensed personnel or family
members with supervision from licensed
personnel twice yearly after four visits, once
weekly, at discharge home. Cost for one
supervisory PT visit per receipts = $100 ID per
visit.
$10,400
$200
$400
No frequency given. At eight years post injury,
Ms. Adams should be completely transitioned
to home care with assistance for ADLs
directed by patient and performed by
unlicensed personnel or family members with
supervision from licensed personnel twice
yearly after four visits, once weekly, at
discharge home. Cost for one supervisory OT
visit per receipts = $100 ID per visit.
$10,400
$200
$400
$20,800
$400
$800
11
Lucy Adams
November 9, 2010
Medication
Annual
Item
(Monroe)
Discussion (Howland)
Costs
One-Time Costs
Monroe
Howland
Monroe
Influenza
vaccination
Recommended for all citizens, not related to
injury, routine care
$75
$0
Pneumovax
Recommended for disabled to decrease chance
of pneumonia. Cost needs to be verified.
Clinics may offer low-cost or free
immunizations to elderly or disabled citizens.
$75
$75
Colace
No medications for bowels noted in Dr.
Madison’ evaluation
$180
$0
Nizoral cream
Unrelated to injury if used for routine fungal/
yeast infection as indicated on packaging (not
a prescription item)
$840
$0
Antispasmodic
medication
None presently in use per Dr. Madison’
evaluation
$2,400
$0
Antibiotics
Duplicate entry from “Supplies.” No billing
history or medical indication for routine use of
antibiotics. It might be reasonable to assume
one course of antibiotics per year for urinary
tract infection. Cost needs to be verified but
average cost in USD would be <$50.
$1,000
$100
$4,570
$175
TOTAL
Howland
Laboratory, Imaging, Investigation
Annual
Item
(Monroe)
MRI
Costs
One-Time Costs
Monroe
Discussion (Howland)
Monroe
Howland
At 8 years post injury Ms. Adams’ injury is
stable. There is no indication for annual MRI
absent acute symptoms. It might be reasonable
to allow for one MRI per 8 years in case this
occurs.
$1,600
$200
Renal
ultrasound
This is standard of care for every 1-2 years.
Cost needs to be verified and prorated for 18
months. Assuming this cost is accurate,
prorated annual cost would be $225.
$300
$225
Cystogram
This is standard of care for every 1-2 years.
Assuming this cost is accurate, prorated annual
cost would be $187.
$250
$187
Urodynamic
study
At this point Ms. Adams’ status is stable. This
is standard of care for every 1-2 years.
Assuming this cost is accurate, prorated annual
cost would be $300
$400
$300
Howland
12
Lucy Adams
November 9, 2010
Annual
Item
(Monroe)
Discussion (Howland)
Costs
One-Time Costs
Monroe
Howland
Monroe
Routine
urinalysis
One UA annually is reasonable to check for
renal function in the presence of risk for
infection. Cost needs to be verified. Routine
UA is $30 USD = $60 ID
$200
$60
Pap smear
Routine care, not related to injury.
$150
$0
Mammogram
Routine care, not related to injury.
$200
$0
$3,100
$972
TOTAL
Howland
Therapeutic Exercise Equipment
Annual
Item
(Monroe)
Costs
One-Time Costs
Discussion (Howland)
Monroe
Howland
Monroe
Howland
Access to a heated pool at a facility two or
three times per week, or membership in a
health club with similar facility, would be
appropriate if available. According to
telephone survey, no fitness clubs in area have
a warm pool for handicap access. Range of
motion exercises can be done by unlicensed
personnel and should be done at least daily in
a warm shower (at home).
$0
$0
$10,609
$0
Pump
maintenance
Annual, $500; weekly cleaning, $50 for total
given
$3,000
$0
Active/passive
trainer
“Exercises
paralyzed and
innervated
muscles,
maintains
cardiovascular
health”
Not indicated, passive exercise does not
increase heart rate, provide increased vascular
resistance, or make paralyzed muscles active,
thus does not promote CV health. Passive
range of motion exercises by unlicensed
personnel will fulfill this need because,
lacking enervation, paralyzed muscles cannot
actually “exercise.”
