Donated livers will go to sickest patients first
Donated livers will go to sickest patients first
Criteria for transplant selection to be monitored
In a time of organ abundance, every transplant patient on a waiting list would receive a transplant. But such an abundance has never happened in the 20- to 30-year lifespan of organ transplantation, and some type of allocation or rationing is a given.
"There is no such thing as a perfect balance between medical utility and justice," says Bruce Lucas, MD, former president of the board of directors of the United Network for Organ Sharing (UNOS) in Richmond, VA.
The organization sought to weigh medical utility and justice issues in defining new criteria for patient selection for liver transplantation, explains Joel Newman, director of corporate communication.
The new liver allocation policy, effective Jan. 20, specifies the following:
1. Categories for status of patients awaiting a liver transplant that include standardized criteria. The new policy moves some patient criteria from one status to another, most significantly the most urgent. The categories are as follows:
• Status I Recipients placed in this category have a life expectancy under seven days due to sudden or complete liver failure as a result of acute viral hepatitis or reaction to prescription or over-the-counter drugs. The category also includes patients who have received a transplant that has immediately failed and pediatric patients with liver disease that would result in irreversible neurological damage without transplantation.
Patients who are listed as Status I automatically revert back to Status II after seven days unless they are relisted as Status I by an attending physician. Within 24 hours of an initial listing and each relisting, physicians must submit a justification form to UNOS.
A continued Status I listing for a patient for longer than 14 days will automatically result in an on-site UNOS review of all patient listings.
The new policy includes a grandfather clause that permits patients hospitalized and awaiting transplant as of the implementation date to remain open to an emergency Status I upgrade, and the increased opportunity to be transplanted.
• Status II Patients in this category require continuous hospitalization, usually in an acute care bed. UNOS policy requires a justification form for these patients within one working day of listing.
• Status III Patients currently need liver transplantation but can be followed at home or near the transplant center. Short hospitalizations for intercurrent problems are not considered justification for a change in status.
• Status IV Patients are temporarily considered unsuited for transplant. They continue to accrue waiting time up to 30 days and are listed as inactive.
2. Regional review boards to assess compliance with standardized criteria for placing patients on the liver waiting list. The new policy will establish regional review boards to analyze whether the standardized criteria outlined above are being used to place patients on waiting lists. "One of the problems with the current system is that patients in different regions have different waiting times for a transplant," explains Phyllis Weber, executive director of the California Transplant Donor Network in San Francisco.
"My personal bias is that public policy should support regulations that give each patient entered on a list the same opportunity to be transplanted based on the acuity of their illness," she says.
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