A thorough life care plan serves as a road map for the provision of future daily, medical, and rehabilitative care for an individual with significant medical issues and associated impairments (Weed, 2007). However, to best meet the ongoing needs of the individual, the plan should have a solid basis in up-to-date medical science. Inclusion of appropriate medical services must recognize the fragmentation and specialization of health care. Additionally, making provision for new technologies is important. Changing service provision should also be considered.
An appropriate life care plan guides the provision of ongoing daily, medical, and rehabilitative care for an individual status post catastrophic injury or illness (Bonfiglio, 2004). However, for a life care plan to appropriately provide for all of the needs of an individual, the plan must have a strong medical foundation. All daily, medical, and rehabilitative care recommendations must be medically necessary and appropriate.
The individual’s unique needs, desires, and aspirations should be considered. The long-term implications of care, including preventing secondary complications, enhancing functional outcome, reducing suffering, and improving quality of life, must be considered (Braddom, 1996). The long-term consequences of living with a catastrophic medical condition that causes significant impairments necessitate developing a long-term plan that takes into account the impact of the aging process. The effect of recurrent secondary complications can be cumulative, especially with organs like the kidney and heart. For example, preventing renal failure for a person with a spinal cord injury is extremely important. Dialysis can be fatiguing and cause blood pressure lability for anyone, but is especially difficult to provide for a person with a spinal cord injury, especially if the person experiences orthostatic hypotension or autonomic dysreflexia.
The impact of the aging process on the person’s medical condition stemming from the condition for which the life care plan has been developed can lead to the need for additional supportive services for the individual later in life. A person who can get by with a few hours per day of attendant care when the plan is first implemented may need 24 hours per day care later in life. The life care plan should reflect these different stages in the person’s remaining life.
A life care plan with a proper medical foundation should also consider recent technological advances and changes in health care delivery. For example, the use of functional electrical stimulation to increase strength or replace an orthosis may greatly enhance function. In recent years, there have also been significant improvements in prostheses, wheelchairs, environmental control systems, and other adaptive equipment and assistive technology. Providing the most appropriate and up-to- date equipment can greatly improve function and quality of life. Health care provision is also rapidly changing and not always to the benefit of patients. Shorter hospital stays and increased use of an outpatient setting for surgery should be reflected in a life care plan development. For example, in the past, annual hospitalizations for an individual status post spinal cord injury were routine for bladder management and review of rehabilitation efforts. Such routine admissions no longer occur.
Physicians specializing in the field of physical medicine and rehabilitation (also known as phy- siatrists) are uniquely trained and qualified to aid in the development and foundation of forward- looking life care plans. Physical medicine and rehabilitation is the medical specialty that focuses on patient long-term functional outcome following catastrophic injuries or illnesses. Additionally, rehabilitation physicians understand the unique physiology of individuals with medical conditions like spinal cord injuries and traumatic brain injuries that cause severe impairments and many potential secondary medical conditions. The team approach that is essential to life care plan development and implementation is also the key to the rehabilitation physician’s approach to patient care.
There is significant legislative and judicial pressure to reduce compensation and limit awards for pain and suffering. Therefore, establishment of the actual losses and ongoing medical and rehabilitative needs becomes increasingly important for litigation (Cooper & Vernon, 1996; Romano, 1996). An individual having suffered a catastrophic injury or illness usually has extensive ongoing lifetime needs. Physiatrists can help prognosticate regarding these ongoing needs and the impact that such care has on life expectancy.
Thus, a sound medical foundation for a life care plan provided by a physician specializing in physical medicine and rehabilitation can help address the patient’s individual medical condition, premorbid medical issues, patient and family preferences, and desired functional outcome, and by that significantly enhance the usefulness of the life care plan. A physiatrist can also help project future care needs based on the impact of the aging process and likely secondary medical complications.
