Identifying Solid Medical Foundation for the Life Care Plan

Written by: Betsy Keesler, BSN, RN, CLCP, InQuis Global, Chicago

A soundly constructed life care plan is an evidence-based document which comprehensively identifies an individual’s current and future care needs, as related specifically 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 items found within a life care plan require recommendations from a healthcare professional acting within his/her 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, the plan may be challenged and may not be accepted into the evidentiary record for the evaluee (subject person).

It is important to understand that the subspecialty practice of Life Care Planning has published consensus and majority statements, relative to the development 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. Cloie B. Johnson, et al., 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, 16 J. Life Care Plan. 15-18 (2018); Life Care Planning and Case Management Handbook (Roger Weed & Debra E. Berens eds., 4th ed. 2018).

These statements were published following completion of a Delphi study of outcomes from multiple, professional summits across a 17-year period. Cloie B. Johnson, et al., Life Care Planning Consensus and Majority Statements 2000-2008: Are They Still Relevant and Reliable? A Delphi Study, J. Life Care Plan. 5-13 (2018). Of note, the purpose of the Delphi research method is to identify best practice consensus among subject matter experts. Currently, there are eighty-nine agreed upon life care planning consensus statements, as determined by most experts in the field.

The Life Care Planning Standards of Practice arose from the cumulative pool of expert consensus statements and opinions. The most recent edition of the standards of practice, (Fourth Edition), were published in 2022 by IARP and IALCP. International Association of Rehabilitation Professional & International Academy of Life Care Planners, Standards of Practice for Life Care Planners (4th ed. 2022). Standards of practice also address the critical component of evidence-based medical opinion from a healthcare provider which practices/provides the same recommendations he/she has opined about in the life care plan. In other words, the opinion falls within his/her healthcare professional scope of practice.

The Fourth Edition Standards of Practice provides 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 healthcare 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 answered for the life care planner through a 2012 IARP publication entitled, “Expert Disclosure: Federal Rules of Civil Procedure 26, 34, & 37.” The authors, Dr. Timothy Field and Mr. Kent Jayne, emphasized the following to the Rehabilitation and Life Care Planning Professionals:

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.

Timothy Field & Kent Jayne, Expert Disclosure: Federal Rules of Civil Procedure 26, 34, 27 (2012).

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

Scope of Practice

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

#64: “Life Care Plans shall rely on medical/allied health professional opinions.”

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

#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.”

When reviewing the life care plan, one must determine if the included medical recommendations emanated from a professional(s) opining within his/her established healthcare scope of practice. Unfortunately, it is not unusual to review life care plan recommendations from people knowledgeable about a given specialty but who are, in fact, not licensed or certified to practice within that specialty. This represents acting outside one’s scope of practice and thus, more likely than not, cancels the legitimacy of the recommendation.

Transparency

Each life care plan recommendation should include an appropriate rationale/foundation relative to the specific injury diagnosis, and/or sequela for the evaluee. Additionally, prior to inclusion in a released life care plan report, the recommendations should be clearly identified through signature confirmation by the recommending professional, unless the life care planner has made the recommendation and it falls within his/her scope of practice. This simple, yet critical, practice of providing signature endorsement of necessary plan items provides transparency to the life care planning process.

The following consensus statements address this requirement:

#51: “Life Care Planners shall consider the integrity of the data.”

#58: “Life Care Plans shall include a basis for recommendations.”

#75: “Life Care Planning products and process shall be transparent and consistent.”

Provision of endorsement by signature and date of the recommending professional, notably, prior to the release date of the Life Care Plan, secures a tangible identity and timestamp as hard evidence.

Evidence-Based Research, Clinical Practice Guidelines, and Medical Records

Another appropriate avenue for establishing solid medical foundation includes directly referencing 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.
Life care planning Consensus Statement #84 speaks to this specifically:

Review of evidence-based research, review of clinical practice guidelines, medical records, medical and multidisciplinary consultation and evaluation/ assessment of evaluee/family are recognized as best practice sources that provide foundation in life care plans.

Clinical practice guidelines and peer-reviewed journals/literature relay the current healthcare industry practice standards and provide authenticity to life care plan recommendations. See Life Care Planning and Case Management Handbook (Tanya Rutherford-Owen, et al., eds., 5th ed. 2024).

