Journal of Nurse Life Care Planning PDF Free Download
1 / 34/34
100%
JOURNAL OF
THE AMERICAN ASSOCIATION OF NURSE LIFE CARE PLANNERS
AUTUMN 2024
NURSE LIFE CARE
PLANNING
vol XXIV, no. 4
CONTINUITY OF CARE
PEER-REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 2
AUTUMN 2024
JOURNAL OF NURSE LIFE
CARE PLANNING
AMERICAN ASSOCIATION OF
NURSE LIFE CARE PLANNERS
299 S. Main Street #1300-91732
Salt Lake City, UT 94111
PH & FAX: 801.274.1184
aanlcp.org
BOARD OF DIRECTORS
PRESIDENT
Jessica Urie, RN, BSN, CLCP, LCP-C, CNLCP
PRESIDENT-ELECT
Anne Gowing, RN, CRRN, CNLCP, MSCC
PAST PRESIDENT
Misty Coffman, RN, MSCC, CNLCP
SECRETARY
Shelly Kinney, MSN, RN, CCM, CNLCP
TREASURER
Kimberly Reen, BSN, BS, RN, CLCP, LCP-C,
CNLCP®, MCP-C
JOURNAL OF NURSE LIFE
CARE PLANNING EDITOR
Stephen Axtell
COMMITTEE FOR THIS ISSUE:
Barbara Bate RN, CRRN, CCM, CNLCP®, CHLCP™,
CMGT-BC, LNCC
Barb Loftus, MA, BSN, RN, CPN, LPC, NCC, LCP-C
Dana Penilton RN, BSN, CLCP, FIALCP
Dawn Cook RN, CNLCP, CLCP
Jennifer Masse, RN, BSN, MBA, CNLCP, CBIS
Kate Smith BSN, RN, CNLCP, LCP-C
Kellie Poliseno RN, CNLCP
Kelly Reilly, BSN, RN, LCP-C, MCP-C
Louvenia Ringuette
Megha Rownd, MSN, BSN, RN, CNLCP, LCP-C,
MCP-C
Melinda Pearson LMSW, CLCP
Misty Coffman, RN, CLNC, MSCC, CNLCP
Patti Mazurkiewicz, MS, RN, CLCP, CNLCP, CRC,
LCPC, NCC
Nellie Kriemer
Rachel Kauffman BSN, MSN, RN, CNOR
Shaun Marie Sever, RN, BSN, MACJ, ALNC, LCP-C
Silvio S. Reyes, Ph.D., CRC, CVE, CLCP, D/ABVE
Stacey White, RN, BSN, CCM, CNLCP
Teresa Hearn, MS, CRC, CVE, CLCP, IPEC
3 A Message from the President
4 Message from the Outgoing Editor
5 Message from the New Editor
6 Information for Authors
7-8 Contributors to this Issue
TABLE OF CONTENTS
DEPARTMENTS
9 Skilled Nursing Task Delegation - Consideraiton
in Life Care Planning
Nellie Kreimer, BSN
14 Delegating for Life Care Planners
Richard Bays, JD, MBA, RN, LNCC
17 A Tour of The Private Pay Market For Seniors-
The Story of Paul & Jane
Gerda Maissel, MD, BCPA
21 Burnout as a Professional and Medical Issue
Stephen Axtell
25 Amputation Case Studies
Victoria Powell, RN, CCM, LNCC, CNLCP, CLCP , MSCC,
CEAS, CBIS
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 3
Dear Members,
As I struggled to overcome writer’s block for this message, it struck me that this was my last
time composing the message for the Journal. My term as AANLCP President concludes at the
end of 2024, and I will move into the Past President role to assist Anne Gowing in her new role
as President.
I want to start my farewell by offering my profound gratitude to the current executive board.
None of us could serve on the board without each other; we truly had an amazing team. A
special thanks to our outgoing Secretary, Shelly Kinney, who is an invaluable resource for her
editing and writing.
When I started in the association 5 years ago as a brand-new life care planner, I was just
trying to take it all in and learn as much as possible. It’s been wonderful watching the association grow and so many
nurses joining the life care planning eld. Our committees have been getting the word out about AANLCP and what
life care planning is. We are collaborating with our LCP, CMSA, NNBA, IARP, and IALCP (to name a few) colleagues. Our
mentorship, outreach, research committees were revitalized in the last few years and are thriving.
I am excited for the upcoming leadership, with Anne Gowing as 2025 President, followed by Craig Felty as 2026
President, along with Kelly Ehrhardt as the incoming 2025-2026 Secretary. I am excited to see what ideas they will bring.
AANLCP’s success is due to our members.
The Executive Board recently met for our annual Strategic Planning Meeting. We have lots of ideas to support the
continued growth of the association. We are currently accepting applications for the new Members at Large positions.
Please be on the lookout for upcoming emails to vote on the new ‘Retired Member’ category.
Thank you, members, for your continued participation, enthusiasm, and support! Please continue to reach out to share
your ideas, suggestions, and comments. Let us know if you would like to get more involved with the association; there is
an opportunity for everyone, and our committees are excited to welcome you!
It has been the honor of a lifetime to serve as AANCLP President.
Best regards,
Jessica
A Message from the President
Jessica Urie, RN, BSN, CLCP, LCP-C, CNLCP
President, AANLCP I president@aanlcp.org
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 4
Greetings and partings!
I have enjoyed my time as the Journal of Nurse Life Care Planning editor over the last
few years in ways that have been hard to quantify in the weeks since my transition
has become a reality. No other profession has the capacity for compassion, analysis,
collaboration, and conict quite like this one. Every single one of you with whom I have
met or corresponded in this association is brilliant and insightful in ways that I simply
could not expect.
Though I am moving on to focus on students in the most need and with such
great potential, I will never forget the times I served as the editor for this exemplary
association. Even as I focus on a social need that will serve to strengthen the future of our nation, I am reassured that
the members of this association will continue to apply their analytical, systematic, and emotional intelligence to protect
the quality of life that is so central to our individual, social, and national survival.
For the past few months, I have had the opportunity to work with and guide the new editor, Vanessa Richie, in
transitioning the journal and all that is entailed with it. She is a capable, intelligent, and incisive editor. I feel that I
couldn’t be leaving the journal in more capable hands than hers.
I want to extend my sincerest gratitude to my committee, the board, and all of the AANLCP membership for being
the reason and the grounding that made this journal everything that it was and will continue to be.
Thank you,
Stephen Axtell, Editor Emeritus of the Journal of Nurse Life Care Planning
Stephen Axtell
JNLCP Editor
journal@aanlcp.org
From the Outgoing Editor
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 5
Greetings and Happy Fall,
I’ve been working with Stephen for the last couple of months, learning about the Journal
of Nurse Life Care Planning. It is clear that this is something that many of you feel deeply
about, and your goal is to provide the best guidance and information available for the
readers. I am honored to be working with all of you, and I hope to be able to help you
continue the excellence that you have achieved.
A little bit about me, I’ve been a technical writer almost since the turn of the century,
writing and updating reports at the Savannah River Site. In 2010, I moved to the Pacic
Northwest to work on much more detailed reports at Hanford. A lot of the reports
focused on environmental contamination and the risk nuclear sites pose to the area around them. I’ve also worked in
the software and aviation elds, so I can help with technology questions, or answer some very basic questions about
ight for those who are interested.
I really look forward to working with all of you.
Thank you for reading,
Vanessa Richie, Editor
Vanessa Richie
JNLCP Editor
journal@aanlcp.org
From the New Editor
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 6
Information for Authors
Information for Authors
AANLCP® invites interested nurses and
allied professionals to submit article
queries or manuscripts that educate
and inform the Nurse Life Care Planner
about current clinical practice methods,
professional development, and the
promotion of Nurse Life Care Planning.
Submitted material must be original.
Manuscripts and queries may be
addressed to the Editor. Authors should
use the following guidelines for articles
to be considered for publication. Please
note capitalization of Nurse Life Care
Plan, Planning, etc.
Text
n Manuscript length: 1500 – 3000 words
n Use Word© format (.doc, .docx) or
Pages (.pages)
n Submit only original manuscript
not under consideration by other
publications
n Put the title and page number in a
header on each page (using the
Header feature in Word)
n Place author name, contact
information, and article title on a
separate title page
n Use APA style (Publication Manual of
the American Psychological Assoc.
current edition)
Art, Figures, Links
n All photos, gures, and artwork
must be in JPG or PDF format (JPG
preferred for photos).
n Line art must have a minimum
resolution of 1000 dpi, halftone art
(photos) a minimum of 300 dpi, and
combination art (line/tone) a minimum
of 500 dpi.
n Each table, gure, photo, or art
must be submitted as a separate le,
labeled to match its reference in text,
with credits if needed (e.g., Table
1, Common nursing diagnoses in
SCI; Figure 3, Time to endpoints by
intervention, American Cancer Society,
2019). Graphic elements embedded in
a word processing document cannot
be used.
n Live links are encouraged. Please
include the full URL for each.
Editing and Permissions
n The author must accompany the
submission with written release from:
n Any recognizable identied facility for
the use of name or image
n Any recognizable person in a
photograph, for unrestricted use of
the image
n Any copyright holder, for copyrighted
materials including illustrations,
photographs, tables, etc. Note that
images harvested online may be
copyrighted.
n All authors must disclose any
relationship with facilities, institutions,
organizations, or companies mentioned
in their work.
n All accepted manuscripts are subject to
editing, which may involve only minor
changes of grammar, punctuation,
paragraphing, etc. However, some
editing may involve condensing or
restructuring the narrative. Authors
will be notied of extensive editing.
Authors will approve the nal revision
for submission. The author, not the
Journal, is responsible for the views
and conclusions of a published
manuscript.
n Submit your article as an email
attachment, with document title
articlename.doc, e.g., wheelchairs.doc
All manuscripts published become the
property of the Journal. Submission
indicates that the author accepts these
terms. Queries may be addressed to the
care of the Editor at: journal@aanlcp.org
Manuscript Review Process
Submitted articles are peer reviewed by
Nurse Life Care Planners with diverse
backgrounds in life care planning, case
management, rehabilitation, and nursing.
Acceptance is based on manuscript
content, originality, suitability for the
intended audience, relevance to Nurse
Life Care Planning, and quality of the
submitted material. If you would like to
review articles for this journal, please
contact the Editor.
Journal of Nurse Life Care Planning is the ofcial peer-reviewed publication of the American Association of Nurse Life Care Planners.
Articles, statements, and opinions contained herein are those of the author(s) and are not necessarily the ofcial policy of the AANLCP®
or the editors, unless expressly stated as such. The Association reserves the right to accept, reject, or alter manuscripts or advertising
material submitted for publication. The Journal of Nurse Life Care Planning is published quarterly in spring, summer, fall and winter.
