Ethical Considerations Surrounding Survival Benefit-Based Liver Allocation

poster abstractThe disparity between the demand for and supply of donor livers has continued to grow over the last two decades, placing greater weight on the need for efficient and effective allocation. Although the use of extended criteria donors (ECD) has shown greater potential, it remains unregulated. Schaubel et al. have recently proposed a survival benefit model which balances waitlist survival and potential transplantation benefit for a given quality of donor liver. The OPTN/UNOS Liver and Intestinal Organ Transplantation Committee considered this and other models in a recent report, concluding that the current allocation method does not require modification. In order to further evaluate the survival benefit model, the various ethical concerns shaping organ allocation were discussed and used to identify strengths and shortcomings associated with the proposed model. Compared to the current MELD/PELD system, the survival benefit model incorporates a greater number of ethical principles, uses a sophisticated statistical model to increase efficiency and reduce waste, minimizes bias, and parallels developments in the allocation of other organs. Conversely, the model fails to address quality of life concerns, prioritization for younger patients, its less promising posttransplant prediction accuracy, and potential issues regarding informed consent and economic burdens. To remedy these issues, we suggested incorporating various improvements based on recent literature. Although limitations exist, the survival benefit model now exists as a better means of improving allocation. We support the model proposed by Schaubel et al., with the amendments we suggested, and urge the OPTN/UNOS Liver and Intestinal Organ Transplantation Committee and the transplant community to strongly consider this model as another step toward better liver allocation

Liver Allocation to Non-Citizen Non-Residents: An Ethical Framework for a Last-In-Line Approach

The incidence of non-U.S. citizen non-U.S. resident patients coming to the United States specifically for deceased donor liver transplantation raises compelling ethical questions that require careful consideration. The inclusion of these often financially and/or socially privileged patients in the pool of potential candidates for an absolutely scarce and life-saving liver transplant may exacerbate disparities already existing in deceased donor liver allocation. In addition, their inclusion on organ transplant waiting lists conflicts with recognized ethical principles of justice and reciprocity. Moreover, preliminary data suggest that public awareness of this practice could discourage organ donation, thereby worsening an already profound supply–demand gulf. Finally, U.S. organ allocation policies and statutes are out of step with recently promulgated international transplant guidelines, which prioritize self-sufficiency of organ programs. This article analyzes each of these ethical conflicts within the context of deceased donor liver transplantation and recommends policy changes that align the United States with international practices that discourage this scenario

Pandemic flu preparedness: ethical issues and recommendations to the Indiana State Department of Health

Four Recommendations are proposed: 1. the State must identify all healthcare workers who are deemed to be critically necessary during the pandemic; 2. the State and healthcare organizations should adopt a “high expectations, no punishment” approach to absenteeism; 3. the State should set and communicate expectations that healthcare institutions have adequate medical supplies and that these institutions ensure these supplies be made available to all personnel expected to interact with patients; and 4. the State should encourage healthcare institutions to establish clear policies for determining sanctions for noncompliance with expected responsibilities that are both fair and responsive to exceptional circumstances.The Indiana State Department of Healt

Opiate Written Behavioral Agreements: A Case for Abandonment

Written behavioral agreements (WBAs) are gaining popularity as part of the effort to manage the alarming increase in prescription drug abuse. The rationale for increased use of WBAs in managing patients with chronic pain is that they are believed to increase adherence to agreed-upon behaviors, reduce addiction to or diversion of prescription drugs, and satisfy informed consent requirements. However, there are no high-quality data to support their widespread use in any of these areas. The evidence used to support the use of WBAs is insufficient to justify their unfairness and the high risk of harm they pose to the doctor-patient relationship. Instead, we contend that WBAs are being used to provide leverage for severing relationships with some of our most challenging patients. We propose that physicians treating patients for chronic pain abandon the use of WBAs. Alternatives include open communication, detailed informed consent processes, carefully documented discussions, and most important, commitment to ongoing relationships even with difficult patients

Making Decisions for Hospitalized Older Adults: Ethical Factors Considered by Family Surrogates