Ensuring the availability of appropriate ongoing medical, rehabilitative, and daily care needs has been significantly enhanced by the development of the science of life care planning. However, the foundation for many life care plans is limited by the plan developer’s experience and the frequently marginal input from treating physicians. Especially in developing a plan for an individual with complex health care needs due to a catastrophic injury or illness, the life care planner and the treating physicians may have very little experience in dealing with a person with similar medical issues, especially for a patient with a spinal cord injury, multiple limb amputations, or a severe traumatic brain injury.
Without adequate medical guidance, the life care plan may not provide for all of the unique needs of the individual, including ongoing medical subspecialist visits, diagnostic testing, and treatment options. Additionally, the recommended services, equipment, and supplies may not be adequate over the individual’s lifetime to prevent secondary complications. The recommended services may not allow for recent or reasonably anticipated future developments in medical and rehabilitative care, including technological and service delivery advances. Conversely, the plan may include items that are not necessary to meet the specific needs of an individual patient.
For example, technological advancements and market forces have led to the development of a wide array of adaptive equipment. Environmental control systems allow individuals with virtually any consistent motor activity to control electronic devices and access, and to use computers, including the Internet. There are now numerous wheelchair options. Powered chairs can be navigated with a variety of inputs, and many power chairs have a self-reclining option. There are even power chairs that can climb stairs. Ceiling-anchored lift devices can ease daily care needs. Identifying the most appropriate adaptive equipment for a severely injured individual is aided with the input from a physician in physical medicine and rehabilitation.
There are physicians specializing in physical medicine and rehabilitation who develop life care plans. The insight a physician in this field develops through training and experience may improve the quality of the plan. However, in this author’s experience, nonphysician life care planners often develop more detailed plans with greater patient specificity and more accurate associated cost figures.
Physicians specializing in physical medicine and rehabilitation (physiatrists) are uniquely qualified to provide a strong medical foundation for life care planning, based on their training and experience in providing medical and rehabilitative services to individuals with various disabilities (Fletcher, 1992; DeLisa et al., 1993; Sinaki et al., 1993; Downey et al., 1994). Physiatrists are, by their training, experienced in dealing with individuals who have catastrophic functional problems. Additionally, physiatrists are trained to anticipate the long-term needs of their patients.
Rehabilitation care is often essential to maximizing the abilities of individuals with significant disabilities. Rehabilitation physicians generally direct the provision of such services in rehabilitation settings. Relying on these physicians to help develop a long-term plan is a natural extension of their usual practice.
However, in this author’s experience, physiatrists are usually optimists. Obtaining realistic information and projections requires selecting a physiatrist expert appropriately. The following checklist can help with the selection of a physiatrist as an expert witness in a case for an individual with a catastrophic injury or complex health care needs and resultant significant disability:
¦ Completion of residency from a recognized leading program
¦ Board certification in physical medicine and rehabilitation
¦ Training or experience in applicable area of subspecialization (like traumatic brain injury or spinal cord injury)
¦ Previous publications and national presentations, especially on related topics
¦ Academic appointment
¦ Recognized by rehabilitation peers
¦ Experience with testimony
¦ Comfort with litigation process
¦ Reputation for objective, thorough assessment and ethical practice
In this author’s opinion, physicians who combine clinical practice and experience with medicolegal work are usually more credible than those who exclusively provide medical opinions. If the treating physician cannot provide the needed basis and support for a life care plan, an expert physiatrist may be needed. (Editors’ note: In litigation, there are occasions when contacting the treating physician(s) is not allowed.)
Initial contact with the physiatrist should help establish the physician’s accessibility, availability, and ability to articulate the key issues in establishing the extent of the individual’s ongoing needs. Physicians appearing to avoid the attorney’s or life care planner’s contact generally make inadequate witnesses. Review of the physicians’ past testimony, especially regarding comparable cases, may be useful in delineating the physicians’ opinions regarding key areas.