Members of AANLCP® receive the Journal subscription electronically as a membership benet. Back issues are available in electronic
(PDF) format on the association website. Journal contents are also indexed at the Cumulative Index of Nursing and Allied Health
Literature (CINAHL) at ebscohost.com. Please forward all emailaddress changes to AANLCP® marked “Journal-Notice of Address
Update.” Contents and format copyright by the American Association of Nurse Life Care Planners. All rights reserved. For permission
to reprint articles, graphics, or charts from this journal, please request to AANLCP® headed “Journal-Reprint Permissions” citing the
volume number, article title, author and intended reprinting purpose. Neither the Journal nor the Association guarantees, warrants,
or endorses any product or service advertised in this publication nor do they guarantee any claims made by any product or service
representative. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the
denitions and dening characteristics of the diagnoses listed in this work.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 7
Nellie Kreimer, BSN
Ms. Kreimer holds a bachelor of science degree in nursing (BSN) from New York University School of
Nursing. During her 27 years of nursing, Ms. Kreimer has worked in a variety of settings, but her passion
for public health, close patient contact, patient advocacy, and holistic approach to patient care have
steered her towards the eld of visiting nursing. Ms. Kreimer holds two masters degrees, one in Health Law
Administration from Bellevue University, and the second in Health Law and Policy from Hofstra School of
Law. As a strong patient advocate, Ms. Kreimer inteds to collaborate with pertinent stakeholders and to
bring about necessary modications to the current healthcare delivery practices, especially for the disabled
and disadvantaged populations. As intermediaries between the healthcare and the legal systems, and
the disabled individuals, the nurse life care planners (NLCPs) have the necessary knowledge and skills to
advocate for the population that they serve, and facilitate access to quality, evidence-based healthcare, and
necessary supportive and assistive devices, treatments and therapies across the life span of the individual.
Gerda Maissel, MD, BCPA
Dr. Gerda Maissel is a private patient advocate and founder of My MDAdvisor. She is a board-certied
Physical Medicine and Rehabilitation physician and a Board-Certied Patient Advocate. After working
as a physician and a C-suite health system leader, she combined her clinical and business skills to start a
company. At My MD Advisor, she navigates people with complex medical problems through our opaque
healthcare system, ensuring that they receive the best care possible. Dr. Maissel helps people maximize
their relationships with doctors, hospitals, and rehabilitation facilities. She translates doctor speak and
supports informed decision-making and problem-solving. Dr. Maissel writes The Foglight, a monthly short
essay with patient stories and tips on health care navigation. You can subscribe for free at
https://thefoglight.substack.com/subscribe
Richard Bays, JD, MBA, RN, LNCC
Richard Bays has served in numerous capacities in the healthcare industry ranging from clinical services
and operations, healthcare billing and policy analysis, medical- legal consulting for healthcare attorney
groups and oversight of accreditation, licensure and regulatory compliance programs. He specializes
in economic aspects of healthcare litigation such as Life Care Plans, Future Medical Cost Projections,
Medicare Set-Asides, accounting and tax considerations, as well as reimbursement issues.
Contributors to this Issue
Stephen Axtell
Stephen Axtell is the former editor of the Journal of Nurse Life Care Planning, professional writing
consultant, and educator who specializes in medical and academic writing. He assists in creating writing that
ranging from novels to Ph.D. theses.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 8
Victoria Powell, RN, CCM, LNCC, CNLCP, CLCP, MSCC, CEAS, CBIS
Victoria Powell RN, CCM, LNCC, CNLCP, CLCP is a registered nurse with 30 years of professional nursing
experience. Her background has primarily been focused on catastrophic injury care with an emphasis on
amputation injury having worked with her rst limb loss individual while working as a work comp case
manager.
Ms. Powell is an active member of multiple professional organizations including the American Association of
Nurse Life Care Planners, the Case Management Society of America, the International Academy of Rehab
Professionals, and the International Society for Prosthetics and Orthotics (US-ISPO) among others. She also
currently serves on the Amputee Coalition’s Science and Medical Advisory Council and current sits on the
Osteointegration Task Force, Wrist Disarticulation Task Force and the Limb Loss Education Task Force. She
is a board member of Enhancing Skills for Life, a 501c non-prot organization focused on education and
support for those with bilateral upper limb loss and more. Powell has presented and published on a variety
of subjects surrounding catastrophic injury.
Victoria Powell is the founder and President of VP Medical Consulting located in Central Arkansas. She can
be contacted at victoria@vp-medical.com or by calling (501) 778-3378.
Contributors to this Issue
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 9
Catastrophically injured, physically, mentally, and
developmentally disabled, and chronically ill individuals
often depend on life-sustaining, skilled nursing procedures,
commonly referred to as skilled nursing tasks, or SNTs.
Depending on the context, SNTs may include, but not
be limited to observation and documentation of patient
Keywords: 1. Self Care, 2. Delegation Practices,
3. Business Concerns
Skilled Nursing Task Delegation —
Consideration in Life Care Planning
By Nellie Kreimer, BSN
condition(s), medication administration (oral, subcutaneous
intravenous, and intramuscular routes), wound care,
administration of supplemental oxygen, oral, nasopharyngeal,
and tracheostomy suctioning, enteral tube feedings, insertion
and management of indwelling urinary catheters, intermittent
urinary catheterization, and others. Registered nurses (RNs)
complete intense nursing education programs that equips
them with specialized knowledge that is necessary to carry out
complex, skilled nursing procedures safely.
The practice of a licensed registered nurse (RN), including
SNTs delegation is regulated by the state Nurse Practice Acts
(NPAs). Additionally, the National Council of State Boards of
Nursing (NCSBN) and the American Nurses Association (ANA)
provide evidence-based guidelines and recommendations
on safe and effective SNTs delegation. Irrespective of state
differences, the NPAs stipulate that a licensed nurse cannot
delegate any SNT to unlicensed assistive personnel (AP)
requiring critical nursing judgement, initial nursing assessment,
formulation of a nursing care plan, infusion via intravenous
NURSING DIAGNOSES TO CONSIDER
NANDA-I 2024-2026
Impaired Memory. Persistent inability to remember or recall
bits of information or skills, while maintaining the capacity to
independently perform activities of daily living.
Risk for Decreased Self-care Ability Syndrome. Decline in
independent performance of multiple daily living activities.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 10
route, injections (outside of insulin and other diabetes related
injectables), sterile procedures, or any delegation that violates
the NPA regulations (NCSBN, 2019; ANA, 2019).
Skilled nursing task delegation provides an opportunity for
the disabled individuals to reside in the community, rather than
in institutional settings. Additionally, SNT delegation decreases
cost of care because HHA services are less costly than those
provided by an RN. For example, the median 2023 annual
salary of the HHA was $33,530 per year, or $16.12 per hour
(U.S. Bureau of Labor Statistics, 2024). On the other hand,
the median 2023 salary for a registered nurse in the home
healthcare setting was $86,070 per year, or $41.38 per hour
(U.S.Bureau of Labor Statistics, 2024). Albeit cost containment
is an important consideration, safe and efcient performance
of delegated SNTs depends on close and effective PA
supervision by an RN.
Delegation of SNTs-Denition, Principles, and
Scope of Practice
The NCSBN and the ANA (2019) dene SNT delegation as
“transfer of responsibility for the performance of a task from
one individual to another while retaining accountability for
the outcome.” Delegation may be from an advanced practice
nurse (APN) to RN, licensed practical nurse (LPN) or PA;
and from RN to LPN, HHA, or PCA (ANA, 2019). The NPA
mandates licensed nurses to adhere to the 5 principles of safe
delegation, including the “right task, the right circumstance,
the right person, the right direction and communication, and
the right supervision and evaluation” (NSBN, 2019; ANA,
2019). The RN is accountable for selection of delegated SNT,
evaluating HHA qualication and task performance, and
patient-and-task specic training and supervision of the HHA.
Additional training and education expands HHA scope
of practice to include monitoring and reporting patient
condition(s), recognizing and responding to emergencies,
and infection control, among others. On the other hand
the PCA assists patients with activities of daily living (ADL)
and instrumental activities of daily living (IADL), that are
incorporated into HHA’s scope of practice. The AHHA is HHA
with a higher level of education and training that permits
them to carry out more complex skilled nursing tasks under
the supervision of an RN. Aligning HHA’s, AHHA’s, and PCA’s
the scope of practice with the level of care necessary to meet
the disabled individual’s needs will facilitate development
of reasonable, effective, and appropriate recommendations
in the life care plan. If the subject only requires assistance
with ADL or IADL, then a PCA can be used. However, skilled,
or complex care is needed, then HHA, AHHA, LPN, or RN
may need to be recommended. The NLCP/LCP must be
knowledgeable in the state NPA, and collaborate with the
healthcare providers, the disabled individual, the family, and
other pertinent stakeholders to identify the level of care (RN,
LPN, HHA, AHHA, PCA) that needs to be incorporated into a
life care plan.
HHA/AHHA Scope of Practice, Certication,
and Level of Care
Whereas the HHA/AHHA scope of practice is governed
by state statues, there are some federal requirements
that establish minimum level of education and training.
“The Federal Code of Regulations Title 42-Public Health
(§ 484.36)-Conditions for participation:Home Health Aide,”
mandates “classroom and supervised practical training at
least 75 hours, with at least 16 hours devoted to supervised
practical training” (Code of Federal Regulations, 2010). The
scope of practice of HHA includes provision of ADL, IADL,
infection control, safety, measurement of vital signs, identifying
emergencies, competency in emergency measures, monitoring
patient status, and reporting changes to an RN.
The scope of practice of AHHA includes all of the HHA
functions in addition of specialized SNTs where AHHA
demonstrated prociency. In NYS, “Chapter 471 of the
Laws of 2016 Article 139 of the Education Law (the Nurse
Practice Act),” was amended in order to allow AHHA to
perform “advanced tasks with appropriate training and upon
assignment by registered nurses and under supervision by
such nurses” (NYS DOH, 2021). The AHHA is permitted to
administer medications, including insulin or other diabetic
injections, “injections of low molecular weight heparin, and
pre-lled auto injections of naloxone and epinephrine”(NYS
DOH, 2021). However, the AHHA is not allowed to inject other
medications, to perform sterile procedures and invasive wound
care, and to manage central line infusions, or site care (NYS
DOH, 2021).
HHA, AHHA, PCA Supervision Frequency
Safe SNTs delegation depends on RN’s adherence to the
NPA guidelines in planning and on-going HHA supervision
and performance monitoring (NSBN, 2019; ANA, 2019).
Projecting the frequency of RN supervisory visits is an
important consideration in the life care plan. The NLCP/
LCP need to be familiar with state NPA and the Department
of Health (DOH) regulations regarding HHA supervision.
For example, the NYS Education Department Ofce of the
Professions in a “Memorandum of Understanding for Nursing
Supervision for Mental Retardation and Developmental
Disabilities recommends annual nursing visits for skilled care
evaluation. In contrast, chapter 471 of the Laws of 2016 Article
139 of the Education Law mandates that RN must make
supervisory HHA and AHHA visits every two weeks. By the
same token, California (Cal. Code Regs. Tit. 22, § 74709-Home
Health Aide/Personal Care Services Supervision) requires
HHA supervision every 14 days if skilled nursing services are
provided. If an RN delegates HHA supervision to an LPN, then
the RN must visit every 3 months. Conversely, in Florida, the
HHA must be supervised every two weeks for skilled nursing
services, and every 60 days if non-skilled, PCA services are
provided (Florida Administrative Code 59A-8.0095 Personnel).
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 11
New York State, Florida, and California
NPA and SNT Delegation
The state of Florida does not enforce state-mandated HHA
certication, however, there are education, training, and
demonstration of skills competency requirements. Florida’s
Administrative Code (State licensed home health agencies
59A-8.0095(5)) certies/licenses home health agencies that
oversee the HHAs mandated 75 hours (with at least 40 hours)
of classroom training, and skills competency demonstration
(Florida Agency for HealthCare Administration, 2024; Florida
Department of State 2022). In Florida, in addition to the ADL
and IADL tasks, the HHA may perform the following under
supervision of an RN:
• “Assisting with the change of a colostomy bag;
• Reinforcement of dressing;
• Assisting with the use of devices for aid to daily living, such
as a wheelchair or walker;
• Assisting with prescribed range of motion exercises;
• Assisting with prescribed ice cap or collar;
• Doing simple urine tests for sugar, acetone or albumin;
• Measuring and preparing special diets;
• Measuring intake and output of uids;
• Measuring temperature, pulse, respiration or blood pressure;
• Keeping records of personal health care activities;
• Observing appearance and gross behavioral changes in the
patient or client and reporting to the registered nurse;
• Supervision of self-administered of medication in the home”
(Florida Administrative Code, Chapter 59A-8; Fla. Admin.
