1
|
Wadhwani SI, Lai JC, Gottlieb L. Medical Need and Transplant Accessibility-Reply. JAMA 2022; 328:679-680. [PMID: 35972489 DOI: 10.1001/jama.2022.10412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
2
|
Wightman A, Bradford MC, Hsu E, Bartlett HL, Smith JM. Prevalence and Long-Term Outcomes of Solid Organ Transplant in Children with Intellectual Disability. J Pediatr 2021; 235:10-17.e4. [PMID: 33794218 DOI: 10.1016/j.jpeds.2021.03.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 03/11/2021] [Accepted: 03/26/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To describe the prevalence and long-term outcomes of kidney, liver, and heart transplant for children with an intellectual disability. STUDY DESIGN We performed a retrospective cohort analysis of children receiving a first kidney, liver, or heart-alone transplant in the United Network for Organ Sharing dataset from 2008 to 2017. Recipients with definite intellectual disability were compared with those possible/no intellectual disability. Kaplan-Meier survival estimates were calculated for graft and patient survival. Cox proportional hazard models were used to estimate the association between intellectual disability and graft and patient survival. RESULTS Over the study period, children with definite intellectual disability accounted for 594 of 6747 (9%) first pediatric kidney-alone, 318 of 4566 (7%) first pediatric liver-alone, and 324 of 3722 (9%) first pediatric heart-alone transplant recipients. Intellectual disability was not significantly associated with patient or graft survival among liver and heart transplant recipients. Among kidney transplant recipients, definite intellectual disability was significantly associated with higher graft survival and lower patient survival, but the absolute differences were small. CONCLUSIONS Children with intellectual disability account for 7%-9% of pediatric transplant recipients with comparable long-term outcomes to other pediatric recipients. These findings provide important empirical support for policies that include children with intellectual disability as transplant candidates.
Collapse
|
3
|
Chen A, Ahmad M, Flescher A, Freeman WL, Little S, Martins PN, Veatch RM, Wightman A, Ladin K. Access to transplantation for persons with intellectual disability: Strategies for nondiscrimination. Am J Transplant 2020; 20:2009-2016. [PMID: 31873978 DOI: 10.1111/ajt.15755] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/21/2019] [Accepted: 12/14/2019] [Indexed: 01/25/2023]
Abstract
Disqualifying patients with intellectual disabilities (ID) from transplantation has received growing attention from the media, state legislatures, the Office of Civil Rights, and recently the National Council on Disability, as well as internationally. Compared with evidence-based criteria used to determine transplant eligibility, the ID criterion remains controversial because of its potential to be discriminatory, subjective, and because its relationship to outcomes is uncertain. Use of ID in determining transplant candidacy may stem partly from perceived worse adherence and outcomes for patients with ID, fear of penalties to transplant centers for poor outcomes, and stigma surrounding the quality of life for people with ID. However, using ID as a contraindication to solid organ transplantation is not evidence-based and reduces equitable access to transplantation, disadvantaging an already vulnerable population. Variability and lack of transparency in referral and evaluation allows for gatekeeping, threatens patient autonomy, limits access to lifesaving treatment, and may be seen as unfair. We examine the benefits and harms of using ID as a transplant eligibility criterion, review current clinical evidence and ethical considerations, and make recommendations for transplant teams and regulatory agencies to ensure fair access to transplant for individuals with ID.