Since the physiatrist may be called on to make projections regarding patient life expectancy, which will serve as the medical basis for lifelong care needs, thoroughness in patient evaluations and medical record review is essential. Requesting a sample report is appropriate for judging the physician’s examination and documentation adequacy. Physiatrists are usually team oriented and are willing collaborators because of the nature of the profession. Physiatrists should be identified who consider the life care planner to be part of the patient’s care team.
Hopefully, the involved physiatrist can be educated about the need for financial settlement to facilitate the provision of needed ongoing medical and rehabilitative services for the individual with an injury or complex health care needs. In litigation-related cases, the physiatrist must educate the jury about all aspects of the involved individual’s disabling condition and its implications. Disability not only often results in physical or cognitive limitations, but also may have emotional and psychological implications. The additional energy requirements and time of performing tasks with a disability often take a toll on the patient.
An individual’s disability can also affect the person’s family. New or altered family dynamics may add to the person’s emotional pressure.
Rehabilitation physicians can also play a key role in a team evaluation of an individual with a catastrophic injury or complex health care needs. Evaluations that include measurement of the patient’s functional abilities by various team members, including physical, occupational, and speech therapists; psychologists; vocational counselors; and rehabilitation nurses, are becoming more common. These evaluations serve as a stronger foundation for life care planning development. Physicians in complementary areas of specialization, including neurologists, psychiatrists, neurosurgeons, orthopedists, and urologists, may also be involved. The physiatrist can play a key role in coordinating these evaluations and developing a holistic approach to the resulting clinical impressions and recommendations.
Rehabilitation evaluation for a person after a spinal cord injury is particularly important because of the alteration in physiology that accompanies such an injury (Blackwell et al., 2001). Virtually every organ system is affected. As an example, blood pressure maintenance is significantly impacted by higher-level spinal cord injuries, secondary to the loss of central connections for the autonomic nervous system. During the early period after spinal cord injury, especially during spinal shock, hypotension is common. During the early rehabilitation process, orthostatic hypotension can interfere with progress. Orthostatic measures like support stockings and an abdominal binder are important treatment measures. Even during the long course, accommodations may be needed, especially with position changes.
After the initial period of spinal shock, the impaired autonomic control can lead to autonomic dysreflexia or hyperreflexia for individuals with higher-level spinal cord injuries, especially above thoracic level 6. Sensations that in an individual with an intact spinal cord would lead to noxious stimulation can trigger this response. Common triggers are bladder overdistention, excessive skin pressure, constipation, and sunburn. Initial treatment should include elimination of the precipitating factor and changing position, especially elevating the individual’s head. Medication management may also be needed, especially when the condition recurs frequently. If this condition is left untreated, life- threatening blood pressure elevations and cardiac arrhythmias can occur (Blackwell et al., 2001).
Management of the individual with a spinal cord injury’s neurogenic bladder is also essential. Periodic urological evaluations should be included in all life care plans for the spinal cord injured. Additionally, periodic urologic diagnostic testing is needed. At a minimum, this should include regular bladder and renal ultrasound testing, urinalyses, urine cultures, and cystoscopy. Additional tests that may be needed include laboratory testing, including electrolytes, BUN, creatinine, and creatinine clearance.
There are many other alterations in physiology after a spinal cord injury, resulting in conditions like spasticity and impaired thermal regulation. Additionally, there are many possible secondary complications like osteoporosis, contractures, heterotopic ossification, pressure ulcers, urinary tract stones, cancer, reduced respiratory reserve, coronary artery disease, gallstones, hyper- lipidemia, and a perforated abdominal viscus. Evaluation of the likelihood or presence of these conditions in an individual case can be done by a physiatrist.
Traumatic brain injuries can range from mild to those leading to persistent vegetative state. Although extensive medical and daily care is required for anyone in a persistent vegetative state, the provision of services still should be specific to the individual’s needs and can be influenced by many factors, including the family support system, available community resources, and architectural considerations. Distinguishing between persistent vegetative state and minimally conscious state can be difficult, but is usually very important in legal cases. An individual in a persistent vegetative state is completely detached from the environment, while a person in a minimally conscious state will have some awareness of the surroundings, but the extent of this awareness can be impacted by many factors including acute medical conditions, the effects of medications, and fatigue.
