Life Care Planning for Acquired Brain Injury – Case study and Conclusion (III)

A 32-year-old client was riding a motorcycle that was hit by a car. At the time of the interview, 3 years postinjury, he stated that he did not remember the incident or anything a couple of weeks prior to the incident. Following the incident, his first consistent memory is approximately 2 to 3  months later. He was treated for 2 months in an acute care hospital and then for 5 months in a brain injury rehabilitation hospital. The client was diagnosed with severe TBI with physical and cognitive deficits, including ventriculoperitoneal shunt and orthopedic injuries requiring extensive care.

Neuropsychological testing results concluded that the client had sustained a very severe TBI. Testing revealed reduced intellectual capacity of one standard deviation, perhaps slightly more, below preinjury levels. His primary deficit is in visual/motor problem solving. He is able to sight read beyond a high school level. He has significant deficits in mathematical calculations, with overall performance at a level much lower than expected given his preinjury educational level. No anomia was noted, and he is able to mildly retrieve words without perseveration or intrusive errors. He has significant difficulty with fine motor coordination, with reduced range in the left upper extremity. He has significantly improved executive function from prior testing, which is the most promising part of the overall evaluation, although he continues to exhibit occasions of temper outbursts. He has moderately to severely impaired short-term memory, especially with verbal short-term memory given the absence of consolidation of information. He has a positive affect, although he has times of unhappiness/frustration, and is basically functioning in a more adaptive manner.

He has a young daughter and must be supervised when with her. His wife is supportive and has quit work to be his caregiver. He must have someone available for assistance with judgment, safety, food preparation, and financial commitments. Work is not a reasonable goal, although volunteer activities part-time would be therapeutic.

LIFE CARE PLAN

Note: For purposes of this plan, the following initials are placed in parentheses according to their respective recommendations:

JP   = Jeffrey Preston, MD, physiatrist

MC = Michael Cathy, MD, psychiatrist

RH  = Robert Hampton, MD, ophthalmologist

IR   = Ian Raston, MD, hand surgeon

WW = William White, MD, internist

AP  = Amy Passy, PT, physical therapist

JH   = John Hurry, PsyD, neuropsychologist

RW = Roger Weed, PhD, life care planner

Routine Future Medical Care—Physician Only

Physiatrist (JP)

X-rays: left hip, knee, or shoulder (JP)

Head CT scan (JP) Head MRI (JP)

EEC (JP)

4  times/year to life expectancy 3 times/year to life expectancy 1 time/year to life expectancy Every 5 years to life 1 time/year to life expectancy

Monitor overall rehabilitation program and prevent/reduce complications, etc. Monitor development of expected degenerative joint disease Assess integrity of shunt Monitor structural changes to brain Assess brain wave activity due to high risk for seizures

$276-320/year at $69-$80/ visit (see Note 1)

Range: $609-1365/year at $203-455 each, 3 times/ year to life

CT scan: $2173-2296/year to life

MRI: $3016-4370 every

5 years to life

EEC: $854/year to life

Note 1: Dr. Preston states in his deposition that a personal computer is medically indicated for the client to include possible access for environmental control unit (ECU) or adaptive devices integration in the future.

Note 2: A one-time-only replacement cost for computer and related equipment/supplies is included in plan. Replacement after that is presumed to be consistent with use of a personal computer by the general population.

Note: The client has no competitive vocational potential. Volunteer activity is a best option for him to increase his sense of productivity and self-worth, and provide a sense of purpose. If professional services are required in the future to develop or cultivate an alternate volunteer program for the client, expect 20 to 40 hours for vocational counseling and related services, including vocational evaluation, labor market research, job site analysis, etc., at $75 to $89/hour. However, costs for these services are not included in the plan.

Architectural Considerations

(List considerations for home accessibility and modifications.)

The client currently lives with his wife and 2-year-old daughter in a ranch-style house that has been modified to accommodate him and generally appears appropriate for his current needs. A ramp has been constructed to the back door, which is the entrance the client uses to enter and exit the home, and grab bars have been installed in the bathroom. The front entrance has steps leading to the front door, although no handrail is available and the client demonstrates he generally is able to ascend and descend the stairs with difficulty in a modified fashion and with altered gait.

