Healthcare Essay, Research Paper

In today’s fast-paced world where technology rules, the medical profession is

also advancing. In 1991, 2,900 liver transplants were performed in the United

States while there were 30,000 canidates for the procedure in the United States

alone (Heffron, T. G., 1993). Due to shortages of available organs for

donation/transplantation, specifically livers, once again science has come to

the rescue. Although the procedure is fairly new in the United States, the

concept of living organ donation is fast growing. Living related liver

transplantion was first proposed as a theoretical entity in 1969 but it was not

until almost twenty years later that the procedure became a clinical reality (Heffron,

T. G., 1993). Living related liver transplants have mainly been performed in the

United States and Japan until recently. In 1991 Europe began trying to institute

the 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 have

not yet been explored in depth and there are sensitive issues involved that need

to be addressed. Live organ donation came about as a means to solve the problem

of the absence of a donor. Many people die every year while waiting for a donor

organ and many others suffer because of complications linked to finding a

suitable donor. Before live organ donation most available organs were

harvested/transplanted from cadavers. This procedure has problems of its own.

Complications include(a) suitable match, (b) legalities, (c) family not wanting

to donate organs, and (d) time. With live organ donation a suitable match should

be easier to obtain and time should be able to be controlled to some extent.

With live organ donor transplantation, "…the organ-damaging hemodynamic

instabiility associated with the death of the donor is avoided, and the

coordinated scheduling of operations in the donor and recipient holds ex vivo

organ 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 experiencing

a variety of signs and symptoms related to their disease process. These can

include(a) jaundice, (b) ascites, (c) GI bleed, (d) ECG changes, (e) malaise,

(f) encephalopathy, (g) body image changes, and (h) fluid and electrolyte

imbalances. Disease process is specific to the individual. Once the need for

transplant has been established the search for a donor can begin. There are a

multitude of steps involved in the procedure. Some of these include(a)

evaluation to determine the need for transplant, (b) search for a suitable donor

who is willing to donate, (c) evaluation of the donor, (d) obtaining the proper

consent, and (e) mapping out the plan of care for both donor and recipient. Due

to legalities and ethical conflicts, the acceptance of live organ donor

transplantation is questionable. Those families and volunteer participants must

meet several criteria in order to be considered for a live liver donor. Once

someone decides that they want to be a donor they must first under go a medical

and psychiatric evaluation. The medical portion of the evaluation includes(a)

compatible blood type, (b) no history of liver disease, (c) normal results of

liver function tests, (d) appropriate size of left liver lobe on CT scan, (e) no

vascular anomalies on hepatic arteriography, and (f) low operative risk. The

psychiatric portion of the evaluation must find that the donor is at low risk

for psychological decompensation and involves obtaining informed consent.

