Anxiety’s Impact upon Informed Consent

Informed Consent and Anxiety

Informed consent is often structured around insuring that the patient has been duly informed of the risk-benefit ratio of clinical procedures. Informed consent does not always seek to determine the depth to which the patient understands the necessity of a procedure or the process of treatment. Perhaps more important is that the anxiety associated with physical disorders that increases when the patient feels they are stripped of control, and often their own identity. 

Regardless of the amount of time or materials provided the patient, the capacity to internalize the data is then compromised. 

The first impact of anxiety upon cognitive functioning is to disrupt attention and its more complex associated skill, concentration. Regardless of the extent to which the patient is “educated,” the question remains, how much information are they capable of retaining? In the absence of the retained data, to what extent is the patient threatened, confused or alarmed by their own lack of education?

Among the means by which these issues can be addressed by the doctor are the following patient queries:


a. Has anyone spent sufficient time with you explaining both your condition and the treatment recommended?


b. Do you have lingering confusion as to what has been found and what treatment is indicated?


c. Are you able to understand the terms used by those treating you, and are you able to ask questions regarding those terms when you need more clarification?


d. Do you feel that the educational material is appropriate for you or are you being provided with too little data to answer your questions or too much data resulting in increased confusion.

Clarifying these issues is not only critical to the patient’s understanding. It is a necessary step of self-protection for the clinician who might otherwise be blamed for unanticipated negative outcomes. 

The Phenomenon of Memory

Repeatedly, we reviewers of medical records note distortions between immediate recall of an injury and successive changes in the description of said event.

Some perceive this as malingering, or at best, an attempt to inflate the value of a legitimate injury.

While exaggeration can be used for financial gain, the phenomenon of false memories is common to us all. Equally, a traumatic memory may be suppressed and forgotten, only to arise unexpectedly when the proper cueing occurs. This is seen with true Posttraumatic Stress Disorder. A patient burned at work functions well at home and around town, until driving past the place of their injury. Memories flood and incapacitate them.

When my children share memories of their childhood, they most vividly recall the negative events that stand out as an aberration. This would be more palatable if they equally recalled the care and love we had shown them on a regular basis, but it is not so. Daily and expected comfort and support, sadly, is not memorable. Pain and loss are more likely to be imprinted or suppressed in their developing psyche.

Within the context of an accident, the injured party must describe the event repeatedly for EMS, the ER, family, their personal physician, subsequent medical specialists, and their attorney.

If patients recover from their injury, eventually their support system will slowly fade away. They no longer need home health or mobility aids, their physicians see them less frequently, and their physical therapy eventually ends. Their family expects a return to normalcy.

But the patient may not have returned to their normal state. And that, to an injured person, is unacceptable. A new physician may hear a different rendition of the original accident, one that serves to impress upon the specialist the heinous nature of the injury.

The most accurate recall, in my experience, is in the emergency room, barring a head injury or loss of consciousness. When the description changes over time, our duty to the truth requires a methodical review of the medical records. In this way, we can often pinpoint the deviation in recall, allowing those who represent the patient to measure the accuracy of the event, and the reliability of their client’s memories.  AMA

Projecting Costs: the Larger Picture

When it’s time to factor future medical costs, a common concern is that the projection may be insufficient to meet a patient’s needs. The strong temptation is to include all potential complications, and choose the highest-end durable medical equipment. However, this is rarely the best approach to meeting that patient’s needs. The resulting exorbitant projection may result in rejection of an otherwise reasonable settlement.

Professionals may confuse Life Care Plans with Medical Cost Projections:

A Medical Cost Projection, or MCP, is confined to reviewing medical records and projecting the costs of a specific surgical procedure or medical course of care. Some of those costs are projected for the lifetime of the patient, or the weeks remaining on a worker’s compensation claim.

Performing a Medical Cost Projection does not require professional certification and although classes are available, many MCPs are constructed by individuals who seek guidance from peers.

MCP’s are factored by geographic adjustment, reimbursement by private insurance or state Board fee schedules, and vary in quality and accuracy depending upon the contractor’s experience.
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A Life Care Plan, or LCP, does require certification since these plans are often associated with depositions and testimony at trial. When a patient has a catastrophic injury or illness, the plan may involve a visit to the patient’s home, interdisciplinary communication, coordination, and anticipation of lifelong healthcare needs.

Life Care Plans are based upon actual charges and are not limited by the concept of reimbursement. The plans require a careful assessment of the patient’s lifetime needs, family resources, community and educational support, medical supplies, and potential complications.

In predicting future complications, Nurse Life Care Planners have the advantage.

In the hospital setting, nurses oversee every aspect of patient care and coordinate scheduling among respiratory, physical, occupational and speech therapies, dietary consults, and diagnostic procedures. Certified Nurse Life Care Planners are attuned to the patient’s need for and response to medication, the status of their hydration, mentation, skin integrity, and early signs of complications. Our experience and utilization of nursing diagnoses guide us in prevention and management.

