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Who should get a transplant?

Posted

Specializes in Management, Emergency, Psych, Med Surg. Has 32 years experience.

Where is the cut off for a transplant? We have a guy in our unit right now, 54 year old alcoholic who has end stage liver disease. He continues to smoke and I suspect he is still drinking. Do you think he should be able to get a transplant?

WalkieTalkie, RN

Specializes in CVICU.

No, if he is still smoking or drinking. Has he been evaluated yet?

NotReady4PrimeTime, RN

Specializes in NICU, PICU, PCVICU and peds oncology. Has 25 years experience.

I think you'll find that most tranpslant centres wouldnot refuse him a transplant. The University of Maryland's take is:

Alcoholic Cirrhosis: Patients with alcoholic cirrhosis are considered for transplant if they meet current criteria for abstinence and rehabilitation.

  • Abstinence of alcohol for six months.
  • Ongoing participation in formal alcohol treatment program.
  • Presence of adequate psychosocial supports as determined by social service and psychiatry consultants.

Patients who do not meet the above criteria at the time of referral will be given the opportunity to fulfill these criteria and undergo re-evaluation. Formal input from the psychiatry staff is required to assess the risk of return to alcohol use following liver transplantation.

Contraindications to Liver Transplantation

    While each patient is evaluated on an individual basis, the presence of one or more of the following will frequently preclude acceptance as a candidate for liver transplantation

  • HIV infection
  • Active alcohol or substance abuse
  • Systemic infections
  • Life limiting co-existing medical conditions: advanced heart, lung or neurologic conditions.
  • Uncontrolled psychiatric disorder
  • Inability to comply with pre- and post-transplant regimens

This is pretty standard around the world.

RN1982

Specializes in ICU/Critical Care.

Yeah, don't think he'll get a new liver if he continues on with his bad habits.

blondy2061h, MSN, RN

Specializes in Oncology. Has 15 years experience.

I did a clinical rotation on a kidney and pancreas transplant floor. We had a patient who came in s/p kidney transplant with an FK506 (Prograf level) of 0. When questioned on it, he admitted to not having taken his Prograf in 2 weeks. He was asked if he was having trouble affording the meds or getting to the pharmacy. Nope- Medicare pays for the meds, and the pharmacy delievers. He admitted he "just didn't feel like taking them." They did a biopsy to determine if he was rejecting the kidney. Lucky him, he wasn't. That was suppose to be an outpatient procedure, but while there it was discovered that he had a gangrenous foot, probably related to his a1c of 14%. He said he wasn't taking his diabetes medications because "he doesn't have diabetes." He absolutely maintained that he wasn't diabetic and didn't need diabetes medications.

The part that floored me about all this, was that the man was listed for a pancreas transplant shortly after all of this.

No, sorry I can't agree with this.

IMO, I think that people who inflict diseases on themselves as a result of something they knew would do it and ARE still doing it should be denied.

If this man had this problem as a result of smoking/drinking when he was younger and has spent the last twenty years staying away from these bad habits and later on has problems, I would say yes because he reformed and should not be punished because he acted negligent at one time.

But, if I was sitting in front of him and a person that needed the same transplant but had no responsibility for the reason he needed it, then I would give the organ to that person.

All I know is I am thankful I don't have this job and I praise those who work in the ethics departments. Tuff, tuff work.

Medic2RN, BSN, RN, EMT-P

Specializes in ER, IICU, PCU, PACU, EMS. Has 15 years experience.

What makes you suspect he's still drinking?

I think you'll find that most tranpslant centres wouldnot refuse him a transplant. The University of Maryland's take is:

Alcoholic Cirrhosis: Patients with alcoholic cirrhosis are considered for transplant if they meet current criteria for abstinence and rehabilitation.

  • Abstinence of alcohol for six months.
  • Ongoing participation in formal alcohol treatment program.
  • Presence of adequate psychosocial supports as determined by social service and psychiatry consultants.

Patients who do not meet the above criteria at the time of referral will be given the opportunity to fulfill these criteria and undergo re-evaluation. Formal input from the psychiatry staff is required to assess the risk of return to alcohol use following liver transplantation.

There is no absolute standard for alcohol. Most centers use the six month rule but there is actually little evidence to support this. A few centers use one year and some use a short as three months. The support issue is probably the best predictor of recidivism. A number of studies have shown that patients with strong family support systems have higher likelihood of abstaining from alcohol. On the other hand there are almost no programs that would transplant someone who is actively drinking.

Contraindications to Liver Transplantation

  • While each patient is evaluated on an individual basis, the presence of one or more of the following will frequently preclude acceptance as a candidate for liver transplantation

  • HIV infection
  • Active alcohol or substance abuse
  • Systemic infections
  • Life limiting co-existing medical conditions: advanced heart, lung or neurologic conditions.
  • Uncontrolled psychiatric disorder
  • Inability to comply with pre- and post-transplant regimens

This is pretty standard around the world.

