CASE PRESENTATION
Mr C is a 37-year-old gentleman with a past medical history significant for cardiomyopathy, which was discovered on a routine varsity college physical examination. The patient was able to perform activities of daily living without difficulty until he noted that he began having shortness of breath, dyspnea on exertion, and fatigue. Mr C readily recognized the signs and sought medical treatment because he has an amazing familial history of idiopathic, nonischemic dilated cardiomyopathy. Mr C's father required cardiac transplantation at the age of years 44 but died soon after his transplantation. His brother, uncle, and aunt have variable degrees of cardiomyopathy.
Despite maximal medical management and complete compliance of his medical regimen, he required hospitalization and subsequent placement of his first of 3 ventricular assist devices (VADs). He had a left VAD (LVAD) placed in late 2000. With the LVAD placement, Mr C faced a barrage of complications, including cerebrovascular accident, with residuals including seizures and central vision loss, atrial fibrillation (requiring cardioversion), bacteremia, and sepsis.
Mr C underwent his first heart transplantation in November 2001. After a protracted course, Mr C recovered and was able to return to his job in management. His job required a great deal of travel, including long flights. His transplantation course was complicated in 2002 by acute grade 2 rejection. He was medically managed and was able to perform most activities of daily living without difficulty until July 2007. In July 2007, the patient reported cramping, nonradiating right upper quadrant abdominal pain. An abdominal ultrasound revealed cholelithiasis; however, results of a hepatobiliary iminodiacetic acid scan were negative. The patient began to experience shortness of breath, dyspnea on exertion, and fatigue. A cardiac catheterization was performed, which showed coronary artery disease in his transplanted heart. His healthcare team did not feel that revascularization was needed. The patient's health continued to decline until he became gravely ill, requiring right VAD and LVAD placements. The patient received his second cardiac transplantation in October 2007; however, in the immediate postoperative period, the patient was noted to have primary graft failure and required a second right VAD/LVAD placement. The patient was relisted as a 1A United Network of Organ Sharing (UNOS) recipient and underwent his third cardiac transplantation in November 2007.
BACKGROUND
In December 1967, South African surgeon Christiaan Barnard performed the first cardiac transplantation on 53-year-old Lewis Washkansky.1 The surgery was successful; however, the immunosuppressive therapy to prevent rejection caused the patient to succumb to pneumonia. The patient died 18 days after his cardiac transplantation. Forty years later, immunosuppression has greatly improved, especially with the addition of cyclosporine. Cardiac transplantation and pulmonary transplantation have revolutionized the treatment of end-stage heart failure and pulmonary conditions. Short-term and long-term patient survival has greatly increased with new advents of immunosuppression after surgery.2,3
Despite drastic improvements in medical management and immunosuppression of patients who underwent transplantation, there are still a great number of patients who experience either acute rejection or primary graft failure that could require retransplantation. Even in the earliest days of transplantation, pioneers realized the inevitability that a proportion of patients would require retransplantation. Although this was recognized, discussion about ethical considerations that must be addressed when dealing with retransplantation, especially in cardiac and pulmonary transplantation, was minimal. Cardiac, pulmonary, and liver transplantation is considered a "life-saving" transplantation, whereas kidney, pancreas, and intestine usually are not considered life-saving.2 Because transplantation requires donation of an organ from a living donor in patients requiring cardiac or pulmonary transplantation, recipients must wait for a donor to die before receiving an organ. Patients requiring liver, kidney, pancreas, and intestinal transplantation may be fortunate enough to receive donation from a living donor. Given that, demand far exceeds supply in cardiac and lung transplantation needs. Because of the shortage of organs, many patients die waiting for transplant. As described in Table 1, at the time of writing this article, there were 2,699 patients awaiting heart transplant and 2,295 patients awaiting lung transplant. Of those patients, 645 patients awaiting heart transplant and 558 patients awaiting lung transplant have been on the UNOS waiting list for 5 or more years!
Because of the limitation of organ availability for patients requiring primary transplantation, many studies have been conducted to ascertain the efficacy of retransplantation. In regard to cardiac and pulmonary retransplantation specifically, retransplantation has not shown favorable outcomes. Aigner and colleagues4 investigated pulmonary retransplantation to establish the long-term survival rates of these patients. In this study, patients requiring retransplantation for bronchiolitis obliterans had comparable survival rates as those receiving primary transplantation. However, those requiring retransplantation for primary graft failure had significantly lower survival rates than did those in the primary transplantation group. In the primary graft failure group, survival rates for 30 days and 1 and 5 years were 52.2%, 34.8%, and 29.0%, respectively. In the bronchiolitis obliterans group, survival rates for 30 days and 1 and 5 years were 89.2%, 72.5%, and 61.3%, respectively.4 Studies conducted by Kotloff5 and Brugiere and colleagues6 all concur with these results.