$2,200
$0
Tilt table and
accessories
“Prevent
osteoporotic
changes and
maintain lower
extremity
vascular health”
Osteoporotic changes in lower extremities
would be addressed by weight bearing, which
cannot occur due to permanent contractures
according to Dr. Madison. There is no
evidence of arterial disease in her legs; venous
circulation is accomplished by active muscle
movements, not upright posture. This is the
indication for support hose, already included.
$2,600
$0
Pool
13
Lucy Adams
November 9, 2010
Annual
Item
(Monroe)
Costs
One-Time Costs
Monroe
Discussion (Howland)
Monroe
Howland
Electric table
exercise mat
“Balance, range
of motion”
Trunk balance is adequate according to Dr.
Madison, due to retained functional
neurological level. Range of motion is passive
by assistive personnel and active by Ms.
Adams with supervision and encouragement
by them. No special equipment needed for
this.
$2,600
$0
Standing frame
and accessories
Contractures prevent standing and
weightbearing, not indicated
$1,000
$0
Dumbbells, 2
each, 2#, 3#, 5#,
10#
Ms. Adams cannot lift more than small
amounts of weight (assessed at strength 3 / 5
in left arm, 1- 2 /5 in right by Dr. Madison).
Cannot grasp dumbbell in right hand anyway.
See below.
$66
$0
Strap-on weight
cuffs, 2#, 5#,
10#
Two cuff weights (one 2# and one 5#) would
be reasonable. These could be used for arms
and legs in sequence. Replacement not likely
for life expectancy. Available at AA Johnson
for $145 ID for both; from ABC for $88
$17
$0
Theratubes with
handles
“Proprioceptive
and weight
training”
Ms. Adams’ proprioception (sense of where
her body parts are in space) is neurologically
stable 8 years post injury and will not change
with any kind of exercises. Weight cuffs and
maximizing her active exercise in transfers,
bathing, dressing, and activities will serve as
an acceptable home program for maintaining
strength, as increases in strength are not likely
at this point. (ABC charge is $15)
$63
$0
Over-door pulley
“For shoulder
ranging”
Not indicated, not necessary, duplicates range
of motion by assistive personnel during
bathing, dressing, and other activities.
$20
$0
Gymnastic balls,
3 sizes, plus ball
pump
“Balance and
strengthening
exercises”
Not indicated. Ms. Adams permanently lacks
joint mobility and proprioception needed for
standing; truncal control is stable, as noted
above.
$93
$0
Hand exercise
balls and hand
gripper “hand
strengthening”
See below. Duplicates putty.
$78
$0
Therapeutic
putties
This is reasonable and safer than hard objects
to use for independent hand exercises. This is
a reasonable cost. (ABC cost $12 x 4 = $48)
$18
$18
Howland
$88
14
Lucy Adams
November 9, 2010
Annual
Item
(Monroe)
Costs
One-Time Costs
Monroe
Discussion (Howland)
Monroe
Howland
Hot/cold packs
“Therapy for
spasming
muscles”
Dr. Madison notes increased tone in legs with
movement but no spasms. Medication for
spasticity was discontinued years ago. Most
households have an ice bag that can also be
used with hot water for comfort. ABC cost,
one-time purchase, $62
$35
$0
Hand massager
and batteries
“Stimulates
flaccid muscles”
This can be done by assistive personnel in
conjunction with daily bathing and applying
moisturizers to skin. Paralyzed muscles
without enervation do not respond to massage
by strengthening or becoming mobile and are
not stimulated by massage, though local blood
flow may increase.
$75
$0
Lower leg
splints, full arm
splints
“Reduce muscle
spasticity”
Spasticity will not be reduced by splinting and
is often increased; prescribed medications for
spasticity discontinued years ago, contractures
are permanent according to Dr. Madison,
range of motion and positioning will be
adequate. Also duplicate item for AFOs, under
Supplies.