While physician diagnoses support the need for medical care and shape the bones of an LCP, nursing diagnoses, of which there are 250, flesh out a life care plan. A nurse with experience in burn care, TBI, cerebral palsy, amputations or the elderly, knows what constitutes a preventable complication. Our plan recommendations align with nursing diagnoses and our only boundaries are those established by the Nurse Practice Act of our state.

But whether a Life Care Plan is constructed by a nurse, social worker, counselor or rehab supplier, the goal remains the same: planning and funding for care that will maximize the patient’s potential for independence while adding to the quality of their remaining years.

The Changing Face of Body Language

As the daughter of an Army Drill Sergeant, I grew up around Fort Jackson, SC. We shopped at the PX, attended the Roman Catholic church on base, bought 29 cent gasoline and went to the movies for a …

Source: The Changing Face of Body Language

You thought this case had merit

Every law firm has a unique philosophy that guides them in their decision to represent a plaintiff or plaintiff’s estate. With that in mind, if a case is turned down, it is always for a good reason that applies to that particular firm. Most attorneys want to clearly explain reasons for denial in layman’s terms with the potential client.  No firm wants to be sued for professional negligence, so part of the explanation will emphasize that the plaintiff or family are free to seek a second legal opinion.

If you are asked to review medical records so that the attorney can determine the merits of a potential case, keep these points in mind:

  • The medical facts were not compelling during the initial review, or perhaps were not “facts”.
  • The firm does not handle this type of case – be certain you have a good understanding of the firm’s preferred specialty area
  • The case has merit but will require more money and resources than the firm can apportion
  • The firm handles high value cases referred to them by smaller firms who find merit, but cannot afford the cost of experts, records, depositions, etc.
  • The medical injury is a high-risk surgery or other event with known complications that are difficult to define as negligent
  • The permanent damages are minimal – the patient feels that past expenses support the severity of damages but in truth, future loss and costs determine the ultimate value

Know the firm’s philosophy, preferred type of work, tolerance for financial risk, and most importantly, the attorney’s first-brush legal opinion of the case. That opinion, more often than not, is accurate.

Authenticity

I believe the greatest barrier/challenge that faces a new LNC is the ability to manage anxiety in new situations, meetings, presentations or interviews with attorneys.

These are the same problems faced by attorneys in preparing a closing argument.

When I began meeting new attorneys, I know that I did not project self-confidence. I will always be grateful for the ones who hired me despite this shortcoming. I was not convinced of my worth or that I could provide what they needed. I knew the lingo and had read the bullet list of 30 benefits of hiring a legal nurse, but I had not yet delivered those benefits.

I grappled for words that would communicate my competence in case analysis, but I was relying upon the success of others to give me courage.

Amy Cuddy is a social psychologist with a fascinating story (find her on TED talks and read her book, “Presence”). She combines multiple philosophies and her own experience to describe that hard-to-capture essence of convincing others that you are worthy.

Convincing others of your worth begins with conviction that you have the qualities you wish to impart. When you truly believe in what you do and who you are, others will also believe. I know after ten years and many hundreds of cases from all sides of the law that I am who I say I am.

True authenticity is not memorized or rehearsed; it comes from the heart.

The Dependency Curve – Guest Post from Dr. David B. Adams

This Week’s Topic: “It’s Curvilenear”

Question: “He clings to me, then resents me, then begs me and then rages against me.”

Dr. Adams replies: ”We enter life entirely dependent aside from vegetative functions. We cannot exist on our own, and this characterizes most living species.

We oft-times terminate our existence by returning to that same position, reliant upon others for the same functions that we had learned to perform independently so many decades ago. It is the curvilinear shape of dependence.

We learn to ambulate, communicate and negotiate our world in stages and steps that enable us to function as separate beings, and, in turn, we then rear our offspring to do the same. This is how society exists and advances.

There are obstacles and trauma that require us to briefly regress to deal with illness and injury, loss and disappointment, but in all cases we return to that path of autonomy.

We marry and become interdependent. We allow others to manage most of our lives and become passive-dependent. We become addicted and co-dependent. We resent those upon whom we must rely and become hostile-dependent.

An injury may require an acute period of return to dependency. We call upon emergency medical services, rely upon primary care, must defer to hospital policies, and for the most part we become conditioned, helpless to the point that we cannot even remove our own sutures (sidebar: Unless you are married to a nurse, but that’s likely off-topic).

Injury becomes a struggle between the inherent need to be independent and the concurrent and often pressing requirement that we temporarily accept our dependent role. This will include passively accepting our providers, their schedules, their treatment approach, as well as the consistency/inconsistency of receipt of benefits. Since this most often is in sharp contrast to how we existed only seconds prior to injury, this is arguably the greatest trauma of all.

For some patients, dependency is a characterological flaw. It is a personality defect awaiting expression. It may have presented multiple times during the patient’s history, times to which we are not privy. But the chronically emotionally dependent patient becomes a challenge in case management.

