An Ethical Framework for the Care of Patients with Prolonged Hospitalization Following Lung Transplantation

Abstract

The lung allocation score system in the United States and several European countries gives more weight to risk of death without transplantation than to survival following transplantation. As a result, centers transplant sicker patients, leading to increased length of initial hospitalization. The care of patients who have accumulated functional deficits or additional organ dysfunction during their prolonged stay can be ethically complex. Disagreement occurs between the transplant team, patients and families, and non-transplant health care professionals over the burdens of ongoing intensive intervention. These cases highlight important ethical issues in organ transplantation, including the nature and requirements of transplant informed consent, the limits of physician prognostication, patient autonomy and decision-making capacity following transplant, obligations to organ donors and to other potential recipients, and the impact of program metrics on individualized recipient care. We outline general ethical principles for the care of lung transplant recipients with prolonged hospitalization and give regulatory, research, and patient-centered recommendations for these cases.

Ethics Consultation for Adult Solid Organ Transplantation Candidates and Recipients: A Single Centre Experience

“…We found that ethics consultation was more common for heart and lung transplant recipients compared to kidney or liver recipients. This may be a function of the relative complexity, longer hospital, and illness severity for heart and lung recipients (Courtwright et al 2019). Overall, 6.8 per cent of all ethics consultations at our institution involved solid organ candidates or recipients.…”

“…Nurses requested the majority of these consultations (81.2 per cent ), although the decision to contact the ethics service was often based on multidisciplinary consensus. In many of these cases, there was a perception among families and non-transplant professionals that the transplant team's recommendations were not fully patient-centred, influenced instead by one-year survival metrics (Courtwright et al 2019). Ethics consultants played multiple roles in these cases, most commonly organizing a transplant/non-transplant team meeting or a team/family meeting.…”

“…While flexibility is important in evolving clinical scenarios, shifting goals and a perceived lack of transparency may increase moral distress among non-transplant providers and patients/families. With regard to transplant recipients, a shared conception of transplant consent, including decision-making when successful post-transplant outcomes no longer appear possible, is essential prior to the transplant surgery itself (Courtwright et al 2019).…”

Noteworthy Literature Published in 2018 for Thoracic Organ Transplantation

“…The PCC group received a median dose of 703 units pre-CPB and 1405 units post-CPB, for a median total dose of 2108 units. [5][6][7][8][9][10]; P < .001), and packed red cells (5 [3][4][5][6][7] vs 2 [1.25-2.75]; P < .001) and had a shorter time to chest closure (619 vs 548 minutes; P = .008). There were no differences in platelet transfusion, ICU stay or hospital LOS, acute kidney injury (AKI), or mortality.…”

“…The United States lung allocation score (LAS) system gives more weight to the risk of death without a transplant compared with survival after transplant; therefore, centers transplant patients who are sicker. 7 One scoring system using both donor and recipient factors seemed to offer a more individualized survival prediction for recipients. 8 There may be benefit to pairing high-risk patients with low-risk organs for optimal outcomes, whereas the converse was not demonstrated.…”