Benefit in liver transplantation: a survey among medical staff, patients, medical students and non-medical university staff and students

Abstract

BackgroundThe allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined.MethodsThis survey with 502 participants examines how urgency and benefit are weighted by different stakeholders (medical staff, patients on the liver transplant list or already transplanted, medical students and non-medical university staff and students).ResultsLiver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care (ECOG 2). An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs.ConclusionsThe strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules.

The Perception of Medical Students at King Abdulaziz University Hospital Regarding the Liver Transplant Allocation System

“…In this study, most respondents agreed that the success of a liver transplant is defined as gaining in both lifetime and quality of life (84.8%). This result coincides with a recent study done in Germany [9]. The resemblance in results from two different populations leads us to perceive that the two criteria are almost equally important.…”

“…On the other hand, if we considered improvement of quality of life as a criterion determining a successful liver transplant, with regard to independence and mobility, 40.1% of the respondents chose “physically restricted,” and 34.7% chose being “fully active.” In another study, most respondents found that being ambulatory and capable of all self-care was essential to call a liver transplant successful [9]. This is possibly due to differences between the two populations, as the previous study had a higher mean age, which is likely to lower their expectations.…”

“…Because decisions involving life and death often arise with regard to organ allocation, the latter must be based on reasonable medical and ethical grounds. Liver donor allocation nowadays follows the Model for End-Stage Liver Disease (MELD), which relies on an algorithm targeting urgency, or a high-risk patient approach [9]. This system has a score ranging from 6 to 40 based on laboratory tests such as total bilirubin, serum creatinine, and the INR and it reduces mortality for patients on the transplantation waiting list [10].…”

Center Variation in Intention‐to‐Treat Survival Among Patients Listed for Liver Transplant

“…Overall, the median MELD at listing was 16 (interquartile range [IQR], 11-23), median age was 58 years (IQR, 52-63 years), and 34.4% were women. The most common etiologies of liver disease were HCV (31.5%), nonalcoholic fatty liver disease (25.0%), and [11][12][13][14][15][16][17][18][19][20][21][22][23][24]. Overall, 6.32% of organs were DCD, and 70.4% were procured locally.…”

Recent advances in liver transplantation for cancer: The future of transplant oncology

“…LT for CRLM: beyond the initial enthusiasm As the concept of transplant benefit is gaining recognition over classic survival after transplantation or simplistic urgency criteria, 123,124 LT for CLRM will likely find its place in future practice. However, before it becomes a recognised indication, definitive evidence is required to address a few outstanding issues:…”