Those assisting the chronically dependent patient become the target of neediness, resentment and fear. The role must remain clinical and, to some degree, sterile in order to address objective damages. The dependency may be emotionally catastrophic for some patients, but it is not often addressed during the course of injury care.

It is essential to recognize that the dependency arising after injury is either something that the patient finds aversive or something to which the patient too readily acclimates.

An injury can be catastrophic to the point of complete and permanent inability to attend to the Activities of Daily Living. In all other instances, the goal from the outset must be a return to whatever level of independence can be achieved. Thus, the inpatient healthcare team includes discharge planning and goals in their initial assessment upon admission.

Mediating with a Full Deck

It’s no secret that most civil cases never go to trial, or that insurers would be happy to settle workers comp cases rather than periodically increase their reserves. Unfortunately, it is also true that plaintiffs have no way of knowing how to value their claim or accept their attorney’s recommendation for a reasonable settlement. They drink the Kool-Aid of TV commercials, uninformed friends, and the back-end advice of their city bus.
More importantly, attorneys  have a difficult time knowing how to place a proper value on their client’s claim for future medical costs. Looking at past costs and lost wages is a cut and dried process. Asking colleagues for a ballpark figure on surgery, or going to a source like Healthbook, never takes into account the individual needs of client. And the client (patient) lives for the future.
Since mediation is often the final chance to intervene in an injured person’s life, make sure the potential costs are known, and presented in a professional format that facilitates acceptance at the table. Using the proper CPT codes, basing the cost on the State workers compensation fee schedules or the 75th percentile of UCR, including recent office visits, diagnoses and current life expectancies, creates a powerful tool for settlement.
Medical Cost Projections should be based upon the recommendations of the treating physician for potential surgery and medical care; annual costs of physical therapy, psychological care, x-rays, lab work, office visits, medications, DME equipment, bath and kitchen aids, yard and home maintenance if this will be an issue, and other costs that might occur with catastrophic injuries.
Big or small, every settlement matters to the patient whose life continues after both sides of the table go home, or on to the next case.

Maintaining the Veil of Anonymity

Just as new LNCs are feeling their way, so are new attorneys. And plaintiff counsel may not have a flexible budget until they have been in practice for a while.

Personal injury and med-mal attorneys who tell their clients that “they won’t pay unless their case is won” still have to cover expenses. Workers compensation attorneys must convince the injured worker that a body of work is important enough to warrant a portion of their settlement.  So even though a merit screen or a chronology is warranted, that attorney may worry that the client will not see the value in such services. After all, they expect the attorney to know if their case is viable.

On rare occasion, a new attorney may ask a nurse consultant to meet directly with a patient in case evaluation, and to accept payment for their service directly from the patient. This practice is not recommended for the independent nurse contractor.

I want my attorney to be comfortable, but I also know that my value resides in anonymity. When asked if I will accept payment from the patient directly, here is my reply.

I understand that you will pass this expense on to your client, but it is in both of our best interests to maintain a veil between me and your client.
1. An assessment for merit is a clinically objective appraisal.
2. Clients (as you know) are emotional and feel they must compel someone to agree with them.
3. My relationship as an independent contractor is with you – you are my client.
4. Merit may be in question because of inconsistencies in the client’s complaint, or because they are over-reaching, or because they equate malpractice with unforeseeable complications and mistakes. This is pivotal, but a hard pill to swallow.
5. My value to you is my invisibility because you are the principal – you are the person they want to hire – I am in the background.
6. My work product is always confidential and my opinion is withheld from experts, even when they use my objective chronology. I cannot control this process if I am accessible or responsible to anyone but you.

That said, I can write a short paragraph that explains exactly what I will be doing and why an experienced nurse should evaluate medical records.

If there is a question of merit and you decide not to take the case, I can craft a short and clear layman’s explanation of the medical injury/condition for you to incorporate into your response.

Please let me know if I can be of any assistance to you in this matter.

I look forward to a long working relationship with you.

All the best,

Stroke and CHI – Key Concepts for Legal Professionals

Stroke and CHI – Key Concepts for Legal Professionals.

Stroke and CHI – Key Concepts for Legal Professionals

Head injuries or brain damage can occur anywhere – in the workplace, in an MVA, in medical malpractice, toxic torts, a domestic fall, and environmental exposures.

Litigated head injuries generally arise from two sources:

1. Accidents
a. blunt trauma (fall, violent blow or MVA)
b. penetrating trauma (gunshot)

2. Medical causation (stroke)
a. ischemic (a clot blocking blood flow to a major artery)
b. hemorrhagic (rupture of a major artery causes damage to the brain)
c. TIA or Transient Ischemic Attack (symptoms resolve within 24 hrs)

In all instances, brain injury is affected by blood: either blocked flow (ischemia) or bleeding that puts pressure on another area, damaging tissue. The location of the injury is the most important determinant of the severity and likelihood of recovery.

