by Betsy Keesler, BSN, RN, CLCP

A soundly constructed life care plan is an evidence-based document that comprehensively identifies an individual's current and future care needs as related to a catastrophic injury or chronic health condition. Such needs may include a person's individual requirements for healthcare, educational/vocational services, home modifications, living arrangements, attendant care, equipment, medications, supplies and community services. Many, if not all, of these items require recommendations from a healthcare professional acting within their professional scope of practice. When a life care plan lacks appropriate medical foundation and is determined to be incongruent with accepted life care planning published standards and consensus statements, it will likely be challenged and ultimately may not be accepted into the evidentiary record for the evaluee (subject person).

There are several appropriate avenues a Certified Life Care Planner (CLCP) can utilize to establish solid medical foundation for the life care plan. The most obvious track is direct consultation and collaboration with the evaluee’s treating and/or evaluating medical, psychological, or allied health professionals. Of note, it is essential such consultations be endorsed by the opining healthcare provider through signature, prior to the date of release of the life care plan report. Another appropriate avenue would include directly referencing and utilizing published clinical practice guidelines, empirical research and/or other reliable and credible peer-reviewed publications to identify the standards of care for items applicable to the evaluee’s needs. Equally important, the life care plan should draw clear links between specific statements made within the analyzed medical records and the items or services included within the life care plan. Finally, cited testimony from evaluating and/or treating providers connected with the evaluee’s health care can also serve as appropriate medical foundation.

It is important to understand the subspecialty practice of Life Care Planning has many published consensus and majority statements, relative to the developmental process of establishing solid medical foundation. In 2018, the International Association of Rehabilitation Professionals (IARP), in conjunction with the International Academy of Life Care Planners (IALCP), published a special issue of the peer-reviewed Journal of Life Care Planning which identified current consensus and majority statements for life care planning professionals. These consensus and majority statements were published following completion of a Delphi study of multiple, professional summits across a 17-year period. Of note, the purpose of the Delphi research method is to identify best practice consensus among subject matter experts.

Relative to establishing medical foundation for the life care plan, specific consensus statements address this matter head on.

Life care planning consensus statement 80: “Life Care Planners may independently make recommendations for care items/services that are within their scope of practice.”

Life care planning consensus statement 81: “Life Care Planners seek recommendations from other qualified professionals and/or relevant sources for inclusion of care items/services outside the individual life care planner’s professional scope of practice.”

From the cumulative pool of expert opinions arose the Life Care Planning Standards of Practice, as published by IARP and IALCP, currently in the Fourth Edition, 2022. Standards of practice also address the critical component of evidence-based medical opinion from a healthcare provider that practices/provides the same recommendations they have opined about in the life care plan. In other words, their opinion falls within their healthcare professional scope of practice. The Fourth Edition Standards of Practice provide this guide regarding appropriate medical foundation:

“To address the future care needs, the life care planner collaborates with other professionals in order to develop a transdisciplinary life care plan inclusive of recommendations outside of the individual life care planner’s professional scope of practice. No single rehabilitation or health care professional is trained to have comprehensive expertise in all areas where recommendations may be needed. Even within a profession, there are specialty and sub-specialty divisions, which may limit the life care planner’s ability to independently make all needed recommendations.”

Why do professional guidelines and standards even matter? This question was expertly answered through a 2012 IARP publication entitled “Expert Disclosure: Federal Rules of Civil Procedure 26, 34, & 37.” Dr. Timothy Field and Mr. Kent Jayne emphasized the following to the Rehabilitation and Life Care Planning Professionals as follows:

“The necessary qualifications for the FRC (forensic rehabilitation consultant) have been well established and documented and any forensic rehabilitation consultant should be familiar and comply with the usual and customary guidelines set forth by professional associations for the profession. Association standards, such as statements on scope of practice, professional ethics, and a standard of practice are all important documents and provide significant information of both the necessary credentials and the guidelines for practice.”

In short, the consensus statements and standards of practice are what give vigor and credibility to the life care planning practice.

The following realistic case scenarios illustrate both appropriate and inappropriate practices for the establishment of life care planning medical foundation.

Case #1: An adult evaluee was involved in a head-on motor vehicle collision and sustained a traumatic brain injury (TBI) as well as cervical vertebrae fracture. Fortunately, the evaluee was not paralyzed but was with permanent cognitive functioning deficits and ongoing neck pain and headaches. The evaluee underwent outpatient therapy with a speech language pathologist, an occupational therapist, and a Physiatrist (Physical Medicine and Rehabilitation Physician) who oversaw all medical care relative to the injury, as well as pain management modalities. A life care plan was developed by Certified Life Care Planner who also held a Doctor of Chiropractic (DC) licensure. The life care plan included many items, some of which were ongoing spinal injections for cervical pain management and narcotic medication for headaches, all for the duration of a lifetime. During deposition testimony, the doctor expounded upon his education and clinical practice as foundation to justify his ability to opine every future care recommendation within the life care plan.

