This column is the collaborative effort of Karen Preston, Cloie Johnson, Sarah Malloy, Tricia Morrison, Tanya Rutherford-Owen, Susan Wirt, and Elizabeth Zaras. The author is grateful for all editorial support, wisdom, and collective experience. The column is meant to be an educational forum for life care planners. It is not designed to offer an authoritative opinion from the editor or editorial board of the Journal of Life Care Planning, the board of the International Academy of Life Care Planners, or the board of its parent organization, the International Association of Rehabilitation Professionals, nor is it designed to represent or replace official opinions from a certifying body or other organizations associated with the practice of life care planning.
Question
In life care plan cases there are some occasions where I need to consult with more than one health care professional (expert and/or treater). But they may disagree with each other about future care or other contents of the life care plan. What is the right way to handle this situation?
Standards of Practice
The following standards apply to this situation (IALCP, 2022). The key concepts are collaboration, qualified professionals, objectivity, congruence, and seeking to resolve inconsistencies.
12. STANDARD: The life care planner seeks collaboration.
PRACTICE COMPETENCIES:
a. Seeks recommendations from other qualified professionals and/or relevant sources for inclusion of items and services outside the life care planner’s scope of practice.
b. Shares relevant information to aid in formulating recommendations and opinions.
13. STANDARD: The life care planner facilitates understanding of the life care planning process.
PRACTICE COMPETENCIES:
a. Provides information about the life care planning process to involved parties to elicit participation.
b. Maintains objectivity while collaborating with others in determining appropriate content for the life care plan.
16. STANDARD: The life care planner ensures that opinions and work product are congruent, consistent, and follow accepted methodological practices.
PRACTICE COMPETENCIES:
a. Reviews and revises the life care plan to seek internal consistency and completeness.
b. Reviews the life care plan for consistency with standards of care and standards of practice and seeks resolution of inconsistencies.
Response
The following conversation provides the ideas and wisdom of seasoned life care planners who, collectively, have over one hundred years of experience. Keep in mind that opinions may come from treaters, medical records, and/or retained experts.
PRESTON: A key concept in standards of practice is that they are general, meant to provide guidance yet allow for the professional judgement of the life care planner. There is no single absolute way to handle conflicts between sources. It is also important to note that there is no obligation for a life care planner to resolve disagreements or consider the impact of disagreements on legal strategy. The life care planner’s role is to be capable of recognizing conflicts, to collaborate with others to address conflicts, and to determine how differing opinions will be presented in a life care plan.
RUTHERFORD-OWEN: Because life care planners often confer with multiple parties in the course of preparing a life care plan, it is not surprising that differences in professional opinions are encountered. Since 2000, life care planners have held Summits to address important issues and reach consensus on how to conduct our practice. Life Care Planning Majority and Consensus Statements since 2002 have repeatedly and specifically addressed the task of addressing differing opinions.
In 2002, one of the areas of consensus reached by attendees resulted in the statement: “To create a foundation for life care plan content, there needs to be a method to handle divergent opinions between experts or between experts and the literature” (Riddick-Grisham, 2002). By the 2010 life care planning Summit, the statement read, “Life Care Planners shall methodically handle divergent opinions” (Berens et al., 2010). The most recent (2018) Majority and Consensus Statements preserve this same statement as presented in statement #65 “Life Care Planners shall methodically handle divergent opinions” (Johnson et al., 2018). This statement clearly places the burden of addressing opinion conflicts on the life care planner.
JOHNSON: We are coordinators of care and facilitators of collaboration. Often, we are in the unique position of being able to bring the various parties together for a conversation.
RUTHERFORD-OWEN: As life are planners, we are typically the only person involved in the process who has reviewed both pre- and post-event medical records, personally observed the evaluee’s living environment, read depositions or reports of various treating or consulting healthcare providers and subsequently integrated all information into one document, the life care plan. Personally, I conceptualize all communication that the life care planner engages in as bi-directional communication. We are professionally trained to research, analyze, and integrate vast amounts of data in our processes. This is best captured in the Ecological Model- ICF Model for Life Care Planning developed by Dr. Mary Barros-Bailey and published in Life Care Planning and Case Management Across the Lifespan, 5th edition (p. 33).
This contrasts with the role of a stenographer, who is there to methodically document the communication of an individual or the provider (or consultant) whose role it is to prescribe care (Weed, 2002). Our recommendations are not prescriptions, nor are we the conduit through which opinions of others are recited. By engaging in bidirectional communication, we approach our communications with healthcare providers involved with the evaluee armed with our own research about aging with disability, within the framework of the Ecological Model- ICF Model for Life Care Planning (Barros-Bailey et al., 2023, p. 33).