Key Concepts

• Rate and degree of recovery after brain injury is quite variable

• The most common form of traumatic brain injury is the subdural hematoma (SDH), with a mortality rate ranging from 50 – 90%. A significant percentage of these deaths result from the pressure on the brain that develops in the days after injury. Treatment of the SDH depends upon the location and age of the lesion. Because bleeding is not static, “Early and sometimes repeated CT scanning may be required in cases of clinical or neurologic deterioration, especially in the first 72 hours after head injury, to detect delayed hematoma, hypoxic-ischemic lesions, or cerebral edema.”

• Approximately 20-30% of patients will recover full or partial brain function. However, post-operative seizures are relatively common in these patients.

• Although recovery from TIA (transient ischemic attack) occurs within 24 hours, these patients may be at a high risk for falls if they may regain mobility before being aware of their surroundings.

• Strokes arising from blood clots usually require anticoagulation therapy to prevent further clotting, but improper medication management can result in a fatal hemorrhage

• Because patients can “go bad” quickly, frequent monitoring of vital signs, ICP (intracranial pressure) measurements, lab values, pupil checks and level of awareness is crucial.

• A critical part of assessment includes changes, even by one point, in the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) numerically represents the level of consciousness and is based upon a 15-point scale for estimating and categorizing the outcomes of brain injury. The patient who is unable to respond verbally or follow commands can nonetheless have a reflexive response to painful stimuli. Families do not appreciate this form of assessment, but the patient’s physical response tells a great deal about how the brain is processing this noxious stimulus. The following signs are associated with a poor prognosis:

• A Glasgow Coma Scale less than 8 in the field
• A Glasgow Coma Scale less than 5 in the ER
• Unequal/changing pupil size
• Motorcycle accident (direct head impact and no airbag)
• Problems with ventilation, further depriving the brain of oxygen

A patient with an acute and severe brain injury may be placed into a medically induced coma to protect and allow the brain to rest by slowing metabolism. Mechanical ventilation controls oxygen and carbon dioxide levels that can aid in reduction of swelling, and sedation allows an override of the patient’s breathing, which is often labored and dysfunctional.

Pain should be managed effectively because it can lead to a rise in intracranial pressure. An intubated patient is treated with short acting sedation and analgesia until time for weaning.

Claims for pain and suffering in the unconscious patient should consider:

• The victim’s awareness of impending danger prior to the head injury (an assertion of this awareness has been successfully argued even with death cases)

• Successfully communicating to a jury the difference between purposeful movements and reflex, and

• Evaluation of post-injury residuals established by Medical Cost Projection or Life Care Plan.

Putting post-injury impairment into perspective, it is very important to know the level of prior intellectual and emotional functioning. This information is sought by defense counsel in quantifying financial responsibility, and is equally important to plaintiff’s counsel in supporting a reasonable demand.

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Alice Adams is a veteran RN who has cared for many acute head injury patients. She has been a legal nurse consultant since 2006 and lives in Atlanta, GA. She evaluated the injury cases in the 2007 Bluffton University Baseball team’s tragic accident and fatalities, and is very active compiling Medical Cost Projections and providing medical analysis for >40 attorneys and law firm.

http://www.aliceMadams.com nurseatlanta@gmail.com 404.771.5155

Questions from Jurors are GOOD, Period.

Really loved this blog.

Not allowing jurors to ask questions is akin to not allowing patients to ask questions of their doctors. We always encourage patients to write down their thoughts before their appointment, lest they forget something critically important.

And honestly, twelve pairs of fresh eyes and ears are bound to think of something that a team of attorneys may have overlooked after months or years of honing in on a theme.

Thank you for allowing a repost.
Alice

Juryology: Art & Science of Jury Persuasion

Pulp Cover_Juror QuestionsThere’s a story in the July 21 online edition of the Boston Globe about a trial in which jurors have asked 281 questions, and in my opinion, the piece skews rather negatively about the whole practice of allowing jurors to ask written questions during trials. That’s wrong: Juror questions are a good thing for you, Counsel, and you should be enabling them in every one of your trials.

View original post 2,037 more words

PTSD – Part One: Causation and Symptoms

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Diagnostic Confusion

One would think from the number of PTSD diagnoses made by family physicians, orthopedists, and neurologists that this condition is rampant if not inevitable for any serious personal injury. It is not that simple.

Posttraumatic Stress Disorder as a diagnosis emerged after the Vietnam War. Prior to the then, “shell-shock” was the terminology used in the WWII and Korean wars. The Diagnostic and Statistical Manual (DSM III) classified the diagnosis as an anxiety disorder, and further refined diagnostic criteria in subsequent editions. The diagnosis as it exists in today’s DSM-5 utilizes the most specific criteria yet, re-categorizing PTSD as a stress (trauma) related disorder.