Collapse
Affiliation(s)
- Ashton Chen
- Department of Pediatrics, Wake Forest University Medical School, Winston-Salem, North Carolina, USA
| | - Mahwish Ahmad
- Center for Bioethics, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Bioethics, Case Western Reserve School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Andrew Flescher
- Program in Public Health, Department of Family, Population, and Preventive Medicine, Stony Brook University, Stony Brook, New York, USA
| | | | | | - Paulo N Martins
- Department of Surgery, Division of Transplantation, University of Massachusetts, Worcester, Massachusetts, USA
| | - Robert M Veatch
- Kennedy Institute of Ethics, Georgetown University, District of Columbia, Washington, USA
| | - Aaron Wightman
- Divisions of Nephrology and Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, Washington, USA
| | - Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, Massachusetts, USA
| |
Collapse
|
4
|
Hammami MM, Hammami MB, Aboushaar R. Modeling Lay People's Ethical Attitudes to Organ Donation: A Q-Methodology Study. Patient Prefer Adherence 2020; 14:173-189. [PMID: 32099336 PMCID: PMC6996217 DOI: 10.2147/ppa.s230286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 12/18/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Organ donation is commonly evaluated by biomedical ethicists based largely on principlism with autonomy at the top of the "moral mountain." Lay people may differ in the way they invoke and balance the various ethical interests. We explored lay people's ethical attitudes to organ donation. METHODS Respondents (n=196) ranked 42 opinion-statements on organ donation according to a 9-category symmetrical distribution. Statements' scores were analyzed by averaging-analysis and Q-methodology. RESULTS Respondents' mean (SD) age was 34.5 (10.6) years, 53% were women, 69% Muslims (30% Christians), 29% Saudis (26% Filipinos), and 38% healthcare-related. The most-agreeable statements were "Acceptable if benefit to recipient large," "Explicit donor consent and family approval for live donation," "Acceptable if directed to family member," and "Explicit donor consent and family approval for postmortem donation." The most-disagreeable statements were "Donor consent and family approval not required for postmortem donation," "Acceptable with purely materialistic motivation," and "Only donor no-known objection for postmortem donation." Women, Christians, and healthcare respondents gave higher rank to "Explicit donor consent and family approval for live donation," "Only donor family consent required for postmortem donation," and "Acceptable if organ distribution equitable," respectively, and Muslims gave more weight to donor/family harm (p ≤0.001). Q-methodology identified various ethical resolution models that were associated with religious affiliation and included relatively "motives-concerned," "family-benefit-concerned," "familism-oriented," and "religious or non-religious altruism-concerned" models. Of 23 neutral statements on averaging-analysis, 48% and 65% received extreme ranks in ≥1 women and men Q-methodology models, respectively. CONCLUSION 1) On average, recipient benefit, requirement of both explicit donor consent and family approval, donor-recipient relationship, and motives were predominant considerations; 2) ranking of some statements was associated with respondents' demographics; 3) Q-methodology identified various ethical resolution models that were partially masked by averaging-analysis; and 4) strong virtue and familism approaches in our respondents provide some empirical evidence against principlism adequacy.
Collapse
Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
- Correspondence: Muhammad M Hammami Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh11211, Saudi ArabiaTel +966-11-442-4527Fax +966-11-442-7894 Email
| | - Muhammad B Hammami
- Division of Gastroenterology, Department of Medicine, John Hopkins University, Baltimore, MD, USA
| | | |
Collapse
|
5
|
Abstract
Transplantation programs commonly rely on clinicians' judgments about patients' social support (care from friends or family) when deciding whether to list them for organ transplantation. We examine whether using social support to make listing decisions for adults seeking transplantation is morally legitimate, drawing on recent data about the evidence-base, implementation, and potential impacts of the criterion on underserved and diverse populations. We demonstrate that the rationale for the social support criterion, based in the principle of utility, is undermined by its reliance on tenuous evidence. Moreover, social support requirements may reinforce transplant inequities, interfere in patients' personal relationships, and contribute to biased and inconsistent listing procedures. As such, accommodating the needs of patients with limited social support would better balance ethical commitments to equity, utility, and respect for persons in transplantation. We suggest steps for researchers, transplantation programs, and policymakers to improve fair use of social support in transplantation.
Collapse
|
6
|
Ladin K, Emerson J, Berry K, Butt Z, Gordon EJ, Daniels N, Lavelle TA, Hanto DW. Excluding patients from transplant due to social support: Results from a national survey of transplant providers. Am J Transplant 2019; 19:193-203. [PMID: 29878515 PMCID: PMC6427829 DOI: 10.1111/ajt.14962] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/08/2018] [Accepted: 05/31/2018] [Indexed: 01/25/2023]
Abstract
Social support is used to determine transplant eligibility despite lack of an evidence base and vague regulatory guidance. It is unknown how many patients are disqualified from transplantation due to inadequate support, and whether providers feel confident using these subjective criteria to determine eligibility. Transplant providers (n = 551) from 202 centers estimated that, on average, 9.6% (standard deviation = 9.4) of patients evaluated in the prior year were excluded due to inadequate support. This varied significantly by United Network for Organ Sharing region (7.6%-12.2%), and by center (21.7% among top quartile). Significantly more providers used social support in listing decisions than believed it ought to be used (86.3% vs 67.6%). Nearly 25% believed that using social support in listing determinations was unfair or were unsure; 67.3% felt it disproportionately impacted patients of low socioeconomic status. Overall, 42.4% were only somewhat or not at all confident using social support to determine transplant suitability. Compared to surgical/medical transplant providers, psychosocial providers had 2.13 greater odds of supporting the criteria (P = .03). Furthermore, 69.2% supported revised guidelines for use of social support in listing decisions. Social support criteria should be reconsidered in light of the limited evidence, potential for disparities, practice variation, low provider confidence, and desire for revised guidelines.