Code R. 64B9-14.0015).
The following tasks cannot be delegated to HHA:
• Irrigating body cavities such as giving an enema;
• Performing irrigation of any wounds (such as vascular
ulcers, diabetic ulcers, pressure ulcers, surgical wounds) or
apply agents used in the debridement of necrotic tissues in
wounds of any type;
• Changing sterile dressings
• Performing a gastric irrigation or enteral feeding;
• Catheterizing a patient;
• Administering any controlled substance listed in Schedule II,
Schedule III, or Schedule IV of s. 893.03 or 21 U.S.C. s. 812;
• Applying heat by any method;
• Caring for a tracheotomy tube;
• Providing any personal health service which has not been
included in the plan of care;
• Filling and removing medications from a pill organizer or
electronic medication dispenser” (Florida Administrative
Code, Chapter 59A-8).
The California NPA can be found in the “California Business
and Professions Code Section 2700, with the Healthcare
Workforce Branch (HWB) of the California Department of
Public Health (CDPH) overseeing HHA certication (California
Board of Registered Nursing, 2024). The California Health and
Safety Code, Section 1725-1742 requires HHAs to complete a
120-hour of class room training in a state-approved program
and successfully pass the certication exam (California
Department of Public Health (CDPH), 2024). California-
certied HHA can provide personal care, home maintenance,
and patient-specic skills delegated by an RN, that may
include changing a colostomy bag, helping patients to self-
administer medications, and assist with mobility. The RN can
only delegate tasks to HHA which are within the scope of
practice of HHA, while RN is responsible for patient-specic
task training, monitoring, and HHA supervision. In California,
medication administration, any invasive treatments, and sterile
techniques cannot be delegated to HHA (California Board of
Registered Nursing, 2024).
Agency Versus Private Hiring
Depending on personal preferences and the degree of control
over HHA/PCA activities, consumers may hire HHAs/PCAs
either through an agency, or privately. HHA/PCA employer
agencies provide valuable consumer services including,
but not limited to hiring, disciplining, ring employees/
contractors, criminal background and immigration checks,
conducting training and education, ensuring stafng, paying
the employee/contractor salaries, and withholding federal and
state taxes. Individuals that decide to private-hire HHAs/PCAs
assume responsibility for hiring, training, ring, withholding
taxes, and others. However, private hiring may be desirable
when the consumer wishes to have the ultimate control over
the HHA’s/PCA’s task performance. Whereas the employer
agencies are mandated to adhere to state NPA, privately
hired HHA or PCA are usually not bound by restrictive state
regulations. Privately hired care assistants can be trained by
the disabled individual, or their care providers to perform
tasks which may not otherwise be performed by an RN. For
example, if an individual with a spinal cord injury (SCI) requires
intermittent urinary catheterization and hires HHA through an
agency, this skilled nursing task cannot be delegated. On the
other hand, if the HHA/PCA is hired privately, then the family
may train them to perform the task. The NLCP/LCP needs to
be familiar with the NPA regulation regarding parameters of
SNT delegation and scope of practice of the HHA. Depending
on the task in question and the state NPA, an RN may have to
perform the task, or the task may be delegated to an HHA. In
any case, the cost of recommendation in the life care plan will
vary based on who will perform the task and if delegated, the
cost for RN visits needs to be incorporated into the projected
cost of life care plan.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 12
Implications for Nurse Life Care Planners
and Life Care Planners
Although NLCP/LCP may use discipline-specic blueprint
methodologies in crafting life care plans, some common
principles are intertwined into the practice of life care
planning. Before considering the delegation authority of
RNs and scope of practice of HHA or AHHA, it is imperative
to identify what constitutes a skilled task and NPA (NSBN,
ANA, 2019). Communication with the disabled individual
and/or primary support persons is essential in determining
individual preferences regarding agency or private hiring,
desired degree of control over HHA functioning, ability and
willingness to assume responsibility for background and
immigration checks, HHA training, withholding federal and
state taxes, and other considerations. Most importantly, if the
disabled individual decides to hire HHA/AHHA privately, the
NLCP/ LCP need to inform them regarding state registries
when selecting home care assistants. Another consideration
that may affect recommendations in a life care plan is the type
of residential setting of the disabled/chronically ill individual.
For example, if an individual resides in an assisted living, a
group home, or any other congregate setting where nursing
oversight may be included in the total residential cost, then no
additional RN supervisory visits may be needed. However, the
nursing services included in the residential cost may not cover
supervision of the HHA and SNT delegation for residents with
complex medical, nursing, and rehabilitative regimens.
Conclusion
The Nurse Practice Act (NPA) oversees the practice of
registered nurses (RNs), including delegation of skilled nursing
tasks (SNTs) to assistive personnel, which may include home
health aides (HHAs), advanced practice home health aides
(AHHAs), and personal care assistants (PCA). The RN may
delegate tasks that are within the scope of practice of the
HHA, however, some SNTs may be delegated when outside
of the scope of practice if patient-and-task-specic training,
education, and supervision is provided. The nurse life care
planners (NLCPs) and life care planners (CLCPs) should
familiarize themselves with state-specic NPA and additional
state and local regulations that govern the scope of practice
of RN and delegation authority to assistive personnel (AP).
The National Council of State Board of Nursing (NCSBN) is a
valuable resource that provides access to state-by-state NPA
information (https://www.ncsbn.org/). Beyond formulating
an appropriate, reasonable, and cost-effective life care plan,
the NLCP need to adhere to professional standards that
include detailed individual assessment, collaboration, health
promotion, coordination of care, research, communication,
ethical consideration, and resource utilization.
Case Scenario (ctional)
John is 33 year old male that sustained a complete spinal
cord injury (SCI) with cervical C1-C4 and lumbar L1-L5 cord
involvement due to a motor vehicle accident (Sheppard
Center, 2020). John is tetraplegic and incontinent of bladder,
with urinary retention and frequent urinary tract infections.
John requires ventilator assisted breathing, suctioning,
intermittent catheterization, tube feeding, blood glucose
monitoring, insulin injections, and colostomy care. John also
has a stage-3 decubitus ulcer, with hydrogel dressing changes
twice weekly.
John lives in California in an assisted living facility with
around-the-clock care from HHA, AHHA, and LPN. John is
considering moving either to New York or Florida. His family
lives in Florida, but his childhood friends live in New York and
were more supportive in his post accident recovery than his
family. John hired the HHAs privately so that they can do tasks
that are not permitted under the NPA in California. John is not
sure if the privately hired HHAs are qualied to meet his skilled
nursing care needs. John prefers to live in an assisted living
setting because he feels socially engaged. Although John won
a settlement of $2 million dollars, given his life expectancy and
the cost of care, John is concerned about depletion of funds.
What will the NLCP/LCP need to discuss with John, and what
will their recommendations be related to delegation of SNT’s
in New York and Florida when compared to California, the
level of care (RN, LPN, HHA, AHHA), and ultimate cost of care?
Task Delegation New York California Florida HHA
Medications Yes - AHHA No No
Wound care Yes - AHHA No No
Intermittent urinary catheter No - HHA No No
Oxygen administration Yes - AHHA No No
Suctioning oral/nasal/tracheal No No No
Enteral tube feeding Yes No No
Insulin injection Yes - AHHA No No
Blood glucose monitoring Yes - AHHA No No
Colostomy care Yes Yes Yes
Wound care Yes - AHHA No No
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 13
REFERENCES
American Nurses Association (ANA, 2019). National Guidelines for Nursing Delegation. https://www.nursingworld.org/~4962ca/
globalassets/practiceandpolicy/nursing-excellence/ana-position-statements/nursing-practice/ana-ncsbn-joint-statement-on-delegation.pdf
American Spinal Cord Injury Association (ASIA, 2019). International Standards for Neurological Classication of Spinal Cord Injury: Revised
2019. https://meridian.allenpress.com/tscir/article/27/2/1/465525/International-Standards-for-Neurological
California Board of Registered Nursing (2024). Nursing Practice Act. https://www.rn.ca.gov/practice/npa.shtml
California Department of Public Health (October 7, 2024). Licensing and certication program. https://www.cdph.ca.gov/Programs/CHCQ/
LCP/Pages/HHA.aspx
Centers for Medicare and Medicaid (2022). 42 CFR Ch. IV (10–1–22 Edition). PART 484 —HOME HEALTH SERVICES. Subpart A—General
Provisions; Subpart B—Patient Care; Subpart C—Organizational Environment. https://www.govinfo.gov/content/pkg/CFR-2022- title42-
vol5/pdf/CFR-2022-title42-vol5-part484.pdf
Code of Federal Regulations (2010). Title 42-Public Health. § 484.36-Condition of participation: Home health aide services.Context: Title
42 - Public Health. CHAPTER IV - CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
(CONTINUED). SUBCHAPTER G - STANDARDS AND CERTIFICATION. PART 484 - HOME HEALTH SERVICES. Subpart C-Furnishing of
Services. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-484
Florida Admin. Code R. 64B9-14.0015 (2024). Section 64B9-14.0015 - Delegated Tasks. https://casetext.com/regulation/orida-
administrative-code/department-64-department-of-health/division-64b9-board-of-nursing/chapter-64b9-14-delegation-to-unlicensed-
assistive-personnel/section-64b9-140015-delegated-tasks
Florida Agency for HealthCare Administration (FAHCA, 2024). Home Health Aides. https://ahca.myorida.com/health-care-policy-and-
oversight/bureau-of-health-facility-regulation/laboratory-and-in-home-services/home-health-agencies/home-health-aides
Florida Department of State (2022). Florida Administrative Code and Administrative Register. Rule: 59A-8.0095. Chapter: MINIMUM
STANDARDS FOR HOME HEALTH AGENCIES. https://www.rules.org/gateway/ruleno.asp?id=59A-8.0095
Moradi T, Rezaei M, Alavi NM. Delegating care as a double-edged sword for quality of nursing care: a qualitative study. BMC Health Serv
Res. 2024 May 7;24(1):592. doi: 10.1186/ s12913-024-11054-4. PMID: 38715066; PMCID: PMC11075185., Published online 2024 May 7.
doi: 10.1186/s12913-024-11054-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11075185/ NIH, National library of Medicine (NLM),
Center for Biotechnology Information.
National Council of State Boards of Nursing (NCSBN, 2019). National Guidelines for Nursing Delegation. https://www.ncsbn.org/public-
les/NGND-PosPaper_06.pdf
New York State Department of Education Ofce of Professions (NYS DOH, 2021). NYS Education Department Ofce of the Professions.
Memorandum of Understanding for Nursing Supervision for mental retardation and developmental disabilities.
