Assessing Potential Altruistic [Non-Directed] Living Organ Donors

1. Assessing Potential Altruistic [Non-Directed] Living Organ Donors Katrina A. Bramstedt, PhD, FRSM Associate Staff, CCF Bioethics City-Wide Case Discussion 3 February 2006

2. Non-Directed Donation • An “anonymous” adult makes an altruistic donation to an unidentified recipient • The donor cannot “direct” the donation to a specific patient or type of patient (gender, race, religion, occupation, etc.) • The donation is directed to the institution who then chooses the recipient

3. Living Donation: Liver R lobe (adult to adult) L lateral segment (adult to child)

4. Living Donation: Kidney

5. Living Donation • Pancreas (partial organ or islet cell donation; very rare) • Lung Lobe (2 adults donate one lobe each) • Intestine (very rare)

6. Statistics, www.unos.org Living Donation, USA (1988-Oct 2005) • Kidney 73,125 • Liver 2,914 • Lung 457 • Pancreas 70 • Intestine 28 --------- Total 76,594* *# non-directed unknown

7. Waiting List, www.unos.org As of 25 January 2006: 65,000 people waiting for a kidney tx 17,300 people waiting for a liver tx 3,100 people waiting for a lung tx

8. Living Liver Donation • RISKS • Bleeding • Need for transfusion • Infection • Stroke, cva • Liver failure/Need for own transplant • Bile duct problems • Pain • Anesthesia complications • DEATH (0.2 – 2%, depending on procedure) • Difficulty in getting insurance/higher insurance rates

9. Living Kidney Donation • RISKS • Lap procedure converts to open procedure • Bleeding, need for transfusion (rare) • Infection • Damage to surround structures during organ removal • Anesthesia complications • Stroke, cva • Pain • DEATH (3 in 10,000. One known case of donor PVS) • No increased chance of kidney failure for donor (though these donors are left with no backup kidney) • Difficulty in getting insurance/higher insurance rates

10. Issues in Non-Directed Donation • What motivates potential donors? • What are their conflicts of interest? • Should donors have their own health insurance? • Does the donor’s spouse support the donation? • Mental & physical health of potential donor • Long term follow up of donors (psych & med) • Donors stalking recipients/privacy issues • Are some types of donation too risky? Should we even be doing these procedures? Require a formal program at take them as they come?

11. Transplant Team Potential Donor Physicians Surgeons Medical Director & Surgical Director Social Worker Chem. Dep. Counselor Tx Coords Psychiatrist Bioethicist

12. Assessment of Potential Donors • First Tier Evaluations: • Social Work, Psychiatry, Bioethics • Second Tier Evaluations: • Hepatologist/Nephrologist, Surgeon, Anesthesia, bood/urine tests, imaging, EKG, etc.

13. Bioethics Eval • Review medical record (if it exists) • Understand the patient’s history and note what meds they are taking—you may not see any Psych notes but you might see Psych meds. • Ask the potential donor about his/her medical hx? WHY? Does what they say match with the medical record? Have they ever had a surgical procedure before? Medical compliance issues?

14. Bioethics Eval • Do they have their own health insurance? • Not all renal transplant patients have Medicare and the private insurance they have will only cover the donor’s costs for a limited time (usually 6mo – 1yr). What if the donor has late or long-term complications?

15. Bioethics Eval • Drug/ETOH use? • Won’t Social Work be asking about that? YES, but with two sets of answers you can compare notes to see if the person is consistent. • Supportive Spouse/Family? • Again, won’t Social Work be asking about that? YES, but with two sets of answers you can compare notes to see if the person is consistent.

16. Bioethics Eval • Ask about his/her financial situation • Recent bankruptcy? No job? Lots of debt? • Significant money problems can be a red flag to a possible ulterior motive of money seeking (from recipient whom they might attempt to identify) • US study: Ave out of pocket expenses for R lobe liver donors $3660 (travel, lodging, meds, time off work). • Japanese study: 16% of kidney donors experienced financial burden (11 of 69 donors) due to costs not covered by recipient’s insurance.

17. Bioethics Eval • For those who want to donate part of their liver, ask them WHY LIVER? Why not a kidney? • Maybe they have a renal problem or a hx of renal disease in their family, but if not, why are they choosing a higher risk procedure (liver donation vs kidney donation)?

18. Bioethics Eval • Assess their level of knowledge about donation. • Do they appear to be grasping the information you talk with them about? • How do they respond when you discuss the risks of donation? • Offer them the opportunity to meet someone who has been a donor.

19. Bioethics Eval • Observe behavior of potential donor • Overeager, extremely anxious, fearless • Inappropriate comments/questions (“I want the organ to go to a Christian”; “How much can I get paid for this?”; “Can I tell my local newspaper about this?”) • Multiple questions about recipient identity or meeting the recipient • “Odd” affect • Under influence of drugs/ETOH • Poor cognition • Poor knowledge about donation/transplant (they have already undergone a detailed phone screening)

20. You’re the Ethicist… • A 45 yr old, Mormon, mother of 6, living in California, presents to CCF for bioethics eval in anticipation of being a non-directed, living liver donor. • No medical record on file. Current meds (per her report) are Xanax and Nexium. • As the Bioethicist, what questions come to mind?

21. Acknowledgement: I thank Carmen Paradis, MD for her thoughtful input during the preparation of this presentation. References: Adams PL et al. Transplantation 2002;74:582-589. Delmonico FL. JAMA; 2000;284:2919-2926. Bramstedt KA. Am J Gastro 2006;101:in press. Trotter JF. Liver Transpl 2001;7:485-493. Isotani S. Urology 2002;60:588-592. End