In most States, PTSD (or any other mental injury) is not compensable under workers’ compensation without a preceding physical injury. Nonetheless, some employers will authorize an evaluation for a significant emotional trauma like a robbery, even in the absence of tissue damage. Morally, it seems the right thing to do, and from a legal (perhaps jaded) perspective, an employer who offers treatment under workers compensation may be shielded from liability.

You may be bringing or defending a claim of Posttraumatic Stress Disorder. While diagnosing the disorder is a clinical process, as you weigh the evidence for likelihood of PTSD, here is some data that may guide your assessment.

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More Than One Form of PTSD

If a trauma occurred more than three days but less than four weeks ago, the diagnosis is Acute Stress Disorder.

This is not to be confused with Posttraumatic Stress Disorder – Acute, meaning the symptoms have been present between four weeks and three months.

Posttraumatic Stress Disorder – Chronic means the symptoms have been present longer than three months.
Posttraumatic Stress Disorder – Delayed Expression applies to symptoms that first arise > 6 months after the trauma.

Further refinement of the diagnosis depends upon severity and degree of impairment in functioning. Extreme symptoms may include depersonalization, or the feeling of being an outside observer of one’s body; derealization, or unreal and dreamlike surroundings; both are symptoms and forms of Dissociative Symptoms. Children under 18 are diagnosed by a different set of criteria and they are very sensitized to the traumas encountered by their parents.

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Symptoms & Diagnosis

In personal injury claims, the diagnosis of PTSD is commonly associated with motor vehicle accidents, fires, airplane incidents, amputations, and assaults. Chronic back pain from an injury does not result in PTSD unless the injury itself was traumatic (such as falling from height or being struck by a car).

What are the criteria for a valid claim of Posttraumatic Stress Disorder, and why is the diagnosis so often misapplied by primary physicians when pain is the only complaint? Rather than dispute what PTSD is not, let us examine the eight criteria for a valid diagnosis of PTSD:

A. There must be a triggering event: exposure to actual or threatened death, serious injury, or sexual violence in one or more of the following ways:
i. Direct experience of the event
ii. Witnessing the event as it occurred to others
iii. Learning that the (accidental or violent) event happened to a close family member or friend
iv. Repeatedly experiencing personal (not via media) exposure to the trauma (such as 911 first responders)

B. A diagnosis of PTSD requires one or more of these symptoms be present following the event:
i. Recurrent intrusive memories that are involuntary
ii. Nightmares of the event –police officers may dream that their family is in great danger and they are powerless to save them.
iii. Flashbacks – the person feels or acts as though the event is happening again
iv. Extreme psychological distress at exposure to internal or external cues of the event (smells, sounds)
v. Extreme physical reactions to internal or external cues of the event (GI upset or vomiting, for instance)

C. The patient persistently avoids reminders of the event in one or more ways:
i. Avoids memories of the event in all forms
ii. Avoids external reminders of the event (people, places, objects, etc)

D. Changes in mood or cognition in one or more of the following ways:
i. Amnesia for important aspects of the event
ii. Pan-negative beliefs about self or the world
iii. Irrational self-blame
iv. Persistent negative emotions of fear, anger or shame
v. Withdrawal from activities
vi. Withdrawal and detachment from others
vii. Anhedonia or the inability to experience happiness or pleasure

E. One or more of the following behaviors are atypical in presence or severity prior to the event:
i. Extreme irritability or aggression
ii. Reckless or self-destructive behavior
iii. Extremely on guard for surroundings/safety
iv. Exaggerated startle response
v. Difficulty concentrating

F. The symptoms in Criteria B-E have lasted > 4 weeks

G. The symptoms are severe enough to impair functioning in social, occupational or other areas of functioning

H. The symptoms are not the result of medication or other medical conditions

Next time: Treatment and Planning

With the Right Chronology, You too May Enjoy a Deposition

Last week, I had fun.

I manage my husband’s forensic psychological practice, and last week he had a deposition. He loves depositions. Really.

The data he needed to review, however, was oppressive; he had performed five Fitness for Duty evaluations over 18 months on a professor not well enough to teach three out of those five times. Between each visit were innumerable telephone calls alternating between anger and accusations, anxiety and fear.

Five charts to organize, papers to shuffle, and “where did I see that?” I surprised him with the same work I have provided my attorneys for years – a medical chronology. Five charts became a five-page table arranged in SOAP format– Subjective, Objective, Assessment, and Plan. I was a hero.

Deposition Day: the attorneys arrive with their respective armload of records, between them producing twenty exhibits. In short order, my husband had distributed a copy of my chronology to both attorneys and ten minutes later, no one referenced their paper charts. My chronology was now Exhibit #21 and provided the focus for the next 90 minutes. The defense and plaintiff attorneys huddled together and swore they had never seen such a wonderful document.

How is that even possible? How do attorneys enter a deposition without this organization? These attorneys specialize in employer law, human resources, EEOC and civil rights violations, and chronologies were not part of their repertoire.
I really should not repeat the inappropriate comments from my husband during deposition. A few were on the record; more were off, and all produced peals of laughter that emanated down the hallway. Work should not be this much fun.

