By Bernard F. Pettingill, Jr PhD, Diana Santa Maria, Esq and Federico R. Tewes, BA
ATTENDANT CARE FOR LIFE CARE PLANS OF SPINAL CORD INJURY PATIENTS IN THE LAST YEARS OF LIFE: A LEGAL AND ETHICAL DILEMMA
The services of attendant care provided by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Home Health Aids (HHA) make up at least two-thirds of the majority of life care plans for patients with severe injuries, like Spinal Cord Injuries (SCI). The spinal cord is the passageway that allows for communication between the brain and the body. After that connection is disrupted by a SCI, the areas below the level of injury may no longer be able to effectively send or receive communications from the brain. The level of SCI refers to the lowest region of the spinal cord where normal motor control and sensation exist. More
1. Denslow, Elizabeth. “Spinal Cord Injury Levels: Cervical, Thoracic, Lumbar & Sacral Sci.” Flint Rehab, 16 Nov. 2021, https://www.flintrehab.com/spinal-cord-injury-levels/. than two thirds of SCI patients are young people involved in motor vehicle accidents and falls, but this article focuses on SCI patients in the last years of their lives. According to physician and rehabilitation expert, Craig H. Litchblau MD: “Thanks to medical advances, SCI patients are living longer than ever before and thus require more care over a longer duration. This care is costly and must be financed if SCI patients are to remain healthy and have adequate quality of life.”
The adequate quality of life depends on who provides theattendant care. Studies show that about 90 percent of SCI patients experience between 8 and 14 complications each year upon returning home from the hospital after their injury. Family and friends do not have the professional licensing and bonding (liability insurance) to care for a SCI patient. Inexperienced attendant caregivers will not know how to deal with common complications like pain, spasticity, urinary tract infections, bowel problems, osteoporosis, respiratory difficulties, autonomic dysreflexia, and pressure ulcers. These complications can be prevented under the services of a qualified professional attendant.
As SCI patients face the last years of their lives, they grow more dependent upon professional attendant care providers. For a Registered Nurse (RN), the average salary in 2020 was $77,460 and forecasted to increase to $143,636 by 2030. For a Licensed Practical Nurse (LPN), the average salary in 2020 was $48,501 and forecasted to increase to $55,025 by 2030.3 For aging SCI patients, medical advances allow them to live longer and require more professional care for longer durations. For this reason, attendant care makes up at least two thirds of the total cost of a life care plan overseen by a rehabilitation expert and computed from the cost point of view by forensic economists. The individual cost per hour for attendant care is not the main source of the expenses in life care plans; but instead, the need for aging SCI patients to have attendant care on a 24/7 basis. This often results in unexpected and preventable hospital visits, which translate to significantly higher cost of any life care plan. In every case, this is unavoidable. If left unattended for extended periods of time, then the aging SCI patient risks dying from the common complications mentioned above.
Research shows that aging SCI patients near the poverty line are more likely to live shorter lives, when compared with aging SCI patients with superior financial means and access to private resources.4 For example, the University of
2. Litchblau, Craig and Warburton, Christopher et al. “Life Expectancy in Spinal Cord Injury: The Importance of High-Quality Care” International Journal of Physical Medicine & Rehabilitation. Volume 10, Issue 1. Number 1000619. 15 February 2022.
3. Pettingill, Bernard F, and Federico R Tewes. “Analysis and Forecast of Nursing Care Costs.” Pettingill Analytics, 30 Sept. 2020, https://www.pettingillanalytics.com/post/vaping-classactions-damages-in the-shadow-of-tobacco.
4. Strauss D, deVivo M, Shavelle R, Brooks J, Paculdo Alabama created a life expectancy calculator specifically for SCI patients, called “Spinal Cord Injury Calculator.” This calculator looked at 10 factors: Age, injury date, sex, ethnicity, highest level of education, type of insurance, whether the patient has used a ventilator, the cause of their injury, their current level of SCI, and current completeness of SCI. Because the care of SCI patients is prohibitively expensive, the life expectancy results vary significantly depending on whether the patient has public versus private insurance.5 In other words, aging SCI patients who do not receive optimal funding to finance a total life care plan, will likely not receive optimal care. Supervision by professional attendant care specialists will help prevent complications from deep vein thrombosis, pulmonary embolus, pneumonia, sepsis, urinary tract infection, cellulitis, osteomyelitis, and automatic dysreflexia, among other complications. Without question, this directly affects the patient’s quality of life and the patient’s quality of care hopefully for long durations of life.
