Chapter 36: Evaluation of Respiratory Impairment and Disability

INTRODUCTION

Management of a patient with chronic lung disease does not end with its treatment. Those with chronic pulmonary disorders need additional assistance and guidance on issues related to respiratory impairment, including causation or attribution; apportionment; eligibility for, and access to, various compensation systems; workplace modifications or removal from the workplace; and vocational and other forms of rehabilitation. Unfortunately, most physicians avoid providing these services, often with disastrous socioeconomic and medical consequences for the patient.

Multiple reasons underlie the general attitude of physician reluctance in addressing impairment. These include a fear and poor understanding of the legal system as it relates to work-related diseases, pervasive confusion about various compensation systems, a mistaken notion that those who seek impairment assistance are usually malingerers, lack of training in impairment evaluation, and a desire to avoid uncompensated, and often onerous, efforts in the context of an already burdensome clinical schedule. This chapter provides an understanding of this complex, but ignored, area in clinical pulmonary medicine.

TERMINOLOGY

This field of impairment and disability evaluation bridges medicine and law; hence, its terminology, drawn from both fields, can be confusing.

Impairment and Disability

The terms impairment and disability are often used interchangeably, but they are not synonymous. In 2001, the World Health Organization (WHO) developed the International Classification of Functioning, Disability and Health (ICF),¹ which identifies the dynamic relationship between impairment, disability, and disease. Impairments are problems in body function or structure, such as significant deviation or loss.^1,2 Disability is an umbrella term for activity limitations and participation restrictions in an individual with a health condition, disorder, or disease.³

For a patient with chronic lung disease, the goal of respiratory impairment evaluation is objective measurement of the extent of loss of function, primarily through application of pulmonary function or exercise testing. The physician plays a key role in impairment evaluation. On the other hand, the impact of the respiratory impairment on a person’s ability to perform day-to-day activities or involvement in life situations, also termed activity limitations and participation restrictions, respectively, is called disability, which is typically determined through application of administrative and legal instruments by experts in these areas. The experts not only rely upon the evaluation of impairment provided by the physician, but also take into consideration other social and legal issues, as well as the energy requirements of the occupation. Impairment may occur without disability, and disability may occur without measurable impairment. Furthermore, two individuals with exactly the same respiratory impairment may suffer differing impacts on their lives and, consequently, have different levels of disability.

Respiratory impairment may be temporary or permanent. In contrast to temporary impairment, permanent impairment is not expected to improve with time or treatment. Disability may be partial or total. Total disability implies that an individual is unable to ...