Orthotropic heart transplantation is an effective treatment for end-stage heart failure. Despite improvement of surgical techniques, donor and recipient management, and immunosuppressant regimens, graft half-life is between 10 and 12 years.1 Allograft failure, whether caused by early graft failure, graft dysfunction, acute rejection, or graft coronary artery disease, elicits a strong sense of responsibility in clinicians to consider the option of retransplantation.

In the mid 1990s, several physicians, nurses, and ethicists called for strict limits to and even complete prohibition of vital organ retransplantation.2-4 These analyses were written in light of the poor prognoses for retransplant recipients when compared with primary transplant recipients. Recent publications have presented and analyzed new data on retransplantation from individual transplant centers, as well as from the Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients. "Restarting the Clock[horizontal ellipsis] Again" by Tracy Andrews in the September/October 2009 issue was therefore a timely and welcome reexamination of the ethical issues surrounding retransplantation and the appropriate role of the critical care nurse in considering allocation of scarce organs.5 This article is a response to some of the ethical questions raised in her discussion.

Background

Retransplants comprise a small minority of heart transplants (3%-4%). At the end of 2005, 5.3% of patients on the transplant registry were awaiting retransplantation. There has been a progressive increase in patients of all ages listed for retransplantation since 1996.6 This trend is likely to continue as the numerous children who received transplants in the early and mid 1990s enter adolescence and young adulthood.7 In addition, some patients, including the one presented in the case study at the start of Dr Andrews' article, are now seeking and receiving third and even fourth transplants.1,8

Vital cadaver organs such as hearts are highly scarce resources. Because the demand for these organs outstrips supply, individuals often encounter long waits, and a number die while on the waiting list. In 2007, the death rate of patients awaiting heat transplantation was 142 per 1,000 patient-years at risk.9 Because of supply constraints, transplant teams must decide who will receive vital organs. As Dr Andrews states, these are emotionally difficult and ethically fraught life-and-death decisions.

Despite the shortage of cadaveric organs, whether a patient has previously received a transplant is not used as an official criterion for determining how to distribute organs. Should prior transplantation be taken into account?

The Role of Poor Prognosis

At present, the literature on survival following cardiac retransplantation reports mixed results regarding retransplantation success.7,10-13 Early graft failure, however, has been clearly identified as a significant risk factor associated with diminished survival after retransplantation.14,15 Dr Andrews asks us as nurses to consider whether patients who have primary graft failure should be excluded from receiving retransplantation.

Prognosis or life-years is one important means of determining how to allocate scarce resources such as organs. In a context of scarcity, prognosis allocation aims to maximize the number of life-years saved by devoting scarce resources to the person(s) most likely to benefit.16 Nurses working with transplant patients should recognize that the present organ allocation system already uses efficacy data to allocate organs. For example, organs are allocated on the basis of ABO compatibility because it improves outcomes. Similarly, some institutions take into account a patient's previous compliance with medical advice because poor compliance can lead to rejection and graft failure. The transplant community "thus acts as if justice is best served by distributing available organs to those more likely to benefit from them."2 It would be inconsistent for transplant teams not to consider poor prognosis after transplantation when deciding whether to list a patient for retransplantation.15

Nurses must take a nuanced view of retransplantation and recognize that prognosis is variable, depending on the indication for retransplantation. It is important for critical care nurses and others working with transplant patients to stay abreast of the evolving literature on postretransplantation survival to ensure that retransplant decisions reflect the current state of knowledge. Moreover, the call Dr Andrews makes for further research about morbidity and quality of life following retransplantation represents a significant opportunity for impactful nursing research.

The Role of Relationships

Although Dr Andrews notes the close relationships that critical care nurses form with transplant patients, she only alludes to a frequent source of moral distress for nurses working with patients eligible for retransplantation. Transplant teams often feel a special obligation to patients for whom they previously performed a transplant and may feel that not listing a patient for retransplantation is a form of abandonment. At this time, retransplantation remains the only viable solution for end-stage cardiac allograft failure.11 Not retransplanting a patient when retransplantation would likely promote long-term survival is synonymous with allowing them to die. This seems to strongly contradict the core values of nursing: patient advocacy and promotion of the patient's best interests.

Yet, this sense of obligation should not change allocation priorities.2 Because organs are a scarce resource, transplant teams have an ethical duty to balance their responsibilities to particular patients against their responsibility to be conscientious stewards of public resources. Undeniably, patient advocacy should remain the primary consideration of the critical care nurse. At a minimum, this requires that the potential benefits of retransplantation are considered by members of the transplant team.4

Retransplantation may not be sufficiently beneficial for all individuals. For certain candidates, retransplantation may exacerbate rather than alleviate physical and psychic pain; it might delay death rather than prolong life. Retransplantation should be refused in these cases. Others on the waiting list should not be penalized by a transplant team's sense of responsibility to a patient. Nurses should recognize this not as abandonment but as fairness to the pool of patients in need of transplantation and an opportunity for early and ongoing patient education. Transplant recipients and their families should be educated about the indications for and contraindications to retransplantation before the need arises. Furthermore, if a patient is denied retransplantation or chooses an alternative course of treatment, there remains a responsibility to provide palliative care.