The reward for my chronology could well be a notice of deposition to testify as a fact witness. That is perfectly okay – I can just reference my own chronology.

The Autopsy – a Dying Recommendation

In recent decades, there has been a marked drop in autopsy requests – an unfortunate occurrence. In the distant past, any death within the first 24 hours of admission triggered an autopsy. Any unexplained death in or out of the hospital; any accidental death with questionable etiology required an autopsy. JCAHO required 20% of hospital deaths to undergo autopsy as part of hospital accreditation; that requirement ended in the mid 70’s.

One objection to autopsy comes from families and we can well understand their reluctance. The loss is acute and painful; the thought of mutilating a loved one overrides the practical need to identify the cause of death.

In my review of medical records, an autopsy trumps any postulation by a treating physician. Why? Because when a patient is gravely ill, they often have a number of morbid conditions, any one of which could be fatal. A physician has the natural tendency to see the cause of death from the perspective of their specialty.

Virtually useless is the Death Certificate. Death certificates do not provide root cause, only an end result. Respiratory or cardiac arrest is inevitable in death, but those diagnoses provide no etiology; they cannot address the “why” of death.
If an employee dies in the course of work, has an MI, stroke or other “illness death”, an autopsy can offer the evidence needed in an otherwise uphill battle for causation.

In negligence or malpractice death claims an autopsy is invaluable, but all too often the family’s last concern is dissecting the cause. When questions later arise, that most valuable source of information – the patient and their true cause of death – is irretrievably lost.

From a public safety perspective, we can only speculate on the number of infectious diseases, chemical exposures and related information that may be lost.

Regardless of JCAHO recommendations, it is incumbent upon healthcare professionals to offer this option when the cause of death is not crystal clear. “Natural causes” is the most frustrating and misleading nomenclature in the healthcare dictionary.

LNCC and CLNC – what do these initials mean, really?

Attorneys are practical professionals. They seek a legal nurse who consistently delivers an excellent work product and sound opinions. They also recognize that certification should be an indicator of experience and expertise in a nurse. Although LNCC and CLNC are often thought of as interchangeable, even by some nurses, they are not synonymous.

Brace yourself for an onslaught of initials.

The LNCC (Legal Nurse Consultant Certified) is the only credential recognized by the Accreditation Board for Specialty Nursing Certification (ABSNC), formerly known as the ABNS Accreditation Council, which is the only accrediting body specifically for nursing certification.

The LNCC is obtained through the ALNCCB (American Legal Nurse Consultant Certification Board); see http://www.AALNC.org:

The LNCC® program is accredited by the Accreditation Board for Specialty Nursing Certification (ABSNC), formerly the American Board of Nursing Specialties (ABNS). ABSNC accreditation means that certification programs have met high standards for testing.

To be eligible to take the examination, candidates must have the following at the time of application:
• current licensure as a registered nurse in the United States or its territories, with a full and unrestricted license
• a minimum of five years of experience practicing as a registered nurse
• Evidence of 2000 hours of legal nurse consulting experience within the past five years.

Those who meet the eligibility criteria and successfully complete the examination will earn the Legal Nurse Consultant Certified (LNCC®) credential” (and must re-qualify by exam every five years).”

Note there is no mention of a specific “course” even though the AALNC does offer continuing education webinars throughout the year, various online courses, and other educational resources. However, their courses are not a prerequisite for taking the LNCC exam.

The LNCC credential is evidence of knowledge-based practice as well as broader knowledge of legal concepts in a wide range of settings from all medical-legal arenas. LNCC designation measures overall competency.

The CLNC designation is acquired through the Vickie Milazzo Institute; see http://www.legalnurse.com:

“2 Simple Prerequisites for Becoming a Certified Legal Nurse Consultant

1. Complete the Basic CLNC® Certification which is included in all 3 CLNC® Success Systems: VIP, Executive and Basic.
2. Maintain an active RN license in the U.S. or Canada. A BSN degree is NOT required.
Exemptions from meeting any of these criteria will not be granted.

Whichever CLNC® Success System you choose, you’ll receive everything you need to know to get started as a highly paid professional consultant – 100% guaranteed. Our Certified Legal Nurse Consultants are 25 to 75 years old and live all over the U.S. in both rural and urban areas. There’s no limit on succeeding as a Certified Legal Nurse Consultant.”

The CLNC program is six days, either in person or online, and offers supportive mentoring as new LNCs start their business. It provides a wealth of information, teaches new nurses how to initiate and self-promote their new business, obtain sample work products from a highly successful businesswoman/LNC/attorney, and many nurses credit the system with “jump starting” their business.

The CLNC credential is achieved after passing an exam of the materials presented during the six-day course. No experience as an LNC is required, and while the course is accredited for continuing education (as are many others); it is not an accredited certification through ABSNC.

