It comes as no surprise to discover that one of the smiling faces on the American Association of Nurse Life Care Planners (AANLCP) homepage is Wendie Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC. Howland is well-known as a Certified Nurse Life Care Planner (CNLCP) and Legal Nurse Consultant Certified (LNCC), for good reason. Her expertise is firmly rooted in extensive research, a wide-range of experience in a variety of nursing fields, academic excellence, enviable prowess, and unrelenting moxie.
Awards & Achievements
Board Certified Registered Nurse (RN-BC)
20 years of experience working in critical care
Critical Care Clinical Specialist
Field case management in worker's compensation insurance industry
Legal Nurse Consultant Certified (LNCC)
Certified Nurse Life Care Planner (CNLCP)
National certification in rehabilitation nursing (CRRN)
Certified Case Manager (CCM)
Editor, Journal of Nurse Life Care Planning, American Association of Nurse Life Care Planners
Editor, Journal of Legal Nurse Consulting, American Association of Legal Nurse Consultants
Contributor to textbook chapters on spinal cord injury, burns, nursing care planning
Co-author and editor of the AANLCP Scope and Standards of Practice
Member of the Massachusetts Bar Association (Legal Nurse Consultant)
Member of the Massachusetts Nurse Practice Advisory Panel
Interview - Question & Answer
Wendie, do Nurse Life Care Planners or Legal Nurse Consultants determine what medical conditions someone is suffering from and how their future is best served?
Legal nurse consulting is work we couldn’t do if we weren’t nurses, but it is not a nursing specialty, let’s be clear on that. We use our nursing and medical knowledge to support attorneys, but we do not have nurse-patient relationships with their clients, and we do not plan, provide for, or implement/delegate nursing care as legal nurse consultants.
Life care planning is a nursing specialty. I can’t say, “This person needs surgery.” That is a medical prerogative. Legally an RN cannot prescribe or perform surgery; that’s not in our job description. However, I can say, based on my nursing assessment, that this patient has had terrible burns on his hands and they’re very deformed. The wounds did not close adequately, and the joints are deformed so he should be evaluated by an orthopedic surgeon. Or, there’s a possibility there may need to be surgery, or plastic surgery.
I cannot prescribe Botox for intractable spasticity that’s not relieved by less invasive means. But what I can say is that the present medical treatment regimen has not been effective or is becoming less effective, so this patient should be evaluated by a qualified physician for possible botulinum therapy.
That makes sense…
Yes, of course it does! Many people think, “All nurses do is follow doctor’s orders.” While even in hospitals, that might be half of what nurses do (or more than half in some settings); it isn’t by any stretch all that we do.
When you do a Life Care Plan for someone with a certain medical condition, do you use it for another person who has that same condition?
Every person, every case is different; that’s one thing we learn in nursing school. How often do I hear a nursing student say, “My patient has congestive heart failure. I need 3 nursing diagnoses in priority order”? That’s not how it works. Tell me about YOUR patient, what you observed and learned about him, and how you decided about how to meet his needs.
If you admit someone who has no medical diagnosis, do you think you can’t do any kind of care planning for him? Of course not. We are nurses. We don’t base everything we do on the medical diagnosis. Unfortunately, many people (especially if all they know about nursing is what they see on television) don’t know how to think like that.
My methodology for life care planning is the nursing process: Assess, analyze, prescribe, implement/delegate, evaluate. There are computer programs out there, often used by non-nurses studying Life Care Planning, based on the medical model. For example, to grossly oversimplify, they’ll give you a long list of life care plan provisions based on the medical diagnosis alone. And many people take it, just like that, to a physician to sign off on it (they can’t do it because they’re not licensed to perform the evaluations needed to prescribe medical or nursing interventions). And that is their Life Care Plan. They can personalize it for things like age, place of residence. But basically, that’s how they look at life care planning—through the medical model.
There is so much that gets left out when you do it that way that physicians aren’t going to recognize. It’s part of our obligation to the patient to make sure that the people who are responsible (or paying the money) understand that also.
Wendie, would you explain the difference between the medical model approach and the nursing approach?
Medical education is diagnosis-based, disease-based. Physicians are trained to diagnose it, fix it, and move on. Physicians very rarely have much instruction at all on holistic care, on looking at the whole patient. Intellectually they realize that if there’s no food in the house and no way for an elderly lady to go out shopping that she’s going to have a problem with food and that’s going to affect her medical condition. But they don’t often look at the person with that in mind; they don’t often act with it in mind; and they are often not able to talk with the family about it either.
Nurses, on the other hand, are taught holistically from the beginning. We look at the whole patient and his life situation. Of course, we need and use medical information, but overall, we start from different places from physicians and we do things differently.
Do you apply that to your role as a Nurse Life Care Planner?
When I’m talking about being a Nurse Life Care Planner working from the nursing model, yes, I have to know a lot about spinal cord injury, or brain injury or what an MRI is, and what those things mean. But then I have to figure out how the diagnostic and functional findings translate into this person’s lifetime needs in all spheres; not just the list of treatments and diagnostic exams he’s going to need over the course of his lifetime.
Am I understanding this correctly: you don't work from a medical model approach?
Well, we certainly wouldn’t be able to do what we do without knowing an awful lot about anatomy, physiology, medical diagnosis, diagnostic testing, normal and abnormal, and that informs our practice. But the basic methodology of nursing, including Nurse Life Care Planning, is patient assessment. “What does this patient need from us?”