New York State Department of Health (January 29, 2019). HCBS 19-02 Subject: Advanced Home Health Aide Agency Requirements.
https://www.health.ny.gov/facilities/home_care/dal/docs/19-02.pdf
The Shepard Center (2020). Understanding spinal cord injury. What you should know about spinal cord injury and recovery.
https://www.spinalinjury101.org/details/levels-of-injury
U.S.Bureau of Labor Statistics (August 29, 2024). Occupational Outlook Handbook. Home Health and Personal Aides.
https://www.bls.gov/ooh/healthcare/home-health-aides-and personal-care-aides.htm
U.S. Bureau of Labor Statistics (August 29, 2024). Occupational Outlook Handbook. Registered Nurses. https://www.bls.gov/ooh/
healthcare/registered-nurses.htm
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 14
Life Care Planners manage an immense number of tasks
when researching and formulating their reports. An initial
review of voluminous medical records can be overwhelming
just to consider. When there are multiple reports and less
than generous deadlines looming, it may be helpful to obtain
assistance. What happens when a Life Care Planner delegates
tasks to third parties? This article examines some of the
questions that arise when delegation occurs.
What is Delegation?
Delegation involves the contracting for the performance of
certain work between two or more parties. This is necessary
in many circumstances to achieve a stated result and meet
deadlines. Frequently, this is done to engage others with
specialized skills and for overall cost-effectiveness.
Allowance of Assignment
The rst step Life Care Planners must take is examining
if their contract with their client prohibits delegation,
outsourcing, assignment, or subcontracting of work. In some
instances, this may not be allowed as the client wants the
individual to personally perform all work. In other situations,
this may be a perfectly acceptable course of action if it is
disclosed and consent is obtained. Some clients do not hold
objections to assistance in developing a Life Care Plan as
long as it is approved in advance. Other clients may have an
agreement with the Life Care Planner does not mention this
issue. In this case, there is no prohibition, but there is also no
permission either. A conversation between the parties would
be productive at this point to ensure the management and
outcome of expectations are met.
Ownership
If a Life Care Planner does obtain part(s) of the product from
outside parties, a question of ownership arises.
Delegating for Life Care Planners
By Richard Bays, JD, MBA, RN, LNCC
Keywords: 1. Self Care, 2. Legal Liability,
3. Business Concerns
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 15
Are these outsourced portions now part of the Life Care
Planner’s opinion? Have they validated the accuracy of the
information? If yes, how? The Life Care Planner must decide
how these issues will be approached.
This leads to an area beyond the report into possible
testimony at deposition and trial. Will the outsourced party
be testifying, or will the Life Care Planner assume sole
responsibility? The client may not require the delegated
parties to present any information, but opposing counsel
may want to depose them. If the outsourced party has made
a mistake, who is responsible? These issues can lead to an
erosion of the strength of the case. A thorough discussion
at the time of engagement can clarify and outline these
potential pitfalls.
Best Practices
When delegating any tasks it is important that all parties
understand their specic duties and obligations.
The three areas that are essential to cover are:
1. Clear and concise description of the task
2. Complete understanding of the objective
3. Correct limits and expectations
When drafting agreements, consider incorporating a sub-
contracting clause that states explicitly whether the parties
can sub-contract their rights and obligations, and if prior
written consent from the other party is required. In general,
obtaining prior consent for the assignment of obligations
under a contract is critical, unless explicitly allowable in the
agreement.
As a practice management issue, Life Care Planner’s may
wish to develop a policy to outline which tasks they will
delegate and items that may not be assigned to others. This
may be especially helpful if you are in a partnership or a
larger entity. This will allow a consistent application across the
practice when engaging outside parties. After developing a
policy, it may be necessary to revise it at future intervals as
changes occur in the practice.
Additionally, a Life Care Planner needs to ensure they
are not delegating tasks that are beyond the scope of the
party accepting the work. This ensures a minimum level
of quality is preserved in the work product and potentially
avoids embarrassing consequences later in the relationship.
Consideration should be given to issues such as the
delegated party submitting unacceptable work products.
Who pays for revisions? What if the delegated party misses
a deadline? Preplanning for problems in the chain of
operations tends to minimize or entirely avoid them.
Conclusion
Life Care Planners process enormous amounts of information
and would benet from assistance in many areas of their
practice. Documenting expectations and limitations can open
opportunities while protecting them from adverse outcomes.
By following a logical outline of clear communication with
their clients, they can avoid misunderstandings and potential
spoilation of relationships.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 16
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 17
Paul is an 81-year-old gentleman who retired and sold his
business for a very nice prot. He is quite energetic, despite
carrying more weight than he knows he should. Part of his
decision to retire was because his high blood pressure had
gotten worse, and his doctor told him he was pre-diabetic.
He wonders if the medications are making him tired, and
he would like to have the time to exercise and take better
care of himself. He never fully bounced back after his
wife died suddenly 3 years ago. He realizes he has been
procrastinating in getting his affairs in order.
Paul is becoming increasingly worried about his older sister
Jane. Despite their 10-year age gap they have always been
close. Paul and Jane each live alone in their own homes
across town. Paul’s children live across the country, and while
they care, they can’t help much. Jane never had children and
is becoming increasingly fragile. Paul wants to ensure that
everything is in place for himself and Jane. He wants them
both to be as healthy and strong as possible for as long as
possible. He wonders if he needs to hire a nurse for Jane.
Paul has been having dinner each Sunday with Jane. Jane
moved back to their childhood home to care for their mother
who has since passed. Sometimes, Jane forgets their weekly
dinner date, or her famous dishes don’t turn out right. He has
wondered if she is showering and has noticed that her hair
and makeup don’t look right.
A Tour of the
Private Pay Market
for Seniors
The Story of Paul & Jane
By Gerda Maissel, MD, BCPA
Keywords: 1. Delegation Options, 2. Networking,
3. Business Concerns
NURSING DIAGNOSES TO CONSIDER
NANDA-I 2024-2026
Impaired Memory. Persistent inability to remember or recall
bits of information or skills, while maintaining the capacity to
independently perform activities of daily living.
Impaired Self Care Ability Syndrome. Susceptible to decline in
independent performance of multiple daily living activities.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 18
When Paul brought in her mail, he noticed several bills
and notices from insurance companies. He and Jane
opened them together, and they were all past due. When
they discussed it, he realized that Jane was struggling to
remember to pay her bills and couldn’t organize her health
insurance paperwork.
Paul likes the idea of having someone else handle Jane’s
day-to-day nancials and also be an extra set of eyes for him.
Daily Money Manager: A Daily Money Manager handles
personal nance. They pay bills, collect statements for taxes,
keep records, straighten out incorrect bills, organize medical
insurance and tax paperwork, and ensure that claims are
paid correctly. Daily Money Managers visit regularly and
connect with the rest of the team. Daily Money Managers
become Certied Daily Money Managers (CDMM) and their
organization is the American Association of Daily Money
Managers (AADMM).
Paul and Jane need to update their wills to ensure they
each have named nancial and healthcare proxies who can
act on their behalf if they can’t speak for themselves. Paul
also has concerns about protecting his children from taxes
when they inherit the proceeds from the business he sold.
He is unsure about Jane’s nancial situation and wants to
determine if she might need to go on Medicaid.
Attorneys:
Trust and Estate Attorneys help people of all ages who are
concerned about what happens to their assets after their
death. They set up trusts and help deal with a decedent’s
assets after death.
Elderlaw attorneys help with retirement and long-term care
planning, elder abuse, nursing home issues, guardianships,
and Medicaid applications.
Attorneys of either type typically offer wills, power of
attorney/proxy documents, and advance directives. Many
attorneys also provide T&E and Eldercare services.
Medicaid Specialists may work with an elder law attorney
or practice independently. They help people ll out the
Medicaid application and guide them through the confusing
Medicaid process. Federal Medicaid laws allow anyone to
assist with ling a Medicaid application. A CMP is a Certied
Medicaid Planner.
All this planning made Paul consider whether he and Jane
have the right Medicare plan.
Medicare Advisors help people choose the best Medicare
plans. The advisors are typically paid a commission by the
insurer. Their services are free for the beneciary.
Although they help people select from traditional
Medicare or Medicare Advantage plans, they earn the
most commission when their client enrolls in a Medicare
Advantage plan. When someone selects traditional Medicare,
a Medicare Advisor will also get a commission from the
sale of a Part D (drug) plan and a Supplemental/Medigap
plan. Some Medicare Advisors work for a fee, either a at
fee or hourly. People who worry that a Medicare Advisor’s
recommendations might be inuenced by their commission
or a potential bait-and-switch offering might prefer a fee
based arrangement.
Medicare Advisors take a certifying exam from AHIP
(formerly America’s Health Insurance Plans).
People interested in selecting a Medicare Advisor can
inquire about how that advisor is paid, how many insurers
they represent, how to reach them when they are available,
and if they are licensed in their state to sell Medicare plans.
Paul has grown frustrated with his primary care doctor, who
has stopped returning calls and insisted that Paul come in
for difcult-to-schedule appointments. Paul also thinks that
Jane needs more thoughtful attention from her doctor. He
has noticed that their various doctors don’t talk to each other,
and no one is coordinating either of their care. He wants to
ensure he and Jane get the best medical care.
Concierge physicians receive private payments from patients
in exchange for better access, more time, and more care
coordination. The models for concierge medicine are
evolving, and there are signicant differences in practices
and costs. Some take insurance, but many tell the patient
they can attempt to get reimbursement from their insurance
on their own. Some are available directly 24/7, while others
use a go-between or charge more outside of business hours.
Some sell supplements or ofce-based tests, while others
don’t. Some make house calls.
The most common specialties to offer concierge medicine
are general internal medicine and family medicine (primary
care physicians). Other specialists, including geriatrics,
pediatrics, psychiatry, and others, have entered this rapidly
growing eld.
New models of wholly or partially private-funded care are
evolving. Many offer more convenient access. Examples
include Amazon, One Medical, and a variety of telemedicine
behavioral medicine companies. These alternatives may
signicantly challenge traditional ofce-based care.
Private Patient Advocates offer another option for
individuals with complex medical needs. A physician or
other health professional who is a private medical advocate
uses their clinical training to help the client ask the right
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 19
questions to the right people at the right time. Instead
of a traditional doctor/ patient relationship, they have a
coach/ client relationship. These advocates bridge gaps in
medical understanding and care coordination by bringing
an understanding of medicine and the confusing processes
inside American healthcare. They empower medical decision-
making and enhance doctor/patient communication.
Board-Certied Patient Advocates (BCPA) are experts
in healthcare and insurance/billing issues. Their national
organizations include the National Association of Healthcare
Advocacy (NAHAC), Health Advocate X, and the Greater
National Advocates (GNA).
As part of his improved future, Paul would like to exercise
more. He is considering joining a gym but would like
someone to help him keep to a schedule and ensure he
doesn’t hurt himself.
Personal Trainers - Personal trainers typically work in gyms
and exercise studios. They provide customized tness
routines and technique coaching for a wide variety of
exercise styles. More recently some personal trainers offer
one-to-one coaching via video or make house calls.
Exercise Classes - There are various group tness classes
available in person, via live streaming, or pre-recorded
sessions. Fees vary widely.
Paul’s trainer asks about his nutrition. Paul admits that he
mostly defrosts his meals and picks up cheeseburgers and
fries for Sunday visits with Jane. Knowing that solo agers,
especially men, are at risk for poor nutrition, Paul’s trainer
recommends that Paul focus on improving his nutrition. Paul
is considering getting advice to help him sort out what he
should eat to reduce his risk of diabetes and lose 10 lbs.
Registered Dieticians are credentialed professionals, usually
with a master’s degree.
Nutritionists are unlicensed and should not do medical
counseling.
After learning more about nutrition, Paul is considering
cooking at home or hiring someone to cook for himself
and Jane.
Meal kits, which offer recipes and ingredients or fully
prepared preservative-free meals, can be excellent options.
