In today’s fast-paced world where technology rules, the medical profession isalso advancing. In 1991, 2,900 liver transplants were performed in the UnitedStates while there were 30,000 canidates for the procedure in the United Statesalone (Heffron, T.
G. , 1993). Due to shortages of available organs fordonation/transplantation, specifically livers, once again science has come tothe rescue. Although the procedure is fairly new in the United States, theconcept of living organ donation is fast growing. Living related livertransplantion was first proposed as a theoretical entity in 1969 but it was notuntil almost twenty years later that the procedure became a clinical reality (Heffron,T. G.
, 1993). Living related liver transplants have mainly been performed in theUnited States and Japan until recently. In 1991 Europe began trying to institutethe procedure. The first transplant of this type took place in 1989 (Broelsch,C.
E. , Burdelski, M. , Rogiers, X. , Gundlach, M.
, Knoefel, W. T. , Langwieler, T. ,Fischer, L.
, Latta, A. , Hellwege, H. , Schulte, F. , Schmiegel, W.
, Sterneck, M. ,Greten, H. , Kuechler, T. , Krupski, G.
, Loeliger, D. , Kuehnl, P. , Pothmann, W. ,; Schulte Am Esch, J. , 1994). This concept still has many areas that havenot yet been explored in depth and there are sensitive issues involved that needto be addressed.
Live organ donation came about as a means to solve the problemof the absence of a donor. Many people die every year while waiting for a donororgan and many others suffer because of complications linked to finding asuitable donor. Before live organ donation most available organs wereharvested/transplanted from cadavers. This procedure has problems of its own. Complications include(a) suitable match, (b) legalities, (c) family not wantingto donate organs, and (d) time. With live organ donation a suitable match shouldbe easier to obtain and time should be able to be controlled to some extent.
With live organ donor transplantation, “. . . the organ-damaging hemodynamicinstabiility associated with the death of the donor is avoided, and thecoordinated scheduling of operations in the donor and recipient holds ex vivoorgan ischemia to a minimum” (Singer, P. A. , Siegler, M.
, Whitington, P. F. , Lantos, J. D. , Emond, J. C.
, Thistlethwaite, J. R. , ; Broelsch, C. E. ,1989, p.
620). Prior to receiving a donor organ, recipients may be experiencinga variety of signs and symptoms related to their disease process. These caninclude(a) jaundice, (b) ascites, (c) GI bleed, (d) ECG changes, (e) malaise,(f) encephalopathy, (g) body image changes, and (h) fluid and electrolyteimbalances. Disease process is specific to the individual.
Once the need fortransplant has been established the search for a donor can begin. There are amultitude of steps involved in the procedure. Some of these include(a)evaluation to determine the need for transplant, (b) search for a suitable donorwho is willing to donate, (c) evaluation of the donor, (d) obtaining the properconsent, and (e) mapping out the plan of care for both donor and recipient. Dueto legalities and ethical conflicts, the acceptance of live organ donortransplantation is questionable. Those families and volunteer participants mustmeet several criteria in order to be considered for a live liver donor. Oncesomeone decides that they want to be a donor they must first under go a medicaland psychiatric evaluation.
The medical portion of the evaluation includes(a)compatible blood type, (b) no history of liver disease, (c) normal results ofliver function tests, (d) appropriate size of left liver lobe on CT scan, (e) novascular anomalies on hepatic arteriography, and (f) low operative risk. Thepsychiatric portion of the evaluation must find that the donor is at low riskfor psychological decompensation and involves obtaining informed consent. Donor’s consent can be influenced by three areas, these include(a) internalpressure, (b) external pressure, and (c) urgency of medical situation. Allinstitutions have their own individual protocols for obtaining consent but manydo require a wait period between consent and procedure. This provides the donorwith time to change their decision, and after all these areas have beenaddressed the donor and recipient are prepared for surgery.
The procedureinvolves donation of the left lateral lobe, which is the safest anatomicalresection (Jones, J. , Payne, W. D. , & Matas, A. J. , 1993).
The surgeries areperformed simultaneously and may take several hours depending upon theexperience of the transplant team and the possibility of complications. Commoncomplications include(a) arterial thrombosis, (b) bile leaks, (c) infection, and(d) stricture at the biliary enteric anastomosis (Wise, B. V. , 1994).
During thepost-operative stage all normal nursing duties apply but there are also specificthings that nurses need to be aware of and look for. Because of the location ofthe liver some patients may experience some degree of pulmonary compromisepost-operatively. Liver function needs to be monitored by assessing lab results,liver enzymes, bilirubin, and bile production. All drains should be assessed forquantity and color. Fluid volume status and intake and output also need to becarefully monitored. PT/PTT coagulation factors are also a sensitive indicatorof graft function and can be expected to normalize in the first few days aftertransplant (Wise, B.
V. , 1994). The transplanted segment of the liver willregenerate to a standard liver volume, regardless of size at transplantation,within four to six months following the procedure. Normal liver enzymes havebeen documented within six weeks of the procedure (Wise, B.
V. , 1994). Organdonation alone is an area where the nurse plays an important role but with theadvances of living organ donation the role has expanded and many nurses are notprepared to play the part. When comparing living donor organ transplantation tothe age old means of organ harvesting/transplantation from cadavers, thedifferences are many. Cadaver organs are usually shipped out , this meant thatthere was one nurse and support system with the grieving family while there wasanother nurse and support system with the recipient and family.
The role is farfrom being black and white and now with living organ donors it weaves an evengreater web. Now the nurse is dealing with a patient who may be facing eminentdeath without a transplant, a concerned family who may be experiencinganticipatory grieving stages and a living organ donor who may or may not berelated who also faces possible complications and maybe even death. Then add inall the legalities and rules and you have one big mess. Support systems will bea key factor in this web. All those involved will be facing challenges andquestions unique to them. Nurses must remember that when caring for thepatient’s condition, they must not forget to also care for the patient andfamily.