The client requires a one-story home with accessibility features and minimal, if any, stairs. If stairs, he requires handrails. See also home accessibility evaluation for one-time-only evaluation to assure the home is accessible both now and for the future as he ages and experiences an expected reduction in his physical capabilities.

Left total knee replacement (JP)

Left knee revision (JP) 2020 (age 50) Approximately 2030-2032 and every 10-12 years (average) thereafter to life expectancy

Initial knee replacement in 2020, then every 10-12 years (average) knee revision to life expectancy

Replacement in approximately 2020: $30,948

1st revision: $35,608 2nd revision: $34,378

Left total hip replacement (JP)

Left hip revision (JP) 2020 (age 50) Approximately 2030-2032 and every 10-12 years (average) thereafter to life expectancy

Initial hip replacement in 2020, then every 10-12 years (average) hip revision to life expectancy

Replacement in approximately 2020: $31,568

1st revision: $39,811 2nd revision: $37,479

*Expected cost for knee and hip replacement/revision includes surgeon fee and average hospital charges and does not include surgeon assistant fee, if applicable, anesthesiologist fee, or sub­acute or rehab unit stay. One case of a client similar in age to this client with diagnosis of degen­erative joint disease required total knee replacement at a cost of $40,733, inclusive.

Note 1: The physiatrist states he expects the client to require joint replacement in both left hip and left knee due to altered gait and increased wear and tear on his lower-extremity joints as well as expected degenerative joint disease. He states the severity of the degenerative joint disease depends on maintenance of the client’s weight and overall health and fitness.

Note 2: According to one orthopedic surgeon who performs knee and hip replacement surger­ies, knee and hip prostheses last on average 10 to 12 years (based on geriatric popula­tion); however, the client may require more frequent revision due to his young age at time of projected initial replacement and expected increased activity level (more so than geriatric activity level). See also Potential Complications.

Note 3: For purposes of future care planning and based on the physiatrist’s recommendation for initial hip and knee joint replacement at approximately age 50, presume two hip and knee revisions over the client’s lifetime at approximately age 60 to 62 and age 72 to 74.

Note 4: The orthopedic surgeon states joint revision surgeries are more difficult than the initial replacement surgery and each subsequent revision is more difficult than the previous one. Recovery also tends to take longer. However, no additional cost for extended recovery is included in plan totals for revision surgeries.

Note 5: Pain medication is expected to be needed following each joint revision surgery as well as probable anti-inflammatory medication. Exact kind, dose, and duration of medica­tion are unknown and no additional cost for medications is included in plan totals.

Note 6: Orthopedic visits following joint replacement/revision generally include one post-op visit (at no cost) plus three other visits at 3, 6, and 12 months postreplacement/postrevi­sion at $60 to $80/visit. Routine follow-up also includes AP and lateral x-rays of hip at $174.25/x-ray and knee at $261.25/x-ray at each post-op visit. Additional medical needs following joint replacement/revision likely include postoperative physical therapy and

probable long-term need for cane or walker for mobility assistance. Aqua therapy also may be indicated following joint replacement/revision.

Ventriculoperitoneal (VP) shunt revision (JP)

Approximately 2011 (15 years after initial shunt placement)

1  time only, assuming no complications

Neurosurgeon evaluation: $286 Revision surgery: $28,927

Note 1: The client was released from the care of his neurosurgeon in February 1998 to be fol­lowed by the physiatrist and return as needed if there were complications with his shunt or changes in his neurologic status. The physiatrist states it is probable the client will require at least one shunt revision over his lifetime due to expected complications.

Note 2: Expected cost for VP shunt revision includes surgeon fee and hospital charges only and does not include diagnostic studies that may be needed such as abdominal x-rays or head CT scan, or anesthesiology charges. See head CT scan, which may be used for diagnostic purposes at time of shunt revision.

Note: Potential complications are included for information only. No frequency or duration of complications is available. No costs are included in the plan.