National brands include Factor, Blue Apron, Purple Carrot,
and HelloFresh offer a range of options.
Personal Chefs prepare multiple meals in advance. They may
be certied through the American Personal and Private Chef
Association (APPCA) of the US Personal Chef Association.
Paul and Jane are now eating better, but then Jane falls and
sustains a hip fracture. She can’t walk and is admitted to the
hospital. When Paul visits her, he nds Jane overly sedated.
Her private patient advocate coaches Paul on who to talk to
and what to say so that it doesn’t happen again. Jane gets
through her stay without delirium or a urinary tract infection.
Paul wants Jane to come straight home after her
hospitalization. Her concierge doctor is willing to make house
calls, and he thinks she will be more comfortable at home.
After learning that Jane’s insurance will provide a nurse once
a week and PT and OT three times a week, he realizes he
needs to hire help. He quickly learned that not all people
who provide care at home are called “nurse”.
Companions provide light housekeeping, meal prep,
shopping, safety supervision, and socialization.
Aides provide similar services to companions as well as
personal care, such as showering, toileting, and incontinence
assistance. They can be certied as Home Health Aides
(HHA).
Nurses are either Licensed Practical Nurses (LPN) or
Registered Nurses (RN). RNs have a greater depth of training
than LPNs, and each state has different laws governing the
scope of practice for LPNs and RNs.
Paul wasn’t sure how to nd help for Jane at home. He
considered various options:
Licensed Home Health Agencies are known as Licensed
Home Care Service Agencies (LHCSA) in New York, Licensed
Home Health Care Agencies (LHHCA) in Connecticut, and
other names in other states. They provide private home care
services, including nurses and aides. They are licensed by the
state and employ the caregiver in exchange for a fee.
The upside of using an agency is that they will take
responsibility for lling a shift for a caregiver who is sick or
has a family emergency. The caregivers are screened, and
oversight is usually performed. They must meet state quality
requirements. The downside is that their fees are typically
high because of their overhead. Staff turnover rates may be
high because the workers receive less than they would in
other arrangements.
Registries match caregivers with individuals looking to
hire privately. They screen workers and then receive a fee
from the person who hires the worker for providing the
match. Registries provide the peace of mind of professional
screening and a blend of economic incentives between
licensed agencies and direct hires.
Direct Private hires are word-of-mouth hires. Individuals
develop unique employer-employee arrangements. The cost
to hire is usually less than going through an agency. At the
same time, the caregiver can make 50 -100% more than they
would working for an agency, so they are often motivated to
stay. However, backup may be limited or nonexistent.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 20
Paul wondered if there was someone who knew all the local
options and who would also oversee the caregivers at
Jane’s home.
Geriatric Care Managers (GCMs) are also known as Aging
Life Care Specialists. They are usually social workers or nurses
by background. They provide boots-on-the-ground problem-
solving to help ensure that individuals age well. They identify
and develop a care plan for a person’s needs. They may be
certied care managers through the National Academy of
Certied Care Managers (NACCM) or the Commission for
Care Manager Certication (CCMC). Their organization is the
Aging Life Care Association (ALCA).
Jane went home and, with the help of aides for 8 weeks,
was able to safely recover. After her insurance stopped
paying for her home PT visits, Paul considered hiring:
Physical Therapy – provides exercises and mobility training.
Private pay arrangements can be made with individuals and
some companies.
Occupational Therapy – provides upper body exercises
and focus on helping people bathe, dress, toilet and feed
themselves independently. Private OT is harder to nd
than PT. There are approximately 4 times as many physical
therapists than occupational therapists in the United States.
A few months later, Jane can stand and walk a little, but
uses a wheelchair when she goes out. Paul has a hard time
getting her in and out of his car for doctors appointments.
He wonders if he’ll have to call an ambulance to take her
to appointments.
Ambulettes are vehicles, often vans, that can transport
someone for medical treatment, but not in a lifesaving
situation. Sometimes, insurance will cover the cost. They are
also called chair vans, mobility vans, or wheelchair-accessible
vans, especially outside of a medical context.
Wheelchair taxis are specially adapted vehicles that make
it possible for wheelchair users to have more comfortable
transportation. They are typically larger vehicles, like vans,
that have enough space to safely secure wheelchairs,
luggage, and passengers. In some places, they are not
allowed to charge extra.
Uber Assist is an option when a wheelchair will t into
the trunk
Uber WAV (Wheelchair Accessible Vehicle) is an option
when the wheelchair doesn’t fold. This is a chair van.
Medical Air Transportation is available for non-emergency
transportation through private companies, such as Flying
Angels and RN Medights. These services are for people
who need to y but can’t travel alone because of dementia
or medical needs such as oxygen. The companies make
travel arrangements, provide a ight nurse for medical escort,
and bring medical equipment when they accompany a
person on a ight.
Unfortunately, Jane’s dementia is progressing, and she
has had several trips to the Emergency Room. Twice, she’s
become very confused and agitated, and once, she fell and
hit her head. Paul thinks that Jane is no longer safe to stay in
her home.
Senior Placement Specialists guide individuals and their
families through assisted living placement options, including
memory care. They try to nd the best t between the
nances and the client’s and their family’s preferences.
The assisted living facility pays the placement specialist a
commission, typically a percentage of several months’ rent.
The service is free for the person being placed. Since nursing
homes don’t offer a placement commission, some placement
specialists will help families locate the best nursing home
option for an hourly or at rate.
Jane and Paul picked out a nice option for her to move
into. Paul decided to sell both of their homes and nd
another house in the community that would meet his future
needs. He wants help untangling the decades of family
ownership documents at Jane’s house. The house has been
in the family for a long time and is full of stuff. He doesn’t
know where to begin.
Senior Real Estate Specialist (SRES) is a special designation
for realtors who meet the unique needs of older adults,
including accessibility and multigenerational ownership knots.
They will buffer the person from potentially exploitive offers.
SRESs take a broader approach than the typical realtor.
Paul wants help cleaning out their houses and moving.
Professional Organizers help people organize documents,
photos, clothing, and household items. Their focus is on de-
cluttering. They may be certied as a Certied Professional
Organizers (CPO).
Move Managers focus on moves and estate cleanouts. They
arrange to sell or donate unwanted possessions. They may
be certied as a Certied Senior Move Manager (SMM-C).
Either Organizers or Move Managers will help clean out the
home to get it ready for sale. Both can provide emotional
support for this often difcult transition.
Jane moved into assisted living and now has a new group
of friends. Paul is eating better, working out regularly, and
joining the ROMEOs—Retired Old Men Eating Out. With the
help of various private professionals, they have each been
supported on their aging journey.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 21
Burnout as a Professional and
Medical Issue
By Stephen Axtell
The idea of delegating or parting with patient responsibilities
of any kind is a thought that causes well-deserved fears
centering on liability and case mismanagement. Delegation
of what responsibilities are transferable is preferable to
suffering the effects of burn out. Burnout among healthcare
workers and caregivers is a growing concern, particularly
for the life care planner, who is often faced with emotional
burdens that are not common to others including catastrophic
case care and management, professional rivalries entangling
themselves in practice, and court cases. Dened by
emotional exhaustion, loss of objectivity, depersonalization,
and a reduced sense of personal accomplishment, burnout
is not just a psychological issue but one that has tangible
effects on patient care, business operations, and the personal
well-being of everyone involved.
Biological Causes of Burnout
Despite “grind-core” culture and archaic psychological
expectations, burnout is not something that someone can
“think themselves out of.” Burnout is a symptom of both
psychological but also biomechanical causes.
Neuroendocrine Responses
Burnout is closely linked to the body’s stress response,
primarily regulated by the hypothalamic-pituitary-adrenal
(HPA) axis. When an individual experiences chronic stress,
Keywords: 1. Self Care, 2. Endocrine Issues,
3. Business Concerns
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 22
the HPA axis activates, leading to the release of cortisol, the
primary stress hormone. While cortisol helps manage stress
in the short term, prolonged elevation can have detrimental
effects, including the following:
• Altered Metabolism: Chronic high cortisol levels can disrupt
normal metabolism, leading to weight gain, especially in
the abdominal area (McEwen, 2006).
• Immune Dysfunction: Elevated cortisol suppresses immune
function, making individuals more susceptible to infections
(Sapolsky, 1998).
Neurotransmitter Imbalance
Burnout is also associated with imbalances in key
neurotransmitters, including serotonin, dopamine, and
norepinephrine. These neurotransmitters are crucial for
mood regulation, motivation, and overall cognitive function.
Chronic stress can deplete these neurotransmitters, resulting
in the following issues:
• Depression and Anxiety: Low serotonin levels are often
linked to mood disorders, while dopamine dysregulation
can lead to a lack of motivation and anhedonia (the inability
to feel pleasure) (Culpepper, 2016).
• Cognitive Impairments: Reduced levels of norepinephrine
may impair attention and decision-making abilities, further
exacerbating the stress cycle (Arnsten, 2009).
Inammation
Recent research highlights the role of systemic inammation
in burnout. Chronic stress can trigger inammatory pathways,
leading to elevated levels of pro-inammatory cytokines. This
chronic inammation can contribute to various physical and
mental health issues, including the following:
• Cardiovascular Disease: Inammation is a known risk factor
for heart disease (Libby, 2002).
• Mental Health Disorders: Inammatory markers have been
linked to increased risk of depression and anxiety (Dantzer
et al., 2008).
These biomechanical causes can result in long-term and
often chronic effects on the body of an individual, including
cardiovascular, metabolic, mental health, and immune
disruption.
Cardiovascular Risks
Individuals experiencing burnout may face an increased
risk of cardiovascular disease. Chronic stress and elevated
cortisol levels can lead to hypertension, increased heart
rate, and atherosclerosis (the buildup of plaques in arteries).
Studies have shown that burnout is associated with a higher
incidence of heart attacks and strokes (Kivimäki et al., 2015).
Metabolic Disorders
Burnout can contribute to the development of metabolic
syndrome, characterized by obesity, insulin resistance, and
dyslipidemia. These conditions signicantly raise the risk
of type 2 diabetes and other metabolic disorders (Miller
et al., 2011).
Mental Health Disorders
As mentioned earlier, burnout is closely related to mood
disorders. The chronic state of stress and resultant
neurotransmitter imbalances can lead to depression, anxiety,
and other psychiatric conditions. This not only impacts the
individual’s quality of life but their ability to function in work
and personal settings (Maslach & Leiter, 2016).
Impaired Immune Function
The immunosuppressive effects of chronic stress can lead
to increased susceptibility to infections, prolonged recovery
times, and greater incidence of chronic illnesses (Cohen
et al., 2012). Individuals suffering from burnout may nd
themselves more frequently falling ill, further exacerbating
their stress.
Burnout is not merely a psychological phenomenon but
an issue deeply rooted in biological processes that can
have severe implications for overall health. Employers and
individuals must recognize the importance of addressing
burnout holistically, taking into account both the mental
and biological dimensions of this complex issue. The risks
involved in ignoring these needs can be serious both for the
individual and for a practice.
Risks of Burnout in Healthcare Practice
Decreased Quality of Care
Burnout signicantly impairs the cognitive function and
decision-making abilities of healthcare workers. This can
lead to increased diagnostic errors, medication mistakes,
and delayed treatment, all of which can compromise patient
safety. According to a study published in The Journal of
Internal Medicine, burned-out physicians are twice as likely
to report medical errors compared to their non-burned-out
peers (West et al., 2018). This jeopardizes patient outcomes
while increasing the likelihood of malpractice lawsuits, which
can have severe professional and nancial consequences.