$94
$0
Vinyl-covered
arm support
“Elevates hand
and arm in
exercises”
Can be done by assistive personnel during
range of motion exercise, bathing, and
dressing; no hardware needed for this
$20
$0
$11,979
$18
TOTAL
Howland
$62
$10,609
$150
Grand Totals are summarized at the beginning of this report on page 5.
Thank you for the opportunity to review this case. Please feel free to contact me at any time with
questions or additional information.
Cordially,
Wendie A. Howland RN-BC MN CRRN CCM CNLCP LNCP-C
Certified Nurse Life Care Planner
Principal, Howland Health Consulting, Inc.
15
Lucy Adams
November 9, 2010
16
Position Statement
Education and Certification for Nurse Life Care Planners
Status: Original Statement
Authored by: American Association of Nurse Life Care Planners (AANLCP®*) and
the Certified Nurse Life Care Planner (CNLCP®**) Certification Board
*AANLCP® is a registered trademark of the American Association of Nurse Life Care Planners
®
**CNLCP® is a registered trademark of the CNLCP Certification Board
Purpose: This position statement serves as a resource for current, as well as prospective
nurse life care planners, for identifying, exploring and promoting educational opportunities and
nurse life care planning certification (CNLCP®).
Statement of AANLCP® and CNLCP® Certification Board Position: The American
Association of Nurse Life Care Planners (AANLCP®) and the CNLCP® Certification Board
affirm that nurse life care planning is a nursing specialty practice that all nurse life care
planners should actively promote through education and the attainment of certification.
The American Nurses Association (ANA) recognizes that “all nursing practice, regardless of
specialty, role, or setting, is fundamentally independent practice” (ANA Scope and Standards,
2010, p.24). Additionally, the registered nurse is responsible for assessing individual
competence and is committed to the process of lifelong learning. Registered nurses develop
and maintain current knowledge, skills and abilities through formal academic programs and
continued education and seek certification when available in their areas of practice. As
independent practitioners, registered nurses are individually accountable for all aspects of
their practice (ANA Social Policy, 2010, p.30-31). The activities in which individual registered
nurses engage in the total scope of nursing practice are dependent upon each individual’s
education, experience, role, and the population they serve. (ANA, Scope and Standards,
2010, p.2)
The primary role of the nurse life care planner is to develop a client specific lifetime plan of
care utilizing the nursing process. The plan contains an organized, comprehensive, and
evidenced based approach that estimates current and future healthcare needs. Also
included, are the associated costs and frequencies of items and services, which can be
utilized as a guide in various applicable sectors (e.g., private, medical-legal, case
management).
This specialty practice predates formalized training programs, certification and/or the
formation of specialty organizations. It evolved from the case management, rehabilitation
nursing and insurance sectors where the importance of proactive collaboration and
coordination of continuum of care needs for the ill and injured were first recognized and
implemented. Expanded knowledge regarding these needs emerged from consultation with
interdisciplinary medical/ancillary teams, attorneys, and through participation in educational
endeavors (e.g., seminars etc.) pertaining to the long-term treatment needs of the chronically
Adopted by AANLCP® Executive Board and CNLCP® Certification Board on
June 6, 2014.
ill and catastrophically injured. Formalized educational programs/courses followed and now
serve as the basis for training resources for nurses entering this specialty.
Initial Education
Numerous educational opportunities are available to nurses who are interested in entering
the field of nurse life care planning. A structured introduction to the specialty practice of
nurse life care planning is highly recommended. Various comprehensive courses are
available.
Continuing Education
The AANLCP® annual conference, webinars, and the AANLCP® Journal of Nurse Life Care
Planning provide educational opportunities for continued development of expertise within
this nursing specialty. Ongoing education relevant to the field of nurse life care planning is
considered a key element in the recertification process.
