Liver Allocation to Non-U.S. Citizen Non-U.S. 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.

Oncology nurses’ views of oncologists’ prognosis-related communication (PRC)

6602

Background: PRC is critical to care, treatment, and decision-making for advanced cancer patients (ACP). Deficits in oncologists’ (MDs) PRC have previously been identified. The role oncology nurses (RNs) play in PRC and their views and experiences of PRC among MDs with whom they work is unknown. Methods: Mail survey of a random sample of Oncology Nursing Society members with at least one year of experience working with cancer patients (pts). Questionnaire was sent to 1338 members of ONS. 394 completed surveys were returned. Overall RR was 29.4%. Significance, if noted, implies p<0.001. Results: Respondent demographics: median age 49.2, 96.6% female, 88.5% Caucasian, median years (yrs) as an RN 18, median yrs working with cancer patients 12, 69.1% had a BSN or ASN, 34.1% inpt RNs, 38.6% outpt RNs. 46% of RNs always/often cared for ACPs who did not appear to understand their prognosis, and 58.6% of RNs always/often encountered questions that suggested pts wanted more prognosis related information (PRI). 26.1% disagreed that the MDs they worked with were skilled at PRC. 72% agreed that MD discomfort with giving bad news is a major barrier to helping pts understand their prognosis. 54.9% of RNs always/often/sometimes felt pressured not to provide pts PRI because they did not want to contradict what MDs had said. 25.1% of RNs felt that MDs rarely or never kept them informed about their PRC with pts (frequency positively associated with yrs as an RN, yrs working with cancer pts, education level). RNs with at least an MSN were more likely to report that MDs more frequently kept them informed about their PRC. 30.2% of RNs felt that MDs rarely or never addressed end of life issues early in the course of their illness. 32.8% of RNs agreed that, when pts did not appear to understand their prognosis, it was because MDs had not discussed it fully (positively associated with working in an inpt setting). 42.6% of RNs were rarely or never present when PRI was discussed (negatively associated with working in an outpt setting and amount of formal education regarding PRC). Conclusions: Oncology RNs identify several deficits in MDs’ PRC with ACPs, including provision of information early in the course of illness, gaps in sharing content of PRC with RNs, and communicative aspects of team-based pt care.

No significant financial relationships to disclose.

The do-not-resuscitate order: associations with advance directives, physician specialty and documentation of discussion 15 years after the Patient Self-Determination Act

BACKGROUND

Since the passage of the Patient Self-Determination Act, numerous policy mandates and institutional measures have been implemented. It is unknown to what extent those measures have affected end-of-life care, particularly with regard to the do-not-resuscitate (DNR) order.

METHODS

Retrospective cohort study to assess associations of the frequency and timing of DNR orders with advance directive status, patient demographics, physician's specialty and extent of documentation of discussion on end-of-life care.

RESULTS

DNR orders were more frequent for patients on a medical service than on a surgical service (77.34% vs 64.20%, p = 0.02) and were made earlier in the hospital stay for medicine than for surgical patients (adjusted mean ratio of time from DNR orders to death versus total length of stay 0.30 for internists vs 0.21 for surgeons, p = 0.04). 22.18% of all patients had some form of an advance directive in their chart, yet this variable had no impact on the frequency or timing of DNR ordering. Documentation of DNR discussion was significantly associated with the frequency of DNR orders and the time from DNR to death (2.1 days with no or minimal discussion vs 2.8 days with extensive discussion, p<0.01).

CONCLUSIONS

The physician's specialty continues to have a significant impact on the frequency and timing of DNR orders, while advance directive status still has no measurable impact. Additionally, documentation of end-of-life discussions is significantly associated with varying DNR ordering rates and timing.