Reduced Patient Engagement and Satisfaction
When healthcare workers experience burnout, their ability
to connect with patients diminishes. They may appear
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 23
less empathetic, more irritable, or emotionally detached,
leading to a poor patient experience. This decline in patient
engagement can result in lower satisfaction scores, which
are often linked to reimbursements and ratings. A study
by Dyrbye et al. (2017) highlighted that patients treated
by burned-out physicians were more likely to express
dissatisfaction with their care, directly impacting the
healthcare facility’s reputation and nancial standing.
Increased Staff Turnover and Recruitment Challenges
Burnout is a leading factor in the high turnover rates seen in
healthcare. The departure of skilled workers not only disrupts
the continuity of care but also places additional strain on
remaining staff, perpetuating a cycle of burnout. Replacing
healthcare professionals is costly and time-consuming, with
estimates suggesting that the turnover cost for a single nurse
can exceed $40,000, while for a physician, it can range from
$500,000 to $1 million (Sinsky et al., 2017).
These practice risks will, not may, affect the business
practice as well.
Risks to Business Practice
Financial Implications of Burnout
The nancial impact of burnout is multifaceted,
encompassing both direct and indirect costs. Direct
costs include recruitment, training, and overtime pay to
cover stafng shortages. Indirect costs, such as reduced
productivity, absenteeism, and decreased patient volumes
due to poor satisfaction, further exacerbate the nancial
burden on healthcare organizations.
Moreover, burnout-related errors can lead to increased
operational costs. For instance, surgical errors necessitate
additional corrective procedures, while medication errors
can lead to prolonged hospital stays or adverse patient
outcomes, increasing overall healthcare costs.
Impact on Organizational Culture and Morale
Burnout can signicantly affect the work environment,
contributing to a toxic culture characterized by low morale,
lack of collaboration, and reduced trust among team
members. This negative atmosphere can deter new talent
from joining the organization and make it difcult to retain
current employees. A study published in Health Care
Management Review found that organizational support and a
positive work environment are critical in preventing burnout
and enhancing job satisfaction (Aiken et al., 2012).
Compliance and Legal Risks
Healthcare facilities are required to adhere to strict regulatory
standards and protocols to ensure patient safety and care
quality. Burnout can lead to lapses in compliance, such as
improper documentation, failure to follow safety procedures,
and inadequate patient monitoring. These lapses increase
the risk of violations, which can result in penalties, nes,
and legal action, further straining the facility’s resources
and reputation.
Personal Risks for Healthcare Workers
and Caregivers
Physical Health Consequences
The physical demands of healthcare work, combined with
burnout, can lead to a range of health issues, including
chronic fatigue, sleep disturbances, and increased
susceptibility to illnesses. Long-term exposure to high-stress
environments is also associated with an increased risk of
hypertension, cardiovascular disease, and gastrointestinal
disorders (Shanafelt et al., 2015).
Additionally, the musculoskeletal strain from tasks such as
patient lifting and prolonged standing can lead to chronic
pain conditions, further exacerbating physical exhaustion and
contributing to absenteeism and decreased work capacity.
Mental Health and Emotional Well-being
Burnout is closely linked to mental health issues, including
depression, anxiety, and substance abuse. The chronic stress
associated with burnout can lead to feelings of helplessness,
detachment, and cynicism, signicantly impacting overall
mental health. A survey conducted by the American Medical
Association found that nearly 50% of physicians experiencing
burnout also reported symptoms of depression, with a
signicant proportion contemplating suicide (Shanafelt et
al., 2015).
Impact on Personal Relationships and Social Life
The emotional toll of burnout often extends beyond the
workplace, affecting personal relationships and social
interactions. Healthcare workers may become withdrawn,
irritable, or emotionally unavailable, leading to strained
relationships with family and friends. The lack of work-life
balance and constant stress can also reduce participation in
social activities, leading to isolation and a diminished support
network. This can diminish the sufferer’s mental resilience.
The risks involved with overwhelming oneself and your
support teams not only justify the concerns involved in
delegating responsibilities, but the risks themselves include
increased liability and reputational risks that can become
serious enough to put a practice at risk. Barring any threats
to professionalism, one should take care to avoid burnout at
any risk.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 24
Arnsten, A. F. T. (2009). Stress signaling pathways that impair prefrontal cortex function. Nature Reviews Neuroscience, 10(6), 410-422.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2012). Hospital nurse stafng and patient mortality, nurse burnout, and
job dissatisfaction. Health Care Management Review, 57(2), 161-168.
Cohen, S., Janicki-Deverts, D., & Miller, G. E. (2012). Psychological stress and disease. JAMA, 298(14), 1685-1687.
Culpepper, L. (2016). The Role of Serotonin in Depression: Implications for Treatment. Journal of Clinical Psychiatry, 77(1), 1206.
Dantzer, R., O’Connor, J. C., Freund, G. G., Johnson, R. W., & Kelley, K. W. (2008). From inammation to sickness and depression: when the
immune system subjugates the brain. Nature Reviews Neuroscience, 9(1), 46-56.
Dyrbye, L. N., West, C. P., Sinsky, C. A., Goeders, L. E., Satele, D. V., Shanafelt, T. D. (2017). Burnout among health care professionals: A call
to explore and address this underrecognized threat to safe, high-quality care. The Joint Commission Journal on Quality and Patient Safety,
43(3), 242-247.
Garg, A. (1991). Long-term musculoskeletal problems and the workplace. Journal of Occupational Medicine, 33(5), 513-514.
Kivimäki, M., Head, J., Ferrie, J. E., & Vahtera, J. (2015). Work stress, personal life stress, and incidence of cardiovascular disease: a
multivariate analysis of the Whitehall II study. Social Science & Medicine, 61(1), 181-188.
Libby, P. (2002). Inammation in atherosclerosis. Nature, 420(6917), 868-874.
McEwen, B. S. (2006). Stress, adaptation, and disease: allostasis and allostatic load. Annals of the New York Academy of Sciences, 840(1),
33-44.
Miller, G. E., Chen, E., & Zhou, E. S. (2011). The forces of life: stress, stress regulation, and health. Journal of Health Psychology, 16(2),
191-202.
Maslach, C., & Leiter, M. P. (2016). Burnout: A Guide to Identifying Burnout and Pathways to Recovery. Harvard Business Review Press.
Sapolsky, R. M. (1998). Why zebras don’t get ulcers: An updated guide to stress, stress-related diseases, and coping. Sloan Management
Review, 40(1), 26-33.Conclusion
Shanafelt, T. D., et al. (2015). The relationship between burnout and medical errors among self-reported care quality and teamwork.
JAMA Internal Medicine, 175(7), 1234-1240.
Sinsky, C., et al. (2017). Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Annals of Internal
Medicine, 165(11), 753-760.
West, C. P., Dyrbye, L. N., Shanafelt, T. D. (2018). Physician burnout: Contributors, consequences and solutions. Journal of Internal
Medicine, 283(6), 516-529.
REFERENCES
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 25
Author’s Note:
When developing the Core Curriculum, the idea of including
case studies was entertained. The expectation was to include
case studies for each type of catastrophic injury along with
some questions for reection and self-study. Due to several
obstacles, this was not included in the latest edition. The
following article is from the original submission to the
Amputation Case Studies
By Victoria Powell, RN, CCM, LNCC, CNLCP, CLCP, MSCC, CEAS, CBIS
amputation chapter of the Core Curriculum. I hope you nd
the case studies thought-provoking and useful. Pictures were
added with the permission of the clients.
Case Studies – Amputations
The Amputee Coalition’s new study, titled Prevalence of Limb
Loss and Limb Difference in the United States: Implications
for Public Policy, was published in February. The ndings
indicate that in the United States today there are more
than 5.6 million++1 people living with limb loss and limb
difference, of which are nearly 2.3 million+ people living with
limb loss and another 3.4 million+ people living with limb
difference (Avalere Health, 2024). With an average of “507
people losing a limb to amputation every day, limb loss has a
momentous impact on the overall health and quality of life of
the U.S. (Ziegler-Graham, 2008).”
Traumatic amputation presents unique and complex
challenges for patients, healthcare providers, and life care
planners. Estimating the lifetime costs of care for individuals
with traumatic limb loss is a multifaceted process, requiring
the consideration of physical, emotional, and nancial factors
that extend far beyond the initial surgical intervention.
Keywords: 1. Amputation, 2. Case Studies,
3. Complications
NURSING DIAGNOSES TO CONSIDER
NANDA-I 2024-2026
Ineffective Health Self-Management Unsatisfactory handling of
symptoms, treatment regimen, and lifestyle changes associated
with living with a chronic condition.
Disrupted Body Image. Negative mental image of one’s
physical self.
Risk for Post-Trauma Syndrome. An overwhelming sustained
sense of exhaustion and decreased capacity for physical and
mental work at the usual level.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 26
For life care planners, understanding the long-term needs
of this population is critical in creating comprehensive,
individualized care plans that address prosthetic technology,
rehabilitation, medical complications, and psychosocial
aspects of recovery.
This article explores three compelling case studies that
highlight the diverse experiences of individuals following
traumatic amputation. These real-world examples highlight
how assessment of the individual’s daily life and functional
needs is paired with advancements in prosthetic technology
to transform lives. Each case underscores the importance of
personalized care planning, taking into account factors such
as body habitus, prosthetic technology, rehabilitation goals,
psychological support, and access to specialized medical
care. By examining these real-life scenarios, life care planners
can better understand the variables that inuence long-
term outcomes, enabling them to provide more accurate
cost estimates and offering new possibilities for mobility,
independence, and quality of life
Upper Extremity
Mr. X was an obese middle-aged truck driver involved in a
rollover accident. He was thrown from the vehicle and found
outside the truck with his left arm outstretched and the
tractor-trailer rig lying on his arm. He was sent to the trauma
center, where he underwent a shoulder disarticulation with
targeted muscle reinnervation and multiple debridement
procedures. Following wound healing, he worked with a
prosthetist to create a hybrid prosthesis involving a shoulder
harness, free swing shoulder joint, myoelectric elbow, wrist
and ngers. Due to his body habitus, the shoulder harness
required special modications. Mr. X was not t with a
body-powered device prior to the myoelectric. This was to
better ensure adherence to the myoelectric device as well
as to use natural movements to move the prosthesis rather
than to relearn these movements after body power training.
Mr. X’s prosthesis included pattern recognition software. He
underwent specialized training with occupational therapy to
learn to utilize the prosthesis and related software. Several
setbacks occurred due to infection and stula development
secondary to a retained stitch. Several minor surface
procedures were performed and nally a more aggressive
wound debridement was required. This aggressive procedure
resulted in a change in the shape of his chest and resulted
in the immediate need for a new socket. Because this was a
nondominant arm, Mr. X learned to do many things with only
one hand. He was proud of his prosthesis and enjoyed the
public curiosity factor. His wife had suffered a catastrophic
injury one year prior, and she was instrumental in encouraging
him during his rehabilitation and prosthetic training.
During the life care planning process for Mr. X, locating
an appropriate prosthetist was a barrier to care. Clients who
live in a rural setting have difculty nding someone with
ANY amputation experience, especially for upper extremity
limb loss, and it is even more challenging with something so
severe as a shoulder disarticulation.
His size was/is a huge issue. Due to his protruding
abdomen and upper chest, the socket tment is an issue. A
good t is important when the socket holds all the electrodes
for the myoelectric functions.