Many CLNC graduates later achieve accreditation as an LNCC after proof of 2000 hours of legal nurse consulting.

There are a number of LNC courses accredited for continuing education, both online and through traditional colleges and universities.

But there is no substitute for experience.

Writing Your First Report

There is no “correct” way to write a consultative report, and so much depends upon what your attorney wants.  What do you think the attorney needs to see?

This is just my personal style. The first thing I write is an introductory paragraph that cites the patient’s name, claimed injury, and brief description of that injury and residual damages. I end it with my opinion, right up front. This may be the last sentence I actually write, but it should be prominent, with any disclaimers.

I might then have a section that lists the supportive evidence. Bullets are great for this. I follow with mitigating information that may work against the claim, probably in paragraph form, to allow your positive bullet points to take center stage.

I also have a bullet list of pre-existing or concomitant conditions that influenced the outcome of the injury. If these conditions are likely to be unfamiliar to the attorney, I will footnote rather than clutter up this section with parenthetical references. If there is a complicated concept I may use a graphic (who wants to describe a foot orthotic or a fundoplication or ICP screw when a simple image says everything). I only use one or at the most two maximize the impact without my report resembling a comic book.

What comes after depends upon the type of report. If I have done a chronology, I do not include all that data into the report – that is why I wrote a chronology. If it is a stand-alone report, I will want more information about the timeline of events and injury, but a chronology is always preferred.

This is where I would address standards of care, if applicable, contributory negligence, and how the case might have resolved but for those issues, whatever they may be.

If I can clearly see the opposing position, I will point that out and offer any counter points.

I end with a list of considerations for the attorney to pursue. This includes the experts that he will need to support his case; specific records to request (always get the ones that predate the event and the most recent since you will rarely have all of either). No matter how strong the evidence, I know that an expert “will be needed to confirm the…” because the attorney cannot base his case upon my opinion. Attorneys will often go forward with a mediation without an expert, and with great success. The decision is theirs.

Elements I like:

• Bullets, as mentioned – using phrases instead of complete sentence structuring allows me to express things succinctly and with more impact

• The use of only one font unless I do something different in a section header • Bolded headers in a larger font, usually in dark gray so that it stands out but isn’t too heavy

• Sentences that are no longer than the ones in this blog • A header beginning on page two that lists “Confidential Attorney Work Product”, with case name under that and the page number under that.

• A complete absence of the use of first person – my opinion is based upon objective evidence, not my feelings

• Absence of emotional input – state the facts clearly and strongly and they will speak for themselves – “this poor dear lady” is just not my style and does nothing to support the case. The attorney will often use that language in his pleading.

• I end with appreciation for the consult, state my availability for further communication, and offer to review further medical records as they arise or fulfill other needs such as expert location

• I sign with “Respectfully Submitted” even if it is an attorney I work with all the time, because it is respectfully submitted

• If I used reference materials for the report, I will cite them.

• I use folders that are hard on the outside (they come in different colors), and have 2 or 3 separators inside, with 2-hole punch on the top. This allows me to organize my work in a logical fashion. I staple my business card to the cover. I include my invoice in a white envelope paper-clipped inside so they do not miss it but it is not the first thing they see.

It is a “process”, and you will find a way that works best for you.

What Your Attorney Needs from You

You should ask this question at the start of each new attorney-client relationship. I am not referring to the attorney’s area of specialization or their orientation towards defense or plaintiff work. I am speaking about their business and personal preferences, their personality, their desires. Despite having your own (no doubt strong) personality, you must adapt yourself to the communication and business style of the attorney.

I have a good rapport with some attorneys who like to share personal information and do not bother to begin and end emails with salutations. They encourage independent thought, brainstorming of theories; we have a mutually respectful and somewhat casual relationship.

There are also very formal attorneys, recognized immediately by their communication style. Respond to them in the same manner they address you. Begin your emails formally, pay close attention to your grammar and do not try to woo them with your witty asides. These attorneys may have a sense of humor but they do not know you well enough to share it.

Most attorneys have a very specific idea of what they need. They may want a detailed chronology and your personal opinion, but they will keep your opinion in-house. They may ask for a second chronology that does not have your name on the report, or your opinion in that optional column. You are their private resource and they need the opinions of experts to be based on clinical facts, not your intuition or experience. Your value is in your invisibility even though/because they are relying heavily upon you.

Some attorneys simply do not know what they want. They may have a case that falls outside their comfort zone. They may ask you how to proceed with experts, and dependently seek input. While this may be flattering, it is the trickiest case to manage because you cannot cross the line between nursing and the law. You are never responsible for their legal decision-making and you certainly don’t want to be responsible for the wrong opinion.