Studies involving cardiac transplantation have shown mixed results regarding retransplantation survival. The main causes of cardiac allograft failure after cardiac transplantation include primary graft failure, acute rejection, and coronary graft disease. A study conducted by Srivastava and colleagues7 showed 1-, 2-, and 3-year survival rates to be 65%, 59%, and 55%, respectively, whereas Topkara and colleagues8 described considerably higher retransplantation survival rates after cardiac transplantation. The researchers conducted a 10-year study of patients undergoing cardiac retransplantation at Columbia University Medical Center in New York, New York. In this cohort, cardiac retransplantation criteria were stringent and excluded patients with primary graft failure. As a result, their survival rates after cardiac retransplantation were considerably higher than those in many other studies. For patients who underwent primary transplantation, Topkara and colleagues8 reported 1-, 3-, 5-, and 7-year survival rates of 85.1%, 79.2%, 72.9%, and 66.8%, respectively, whereas retransplantation patients had 1-, 3-, 5-, and 7-year survival rates of 72.2%, 66.3%, 47.5%, and 40.7%, respectively.8 Other studies have not shown survival rates as high; however, most studies concur that patients who present with primary graft dysfunction do not have favorable results after cardiac retransplantation.9-11
All studies related to cardiac and pulmonary retransplantation have focused on patient survival rates and postoperative mortality. There have been no studies focused on morbidity after retransplantation. Given that these patients have undergone significant immunosuppression, many suffer from infections and other complications of this therapy. Also, because of protracted rehabilitation courses, many patients have variable quality of life.
ETHICAL CONSIDERATIONS
Transplantation healthcare teams have a grave obligation when deciding which patient receives an organ. Basically, they decide who lives and who dies. Given that life is precious to most patients, there are considerable ethical considerations when dealing with organ allocation. How should transplantation healthcare teams decide who lives or dies? Should this decision be based on age? Multiple studies have shown that age is an independent predictor of outcome in both primary transplantation and retransplantation. Should this decision be based on sex? The study of Topkara and colleagues8 showed that female sex yielded worse outcomes in cardiac retransplantation.
The ethical principles of nonmaleficence, benevolence, and justice can all be applied when discussing retransplantation. According to Beauchamp and Childress,12 nonmaleficence implies that evocation of harm is not performed. Definitions of nonmaleficence are varied and often include the maxim Primum non nocere: "Above all do no harm."12(p113) Although no direct link to Hippocrates has been established with this maxim, this Hippocratic oath is widely used in the medical field and definitely expresses an obligation to nonmaleficence as well as an obligation to beneficence. Because retransplantation is considered the "gold standard" of treatment of patients who have lost function oftheir transplanted organ, should the act of refusing retransplantation be considered doing harm? Without another organ, the patient could die; therefore, withholding of another transplantation would be deemed as withholding care. Should this be the primary consideration rather than organ scarcity or availability for those who await their primary transplantation?
Although each situation must be individualized, consideration of burden versus benefit and possibility of double effects should be considered when making choices based on this ethical principle. If the burden will outweigh the benefit, then consideration to not proceed with the identified treatment should be considered.12 In retransplantation, patients who have bronchiolitis obliterans have shown markedly decreased survival rates. Should these patients be completely excluded from consideration? In cardiac transplantation, patients who have primary graft failure have been shown to have considerably lower survival rates when compared with those who do not. Should they be excluded?
Beneficence implies to ensure that good is done. Does this include assurance of retransplantation if the primary transplant fails? In consideration of retransplantation, does assurance of retransplantation always yield the notion of beneficence? Are we doing the patient a disservice by not providing another organ?
Finally, justice implies fairness and, by formal definition, equality. Equality assumes that everyone is treated equally. In the United States, citizens have equal access to public services, equal treatment under the law, and equal political rights. Is there a comparable fairness or equality in healthcare? Depending on the agent addressed, the answer to that question will vary. Distributional justice implies that resources will be shared equally by those in need.12 If taken at face value, distributional justice would suggest that once a patient has received transplantation, he/she is no longer in contention for an organ. The next person on the list would then be given priority. Retransplantation disturbs the notion of distributive justice. Is it fair that someone is given 2 and often more transplantations when others have been waiting for up to more than 5 years for their first organ? In response to the many outcries regarding ethical disparities, UNOS13 has developed an ethics committee and even published a statement regarding repeat transplantation.