Mr. X’s wife was instrumental in his acceptance of the
prosthesis. Because he had pushed her in her rehab the year
prior, she encouraged him to use his prosthesis. Others in a
similar situation might abandon prosthetic use.
Mr. X was unable to return to his job as an over-the-road
truck driver due to his inability to pass the Department
of Transportation physical with one arm. Considerations
for work are the ability to charge a device, the amount of
reaching over chest height, and the amount of dirt, water,
and humidity in the work environment.
Bilateral Upper Extremity Amputations
Mrs. W was a new mother of a bouncing baby boy. A severe
bout of postpartum depression resulted in a suicide attempt
nine days after delivery when she dropped both wrists onto
a table saw in her garage. This resulted in bilateral arm
amputations just proximal to the wrists. She was initially
evaluated for hand transplantation, but necrotic tissue
resulted in amputation rather than transplantation.
Mrs. W complained of pain in her shoulders that awakened
her at night. The pain was described as aching and sore,
and she found it to be worse with overuse when wearing her
body-powered prostheses.
Mrs. W had an obvious lack of range of motion with the
shortening of her upper limbs. She was unable to reach as
far and even using the prosthesis she is limited in her range
because of the necessary contraction of muscles used to
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 27
Potential complications more than likely included overuse
syndrome, accelerated joint disease, prosthetic t issues, and
dental issues.
In the life care plan for Mrs. W, a Skills For Life2 workshop
was recommended. Routine shoulder diagnostic studies
were included. A large portion of the plan consisted of
recommendations for one-handed or no-handed equipment
and aids for independent living. This included adaptive
clothing, touch lamps, a dressing tree magnetic jewelry
clasps, elastic shoe laces, a mounted hair dryer, a toothpaste
dispenser, and more. Minimal hours of assistance were
provided for housekeeping, minor maintenance, and
assistance for those care needs of the children that she was
unable to manage on her own even with adaptations.
Work accommodations consisted of voice-activated
software and related training, and a foot-activated computer
mouse. Home modications included pull-out shelving,
lazy-susan, accessible appliances, accessible bathroom, and
laundry storage, lever door handles throughout, keyless
entry, voice-activated environmental controls, pull-down
clothing rods, safety step stool integration, specialized
hardware for cabinet drawers and doors, automatic water
faucets and lever-style faucets, and a microwave pull out.
Unilateral, Below-Knee (Transtibial) Amputation
Mr. R was working for a railroad company when his left
foot was crushed by a railcar. Numerous attempts were
made to salvage his foot, but he ultimately underwent
a left, partial foot amputation. Mr. R. later elected a left
transtibial amputation to promote healing and maximize his
rehabilitation potential.
Mr. R was married with three children. Following his
amputation, he went through a divorce. He shared custody of
his children. His lack of support network and responsibilities
with his children, coupled with the daily energy expenditure
required to mobilize with his amputation resulted in a loss
of nearly all non-vocational, enjoyable activities including
coaching his son’s sports teams, woodworking, and
motorcycle riding.
Mr. R struggled with severe folliculitis. He underwent laser
hair removal in an attempt to minimize this. He underwent
six treatments followed by periodic maintenance every six
months or so. The folliculitis increased after he returned
to work. When it rst began he had are-ups on occasion,
but after returning to work it became constant. The areas
most affected were the back of his calf and skin around the
proximal area of the socket.
Mr. R reported he could wear his current prosthesis about
16 hours a day. The bulk from the battery associated with his
prosthesis caused his pant leg on the left to be shorter or
open and close the hooks or hands. She was able to write
using both of her residual limbs held together without
prosthetic devices. She was provided a wristband that she
used to attach various utensils and a pen, but her residual
limbs became very sore from use.
Temperature extremes were especially bothersome for
her. The cold temperatures in her home climate caused
discomfort in her forearms. Warm/hot temperatures caused
her arms to sweat which made her prosthesis not t as
well and caused friction on her forearms resulting in
skin breakdown.
Mrs. W also had safety concerns. She had one of her body-
powered devices break and it greatly concerned her that
this might happen when she was driving, with her infant son
in the car. She had a ring on the steering wheel installed to
assist her with turning but also had four or ve instances of
her prostheses becoming stuck in the ring. She had instances
that required her to stop and pull over to x it. Luckily, she
had been in an area where she could safely pull over and
was not in much trafc, but she was concerned about the
potential for accidents in the future.
She quit wearing makeup since she could not apply it.
She was limited in the types of clothing she could wear.
She typically wore long sleeves in an effort to cover her
prostheses and could not wear shirts that button. She
discontinued wearing jewelry as she could not put it on and
take it off. Her hair was cut short following her amputations
and she was unable to curl her hair or style it in the way
she would like. She could no longer tie her shoes and was
unhappy with her limited slip-on or Velcro-type shoes.
Since her amputation, Mrs. W continued to do the
shopping but complained it took much longer as she tried to
obtain items from the shelves, load and unload her cart, take
the bags from her car into her home, and put the groceries
away. She could not tie shoes, including those of her young
son. She needed assistance with cooking. She could not
take care of her daughter’s hair or help her brush her teeth.
Her children were also limited from wearing anything with
buttons. Mrs. W was concerned about her inability to help
her son with potty training when she was so limited in what
she could do for him. She could not clip his toenails. She was
concerned about the winter weather and how she was going
to manage shoveling the snow.
Mrs. W used her teeth to perform many tasks. She held
things, opened things, dressed her son, etc. using primarily
her teeth.
Mrs. W’s treatment regimen consisted of medications, the
use of a variety of prosthetics and aids, routine medical and
psychiatric counseling appointments, and a reduced work
schedule with some accommodations.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 28
ride up in comparison with the right leg. In addition, his pants
were noted to have small worn spots in them from the wear
and tear of the prosthesis. Mr. R. bought a pair of work pants,
took them to a tailor, and had them altered. A zipper was
added to the pants so he could access the prosthesis while
dressed. This allowed him to remove his prosthesis when
required to air it out, remove moisture, and change liners.
The tailor adjusted the length of one leg of the pants so they
were even at the bottom.
Mr. R returned to work on modied/transitional duty.
Once he returned to work, he quickly realized he still needed
more therapy, particularly to focus on balance and strength.
Mr. R would have more issues arise with each job he tried,
and therapy would have to work to resolve each new thing
that came up. For example, in one of the jobs, Mr. R was
required to operate a pedal. He found he needed more
strength to hover his foot over the pedal and also needed to
work on his weight distribution. In another job, he found that
carrying things with weight changed his gait and this required
more training. His therapist worked with him once a week
in an aggressive training program with lots of focus on
home exercises.
Mr. R also reported issues with stamina. Whenever possible,
he would limit himself to 1 or 1 ½ hours of activity before
taking a break. He recognized that his fatigue worsened with
an increase in body weight. He found standing in one place
impossible and stated he could never stand in one place at
work for 8 hours a day. He found continuous movement much
less difcult. Despite his reports of fatigue, Mr. R noted a
“night and day difference” in fatigue after his BiOM device
tting. He was then able to walk and climb step over step,
which he could not do before.
Mr. R’s prosthetist noted that his yearly cost for just the
liners and suspension sleeves was more than $1,700. The
suspension sleeve is the weakest point. Mr. R noted he had
to replace these items every 4 to 6 weeks due to his very
active lifestyle.
Below Knee Revision to Above Knee
Due to Osteomyelitis
Mr. G was struck while riding his motorcycle. He suffered an
extensive tendon injury and fracture to the right leg, right leg
patellar injury resulting in ORIF, right-hand injury, and mild
traumatic brain injury. Orthopedic repair with rods and screws
was rst completed, but due to complications, he underwent
a below-knee amputation.
His right-hand injury compounded his difculties with
ambulation as he could not wheel his wheelchair on his own
and his walker required a special platform to prevent weight
bearing on his hand.
Mr. G was married with three children; one of whom had
Asperger’s. His wife was scheduled to start a new job the
same week the accident occurred. Neither of them had any
family in the state. They rented a home near the husband’s
job, but they also owned a two-story home several hours
away. They had been unable to sell or rent the home, and
due to its two-story nature, it was not conducive for them
post-amputation.
Mr. G loved his job, but it required working outdoors, on
uneven surfaces, in harsh environmental temperatures and
weather-related hazards. His work area required maneuvering
obstacles such as very large pipes and hoses lying across the
ground, climbing stairs, and repeatedly entering and exiting
a truck. Drilling in the area resulted in a mixture of oil and
sand which resulted in slick surfaces that could be up to two
feet thick at times.
Mr. G had sleep disturbances which were thought to be
PTSD related to the accident. His provider recommended a
sleep study to conrm.
The right-hand injury healed, but he was left with a
Boutonniere’s deformity. Further surgery was recommended
on the tendon to improve this deformity.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 29
Mid-litigation, Mr. G had a setback. His wife reported
unusual behavior with some “spells” in which he thought
he may have blacked out. He had been very ill. His wife
reported he had never emotionally recovered from his last
surgery (revision of his amputation). She noted he was acting
out of character, and she was extremely worried about
him. After an admission to the hospital, he was found to
have osteomyelitis. Bone biopsy was recommended then
Vancomycin via PICC line by home infusion.
Mr. G continued to have chronic osteomyelitis. It was felt
to be related to a screw head left at the proximal end of the
bula. After multiple surgeries, Mr. G ultimately underwent an
above knee amputation.
Mr. G had returned to modied duty with his below-knee
amputation, but once the above-knee amputation took place,
he was no longer able to work for the company. The energy
expenditure required to walk with the above knee prosthesis
and the challenging terrain was a detriment. He eventually
went into a private business with his spouse.
Bilateral AKA
Mr. L suffered bilateral above knee amputations in a railcar
accident while working out of state. Prior to his limb loss
he loved hiking, shing, hunting, canoeing, golf, and was a
volunteer scout leader.
A few weeks before his traumatic
amputations Mr. L enjoyed a
beach vacation. After seeing
beach photos of himself, he was
desperate to do something about
his weight. His preinjury weight
was 322 pounds at 6’2” tall. He
returned to work and started
the Atkins diet and dropped
12 pounds quickly but then
plateaued, so he reached out
to a friend who recommended
the Optiva diet. At the time of
his accident, he weighed 240
pounds. After his bilateral amputations and a hospitalization
he returned home at only 169 pounds. He knew he needed
to increase his strength and stamina if he was going to get
out of his wheelchair so in addition to a high protein diet he
started an adaptive CrossFit program at a local gym.
Mr. L’s son came to him one day with some Tik Tok videos.
His son had seen a bilateral above knee amputee on TikTok
who was doing remarkable things, so they reached out to
him. The TikTok gentleman shared that his prosthetist has
a niche practice treating bilateral AKA patients and getting
them back to living their best life. Mr. L traveled from Ohio
to Oklahoma specically to interview the prosthetist before
deciding to use them for himself.
The prosthetic clinic hosts a DreamTeam LifeCamp3 each
year. This is a three-day camp where attendees are trained
in environmental obstacles such as ramps, hills, curbs, stairs,
etc. There is no cost to attend the event other than travel,
lodging, and meals while they are in Oklahoma.
Using a graduated approach to becoming a bilateral
prosthesis user, Mr. L was able to transition from walking on
stubbies4, to increasing his limb length and eliminating use
of the wheelchair for daily ambulation, walking on full length
legs with microprocessor knees, to increasing his ability to
walk on uneven terrain, and maneuvering stairs and other
normal obstacles.
During this process he did experience a setback. His femur
was found to be piercing a muscle and another revision of
his right limb had be performed before he could get into
full legs.