PTs with HIV are being transplanted at a number of centers with good results.

Listing a patient for transplant is a long process. There are a number of hoops to jump through. These hoops become barriers for patients that would not do well after transplant. For example if someone is unable to keep appointments or follow instructions before transplant then they probably can't after transplant. Most programs have a pretty extensive system for assessing the patient prior to transplant and deciding which one will be a good candidate.

David Carpenter, PA-C

tlh65

Specializes in Med-Surg/Orthopedic.

My brother had alcoholic cirrhosis. He met all the requirements for transplant, was in an ICU bed for 2 months before a liver was found for him. He had a successful transplant (liver) almost 5 years ago. He has not had a single drop of alcohol since then and is doing wonderfully. I thank God everyday that he wasn't denied because he had had an alcoholic history only 6 months before that.

BabyLady, BSN, RN

Specializes in NICU, Post-partum.

I personally do not believe in drug addicts and alcoholics receiving organ transplants unless in the very rare case that the organ would otherwise go to waste.

That is where they sure as heck wouldn't want to put me in charge of a program like that.

I have to agree that if you trash your liver with alcohol and/or drug use, it is very sad, but in NO way should an organ go to such a person. The reason why I think this is because the organs are so precious and few and should be saved for those who have had no control over the diseases that have ruined their own organs. If there were more available, then I'd have no problem with an alcoholic/drug user getting a new liver.

diane227, LPN, RN

Specializes in Management, Emergency, Psych, Med Surg. Has 32 years experience.

Because he comes into the hospital with a positive alcohol level.

NurseKatie08, MSN

Specializes in Geriatrics, Transplant, Education. Has 13 years experience.

I have to agree that if you trash your liver with alcohol and/or drug use, it is very sad, but in NO way should an organ go to such a person. The reason why I think this is because the organs are so precious and few and should be saved for those who have had no control over the diseases that have ruined their own organs. If there were more available, then I'd have no problem with an alcoholic/drug user getting a new liver.

I'm willing to bet that neither you, or any of the posters who'd deny an alcoholic/drug addict a liver have any personal connection to someone with a substance abuse problem. While they may have chosen to pick up that first drink, they have no control over their disease. They can't just not drink--many of them end up at liquor stores (packies, in my neck of the woods) with NO idea how they got there, or where they even got the money to buy their booze. If it were that simple, there wouldn't be so much success from programs such as AA.

I wouldn't deny anyone a liver transplant. I understand that it's difficult to allocate scarce medical resources, but if an alcoholic met the appropriate criteria, I'd have no trouble considering them.

WalkieTalkie, RN

Specializes in CVICU.

PTs with HIV are being transplanted at a number of centers with good results.

Yes, and actually, I've done some research and it looks like a fair amount of them do better post transplant (possibly because their immune systems don't react so strongly to the foreign organ).

ghillbert, MSN, NP

Specializes in CTICU. Has 20 years experience.

It's determined on a case-by-case basis at my institution where we have a patient selection committee meeting once a week. We look at many factors - compliance is a huge one. People who don't make appointments, don't take meds as prescribed, don't go to PT etc pre-transplant are rarely going to be a good bet post-transplant. We get patients to sign a contract regarding substance abuse which states they will abstain for at least 6 months, go to meetings, see psych etc as required. They don't make it, we don't list them.

tlh65

Specializes in Med-Surg/Orthopedic.

Before my brother was listed for transplant, the committee met frequently to discuss his case. They felt he was a good candidate - and they were right. He got his life back, has a great family with children, does not drink, stays busy. He's a different person and he is so thankful he got a second chance. I wonder if some of you would think differently if this hit you on a personal level? When I am working, I ALWAYS try to empathize and put myself in the patient and/or family position. I try very hard not to be judgmental.

I'm willing to bet that neither you, or any of the posters who'd deny an alcoholic/drug addict a liver have any personal connection to someone with a substance abuse problem.

Wrong.

I had an alcoholic Uncle who died a couple years ago. He was in and out of rehab, went to jail many times, had to live with my Grandparents, had no job, no car, and no life. He tried many, many times to get sober, but he eventually just gave up. (There were a lot of family problems going on, too, but that isn't anyone's business.)

If he were still alive and in need of a liver transplant, I would not want him to get it one. Knowing his history, and how he just gave up on himself, I feel the liver would be better off with someone else.

I'm all for giving people a second chance. Therefore, I think these kind of situations need to be taken on a case by case basis. To say that I would never want an alcoholic/drug user to get a transplant is unfair; every person is different and so is their situation.

I think ghillbert's hospital policy is excellent.

ghillbert, MSN, NP

Specializes in CTICU. Has 20 years experience.

The other consideration is that there is an "expanded donor list" with more marginal organs for people that have no other options, but that we're not sure about their commitment, or likelihood for successful transplant for a variety of other reasons.

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