Multiple and/or Divergent Medical Opinions

At times, the medical records may reflect multiple professional opinions from multiple specialists (i.e., three different qualified orthopedic opinions for the same diagnosis.) It is incumbent upon the life care planner to acknowledge the existence of differing opinions and manage them methodically.
Consensus Statement #65 states: “Life Care Planners shall methodically handle divergent opinions.” This circumstance will result in the need to outline different future care options in the written life care plan. To not do so, would be ignoring the necessary tenants and consensus for evidenced-based life care planning and could represent a bias.

Case Studies

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

Case #1: 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 later, she began complaining of neck pain radiating into her left arm. The first orthopedic physician rendering treatment advised rest, Tylenol, and physical therapy. Medical reporting outlined she completed eight 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 was eligible for a four-level spinal fusion surgery. She then sought another orthopedic opinion (third one), where additional MRI studies and a nerve conduction study were ordered. 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 she needed ulnar nerve decompression surgery, which she completed. The same fourth orthopedist then 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. Through deposition testimony, this orthopedist advised being smoke-free for one year before considering spinal surgery.

However, the life care plan was developed by a registered nurse (RN) and certified life care planner (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 documented medical opinions or successful treatments the evaluee had received, 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 spinal fusion 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 #2: 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 sustained 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 a CLCP who also held a doctor of chiropractic (DC) licensure. The life care plan included recommendations such as ongoing spinal injections for cervical pain management and narcotic medication for headaches, all for the duration of a lifetime. The plan recommendations were all attributed to the life care planner, relative to his practice as a chiropractor. Of note, during deposition testimony, the doctor expounded upon his education and clinical practice as foundation to justify his ability to opine on 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 any ill or injured person may need. The chiropractic field of healthcare, while incredibly helpful for many people, does not perform spinal injections for pain management, nor 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, nor 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 which was consistent with life care planning standards and expert consensus.

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 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 evaluee.

The life care planner did not make any recommendations outside of his professional scope of practice as a CRC. The life care plan report contained the medical records reviewed, a treatment summary, and recommendations from the treating healthcare providers, and all associated costs. Also included were the written, consultative recommendations for future care opined by the treating healthcare providers, with signature endorsement, secured prior to the release of the report. Additionally, recommendations included in the plan were all evident through the medical records, researched clinical practice guidelines and endorsements. Thus, the life care plan was based on sound medical evidence. Of note, this scenario would be equally effective if the life care planner did not have access to the treatment providers and relied on evaluating providers, acting within their scope of practice, instead.

Sometimes securing the appropriate medical recommendations takes extra leg work, but in the end, it is the foundation for which the life care plan will hold up under scrutiny. Understanding and following the standards of practice and consensus statements is the key to creating a solid evidence-based plan. Karen Preston, et al., Standards of Practice for Life Care Planners, Fourth Edition, 20 J. Life Care Plan. 5-24 (2022). But when the life care planner does not follow these well-established, peer reviewed, guiding principles, the life care plan may be difficult to defend.

About the Author

Betsy Keesler earned a Diploma in Nursing from Presbyterian Hospital School of Nursing in 1987 where she was awarded Clinical Excellence in Pediatric Nursing upon graduation. Ms. Keesler subsequently completed a Bachelor of Science in Nursing during 1990 with receipt of High Distinction through George Mason University. In 2021, she completed 120-hours of post graduate training for life care planning through the Institute for Rehabilitation Education and Training (IRET). Ms. Keesler is a registered nurse (RN) and a certified life care planner (CLCP). She has worked in the hospital setting as a registered nurse (RN) for Pediatric and Neonatal Intensive Care Units and within the outpatient medical setting as a community health nurse. As a community health nurse, she coordinated and provided care for a large and diverse patient population within the school system. Also, Ms. Keesler was a nursing manager for the Adult Evaluation and Review Service within the Maryland Department of Health. Her clinical work through the public health department involved the coordination of medical and nursing services to support ongoing safe community living for persons with catastrophic diagnoses and chronic health conditions. Ms. Keesler has held numerous leadership positions throughout her nursing career and was the recipient of the Maryland Nurse of the Year award during 2009. She currently works full-time as a life care planner with InQuis Global, LLC.

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