PRESTON: Discuss some ideas for preventing conflicts. Does our facilitation and collaboration obligation give us ways to avoid conflicts?
WIRT: The first and most obvious step is approaching collaboration with respect for each of the professionals. Conflict has, at least in my experience, happened when they are from different medical specialties. Thus, it is important to recognize that their areas of training and the patient populations they followed were different.
During the introductory portion of the conversation, I offer any insights and opinions I have obtained from other experts, so they know what has been provided to date. When this expert offers a differing opinion, it is helpful to point out the conflict and ask for insights into why these opinions differ. The explanation may be enough to resolve the conflict. For example, when the plastic/reconstructive surgeon provided opinions related to an evaluee’s ability to independently perform ADLs and IADLs that dramatically differed from those of the physiatrist, once the surgeon understood the differences, those were resolved with an agreement to let the physiatrist address the issue.
RUTHERFORD-OWEN: It is incumbent upon life care planners to share the knowledge that we have gained through our analysis of data when conducting communication so that the consultant can make their recommendations in a fully informed and wholistic manner. This informed approach can often prevent divergent opinions, as often the divergent opinions are based upon one individual having a different set of data than another. Additionally, clearly state that the opinions being sought are to a reasonable degree of certainty and inform each of them in the beginning that they may have no opinion and may defer to another specialist. Many providers/consultants will exercise these options, again preventing potential differing opinions.
MORRISON: In seeking the input of both physicians and allied health professionals, I consider their scopes of practice and the nature of their involvement to date (i.e., as per the reviewed records). I seek data from each professional as per their scopes of practice and scope of intervention with this client to date. Given limited (Canadian) resources, two physicians or treatment providers are not typically involved in overlapping treatment and as such, this method of deferring to scope and past treatment focus can serve to delineate whose opinions are to be included.
PRESTON: An important question for the life care planner is to determine the best options when conflicts are unresolved. There are situations where physicians and other health professionals involved in the case will continue to differ. Can the life care planner choose which opinion to include or discard?
ZARAS: One approach to managing conflicting expert opinions is to adopt a tiered methodology where various professional’s input is categorized based on their degree of specialization and relevance to the specific needs of the patient. Specialists like orthopedic surgeons might weigh more heavily on surgical recovery, while physical therapists could provide deeper insights into rehabilitation needs. In an ideal scenario, systematically layering the input based on direct expertise related to each aspect of care will move the life care plan beyond simply reconciling conflicts and create a multidimensional care strategy.
JOHNSON: Differing medical opinions can be outlined according to the reliance materials. The professional coordinating the life care plan can simply state the options and leave it to the trier of fact. For example:
Or the options can be shown as a range:
MALLOY: Given the guidance and clear direction from the standards and consensus statements, all opinions must be considered, encompassed within the life care plan, and acknowledged. When providing a range it is important to include who is providing the opinions.
MORRISON: In the event of a remaining difference of opinion, seeking a consensus based upon scopes of practice, intervention delivered to date, and objective data would be ideal. A second option is to look for the general consensus/majority opinion among the team of providers to determine if one opinion may serve as an outlier. Investigating the reason/rationale for an outlier opinion may be indicated. If credence remains for the outlier opinion, outlining the difference of opinion in a separate model within the life care plan for the trier of fact to consider may be the most valid and valuable manner in which to justly present the evaluee’s needs.
WIRT: Unfortunately, there are situations where no consensus is reached. Clinical practice guidelines can offer some guidance. I can also consider my personal scope of practice. For example, my training and experience allows me to determine home care services. This allows me to provide the recommendation myself or to explain to another expert why I recommend something different.
PRESTON: How should the referring/retaining attorney be involved in resolving conflicting opinions? Keeping an attorney apprised of the status of the development of a life care plan is appropriate. However, the role of the attorney when there are conflicts needs to be handled carefully.
MORRISON: Lawyers are neither health care professionals nor life care planners. I do not think that they should be tasked with weighing the evidentiary foundation for the needs outlined in the life care plan.
ZARAS: Organizing a conference call with all parties, including the experts and the attorney, allows for a structured discussion. During this process, each expert can present their opinion, followed by clarifying questions from both the life care planner and the attorney. This approach not only promotes collaboration but also helps delineate specific areas of agreement and disagreement, guiding the life care planner and attorney in making informed decisions on who will be delineated as the expert.
WIRT: When it comes down to final expert disclosures the attorney will decide which experts will have opinions presented to the trier of fact. This will influence which expert opinions can be included in a life care plan.
Summary
Life care planners have repeatedly called for practitioners to be responsible for addressing inconsistencies and disagreements in life care plans. This is a long-standing belief and inclusion in standards of practice. For each case, the life care planner can consider the circumstances and determine which course of action to follow. Choosing, or failing, to act is not within standards of practice.