Shopping for a transplant: when noncompliant patients seek wait listing at multiple hospitals

Progress in Transplantation, Sep 2004 by Bramstedt, Katrina A, Stowe, Judy, Kotz, Margaret

United Network for Organ Sharing policy allows patients to be listed for a transplant at multiple hospitals. This strategy can sometimes lessen the transplant waiting time for patients because waiting times vary geographically. We explore the ethical dilemma of "shopping for a transplant" by presenting the case of a patient with an addictive disorder who was listed for liver transplantation at one hospital on the east coast of the United States and was seeking listing at 2 additional hospitals in midwestern United States, when marijuana use was suspected by 1 of the latter 2 facilities. Although the transplant team at this facility deferred listing the patient, the team's bioethicist posed the concept of a duty to notify the facility where the patient was already listed for transplantation about any confirmed substance abuse, in an effort to prevent a scarce resource from being allocated to an individual who is noncompliant. (Progress in Transplantation. 2004; 14:217-221)

As of January 3, 2003, there were 17200 patients waiting for a liver transplant on the United Network for Organ Sharing (UNOS) patient waiting list,1 yet yearly, only approximately 5000 cadaveric livers are donated for transplantation.2 Although clinical trials are underway, artificial and bioartificial livers as either bridge or permanent interventions are not yet clinical reality,1 and it is unclear if xenotransplant livers will receive regulatory approval.4 Living liver donation5 and cadaveric split liver transplantation6 provide only small increases in the number of available allografts because of the limited number of available living liver donors, as well as the limited number of transplant centers that provide such specialty services. Because of the ongoing shortfall of allografts, it is ethically essential that allocation favors those patients likely to benefit most (improved quality of life and duration of improved quality of life). To this end, patients are routinely assessed for clinical and psychosocial information that is relevant to candidacy as potential organ transplant recipients.

The United States is divided into 11 transplant regions, and waiting times for transplantation varies among these regions.1 Because UNOS policy permits patients to be wait listed at multiple transplant facilities,7 patients can "shop" for transplant facilities that have the shortest waiting times and potentially get listed at various facilities they choose (pending medical and psychosocial approval at each facility). Local regulations such as those in region 10 (Ind, Mich, Ohio) contain specific criteria for those diagnosed with chemical dependence or abuse that must be satisfied before transplantation.8 Even with multiple listing, when an organ becomes available, patients must be able to travel to the hospital in a timely manner; otherwise, they will lose their chance at the organ in question. It is a simple process to search the UNOS transplant database (available on the Internet) and strategize a plan for multiple transplant listing on the basis of moving to a geographic location that facilitates listing at multiple centers within multiple transplant regions. For example, it is theoretically possibly to live in UNOS region 2 (Del, DC, Md, NJ, Pa, WV, northern Va) and also be listed at facilities in UNOS region 9 (includes New York), UNOS region 10, and UNOS region 11 (includes NC and southern Va).

Case Report

A 57-year-old man with Laënncc's cirrhosis and a hepatitis C virus RNA titer of nearly 600000 IU, who was on the waiting list for a liver transplant at a UNOS region 11 hospital, requested consideration for placement on our facility's liver transplant waiting list. He indicated he was also seeking transplant listing at a third hospital in another state. His wait list status had oscillated from "active" to "inactive" at the region 11 facility for several years. His model for end-stage liver disease score at the time of our evaluation was 19. Clinical workup revealed portal hypertension, minimal ascites, elevated total bilirubin, and elevated international normalized ratio. His risk factors included past intravenous drug abuse, tattoos, and blood transfusions.

Data collected during his chemical dependency assessment at our institution indicated a history of alcohol, marijuana, and opiate dependence characterized by tolerance, loss of control, withdrawal, and such dependence continued despite family, marital, and physician concerns. Beginning in his late teens, he drank 6 to 9 beers and smoked half a joint of marijuana daily. While recuperating from multiple injuries sustained in an accident, he became cross-addicted to opiates. After release from the hospital he switched to daily use of intravenous heroin over a 3- to 4-month period until he was detoxified in a methadone program. Although he reportedly stopped drinking in the late 1990s, his marijuana use continued. According to archival information from the region 11 hospital, results of his urine toxicology screen were positive twice while actively listed for transplantation-marijuana was detected on one occasion, and marijuana and barbiturates were detected 3 months later. After the latter, the patient was placed on hold, referred for counseling and urine screened for 3 months. On the basis of documented negative toxicology results (yet despite non-compliance with counseling), the patient was relisted for transplantation at the region 11 facility.