Isn’t that what holistic nursing care is all about? We must care for thepatient as a whole and this would include the patient’s family. Nurses need toassess: (a) psychosocial needs, (b) functional outcomes, (c) quality of life,(d) daily living, (e) psychiatric outcome, and (f) financial needs. The nursemust use skills in crisis intervention to help ease the disequilibrium of thefamily. Nurses need to be sensitive to patient and family needs. Nurses musthelp the patients and their families to cope with(a) disease chronicity, (b)waiting period, (c) role reversal, (d) hospitalization, and (e) complicatedmedical regimen as well as take into consideration the demands on(a) time, (b)energy, (c) finances, and (d) relationships that the disease has placed onpatients and their families.
The burdens and challenges that this crisis placeson patients and their families are many. These can also include(a) theuncertantity of rejection, (b) the uncertantity of future health and well-being,(c) social isolation, (d) financial burdens, (e) possible organ failure, (f)increased risk of two family members undergoing surgery, and (g) feelings ofguilt from non-donating persons or family members (Ganley, P. P. , 1995). Astransplant moves into the critical care setting, nurses are going to have to beprepared for optimal management of donors, canidates, and recipients. They needto optimize patient outcomes through extended knowledge bases and educationabout:: (a) the procedure, (b) the human immune response, (c) the pharmacologyof immunosuppression, and (d) physiological and psychologic and behaviorresponses to transplantation (Smith, S.
L. , 1993). Nurses need to continue to bepatient advocates. We need to encourage communication, allow families toventilate anger, fear, and guilt and to educate patients and families about whatto expect. Nurses need to remember when designing care paths and nursingdiagnosis that it is important to include the necessary ones related to thepatients condition such as, potential for infection related to interrupted skinintegrity, which is the nursing diagnosis that the current nursing research isfocused on; but we also need to include nursing diagnoses that focus on thepatient and family as a whole. A key nursing diagnosis would be anxietysecondary to knowledge deficit about liver donation/transplantation.
We need toeducate patients and their families and take the time to answer their questionsand listen to their fears and concerns. All too often nurses get caught up inthe machines that are taking care of the patient’s condition but we mustremember that there is no machine that can care for the patient and family, onlythe human response and caring of a nurse can preserve the “person”. There are still many ethical issues that surround living donor organtransplantation. Issues that arise include(a) risks versus benefits, (b)selection of donor and recipient, and (c) informed consent.
The largest risks torecipients include(a) organ rejection, (b) organ failure, and (c) possibledeath. Benefits to recipients include a normal life or closer to normal life. Risks to donors include(a) partial hepatectomy, (b) complications, and (c)possible death. Benefits to donors include psychological benefits and the degreedepends upon the relationship between donor and recipient (Singer, P.
A. et. al. , 1989). Arguments for living donor organ transplantation include(a)reduction of pre- transplant mortality, (b) provides a new source of livers fortransplantation, (c) allows the transplant to be performed before therecipient’s condition deteriorates from complications, (d) immunologicadvantage, and (e) fulfills powerful motivation of parent/other to participate(Lynch, S. V.
, Strong, R. W. , ; Ong, T. H. , 1992). Arguments against livingdonor organ transplantation include(a) may be uneccessary, (b) frequentlyrequire retransplant from cadaver source, and (c) poses unknown risk to donor(Lynch, S.
V. , et. al. , 1992).
But most medical decisions are based on thequestion of whether or not the risks outweigh the benefits and in the case ofliving donor organ transplantation, the decision should be made on an individualbasis but keep in mind that, “. . . when a donor is genetically andemotionally related to the recipient, the intangible benefits of saving a lifeare most rewarding, and the risk-benefit ratio is most favorable” (Singer,P. A.
, et. al. , 1989, p. 621). Although the procedure of living donor organtransplantation is truly a controversial issue, the nursing care of thesepatients and their families has not been well documented. The medicaldocumentation and research on the actual procedure has been minimal and thelittle nursing research that is out there is out-dated and incomplete.
Becauseof the specialty of transplantation and the uniqueness of the procedure there isa need for more research and detailed information in order for all nurses andhealth care providers to provide optimal care to patients and their families whoare experiencing living donor organ transplantation. Since living donor organtransplantation will probably become a more common procedure, research andknowledge related to the topic will help nurses better function in their role ascaregiver and patient advocate. Therefore we need to continue searching for theanswers and better ways to optimize patient outcomes. Although I have notexperienced this clinical concept in my nursing practice, I am currentlyexperiencing it in my personal life.
I have found that it is sometimescomplicated to separate one’s nursing skills and behaviors from one’s personalfeelings. I was disappointed in my search for information related to livingdonor organ transplantation. It is also disheartening that nurses in this fieldhave not tried to educate their fellow nursing professionals in this area ofstudy. BibliographyBroelsch, C. E. , Burdelski, M.
, Rogiers, X. , Gundlach, M. , Knoefel, W. T. ,Langwieler, T. , Fischer, L.
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, Kuechler, T. , Krupski, G. , Loeliger, C. , Kuehnl,P. , Pothmann, W. , ; Schulte Am Esch, J.
. (1994). Living donor for livertransplantation. Hepatology, 20 (1), 495-555. Ganley, P.
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D. , Emond, J. C. , Thistlewaite, J. R.
, ;Broelsch, C. E. . (1989). Ethics of liver transplantation with living donors. TheNew England Journal of Medicine, 321 (9), 620-621.
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