To analyze this scenario, it is important to understand that not all doctors can provide all interventions that any ill or injured person may need. Some people do not understand this. The Chiropractic field of healthcare, while incredibly helpful for many people, does not perform spinal injections for pain management, nor do they prescribe narcotic medications. Thus, the life care planner was working outside his scope of practice in recommending spinal injections and narcotic medications. Unfortunately, he did not consult with the treating Physiatrist, or the allied health professionals providing current treatment. There was no evidence that an appropriate evaluating healthcare practitioner, such as a Neurologist or Interventional Pain Management Specialist, was retained to provide future treatment recommendations. There was no evidence of connection drawn between the current treatment found outlined in the medical records and what the life care planner recommended. There were no supporting clinical practice guidelines relative to the recommendations made. Ultimately, the life care plan lacked the required credible and reliable data, as well as the overall foundational information necessary, to formulate an evidence-based plan that was consistent with life care planning standards and expert consensus.

Case #2: An evaluee, with a 30-year history of smoking a pack of cigarettes a day, was rear-ended in a motor vehicle collision. Several days afterwards she began complaining of neck pain with radiating pain down her left arm. The first physician she sought treatment from advised rest, Tylenol and physical therapy. Medical reporting outlined she completed only 8 sessions of physical therapy and stated there was no improvement in her symptoms. She sought a second opinion from a Spinal Orthopedist who opined she had failed conservative therapy and therefore was eligible for a four-level spinal fusion surgery. Then, she sought another Orthopedist opinion (third one) who ordered additional MRI studies and a nerve conduction study. He diagnosed her with ulnar nerve compression and mild herniation at the C6-7 level. He then recommended only conservative therapy and did not agree with spinal fusion. Finally, the fourth Orthopedic opinion she sought indicated that she needed Ulnar Nerve decompression surgery, which she completed. Then, the fourth Orthopedist treated her with a cervical spinal steroid injection, which she reported gave total relief of all her pain. Additionally, this same Orthopedist reported clinical research strongly suggested the evaluee’s extensive smoking history predisposed her to significant surgical complications, including a lack of union at the surgical site, if she were to undergo spinal fusion.

However, the life care plan was developed by a Registered Nurse (RN) and CLCP. She provided a future cost analysis for only the four-level spinal fusion surgery treatment opinion. The life care planner did not acknowledge any other medical opinions or successful treatment the plaintiff had received as was documented within the medical records, nor did she acknowledge the clinical practice research citing smoking as detrimental to the success of spinal fusion. The life care planner acted outside her scope of practice by determining that the surgical opinion was the only opinion appropriate for the evaluee. An RN is not an operative practitioner and therefore not in a position to make any surgical decisions. Clearly, she did not consider all the evidence available to make a solid and credible life care plan for the evaluee.

Case #3: An adult evaluee sustained an upper extremity amputation secondary to malfunctioning equipment while working as a machinist. The life care plan was developed by an experienced and licensed certified rehabilitation counselor (CRC) who was also a certified life care planner (CLCP). The evaluee’s treating health care providers included a Physiatrist, a physical therapist, a psychologist, and a prosthetist. The life care plan included recommendations for the specific type, frequency and duration of future psychological counseling, medical care, medications, diagnostic tests, and prosthetic equipment for the evaluation.

The CRC/CLCP did not make any recommendations outside of his scope of practice. The life care planner noted the medical records reviewed and included a treatment summary within the life care plan as well as recommendations for future care that were secured in collaboration with the treating providers and signed by them, prior to the release of the life care plan report. The recommendations included in the plan were all evident through the medical records, supporting clinical practice guidelines and endorsements.

Sometimes securing the appropriate credible medical recommendation takes extra leg work, but in the end, it is the foundation for which that life care plan will hold up under close scrutiny.

References:

Field, T. & Jayne, K. 2012. Expert Disclosure: Federal Rules of Civil Procedure 26, 34, 27. Athens, Georgia: Elliott & Fitzpatrick, Inc.

International Association of Rehabilitation Professional & International Academy of Life Care Planners (2022), Fourth Edition. Standards of Practice for Life Care Planners.

Johnson, C; Pomeranz, J. & Stetten, N. 2018. “Life Care Planning Consensus and Majority Statements 2000-2008: Are They Still Relevant and Reliable? A Delphi Study.” Journal of Life Care Planning, 16 (4), 5-13.

Johnson, C; Pomeranz, J. & Stetten, N. 2018. “Consensus and Majority Statements Derived from Life Care Planning Summits Held in 2000, 2002, 2004, 2006, 2008, 2010, 2012, 2015 and 2017 and updated via Delphi Study in 2018.” Journal of Life Care Planning, 16 (4), 15-18.

Preston, Karen, et al. “Standards of Practice for Life Care Planners, Fourth Edition.” Journal of Life Care Planning, 20 (3), 5-24.

Weed R. & Berens D.E., (editors). 2018. Life Care Planning and Case Management Handbook. (4th ed.). New York, NY: Routledge.

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