Many people don’t remember, or they never knew, or they don’t believe, that probably only about half of what nurses do in hospitals and hands-on care has to do with implementing a medical plan of care. The other half is implementing a nursing plan of care, and that’s not prescribed by physicians, therapists, social workers, or anybody else. It’s prescribed by registered nurses based on nursing assessment.
Nurse life care planning is like that too. We do make provisions for implementing recognized parts of a medical plan of care because it would be irresponsible not to do that; those are needs the particular patient is going to have. We collaborate with physicians, therapists, psychologists, whoever is involved in the care of that patient, to get a holistic overview of what is going on with this person. Then we can research options and associated costs.
From a financial standpoint, too, usually if people are hurt badly enough to need a life care plans they are probably going to have lifetime care needs involving assisted living, nursing home care, and residential care in addition to medical care. Those costs are usually more than half of the average total life care plan. That is why it’s not responsible to base everything on the medical model and leave it at that.
Can you give me a hypothetical example?
Let’s say I were to have a case that involves a young male with a brain injury. One of the things I would ask the family is if they felt he would ever be interested in having a relationship with a woman. Assuming the family says yes, they now have a new outlook on his life. His mother might be grateful for the idea of grandchildren, while his father and siblings still can perceive him as a man.
Does the medical plan of care for a diagnosis of a traumatic brain injury offer any consideration of his future relationships with a woman? Not usually. But I would certainly consider it (among many, many other things) based on his cognitive abilities. Some nice woman might come into his life and love him anyway, just the way he is. And she might want to have children, and he might want to have children. He might not be able to physically perform, but it might be appropriate for him to be evaluated for sperm retrieval making it possible for her to have artificial insemination. There are clinics that deal specifically with this and these types of disabilities. There are also companies that make beds so that two people in a situation like this could sleep together, so he wouldn’t have to sleep alone. I would take this into consideration as part of my looking at him holistically.
That is a very thoughtful and kind way to approach situations.
Well, I might get challenged on it in a legal deposition or at trial, but these are the kind of things I do. But you know, in a hypothetical situation like this, these are the kinds of things that would be appropriate to add into his life care plan. We also look at recreation, ability to get out into the community, perhaps spiritual needs, aids for independence, and more.
You bring a lot of hope to the table!...
Well, I don’t know about that, but this approach recognizes the reality of a young man’s life, as opposed to the small slice of time approach he would get in a visit to the physician’s office. The nursing approach tries to look at the whole gestalt. Another thing I would do, in a case like this, is recommend they do a day-in-the-life video, to more fully demonstrate what the patient’s life is like, and perhaps what it could be.
You are a very strong and tough woman; it would be hard to go up against anyone in court who wanted less for a patient than was right and fair. It would also take a lot to actively work with those suffering from catastrophic conditions. How do you do it?
Most of us, at our age, have developed a pretty good sense of boundaries. I can remember when I was a lot younger being so wrapped up in the tragedy of someone needing care over a long period of time that I became less effective myself.
What did you do in that situation?
I just had to take a little time off from work; I had to just do something else. I had to heal myself. I learned from how to give myself permission to have less intensive relationships with people I nursed. Of course, we care about people. But it’s like what backpackers say about hiking the Appalachian Trail: you have to hike your own hike. And someone’s tragedy is not my hike. I am just here to help them along.
You have to know your own boundaries, your own capabilities. I worked in critical care for a long time, but once when I was younger I was floated into a burn unit. I’d never set foot in a burn unit! They didn’t assign me patients who needed really skilled burn care because obviously I didn’t have those skills. They gave me somebody who was about to transfer out either that day or the next day. He needed some specialized care, but they said they would do that part, but would I do the rest? I said, “Oh yes, I can do that.” So that was fine. But then one of them said, “We are going to take another patient to the tank and do wound care, would you like to come and watch?” I said, “No, I think I’ll pass.” The guy said, “A critical care nurse turning down a learning opportunity?” I said, “I totally understand what you are saying. And as a critical care nurse I have seen and done many, many, many awful things in ICU. But most all of my patients had skin, and for me, that’s where I have to draw the line.” I just realized, “This is more than I can do.”
Wendie, you have been so kind to share your life's experiences with us today. Would you be willing to tell us a little about yourself from a personal viewpoint?
I work in an office accompanied by a fish in an aquarium and whatever cat wanders in; I travel a bit but it’s wonderful to come home. I live in a mid-19th-century house surrounded by lilacs on Cape Cod with my much beloved husband (who puts up with quite a lot from me), ringed by woods. We have four loony cats, an indeterminate number of rodents, and a black snake in the cellar in the winter. We have wild turkeys and foxes. We have a nuthatch nest in the siding of the house this spring and are loving watching the parents fly in and out all day feeding nestlings, but when they go at the end of the season we’ll have to plug up the hole in the wall.
My husband grows a big garden, I put up the produce and we eat it all winter. He keeps the woodshed filled and we heat mostly with a woodstove. We have solar panels for the hot water and can walk to the ocean. We’re life-long Red Sox fans.
I volunteer for the local STEM academy at the 7-12 level. I was a 25-year volunteer with the Boy Scouts as an assistant Scoutmaster, council risk management chair, council training chair, and youth sexual abuse and neglect prevention trainer. I served three tours at National Jamborees in the National Health and Safety Service. My kids are a PhD physics education researcher and a nuclear engineer building submarines. Everybody gets a homemade baby quilt, a big-kid bed quilt, and a wedding present quilt, and a crocheted Christmas stocking. You just never know what life will bring you, but life is sweet.
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