DNR patterns in cancer patients (pts) 16 years after the Patient Self Determination Act (PSDA)

6582

Background: In 1991, the PSDA required institutions receiving federal funding to inform pts about the right to refuse life prolonging treatments such as CPR. Studies conducted around 1991 suggest that most DNR orders are written by oncologists less than 3 days prior to death in hospitalized pts, raising ethical concerns. 16 years later, are oncology clinicians writing DNR orders earlier in cancer pts’ hospital course compared to non-cancer pts? Methods: We conducted a chart review of 284 of the 296 total adult deaths during 2005 at Indiana University Hospital. Demographic, diagnostic, and attending service info was collected from hospital billing records. Pts’ DNR status, timing of DNR orders, and presence of a written advanced directive (AD) were assessed through chart review. Results: 76 of 284 (26.8%) patients had cancer diagnoses. Of these, 59 had documented DNR orders. There was no difference in presence or absence of DNR orders at the time of death for cancer vs. non-cancer pts (77.6 vs 72.7%, p=0.35). Mean time from writing of the DNR order to death was 3.51 ± 4.61 days for cancer pts compared to 3.26 ±3.81 days for non-cancer pts (p=0.40), however, the majority of DNR orders written by oncologists were written less than 2 days prior to death. We calculated a ratio of the time between DNR order writing and death to the overall length of stay for cancer and non-cancer pts, excluding pts with very short lengths of stay ( = 5 days). In univariate analyses, this ratio trended toward statistical significance (p=0.08). In multivariate analyses, cancer pts had a higher ratio of the time between DNR order and death to LOS (0.30 vs 0.21, p=0.05). Existence of an AD had no significant impact on this ratio. Surgical specialists wrote DNR orders less frequently (64.2 vs 77.3%, p=0.02) and later than non-surgical specialists (mean 21 vs 10 days from admission, p=0.0008). Conclusions: In this study, DNR ordering patterns among hospitalized cancer and non-cancer pts have changed little since the PSDA. Although cancer pts on average had DNR orders written relatively earlier in their terminal hospital stay than non-cancer pts, the timing varied little from pts in prior studies. Although the majority of hospitalized pts in this sample died with DNR orders, these orders were written very late in their hospital stay.

No significant financial relationships to disclose.

Cancer patients’ attitudes toward future research uses of their donated tissue: Preliminary results of a mail survey study

6009

Background: Millions of tissue samples are stored in the United States, but little is known about the attitudes of tissue donors. Understanding the attitudes of those who donate tissue for use in future research would inform the design of studies using stored tissues (ST). Methods: Eligible subjects included cancer patients who donated remaining tissue after biopsy or surgery to the Indiana University Cancer Center Tissue Bank. All subjects signed informed consent to donate tissue. A convenience sample were approached for participation. A survey instrument was developed from literature review and expert input, and refined by focus groups. Results: 243 surveys were mailed, and 196 completed surveys were returned (response rate 80.7%). Respondents were 70% married, 93% white, 54% female. 57% had completed at least some college. Average age was 60. Average time since diagnosis was 13.8 months. 81% of respondents remembered donating tissue. 61% were not at all or a little concerned about the privacy of their ST. >80% of subjects agreed that their ST could be used in future research on their type of cancer, other cancers, and other diseases,. Non-whites were less likely than whites to allow tissue to be used in research (p = 0.0128). Around 40% of respondents agreed that researchers should have to recontact them before using their ST. Non-whites and less educated subjects were more likely to want to be recontacted for each research use of their ST. 90% of subjects would allow their ST to be used by university researchers, but only 60% agreed that ST could be used by pharmaceutical companies. 39% objected to the use of STs to develop a treatment for profit. No differences were found in willingness of ST to be used in future research whether samples were identified, de-identified, or linked. 60% of respondents wanted to be notified of research results that would impact their, or their children’s, health whether treatments were available or not, and whether results had been validated or not. Conclusions: This cohort of cancer patients was very willing to allow their ST to be used in future research on all conditions, but a significant minority desired to be recontacted each time ST were used. These findings do not support policies based on a simple presumed consent model.

No significant financial relationships to disclose.