Individuals with severe traumatic brain injuries usually require ongoing medical, rehabilitative, and daily care services (Rosenthal et al., 1990; Ripley & Weed, 2004). A physiatrist can help to delineate the needed care. This medical foundation can aid the life care planner in establishing the medically most appropriate plan. Maximizing the individual’s functional improvement is important. Anticipating potential future complications is also needed.
Even for an individual diagnosed as having a mild traumatic brain injury, the functional implications may be very significant. Neuropsychological testing to determine the extent of these functional effects is important. A physiatrist can help to translate these functional limitations to life care planning effects.
Many individuals develop chronic pain because of trauma or illness. Establishing the etiology and relating it to a specific event can be difficult. Additionally, defining the extent of pain and its functional implications can be problematic. Because of the experience of physiatrists in looking at functional implications of disease and disability, they can be helpful in establishing such links. Chronic pain is also a frequent sequela of spinal cord and brain injuries.
A physiatrist can help determine the appropriate prosthetic device for an individual after an amputation. Recognizing the functional implications of an amputation and appropriate adaptive equipment is also within the experience of physiatrists. Many amputees experience vascular and chronic pain, and physiatrists are appropriate resources for this care as well. A physiatrist is especially needed to help develop a life care plan for an individual with multiple limb amputations. Care for a person with quadrilateral amputations (both arms and both legs) is particularly complex.
Provision of adequate funding for lifetime medical, rehabilitative, and daily care needs is dependent on an accurate prediction of life expectancy. Unfortunately, there is no medical literature for
individuals with catastrophic injuries that projects life expectancy based on the level of care that is typically outlined in a life care plan. Additionally, the medical literature addressing life expectancy for those with catastrophic injuries or illnesses leading to brain or spinal cord injury has many other flaws. The literature does not generally reflect current health care provision or technological advances. Additionally, such population studies do not address the unique situation of any particular patient. Therefore, in this author’s opinion, an opinion provided by an experienced physiatrist can better predict life expectancy. However, such determinations require a thorough review of available medical records, especially to identify the already existing medical conditions and secondary complications that have occurred. The physiatrist can help determine which complications can be prevented or treated with the services outlined in the life care plan and which are likely to occur despite the recommended ongoing medical and rehabilitative care. The physiatrist can provide an opinion of the effect of the patient’s underlying condition and secondary complications on life expectancy.
In litigation-related cases, physiatrists can provide the medical foundation for plaintiff life care plans (Culver, 1990; Cooper & Vernon, 1996; Romano, 1996; Council on Ethical and Judicial Affairs, 1997). Recognizing the unique needs of patients with disabilities is a regular part of the practice of physical medicine and rehabilitation.
Physiatrists can equally well evaluate plaintiff-generated life care plans for medical accuracy and necessity. Determining whether recommended medical services are medically necessary and appropriate is important to the defense.
Physiatrists can also provide testimony regarding the medical basis for life expectancy determinations.
Each entry in the life care plan requires certain data. Each recommendation must include the medical specialty, start date, stop date, frequency of service, and duration. A base or procedure cost is added that will allow an economist to estimate the total value of the services or procedures. To provide an example, in the table that follows are a few entries associated with the care of a 73-year-old woman with C5—C6 tetraplegia, which is within the domain of the physiatrist.
Outpatient spinal cordinjury reevaluation to
include MD, RN, OT, PT,
RT, dietaryIVP or renal ultrasound,
CBC, UA, and others as
neededIncluded in yearly
evaluation
Note: Partial plan only. Illustration of physician-related minimum needed data.
Aucun commentaire:
Enregistrer un commentaire