Living donor near-misses underreported

Consider individual donors' needs

Aborted hepatectomies and potentially life-threatening near-miss events — during which a donor's life may be in danger but after which there are no long-term sequelae — are rarely reported, according to a survey of 71 transplant programs that performed donor hepatectomy 11,553 times.¹ Here are key findings:

• The average donor morbidity rate was 24%, with five donors (0.04%) requiring transplantation.
• The donor mortality rate was 0.2%, with the majority of deaths occurring within 60 days, and all but four deaths related to the donation surgery.
• The incidences of near-miss events and aborted hepatectomies were 1.1% and 1.2%, respectively.
• Program experience did not affect the incidence of donor morbidity or mortality, but near-miss events and aborted hepatectomies were more likely in low-volume programs.

Potentially life-threatening near-miss events and aborted hepatectomies are underappreciated complications that must be discussed as part of the informed consent process with any potential living liver donor, write the researchers.

Typically, the core set of information that must, at minimum, be disclosed to patients as part of the informed consent process includes the rationale for the proposed treatment, the risks, benefits, alternatives, and the expected prognosis, notes Leslie M. Whetstine, PhD, an associate professor of philosophy at Walsh University in North Canton, OH.

"Informed consent should ideally empower patients to make decisions that are consistent with their values, rather than simply serve as a legal protection for clinicians," she says. "In this tradition, all relevant information that a hypothetical 'reasonable person' would want to know is generally considered ethically appropriate."

For living donors, though, the consent process might need to be approached differently. This is because their choice to donate is entirely elective, and provides no direct medical benefit to them. "The argument could be made that by virtue of the unique situation of living donors, the subjective standard may be a more comprehensive ethical approach than the traditional reasonable person standard," says Whetstine.

The subjective standard essentially requires that clinicians disclose all the information that a particular patient would need in order to make an informed decision. "Unfortunately, this standard is logistically difficult to implement in practice, since it usually takes some time to establish this kind of deep interpersonal relationship," says Whetstine. "Given the nature of living donors, perhaps it is a model worth working toward."

Information regarding aborted hepatectomies as well as potentially life-threatening and/or near-miss events should be disclosed using the subjective standard so that individual donors' needs are considered, advises Whetstine. "While donors' needs may vary, it would be beneficial to collect these data and have a standardized system," she says. "Whether every living donor would want or need such information remains to be seen, but it seems to represent a positive step in enhancing their autonomy."

Reference

1. Cheah YL, Simpson, MA, Pomposelli, JJ, et al. Incidence of death and potentially life-threatening near-miss events in living donor hepatic lobectomy: A world-wide survey. Liver Transpl 2013;19:499-506.

SOURCE

• Leslie M. Whetstine, PhD, Associate Professor, Philosophy, Walsh University, North Canton, OH. Phone: (330) 244-4697. Email: lwhetstine@walsh.edu.