Background Hospitalized older adults frequently have impaired cognition and must rely on surrogates to make major medical decisions. Ethical standards for surrogate decision making are well delineated, but little is known about what factors surrogates actually consider when making decisions. Objectives To determine factors surrogate decision makers consider when making major medical decisions for hospitalized older adults, and whether or not they adhere to established ethical standards. Design Semi-structured interview study of the experience and process of decision making. Setting A public safety-net hospital and a tertiary referral hospital in a large city in the Midwest. Participants Thirty-five surrogates with a recent decision making experience for an inpatient age 65 and older. Measurements Key factors surrogates considered when making decisions. Interview transcripts were coded and analyzed using the grounded theory method of qualitative analysis. Results Surrogates considered patient-centered factors and surrogate-centered factors. Patient-centered factors included: 1) respecting the patient’s input, (2) using past knowledge of patient to infer the patient’s wishes, and (3) considering what is in the patient’s best interests. Some surrogates expressed a desire for more information about the patient’s prior wishes. Surrogate-centered factors included 1) Surrogate’s wishes as a guide, (2) The surrogate’s religious beliefs and/or spirituality, (3) The surrogate’s interests, (4) Family consensus and (5) Obligation and guilt. Conclusion These data show that surrogate decision making is more complex than the standard ethical models, which are limited to patient autonomy and beneficence. Because surrogates also imagine what they would want under the circumstances and consider their own needs and preferences, models of surrogate decision making must account for these additional considerations. Surrogates’ desire for more information about patient preferences suggests a need for greater advance care planning

Doctor, What Would You Do?: An ANSWER for patients requesting advice about value-laden decisions

This article presents a previously published framework, summarized in the mnemonic ANSWER (A, Active listening; N, Needs assessment; S, Self-awareness/reflection; W, Whose perspective?; E, Elicit values; R, Respond) for how to respond to the question, “Doctor, what would you do?” when considering medical decisions that are preference-sensitive, meaning there is limited or debatable evidence to guide clinical recommendations, or are value-laden, such that the “right” decision may differ based on the context or values of a given individual. Using the mnemonic and practical examples, we attempt to make the framework for an ethically appropriate approach to these conversations more accessible for clinicians. Rather than a decision rule, this mnemonic represents a set of points to consider when physicians are considering an ethically acceptable response that fosters trust and rapport. We apply this approach to a case of periviable counseling, among the more emotionally challenging and value-laden antenatal decisions faced by providers and patients

International Travel for Living Donor Kidney Donation: A Proposal for Focused Screening of Vulnerable Groups

As the gap between organ donors and patients on the recipient waiting list grows, residents of the US who are in need of kidney transplantation occasionally contract with living donors from outside the US. Those donors then travel to the US to undergo living donor kidney donation at US transplant centers. This practice is not limited to the US and occurs with some regularity around the world. However, there is very little written about this practice from the perspective of the US transplant system, and there is little in the way of guidance (either legal or ethical) to assist centers that accommodate it in distinguishing between ethically permissible travel for transplant and what could potentially be human trafficking for organ removal. This paper will present an ethical analysis of travel for organ donation with particular attention to lessons that can be drawn from living donor donation in other countries. This inquiry is particularly germane because OPTN has promulgated guidelines with respect to obligations owed to living donors, but those guidelines appear to assume that the donor is a US resident. The critical question then, is whether and/or to what extent those guidelines are applicable to the instant scenario in which the living donor is a non-resident. In addition, this paper addresses several critical ethical concerns implicated by the often vulnerable populations from which donors are drawn. Finally, this paper proposes that focused inquiry by transplant centers is necessary when donors are non-residents

CEASE: A guide for clinicians on how to stop resuscitation efforts

Resuscitation programs such as Advanced Cardiac Life Support, Cardiac Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program offer inadequate guidance to physicians who must ultimately decide when to stop resuscitation efforts. These decisions involve clinical and ethical judgments and are complicated by communication challenges, group dynamics, and family considerations. This article presents a framework, summarized in a mnemonic (CEASE: Clinical Features, Effectiveness, Ask, Stop, Explain), for how to stop resuscitation efforts and communicate that decision to clinicians and ultimately the patient’s family. Rather than a decision rule, this mnemonic represents a framework based on best evidence for when physicians are considering stopping resuscitation efforts and provides guidance on how to communicate that decision

A Conceptual Model of the Role of Communication in Surrogate Decision Making for Hospitalized Adults

OBJECTIVE: To build a conceptual model of the role of communication in decision making, based on literature from medicine, communication studies and medical ethics. METHODS: We proposed a model and described each construct in detail. We review what is known about interpersonal and patient-physician communication, described literature about surrogate-clinician communication, and discussed implications for our developing model. RESULTS: The communication literature proposes two major elements of interpersonal communication: information processing and relationship building. These elements are composed of constructs such as information disclosure and emotional support that are likely to be relevant to decision making. We propose these elements of communication impact decision making, which in turn affects outcomes for both patients and surrogates. Decision making quality may also mediate the relationship between communication and outcomes. CONCLUSION: Although many elements of the model have been studied in relation to patient-clinician communication, there is limited data about surrogate decision making. There is evidence of high surrogate distress associated with decision making that may be alleviated by communication-focused interventions. More research is needed to test the relationships proposed in the model. PRACTICE IMPLICATIONS: Good communication with surrogates may improve both the quality of medical decisions and outcomes for the patient and surrogate