Every SCI injury is different, and the patient’s mental health status is a significant factor in coping with life after the injury. Medical professionals will find ‘quality of life’ difficult to measure for an aging SCI patient, but they are likely to use two methods. First, the Spinal Cord Injury — Quality of Life (SCI-QOL) measurement system. Second, the 36-Item ShortForm Health Survey (SF-36). The first is mainly a subjective measure and the second is mainly an objective measure. One particular factor that may cause depression or anxiety in many SCI patients is repeatedly comparing their lives before and after their injury, consequently affecting the patient’s mental health status. Studies focused on the benefits of meditation cite daily meditation and the practice of mindfulness for helping aging SCI patients become more present-minded and accepting of themselves. Another important factor in the patient’s mental health status is the feeling of loneliness, which is frequently reported as a source of lower quality of life after the date of injury and sometime suicide. Although an SCI affects the patient’s mobility and their ability to lead productive and independent lives, friends and family members want to see the patient recover both mentally and physically. For example,the use of adaptive tools if necessary. Many SCI patients request car adaptations, such as hand controls or wheelchair ramps installed, allowing the SCI patient to enjoy a change of scenery and time outside the home. Adaptive tools will help the individual perform tasks that they may not be able to perform on their own. Another example are the adaptive utensils for SCI patients, which are wrapped around the forearm and allow the patient to feed themselves independently, without relying on assistance from someone else. These changes will help D. Economic factors and longevity in spinal cord injury: A reappraisal. Arch Phys Med Rehabil. 2008;89(3):572-574.
5. “Spinal Cord Injury Life Expectancy Calculator.” NSCISC Application, 2013, https://www.nscisc.uab.edu/Public_Pages/LifeExp. boost self-confidence and feelings of independence, indirectlyimproving a patient’s mental health status.
Physical and occupational therapy can help boost selfconfidence and feelings of independence. To regain some mobility after an SCI, physical therapy through consistent, task-specific repetition may help retrain brain, spinal cord, and muscles to work in sync again. Physical and occupational therapy may frustrate an SCI patient who feels like friends and family do not understand what they are going through. A highly recommended solution is a spinal cord injury support group to connect with people facing the same challenges. Attending these meetings will allow patients to express their concerns, learn from the experiences of others, discover helpful resources, while being there to listen will help others struggling with SCI by sharing the patient’s experience.
Regardless, professional attendant care will most likely mean numerous hours per day for the care of the aging SCI patients. Being near and conversing with the patient will provide input to other medical professionals and physical therapists who strive to improve the patient’s quality of life after the injury.
Most personal injury attorneys do not have the expertise to evaluate a proper life care plan. Instead, they are likely to look at the total cost of the life care plan and conclude that it is too costly to provide professional care over a long duration, perhaps the remaining life of the patient. However, as the SCI patient ages, there will be a greater need for more and more supervision
6. “Quality of Life after Spinal Cord Injury: How to Improve It.” Flint Rehab, 15 Dec. 2021, https://www.flintrehab.com/qualityof-life-after-spinal-cord-injury/. by professional attendant caregivers as referred above. As explained previously, the 24-hour duration on a daily and weekly basis will represent nearly two thirds of the total cost of any life care plan for most SCI patients. If the date of injury takes place at an advanced age, then the professional attendant care may represent nearly 90 percent of the total cost of the life care plan.
Alternatively, if a SCI patient pursues a personal injury lawsuit with ample financial resources to pay for optimal care, the plaintiff attorney structures the claim to provide optimal professional care for the SCI patient, always resulting in 24/7 care in the last 5 to 10 years of life. However, as referenced above in the University of Alabama “Spinal Cord Injury Calculator,” the last 5 to 10 years may be accelerated far in advance of the average life expectancy of the patient.
In a court of law, how do the plaintiff and the defense attorney view this issue?
The defense attorneys would like to disregard the last 5 to 10 years of the 24/7 care of the truncated life expectancy as measured by the University of Alabama “Spinal Cord Injury Calculator,” often resulting in a reduction of some $2 million or more in the total cost of the life care plan. On the other hand, the plaintiff attorneys seek to accelerate the need for 24/7 care for the last 5 to 10 years, minimizing the need to reduce the damages by $2 million.
This legal and ethical dilemma will continue to disrupt all SCI medical claims for damages until resolved by the highest level of the judiciary.