Attitudes of Liver Transplant Candidates Toward Organs From Increased‐Risk Donors

Abstract

Increased‐risk donor (IRD) organs make up a significant proportion of the deceased organ donor pool but may be declined by patients on the waiting list for various reasons. We conducted a survey of patients awaiting a liver transplant to determine the factors leading to the acceptance of an IRD organ as well as what strategies could increase the rate of acceptance. Adult liver transplant candidates who were outpatients completed a survey of 51 questions on a 5‐point Likert scale with categories related to demographics, knowledge of IRDs, and likelihood of acceptance. A total of 150 transplant candidates completed the survey (age 19‐80 years). Male patients constituted 67.3%. Many patients (58.7%) had postsecondary education. Only 23.3% of patients had a potential living donor, and 58/144 (40.3%) were not optimistic about receiving an organ in the next 3 months. The overall IRD organ acceptance rate was 41.1%, whereas 26.2% said they would decline an IRD organ. Women were more likely to accept an IRD organ (54.3% versus 34.7%; P = 0.02). Those who had a college education or higher tended to have lower IRD organ acceptability (28.3% versus 47.4%; P = 0.07). Acceptability also increased as the specified transmission risk of human immunodeficiency virus or hepatitis C virus decreased (P < 0.001). Patients were also more likely to accept an IRD organ if they were educated on the benefits of IRD organs (eg, knowledge that an IRD organ was of better quality increased overall acceptance from 41.1% to 63.3%; P < 0.001). Our survey provides insight into liver transplant candidates who would benefit from greater education on IRD organs. Strategies targeting specific educational points are likely to increase acceptability.

The 3-T Model of Informed Consent for Nonstandard Risk Donors: A Proposal for Transplant Clinical Practice

“… 14 , 16 , 24 , 41 A study of liver transplant candidates revealed that variations may occur also based on transplant candidates’ demographics, opinions on donor’s high-risk behaviors, and information received by healthcare professionals. 43 A study on kidney transplant candidates found a significant association of multiple factors including longer waiting time for transplant, lower donor age, inferior donor HIV risk, potential recipient being on dialysis treatment, or being of an older age with a higher chance to consider the NSRD option. However, the study revealed that patients have an equal likelihood of accepting an NSRD kidney from a younger donor as from an older donor with an inferior chance of having HIV.…”

“…Furthermore, there is an ethical duty to protect the donor’s right to privacy and to prevent stigmatization of the nonclinical data of NSRDs with the potential to negatively influence the recipient’s understanding. 43 Last, because some transplant candidates may fear the acquisition of personality traits or behaviors of their donors, 55 , 56 clinicians should prevent undesirable psychological reactions in the posttransplant period.…”

“…Some clinicians contend that the ultimate decision is a clinical one, with little room for patient participation in decision making. 57 However, studies have demonstrated that, although some patients rely exclusively on trust in their physician(s), 43 most want to be involved in SDM in the event of an NSRD offer across different organ settings. 23 , 27 For instance, Article 6 of the European Directorate for the Quality of Medicines and HealthCare document on Safety, Quality and Ethical Matters Related to the Use of Organs, Tissues and Cells of Human Origin states that “the ultimate responsibility for deciding whether to use a particular graft lies with the recipient’s [transplant] team.…”

Organ utilization – the next hurdle in transplantation?

“…Involving patients in this decision‐making process is clearly desirable and is preferred by many patients [88] but not only poses logistic challenges in a time‐ and resource‐limited situation but also assumes a good level of understanding of complex issues made in a challenging situation and a high degree of health literacy and education and understanding of complex medical language. Those with a higher level of education may be more likely to decline an IRD organ [89]. While it is possible for vulnerable patients to delegate the patient advocacy to another, this adds a further degree of complexity [90].…”

“…Other (and much more controversial) approaches would be to hold surgeons more accountable for declining organs or to question those centres with a very low rate of nonfunction. Publishing decline rates is already done by several organizations, usually at a centre‐level, and may support increased organ utilization [89]. It could be argued that a unit that has no early graft failures may be declining too many organs.…”