While AANLCP® and the CNLCP® Certification Board do not recommend, nor endorse any
one particular educational program, the following criteria should be considered when
choosing life care planning educational endeavors:
Educational Programs
Universities, colleges, and for-profit, as well as not-for-profit organizations offer life care
planning education. In assessing the value of any given program, the reputation and
accreditation of the sponsoring institution should be considered along with the program’s
course content. Nurse life care planning educational opportunities should be grounded in
nursing science, which utilizes essential elements of the nursing process, critical thinking,
and evidence-based practice. Advanced educational courses, which include application of
clinical practice guidelines, outcomes evaluation and contribution to nurse life care
planning research, should be considered as well.
Program Directors and Instructors
AANLCP® and the CNLCP® Certification Board recommend that nurse life care planning
education programs be developed and presented by nurse life care planning educators in
collaboration with other specialty practitioners such as physicians, therapists, attorneys, etc.
The qualifications of the program directors and instructors should include a solid knowledge
base in the application of the nursing process. Of further importance is actual nurse life care
planning experience that incorporates the nursing process, the ability to articulate and
substantiate care plan recommendations, and a proven track record within the specialty field
of life care planning.
Curriculum
AANLCP® and the CNLCP® Certification Board recommend that A Core Curriculum for
Nurse Life Care Planning and the CNLCP® Examination Content Outline
(www.ptcny.com/PDF/CNLCP.pdf) be utilized as the framework for educational programs,
as well as use of current resources in course material (e.g., peer-reviewed journal articles,
medical and nursing texts). Courses of study vary in length; and, nurses are encouraged to
choose a course of study that meets their professional needs and goals.
Adopted by AANLCP® Executive Board and CNLCP® Certification Board on
June 6, 2014.
Certification
In 1999, AANLCP® established the American Association of Nurse Life Care Planners
Certification Board to develop and administer the Certified Nurse Life Care Planner (CNLCP®)
certification exam. In 2009, The Certified Nurse Life Care Planner (CNLCP®) Certification
Board was incorporated as a separate entity and is recognized by the AANLCP® as the
Association’s certifying body.
The goal of the CNLCP® Certification Board is to promote a level of expertise and
professionalism in nurse life care planning. Nurse life care planners must meet the specified
educational and nursing requirements in order to be eligible to earn the CNLCP® designation
through examination or reciprocity. As with many clinical nursing certification programs, the
CNLCP® credential is designed for those nurses who have demonstrated experience and
knowledge within the specialty. Achieving CNLCP® certification is an expected goal for those
who are committed to professional practice.
Many life care planning educational programs offer a certificate of course completion; and, in
some cases, evidence of having passed an examination relevant to the course material.
Such certificates should not be confused with the nurse life care planner certification
(CNLCP®) offered by the CNLCP® Certification Board, which is affiliated with the AANLCP®.
Accreditation
The CNLCP® Certification Board is in the process of obtaining accreditation through the
Accreditation Board for Nursing Specialty Certifications (ABNSC, formally known as the
American Board of Nursing Specialties or ABNS).
Summary/Conclusion
Nurse life care planning is a well-recognized specialty practice within the field of nursing.
Standards regarding entry into this specialized field, certification and ongoing education
opportunities are essential.
Educational programs developed and taught by experienced nurse life care
planners/educators, currently practicing in this specialty field, are preferable.
AANLCP® supports certification through the CNLCP® Certification Board.
This position statement is the outcome of extensive discussions and dialogue about the
AANLCP® Scope and Standards of Practice and the AANLCP® Code of Ethics.
Adopted by AANLCP® Executive Board and CNLCP® Certification Board on
June 6, 2014.
Resources:
American Association of Nurse Life Care Planners, Standards of Practice, 2008, Salt Lake
City, UT.
American Association of Nurse Life Care Planners, Scope of Practice, 2011, Salt Lake City,
UT.
American Nurses Association, Nursing Scope and Standards of Practice, 2010, Silver Spring,
MD.
American Nurses Association, Nursing’s Social Policy Statement, 2010, Silver Spring, MD.
Adopted by AANLCP® Executive Board and CNLCP® Certification Board on
June 6, 2014.
Adopted by AANLCP® Executive Board and CNLCP® Certification Board on June 6, 2014.