The Ethics Committee acknowledges the issue of justice in considering repeat transplantation. Graft failure, particularly early or immediate failure, evokes significant concerns regarding repeat transplantation. However, the likelihood of long-term survival of a repeat transplant should receive strong consideration.
NURSING IMPLICATIONS
With studies showing mixed results regarding retransplantation success, healthcare professionals are in a precarious situation regarding approaches to patients needing retransplantation. Obviously, at first thought, prudent practitioners would advise patients to consider retransplantation. "Life at all cost" has been a mantra of many healthcare professionals, especially physicians. Unfortunately, when healthcare outcomes do not meet patient expectations or those of healthcare practitioners, the healthcare team may feel that they have failed the patient. With advancements in technology, pharmacology, and postsurgical management, mortality and morbidity in patients who underwent transplantation have greatly improved. Subsequently, our expectations for all patients to have comparable results have also risen.
Just as transplantation has evolved, so has nursing. Nurses have become an integral part of the healthcare team and have considerable input into patients' health management plans. Because nurses are involved in all stages of patients' transplantation, they should also be an integral part of the decision-making process. Just as physicians, social workers, and pharmacists, nurses should be vocal in their feelings regarding patients receiving transplantation. Exploitive means of gaining organs has been thwarted by healthcare professionals speaking out about the ethical consequences of allowing this practice. Likewise, discussion of inclusion and exclusion criteria should have a multidisciplinary approach rather than pure allopathic approach. Many nursing educational programs are now introducing ethics courses early in students' educations, thereby preparing nurses to fully understand ethical concepts and implications in their practices. Nurses are at the bedside 24 hours a day and have consistently shown considerable insight into patients' assessments, emotional well-being, and family wishes. Nurses function as patient advocates. As this advocate, nurses can assist patients and their families with the emotionally exhausting task of deciding if retransplantation is truly a feasible option for them.
Because all patients who undergo transplantation are eventually in a critical care setting, critical care nurses have a distinct role in the decision-making process in transplantation cases. Because of the intense nature of critical care, critical care nurses are often at the bedside for much longer periods of time than are nurses employed in other areas. As a result, critical care nurses play an integral role in communication between patients, families, and the managing practitioners. Family members often confide in critical care nurses, more so than with other healthcare team members. As a result, critical care nurses must ascertain their own feelings regarding organ transplantation and retransplantation. As with other controversial procedures (abortions, birth control, etc), critical care nurses must be prepared to balance personal beliefs with professional duty. In the event there is a mismatch, nurses should use their resources, such as the ethics committee, clergy, and colleagues. Because of advanced physical assessment training, critical care nurses are often able to alert the medical team of problems before they arise. Nurses should also be prepared to alert the managing practitioners of any changes in patients' conditions that may warrant reconsideration of retransplantation or hastening of transplantation ranking.
CONCLUSION
Considerable improvement has been noted in patient survival rates after transplantation, specifically of the heart and lung. Many patients requiring transplantation live long, productive lives. However, other patients who have undergone cardiac and pulmonary transplantation do not have comparable, favorable results. Some patients die. Others need retransplantation. With studies showing variable results in retransplantation survival rates, healthcare professionals are faced with the taxing decision of whether to re-list these patients for retransplantation. Coupled with the obvious postoperative complications noted with any transplantation, ethical dilemmas are also faced. Organ scarcity is a well-known fact. Healthcare professionals as well as patients must face the ethical decision of the justice of retransplantation. Also, consideration into the nonmaleficence and benevolence of each individual case must also be faced. With considerable evidence showing decreased survival rates after retransplantation, paucity of sufficient evidence supporting retransplantation is also a significant criterion for possibility of retransplantation.
Given that studies have not specifically focused on morbidity and quality of life, the recommendation for more focused studies on these aspects should be undertaken. Although patients want to live, most also want a concomitant improvement in quality of life. Focusing purely on survival rates does not help practitioners and patients truly make informed decisions regarding the possibility of retransplantation. If those results were made available along with survival rates, perhaps the ethical dilemma of retransplantation would be less dramatic. Critical care nurses are in a pivotal position to assist with all of these studies and considerations. Using a multidisciplinary approach rather than a paternalistic approach to patient management will assist patients and healthcare teams better understand this complex topic. Until further studies can be performed and better consensus on utility, considerable thought should be made regarding the ethical implications of retransplantation.
References