Collapse
Affiliation(s)
- Keren Ladin
- Departments of Occupational Therapy and Community Health, Tufts University, Medford, MA, USA,Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA, USA
| | - Joanna Emerson
- Research on Ethics, Aging, and Community Health (REACH Lab), Tufts University, Medford, MA, USA
| | - Kelsey Berry
- Interfaculty Initiative on Health Policy, Harvard University, Cambridge, MA, USA
| | - Zeeshan Butt
- Departments of Medical Social Sciences, Surgery, and Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elisa J. Gordon
- Departments of Medical Social Sciences, Surgery, and Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Norman Daniels
- Department of Global Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Tara A. Lavelle
- Center for the Evaluation of Value and Risk, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | | |
Collapse
|
7
|
Gómez Gavara C, Esposito F, Gurusamy K, Salloum C, Lahat E, Feray C, Lim C, Azoulay D. Liver transplantation in elderly patients: a systematic review and first meta-analysis. HPB (Oxford) 2019; 21:14-25. [PMID: 30146227 DOI: 10.1016/j.hpb.2018.07.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/13/2018] [Accepted: 07/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Elderly recipients are frequently discussed by the scientific community but objective indication for this parameter has been provided. The aim of this study was to synthesize the available evidence on liver transplantation for elderly patients to assess graft and patient survival. METHODS A literature search of the Medline, EMBASE, and Scopus databases was carried out from January 2000 to August 2018. Clinical studies comparing the outcomes of liver transplantation in adult younger (<65 years) and elderly (>65 years) populations were analyzed. The primary outcomes were patient mortality and graft loss rates. This review was registered (Number CRD42017058261) as required in the international prospective register for systematic review protocols (PROSPERO). RESULTS Twenty-two studies were included involving a total of 242,487 patients (elderly: 23,660 and young: 218,827) were included in this study. In the meta-analysis, the elderly group had patient mortality (hazard ratio [HR]: 1.26; 95% confidence interval [CI]: 0.97-1.63; P = 0.09; I2 = 48%) and graft (HR: 1.09; 95% CI: 0.81-1.47; P = 0.59; I2 = 12%) loss rates comparable to those in the young group. CONCLUSIONS Elderly patients have similar long-term survival and graft loss rates as young patients. Liver transplantation is an acceptable and safe curative option for elderly transplant candidates.
Collapse
Affiliation(s)
- Concepción Gómez Gavara
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France; Department of Surgery, Royal Free Campus, UCL Medical School, Pond Street, London, NW3 2QG, UK
| | - Francesco Esposito
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Kurinchi Gurusamy
- Department of Surgery, Royal Free Campus, UCL Medical School, Pond Street, London, NW3 2QG, UK
| | - Chady Salloum
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Eylon Lahat
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Cyrille Feray
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France; Unité INSERM 955, Créteil, France
| | - Chetana Lim
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France
| | - Daniel Azoulay
- Service de Chirurgie Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris, Université Paris-Est, Créteil, France; Unité INSERM 955, Créteil, France.
| |
Collapse
|
8
|
Wightman A, Diekema D, Goldberg A. Consideration of children with intellectual disability as candidates for solid organ transplantation-A practice in evolution. Pediatr Transplant 2018; 22. [PMID: 29218833 DOI: 10.1111/petr.13091] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/27/2022]
Abstract
Children with intellectual disability were historically excluded from consideration as recipients of solid organ transplants. In light of an evolution in provider practices, this commentary will define intellectual disability and review the relevant provider attitudes and guidelines and known outcomes of solid organ transplant in this population.
Collapse
Affiliation(s)
- Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA
| | - Douglas Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA, USA
| | - Aviva Goldberg
- Department of Pediatrics, University of Manitoba College of Medicine, Winnipeg, MB, Canada
| |
Collapse
|
9
|
Martins PN, Kim I, Bozorgzadeh A. Allocation of organs to cognitively impaired patients. Pediatr Transplant 2017; 21. [PMID: 28574199 DOI: 10.1111/petr.12999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Paulo N Martins
- Transplant Division, Department of Surgery, University of Massachusetts, Worcester, MA, USA
| | - Irene Kim
- Transplant Division, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Adel Bozorgzadeh
- Transplant Division, Department of Surgery, University of Massachusetts, Worcester, MA, USA
| |
Collapse
|
10
|
Howe EG. Fourteen Important Concepts Regarding Moral Distress. The Journal of Clinical Ethics 2017. [DOI: 10.1086/jce2017281003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|