Who should get a transplant?

NurseKatie08, MSN · Feb 28, 2009

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 · Feb 28, 2009

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).

allnurses Guide · Feb 28, 2009

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 · Feb 28, 2009

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.

ToxicShock · Feb 28, 2009

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.

allnurses Guide · Feb 28, 2009

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.

ChristineN, BSN, RN · Feb 28, 2009

I've taken care of a young man that needs a double lung transplant related to CF. He could have gone much, much longer in life without one, but he refuses to take he meds, do his breathing treatments, etc. I was really surprised to hear the doctors let him have a place on the lung transplant list. That didn't last long, as the next month he came in and tested positive for heroin. While I applaude them for taking him off the list after the positive drug test, I never understood how the most noncompliant patient I know got on the list!

rngolfer53 · Feb 28, 2009

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.

:twocents:As a recovering alcoholic, I now realize I would have been a terrible txplant candidate while I was drinking. I wouldn't have thought so, naturally. So, I think it's perfectly ok, indeed necessary to ask that a candidate demonstrate a period of sobriety and responsibility. The length of that period is open to question and individual circumstances.

I think it useful for members of the IDT to put themselves in the place of a hypothetical person having to explain to the person (and family) who did not get the liver why it was given to someone else.

That is what happens. Someone doesn't get that organ and their health probably continues to deteriorate, perhaps to the point of death before another suitable organ is available.

While it sounds good to be non-judgmental, in reality judgment is mandatory when a decision must be made between several people "competing" for an organ.

You have to have a good case for allocating it to someone like me. I've been sober for years, but I'm still a risk greater than that of someone w/o a susceptibility to alcohol abuse. I think I'm a good risk--thank God I don't need an organ--but the due diligence has to be done rigorously by the transplant team.

Imho, what should never happen is to txplant a scarce organ into someone with active contraindicative behavior as an incentive to improve. (I don't think that was what you were saying happened with your brother.)

I'm very happy your brother has such a rewarding life now. :yeah:

core0 · Feb 28, 2009

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.

Monitored programs are also big. A lot of places use a system similar to what the courts use. If you are in treatment you have a color. Every day you call up and find out what the color of the day is. If its your color you have until 5pm to get in to give a **** test. If you miss one then you start your time all over again.

The way our patient selection works is the patient is evaluated by hepatology, surgery, cardiology (if necessary) that takes care of the surgical risk part. They also see a multidisciplinary committee that includes dietary, social work, an addiction specialist, nurse coordinators and financial counselors. All of this is discussed in committee before deciding to list. For most people with recent addictive behaviors the decision is to defer pending rehab. The real hard issue comes when someone is too sick to participate in rehab. Especially if they have been high functioning and then have a sudden decompensation. If you don't transplant these people they are going to die.

Transplant is really the only medical area where we decide treatments based on behaviors. We wouldn't think of denying someone an antibiotic because of their lifestyle. On the other hand we do this frequently for transplant. This is related to the scarcity of organs and outcomes. We know historically that people who are actively drinking will not do well. We also know that patients with alcoholic cirrhosis do well post transplant in the short term at least. Interestingly they tend to do well regardless of whether they resume drinking or not. We also know that a large percentage of patients will drink at least some after transplant. This is the reality given the pervasiveness of alcohol in American society. In the end all that most programs do is give their best assessment of the patient when making the decision. In some ways its a Morton's fork. Deny too many people transplant and you will undoubtedly deny some people who would have done well. Take too many marginal candidates and your survival rate will suffer imperiling the program. Most programs try to walk the line between that.

David Carpenter, PA-C

Vito Andolini · Feb 28, 2009

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.

The trouble is, someone HAS to judge.

I'm happy for your brother.

leslie :-D · Feb 28, 2009

the subject of transplantation, is always a sad topic to discuss.

no matter who wins, there is always, Always (ALWAYS) tragedy involved.

my goodness, i don't think we'd be human if we didn't want every single person to get a transplant.

our intellects normally provide the criteria to whom we 'decide' would be worthy.

but it is our emotions that define our mercy on all...

including those who have done this to themselves.

unless one is a sociopath, i don't think there is 1 person who wouldn't want their fellow being, to have just 1 more chance...

over and over again.

many people wonder how i can do hospice.

yet i wonder about folks who work transplants.

i am overcome just thinking about it.

leslie

core0 · Mar 1, 2009

the subject of transplantation, is always a sad topic to discuss.
no matter who wins, there is always, Always (ALWAYS) tragedy involved.
my goodness, i don't think we'd be human if we didn't want every single person to get a transplant.
our intellects normally provide the criteria to whom we 'decide' would be worthy.
but it is our emotions that define our mercy on all...
including those who have done this to themselves.
unless one is a sociopath, i don't think there is 1 person who wouldn't want their fellow being, to have just 1 more chance...
over and over again.
many people wonder how i can do hospice.
yet i wonder about folks who work transplants.
i am overcome just thinking about it.
leslie

Its a different paradigm. In some ways its a lot like surgical oncology. Even if you do everything right a percentage of your patients will be dead by the end of the year. On the other hand the rewards are immense. Seeing somebody that was at deaths door a month ago come walking through your clinic door is the ultimate rush.

I also give thanks every day to those that can think of others when they are experiencing their own tragedy. Those are the true heroes.

David Carpenter, PA-C