The Role of Justice

Dr Andrews states in her article that retransplantation disturbs the notion of distributive justice. An inherent inequality seems to exist between patients awaiting retransplantation and those awaiting primary transplantation. The retransplant candidate has already received a scarce vital organ! However, this distinction may not withstand analysis.

A recent minireview of retransplantation in the American Journal of Transplantation reported: "If patients with primary graft failure less than 6 months following transplantation were excluded, survival following retransplantation did not differ from that following primary transplantation."6 If a potential retransplant recipient has a comparable prognosis and a comparable medical need when compared with a potential primary transplant recipient, these patients are effectively equals. Under such circumstances, neither a utilitarian theory of allocation (maximizing total good) nor a needs-based theory of allocation (giving to the most needy) would distinguish between them on the grounds of transplantation or retransplantation status. Proponents of either theory would find each patient equally deserving of a transplant.

Dr Andrews advocates a more commonsense view of justice-that we all deserve an equal slice of the proverbial pie. Giving a second (or third) organ to someone who has already received one while others wait for a first would, in fact, turn this view of justice on its head. But, it has been argued in the literature that such a view asks us to view the healthcare pie too narrowly. Basing allocation solely on transplant status ignores many other medical services and social goods that can affect health.2 Expanding a notion of justice or fairness to consider a context of overall availability of health resources would not inherently favor primary transplant recipients over retransplant recipients.

Recognizing that providing retransplantation cannot be judged intrinsically unfair nor unjust, there still may be good reasons to distinguish between primary transplant and retransplant recipients when allocating organs. Society might value distributing organs in such a way that the most individuals benefit from receiving them, regardless of whether such a scheme would maximize life-years saved. Such a value could lead to the development of an alternate list for retransplant recipients. While assuring retransplant candidates access to scarce lifesaving resources, such a mechanism would also favor primary transplant recipients.8,17 Nurse researchers are in an excellent position to contribute their skills and insights to eliciting social preferences and deriving normative principles for organ allocation.

Conclusion

I agree with Dr Andrews that critical care nurses are in a pivotal position to inform and to shape the retransplantation dialogue going forward. More broadly, I would like to highlight that many of the ethical issues raised here and in "Restarting the Clock[horizontal ellipsis] Again" are relevant to all situations in which healthcare is provided in a context of resource scarcity. Allocation of very scarce medical resources, of which organs are but one example, poses a persistent ethical challenge. The current efforts at healthcare reform have made us all more mindful of this reality. Critical care nurses, particularly nursing leaders, have a responsibility to understand the morally relevant considerations that inform difficult allocation decisions so that they can step forward in this time of change and fulfill their responsibilities as patient advocates.

Emily Largent, BSN, RN

National Institutes of Health

10 Center Dr

Bldg 10, Room 1C118

Bethesda, MD 20892-1156

[email protected]

Disclaimer: The opinions expressed are those of the author and do not reflect the position or policy of the National Institutes of Health, the Public Health Services, or the Department of Health and Human Services.

Ms Largent is a fellow in the Department of Bioethics at the National Institutes of Health Clinical Center. She previously worked in the cardiothoracic intensive care unit at the University of California, Los Angeles, Medical Center with a large transplant population and received her BSN from the University of Pennsylvania. Her research interests include distributive justice in scarce resource allocation and the ethical justification for emergency research conducted with a waiver of informed consent.

The Author's Response

Thank you so much for your comments on my recent article. Your comments were definitely an added benefit to my article and convey a tone that I had hoped to carry in my article. I definitely think that nurses play a major role in the bioethical process of patients facing possible retransplantation. Obviously, death is a possibility for patients who face this issue; however, death also faces those who never received organs because of unfortunate preferential treatment of some patients. Albeit distasteful, this sort of treatment is seen in our healthcare system. As nurses, both bedside and in advanced practice, I truly believe that we must unite to form a coalition to address some of these issues. I would be happy to become involved in this effort if others would also take part.

Tracy D. Andrews, DNPc, MSN, CCRN, ACNP, APRN-BC

Clinical Director, Aortic Surgery and

Cardiac Surgical Outcomes

Columbia University/New York

Presbyterian Hospital

177 Ft Washington Ave

Milstein Hospital

7GN-435

New York, NY 10032

[email protected]

References