Ethical questions on organ transplantation have focused mainly on resource allocation — access to transplantation and prioritization of donor organs. A recent analysis revealed few consults were called for questions about appropriate resource allocation.1
“The actual experience with ethics consultation in this population can reveal unanticipated complexities in organ allocation decisions and the care of transplant candidates and recipients,” the authors wrote.
To learn more about reasons for ethics consults involving transplants, researchers analyzed all adult ethics consultations from 2007-2017 at Massachusetts General. Taken together (candidates and recipients), nurses and physicians requested consults with equal frequency. However, nurses called ethics consults for transplant recipients far more often than physicians (80% vs. 20% of cases).
“In their bedside role, clinical nurses may be more attuned to patient suffering and the burdens imposed by ongoing or escalating interventions,” the authors wrote.
Nurses also spot communication breakdowns because of conversations with different medical services that happen throughout the day.
“There are particular complexities to transplant recipients that make them more susceptible to this type of breakdown,” says Andrew Courtwright, MD, PhD, the study’s lead author and an assistant professor of clinical medicine at University of Pennsylvania’s Perelman School of Medicine.
Cases entail multiple providers, regulatory considerations about one-year survival, and high-intensity treatments. Of 880 ethics consults, 60 involved solid organ transplant (39 for candidates and 21 for recipients). The most common issue differed, depending on whether the patient was a candidate or recipient.
For transplant candidates, the most common issue was conflict over treatment intensity once the patient was determined not to be a candidate for transplantation. For transplant recipients, the most common issue was a disagreement between surrogates and providers over intensity of treatment.
These usually are cases in which surrogates (or patients themselves) do not want to continue life-sustaining treatment after transplant because of ongoing burdens or quality of life. The transplant team wants to continue because they believe a good outcome is still possible.
“Our study has several implications for clinicians and bioethicists,” Courtwright says.
The findings underscore the need for better communication — specifically, the expectations around the care of transplant candidates and recipients. For example, patients should talk about goals of care if it turns out transplant is not possible. “Only a third of patients undergoing transplant evaluation in our cohort had advance care planning documents,” Courtwright reports.
Clear criteria regarding inactivation — when the patient is no longer a transplant candidate — also are needed, as well as specific benchmarks for reactivation.
“While flexibility is important in evolving clinical scenarios, shifting goals and a perceived lack of transparency may increase moral distress,” Courtwright and colleagues wrote.
Unit-based conversations on specific ethical issues in transplant patients can help prevent conflicts and “may provide a forum for giving voice to ethical concerns before formal ethical consultation is needed,” the authors added.
- Courtwright AM, Erler KS, Bandini JI, et al. Ethics consultation for adult solid organ transplantation candidates and recipients: A single centre experience. J Bioeth Inq. 2021.