Be comfortable with yourself. Never accept demeaning or verbally abusive behavior even when putting your ego on the back shelf. This is a challenge for most nurses. We are an opinionated bunch and our opinion is what gives us value. Nonetheless, remember that no matter how close your affiliation with an attorney may become, it is first and foremost a business relationship. Their chief goal is to advise and satisfy their client. You will be most helpful if you ask them what kind of report, what kind of information, and what type of presentation they need from you. Then deliver a product that is unequivocal and fact-based, because the one thing all attorneys need is the truth.

The Mental Health Divide, Part II

continued from October 24, 2013)

More about the five axes of the DSM-IV-TR:

• Axis I relates to Clinical Disorders, which include all forms of depression (severity and recurrence), anxiety and mood disorders, PTSD, schizophrenia and psychoses. Think of these as disorders that are acute or chronic, biologic or reactive, but generally responsive to psychotherapy alone or in combination with medication. • Axis II reflects Personality Disorders, or features and traits that are lifelong characteristics that often interfere with daily functioning, relationships, and adaptability. Depending upon the patient’s insight and motivation, these traits are addressed via a range of psychotherapeutic approaches, either alone or in combination. Examples include Dependent, Avoidant, Obsessive-Compulsive and Narcissistic Personality Disorders. The most commonly used diagnosis is 301.9 – Personality Disorder NOS with (fill in the blank) Features when more than one trait is problematic. An IQ that falls below a certain threshold is also listed under Axis II. • Axis III lists the physical conditions present in the individual, and these are particularly pertinent to patients with chronic pain, injury or serious illness. • Axis IV outlines the psychosocial factors such as family dynamics, housing, occupation and finance that are affecting, or affected by, the individual. • Axis V measures the Global Assessment of Functioning (GAF), a numerical scale that assesses an individual’s ability to function in all areas of life, based upon the combination of Axes I-IV.

The DSM-IV-TR vs the DSM-V

Since its inception in 1952 and throughout its revisions, the accuracy and validity of the Diagnostic Statistical Manual (DSM) for classification of psychological symptoms has been challenged. Dr. Allen J. Frances, Professor Emeritus at Duke University, chaired the DSM-IV-TR task force (year 2000 Text Revision) and publicly objects to the impending release of the DSM-V.

An active blogger for the Huffington Post, he urges clinicians to ignore it’s changes altogether, asserting that the new version is vaguer than ever and will lead to labeling healthy individuals with its lowered threshold for criteria. In one of his blogs he states that the DSM-V is “offering its untested new diagnoses that will mislabel millions of the worried well as mentally ill”.  Parents of autistic children have the opposite concern, that their child will no longer fit in that diagnostic category and be denied access to medication and therapy.

Frances states that the DSM-V offers no leeway in differentiating, for instance, alcohol addiction vs dependence vs social use. The manual’s authors counter that early recognition will result in early intervention, but many practicing clinicians fear that the endpoint will be over-diagnosis that misidentifies normal variations in behavior.

The National Institute of Mental Health (NIMH)

On July 3, 1946, President Harry Truman signed the National Mental Health Act, which called for the establishment of a National Institute of Mental Health (NIMH). The process of diagnosing without etiology is the fundamental distinction between the DSM’s function and the conceptual model now proposed by the National Institute of Mental Health.

NIMH rejects all DSM versions and is devoting its considerable financial and scientific resources to the premise that all psychological conditions are biologic or chemical in nature, originating in specific regions of the brain, and thus amenable to medical intervention.  The stakes are significant – for insurance reimbursement, financial grants for research, pharmaceutical financing, and one hopes, the well-being of patients. Citing the difficulty in properly diagnosing mental health disorders when forced to choose an ICD code, in 2008 NIMH implemented its Strategic Plan, a diagnostic process using Research Domain Criteria (RDoc).

This plan utilizes a matrix of Constructs (rows) that are grouped into five Domains of Functioning, and seven classes of Variables (columns) with an eighth column for paradigms. The goal is to classify mental disorders along a continuum of biologic and genetic markers, neurological circuitry and specific regions of the brain. The attempt is not to diagnose a mental disorder by looking at the overall patient presentation, but to find one symptom that is present across a variety of disorders, eventually pinpointing the physical location of the symptom. This intersection would identify the origins of disease, and science (psychopharmacology) would intervene to avert mental disorder. This theory ignores the empirical research on the greater efficacy of “talking therapies” either alone or in combination with psychopharmacology, and even NIMH agrees that this lengthy research offers no immediate relief to patients.

Opponents to RDoc fear that severe illness (schizophrenia, bipolar disorder) may go untreated if the affected individual does not express a specific gene. They question the validity of research that is conducted solely in laboratories and does not involve practitioners in the field. NIMH counters that RDoc is an open document for which they have sought input from the medical community.

The term “Ivory Tower” designates an environment or atmosphere where intellectuals engage in pursuits that are disconnected from the practical concerns of everyday life” . The last sentence in the first paragraph of Draft 3.1: June, 2011 states that one of RDoc’s goals is “…to facilitate commentary from scientists and other interested stakeholders…” Should there be concern that patients and practicing clinicians are not mentioned in this sentence?