Mr. L had several complaints that were specic to his above
knee amputations. His underwear did not last six months and
shorts rarely lasted a year due to the wear and tear of the
ischial containment socket against the fabric when sitting. Bar
stools in the home were scarred and scratched. The toilets in
the home were scratched or cracked. In addition the process
of donning and dofng his prostheses would require nearly
two hours for him to be ready to leave the house.
Ankle weights applied in addition to stubbies prostheses.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 30
One thing to note is that K levels do not apply for the
bilateral amputee. Previous studies have shown that unilateral
transfemoral amputees use 88% more metabolic cost over
an able-bodied individuals. Mr. L’s prosthetist estimated he
had a 400% increase in energy consumption with bilateral
above knee amputations using stubbies. Living with bilateral
lower limb amputations requires a considerable amount of
trunk control, stamina, and arm strength. It is much more
difcult to walk for longer distances due to the higher energy
expenditure of walking on two prostheses. Mr. L was highly
committed to making the necessary changes in order to do
so. He continued with adaptive CrossFit classes and attended
the annual LifeCamp while on stubbies. Since then he has
continued he quest for a full life and has graduated to full
legs. His most recent trip to LifeCamp was on his full legs and
microprocessor knees.
Unliteral BE to AE
A traumatic vehicular crash left Mr. M without the lower
portion of his dominant arm. The accident occurred while on
his own time but it affected his ability to work and participate
in recreation. Mr. M was a waste management truck driver. He
loved his job and had a strong desire to return to work. His
job required a CDL license to operate the truck. In his spare
time, Mr. M was also a fast pitch softball coach.
The accident resulted in his being ejected into a swampy
drainage area. This caused an infection which resulted in
multiple debridement surgeries. The extensive debridement
left him with the lack of nerve impulses necessary to operate
a myoelectric prosthesis. His residual limb was very short with
only an inch of ulnar and radius. With a lack of nerve impulse
his exion was almost nonexistent even after extensive
occupational therapy.
To address his prosthetic needs Mr. M was advised of two
options. One option was surgery to amputate his arm above
the elbow eliminating the extensive scarring, contracture,
and getting back to an active nerve. In addition, the surgeon
recommended Targeted Muscle Regeneration (TMR) to
improve pain and help with pattern recognition software
for the myoelectric prosthesis. This option would require a
two-joint prosthetic device which is more expensive, requires
extensive training, and increases weight and complexity. The
other option was to perform surgery to clear any scar tissue
in hopes of improving his nerve impulse, muscle contraction,
and allowing him to utilize a myoelectric prosthesis.
Mr. M. was very confused about his options. His wife did
not wish him to have any further surgery. Mr. M was leaning
toward the higher level amputation since he felt that this
surgery was going to be necessary at some point in the future
anyway. Consultation with a bilateral specic Occupational
Therapy specialist and a new prosthetist assured Mr. M
he could be t for a body-powered device even with his
short residual and his residual could even be bypassed by a
step-up hinge device allowing him a longer residual limb. In
addition, his goals of returning to truck driving and coaching
softpitch ball were possible with a body-powered device. A
terminal-end device with a ball cup could be used to toss a
ball into the air and he could bat with his left hand, but this
is not allowed with a myoelectric device, and it would not be
possible with an above-elbow amputation.
By electing to forego surgery,
this option remains available to Mr.
M. He was t for a body-powered
device with a terminal end device
and quick disconnect allowing him
to return to coaching softball. He
continues to ght for his right to
return to work. He has been cleared
to drive with his prosthesis, but the
waste management truck requires
his right/dominant hand to operate
various leavers and buttons which
continue to be a limiting factor.
Traumatic amputations pose lifelong challenges that
extend far beyond the initial surgical procedures, requiring a
multidisciplinary approach to care that is both individualized
and adaptive. As demonstrated through the case studies
in this article, each patient’s journey is shaped by unique
physical, psychological, and environmental factors that
inuence their rehabilitation and long-term well-being. The
role of the life care planner is pivotal in addressing these
diverse needs.
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 31
The complexities of prosthetic management, compounded
by issues such as infection, body habitus, and functional
limitations, underscore the necessity of tailored care plans
that evolve as the patient ages or their condition changes.
Furthermore, the psychological and social dimensions of
living with amputation, including the patient’s self-image,
return to work, and family dynamics, must be thoroughly
integrated into life care planning.
Ultimately, life care planners must stay informed about
advancements in prosthetic technology, rehabilitation
techniques, and best practices for managing secondary
conditions such as overuse injuries and joint deterioration.
By doing so, they can more accurately estimate lifetime
costs, ensuring that patients receive the resources and care
necessary for maintaining quality of life. The case studies
presented here illustrate the critical importance of a holistic,
patient-centered approach, reinforcing the need for ongoing
education and collaboration among healthcare professionals
to best serve this population.
Self Study Assessment
1. List three special considerations for the aging amputee
2. What is the anticipated time from implantation of the
implant for osseointegration to functional use of the limb?
3. How are K Levels used to determine the appropriateness
of lower limb prosthetic devices?
4. A 45-year-old male with a BMI of 42 presents with
a unilateral above-knee amputation. What special
considerations must be made?
5. What consideration, if any, should be made regarding
hand dominance when planning care for the upper limb
amputee?
6. What additional resources should be queried when
assessing the needs of a child with amputation?
Nursing Diagnoses
• Activity intolerance
• Chronic pain syndrome
• Disturbed body image
• Impaired comfort
• Impaired home maintenance
• Impaired physical mobility
• Impaired skin integrity
• Impaired social interaction
• Impaired standing
• Impaired walking
• Ineffective activity planning
• Risk for activity intolerance
• Risk for falls
• Risk for injury
• Sedentary lifestyle
• Self-care decit; bathing
• Situational low self-esteem
• Social Isolation
Bibliography
Avalere Health. (2024). Prevalence of limb loss and limb
difference in the United States: Implications for public
policy. Amputee Coalition. https://avalere.com/wp-content/
uploads/2024/02/Prevalence-of-Limb-Loss-and-Limb-
Difference-in-the-United-States_Implications-for-Public-
Policy.pdf
1 The “plus-plus” part of this 5.6 million++ gure acknowledges that the known estimate does not include everyone. Most notably, by using insurance claims
data the study could only capture people covered under specic types of insurance. The analysis could not account for individuals who are uninsured or
covered by Veterans Affairs or TRICARE. Data sources for this report include Medicare, Medicaid, and commercial insurance claims.
2 https://www.enhancingskillsforlife.org/skills-for-life
3 http://dreamteamprosthetics.com/bilateral-above-knee-amputee-training-camp/
4 Stubbies are foreshortened prostheses used during and sometimes after initial ambulatory rehabilitation. They are custom tted and are usually made up
of standard sockets, no articulated knee joints or shank, with modied rocker bottoms or Sach feet turned backward to prevent the individual from falling4.
This design allows the bilateral leg amputee to achieve a lower center of gravity for better balance and stability
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 32
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 33
2024
Winter: Foundations in Life Care Planning
2025
Spring: Delegation of Care and Caregivers
Summer: Psychology
Autumn: Orthotics
LOOKING AHEAD
Spring 2014 XIV.1
Technology
Updates
P E E R - R E V I E W E D E X C E L L E N C E I N L I F E C A R E P L A N N I N G S I N C E 1 9 9 8
LCP
and
the
ACA
Winter 2014 vol. XIV, no. 4
Winter 2019
vol. XIX, no.1
PRESIDENTS
1998
ISSUE 2018
JOURNAL OF
NURSE LIFE CARE
PLANNING
Summer 2019 vol. XIX, no.3
THE AMERICAN ASSOCIATION OF NURSE LIFE CARE PLANNERS
PEER-REVIEWED EXCELLENCE IN LIFE CARE PLANNING SINCE 2006
Spring 2014 vol. XIV, no.2
Life care
planning
across all
ages
Summer 2014 vol. XIV, no.2
P E E R - R E V I E W E D E X C E L L E N C E I N L I F E C A R E P L A N N I N G S I N C E 1 9 9 8
Licensure | Qualicaons | Cercaons
PEER-REVIEWED EXCELLENCE IN LIFE CARE PLANNING SINCE 2006
AUTUMN 2024 PEER REVIEWED EXCELLENCE IN NURSE LIFE CARE PLANNING SINCE 2006 VOLUME XXIV ISSUE 4
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 34
Index of Past Issues
all past issues from 2009-present area available
as PDFs for free download at www.aanlcp.org
2015
XV.1 Topics in Translation
XV.2 Updates in Spinal Cord Injury
XV.3 Burns
XV.4 Perinatal / Childhood
2016
XVI.1 Pain
XVI.2 GI Issues
XVI.3 International LCP
XVI.4 Home Care
2017
XVII.1 Brain Injury
XVII.2 The Business of Life Care Planning
XVII.3 Back and Spine
XVII.4 Mobility and Extemity Function
2018
XVIII.1 Costing and Coding
2019
XIX.1 Presidents Issue
XIX.2 Licensure I Quali cations I Certi cations
XIX.3 New Directions in Pain Management
XIX.4 Technology Updates
2020
XX.1 Spinal Cord Injury Updates
XX.2 Advances in Amputation
XX.3 Evidence Based Practice
XX.4 Durable Medical Equipment and NLCP
2021
XXI.1 Therapeutic Modalities
XXI.2 The Business of NLCP
XXI.3 Ages and Stages in Life Care Planning
2022
XXII.1 Expert Witnessing and Testimony
XXII.2 Pain Management Revisited
XXII.3 Orthopedics, Pain, and Research
2023
XXIII.1 Pediatrics
XXIII.2 Business of Life Care Planning
XXIII.3 Mental Health
XXIII.4 Interacting with Other Disciplines
2024
XXIV.1 Assistive & Durable Medical Equipment
XXIV.2 Nervous and Spinal Injury Considerations
XXIV.3 Ethics
XXIV.4 Delegation of Care and Caregivers
P E E R - R E V I E W E D E X C E L L E N C E I N L I F E C A R E P L A N N I N G S I N C E 1 9 9 8
LCP
and
the
ACA
Winter 2014 vol. XIV, no. 4
Spring 2015 PEER-REVIEWED EXCELLENCE IN LIFE CARE PLANNING SINCE 1998 Vol .XV No. 1 1
Spring 2015 vol. XV, no.1
Topics in
Transplantation
P E E R - R E V I E W E D E X C E L L E N C E I N L I F E C A R E P L A N N I N G S I N C E 1 9 9 8
AANLCP JOURNAL OF NURSE LIFE CARE PLANNING ISSN 1942-4469 801
Summer 2015 PEER-REVIEWED EXCELLENCE IN LIFE CARE PLANNING SINCE 2006 VOL. XV NO. 2
Spring 2014 vol. XIV, no.2
Life care
Summer 2015 vol. XV, no.2
Updates in
Spinal Cord
Injury
SUMMER 2015 VOL. XV NO. 2
Technology
Update
JOURNAL OF
NURSE LIFE CARE
PLANNING
THE AMERICAN ASSOCIATION OF NURSE LIFE CARE PLANNERS
Fall 2019 vol. XIX, no. 4
PEER-REVIEWED E X CELLENCE IN LIFE CARE PLANNING SINCE 2006
JOURNAL OF
NURSE LIFE CARE
PLANNING
Winter 2016 vol XVI, no.4
THE AMERICAN ASSOCIATION OF NURSE LIFE CARE PLANNERS
PEER-REVIEWED EXCELLENCE IN LIFE CARE PLANNING SINCE 2006
Home Care
