Who should get a transplant?

Nurses General Nursing

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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?

Specializes in NICU, PICU, PCVICU and peds oncology.

I took care of 3 out of 4 children in a single family of who we transplanted hearts. Congenital cardiomyopathy. Genetically, they did not have a chance- the parents underwent genetic testing after the first kid was diagnosed and were told their chances of having a child without the defect were slim to none. Their culture did not believe in birth control so............. needless to say.

It is hard not to judge.

I think I know this family! (Not really, but I know one very much like it.)

Specializes in ED, ICU, PACU.

I have always thought that to avoid imposing standards on who gets the organ, we should give it to the person on the transplant list who is the closest match (has the least chance of rejection and needs the lower doses of anti-rejection drugs). The priority cases (higher on the list) should be used only if there are multiple 'winners' using this criteria; otherwise, fate decides through the genetic marker matching. Now, in the case you describe, there should also be an allowance for the receipient's history if they are an equal match to another person on the list.

I have specified that these are the conditions for my organ donation; and, I included a statement that if the closest match does not have the money to anti up, then I expect a donation of transplant services of all involved that is equal to my donation.

Specializes in CTICU.
I included a statement that if the closest match does not have the money to anti up, then I expect a donation of transplant services of all involved that is equal to my donation.

Nice idea, but the person who couldn't afford the transplant would not be listed in order to be the "closest match". Financial status is another disqualifier to listing. If people aren't going to be able to afford the $3000-4000/month medications post transplant, it's not a good use of the organ because the outcome is likely to be bad.

This thinking was a huge shock to me, coming from Australia with public health for all where finances are not a consideration pre-transplant. Here in the US, it's a necessary evil.

There are some exceptions, but few.

Specializes in Operating Room Nursing.

My opinion on this issue is that the organ should go to the person with the best chance of survival. If it's an alcoholic who is non compliant then that's not a good option because chances are they'll destroy their new liver.

I don't believe anyone should be denied the gift of an organ because of past mistakes. Everyone deserves a second chance. It's just a matter of assessing on a case by case basis on who is going to stop using drugs/alcohol.

I have always thought that to avoid imposing standards on who gets the organ, we should give it to the person on the transplant list who is the closest match (has the least chance of rejection and needs the lower doses of anti-rejection drugs). The priority cases (higher on the list) should be used only if there are multiple 'winners' using this criteria; otherwise, fate decides through the genetic marker matching. Now, in the case you describe, there should also be an allowance for the receipient's history if they are an equal match to another person on the list.

I have specified that these are the conditions for my organ donation; and, I included a statement that if the closest match does not have the money to anti up, then I expect a donation of transplant services of all involved that is equal to my donation.

By law liver and heart transplants (and I believe lung) transplants go to the patient who is sickest in the OPO then region where the organ is procured. All of these organs are relatively insensitive to how close the match is. There is no correlation between any factors outside of blood type and rejection.

For kidneys the match is by closest match and time on the waiting list. Patients with multiple antibodies may never receive an organ under this system or may receive one quickly. For most patients this defaults to the time on the waiting list.

The real discrepancy in organ transplant comes in regional variation. A patient in New York for example is going to have to be sicker than a patient in northern Florida for example to get a liver transplant. There are a number of reasons that this will probably not change in the near future.

David Carpenter, PA-C

My opinion on this issue is that the organ should go to the person with the best chance of survival. If it's an alcoholic who is non compliant then that's not a good option because chances are they'll destroy their new liver.

I don't believe anyone should be denied the gift of an organ because of past mistakes. Everyone deserves a second chance. It's just a matter of assessing on a case by case basis on who is going to stop using drugs/alcohol.

Right now thats kind of how it works. Basically the first part is binary. Is this person an acceptable candidate or not. Once they are deemed acceptable (physically, mentally and financially) then they are listed. Once listed the allocation is essentially controlled either by severity of illness (Liver, heart, lung) or by organ compatibility (kidney). Because of the competitive nature of transplant programs in this country (Chicago, UC Irvine, St Vincents etc) the computerized allocation is the only fair way to do this.

David Carpenter, PA-C

Specializes in CTICU.

We do prospective cross matching for hearts, lungs and heart-lungs if people are pre-sensitized with high PRAs. We have a lady listed 1A right now with 100%/100% PRAs... it's unlikely she'll get an organ. We've tried meds, plasmapheresis etc but can't get the antibodies down.

Specializes in ICU, Research, Corrections.
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.

Ahh, he probably thought he wasn't diabetic because it is a side effect in approximately 30% of patients on Prograf. I am in the lucky 30%. Sounds like he needs a good teaching session.

Since I am a liver recipient of 9 years, I can definitely say it is vary arduous task to be listed with weeks of physical tests, pysch evals, social worker evals, interviews of family members, and finally the "wallet biopsy". If you can't prove you can afford and pay for the immuno drugs, you can't get listed. Also, your health insurance must agree to pay or you have to put down 350K (and that was 9 years ago!)

I work with renal pts, and they are routinely removed from the transplant list for non-compliance.

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