Donor’s consent can be influenced by three areas, these include(a) internal

pressure, (b) external pressure, and (c) urgency of medical situation. All

institutions have their own individual protocols for obtaining consent but many

do require a wait period between consent and procedure. This provides the donor

with time to change their decision, and after all these areas have been

addressed the donor and recipient are prepared for surgery. The procedure

involves donation of the left lateral lobe, which is the safest anatomical

resection (Jones, J., Payne, W. D., & Matas, A. J., 1993). The surgeries are

performed simultaneously and may take several hours depending upon the

experience of the transplant team and the possibility of complications. Common

complications include(a) arterial thrombosis, (b) bile leaks, (c) infection, and

(d) stricture at the biliary enteric anastomosis (Wise, B. V., 1994). During the

post-operative stage all normal nursing duties apply but there are also specific

things that nurses need to be aware of and look for. Because of the location of

the liver some patients may experience some degree of pulmonary compromise

post-operatively. Liver function needs to be monitored by assessing lab results,

liver enzymes, bilirubin, and bile production. All drains should be assessed for

quantity and color. Fluid volume status and intake and output also need to be

carefully monitored. PT/PTT coagulation factors are also a sensitive indicator

of graft function and can be expected to normalize in the first few days after

transplant (Wise, B. V., 1994). The transplanted segment of the liver will

regenerate to a standard liver volume, regardless of size at transplantation,

within four to six months following the procedure. Normal liver enzymes have

been documented within six weeks of the procedure (Wise, B. V., 1994). Organ

donation alone is an area where the nurse plays an important role but with the

advances of living organ donation the role has expanded and many nurses are not

prepared to play the part. When comparing living donor organ transplantation to

the age old means of organ harvesting/transplantation from cadavers, the

differences are many. Cadaver organs are usually shipped out , this meant that

there was one nurse and support system with the grieving family while there was

another nurse and support system with the recipient and family. The role is far

from being black and white and now with living organ donors it weaves an even

greater web. Now the nurse is dealing with a patient who may be facing eminent

death without a transplant, a concerned family who may be experiencing

anticipatory grieving stages and a living organ donor who may or may not be

related who also faces possible complications and maybe even death. Then add in

all the legalities and rules and you have one big mess. Support systems will be

a key factor in this web. All those involved will be facing challenges and

questions unique to them. Nurses must remember that when caring for the

patient’s condition, they must not forget to also care for the patient and

family. Isn’t that what holistic nursing care is all about? We must care for the

patient as a whole and this would include the patient’s family. Nurses need to

assess: (a) psychosocial needs, (b) functional outcomes, (c) quality of life,

(d) daily living, (e) psychiatric outcome, and (f) financial needs. The nurse

must use skills in crisis intervention to help ease the disequilibrium of the

family. Nurses need to be sensitive to patient and family needs. Nurses must

help the patients and their families to cope with(a) disease chronicity, (b)

waiting period, (c) role reversal, (d) hospitalization, and (e) complicated

medical regimen as well as take into consideration the demands on(a) time, (b)

energy, (c) finances, and (d) relationships that the disease has placed on

patients and their families. The burdens and challenges that this crisis places

on patients and their families are many. These can also include(a) the

uncertantity 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 of

guilt from non-donating persons or family members (Ganley, P. P., 1995). As

transplant moves into the critical care setting, nurses are going to have to be

prepared for optimal management of donors, canidates, and recipients. They need

to optimize patient outcomes through extended knowledge bases and education

about:: (a) the procedure, (b) the human immune response, (c) the pharmacology

of immunosuppression, and (d) physiological and psychologic and behavior

responses to transplantation (Smith, S. L., 1993). Nurses need to continue to be

patient advocates. We need to encourage communication, allow families to

ventilate anger, fear, and guilt and to educate patients and families about what

to expect. Nurses need to remember when designing care paths and nursing

diagnosis that it is important to include the necessary ones related to the

patients condition such as, potential for infection related to interrupted skin

integrity, which is the nursing diagnosis that the current nursing research is

focused on; but we also need to include nursing diagnoses that focus on the

patient and family as a whole. A key nursing diagnosis would be anxiety

secondary to knowledge deficit about liver donation/transplantation. We need to

educate patients and their families and take the time to answer their questions

and listen to their fears and concerns. All too often nurses get caught up in

the machines that are taking care of the patient’s condition but we must

remember that there is no machine that can care for the patient and family, only

the human response and caring of a nurse can preserve the "person".

There are still many ethical issues that surround living donor organ

transplantation. Issues that arise include(a) risks versus benefits, (b)

selection of donor and recipient, and (c) informed consent. The largest risks to

recipients include(a) organ rejection, (b) organ failure, and (c) possible

death. 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 degree

depends 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 for

transplantation, (c) allows the transplant to be performed before the

recipient’s condition deteriorates from complications, (d) immunologic

advantage, and (e) fulfills powerful motivation of parent/other to participate

(Lynch, S. V., Strong, R. W., & Ong, T. H., 1992). Arguments against living

donor organ transplantation include(a) may be uneccessary, (b) frequently

require retransplant from cadaver source, and (c) poses unknown risk to donor

(Lynch, S. V., et. al., 1992). But most medical decisions are based on the

question of whether or not the risks outweigh the benefits and in the case of

living donor organ transplantation, the decision should be made on an individual

basis but keep in mind that, "…when a donor is genetically and

emotionally related to the recipient, the intangible benefits of saving a life

are most rewarding, and the risk-benefit ratio is most favorable" (Singer,

P. A., et. al., 1989, p. 621). Although the procedure of living donor organ

transplantation is truly a controversial issue, the nursing care of these

patients and their families has not been well documented. The medical

documentation and research on the actual procedure has been minimal and the

little nursing research that is out there is out-dated and incomplete. Because

of the specialty of transplantation and the uniqueness of the procedure there is

a need for more research and detailed information in order for all nurses and

health care providers to provide optimal care to patients and their families who

are experiencing living donor organ transplantation. Since living donor organ

transplantation will probably become a more common procedure, research and

knowledge related to the topic will help nurses better function in their role as

caregiver and patient advocate. Therefore we need to continue searching for the

answers and better ways to optimize patient outcomes. Although I have not

experienced this clinical concept in my nursing practice, I am currently

experiencing it in my personal life. I have found that it is sometimes

complicated to separate one’s nursing skills and behaviors from one’s personal

feelings. I was disappointed in my search for information related to living

donor organ transplantation. It is also disheartening that nurses in this field

have not tried to educate their fellow nursing professionals in this area of

study.

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Langwieler, T., Fischer, L., Latta, A., Hellwege, H., Schulte, F., Schmiegel,

W., Sterneck, M., Greten, H., Kuechler, T., Krupski, G., Loeliger, C., Kuehnl,

P., Pothmann, W., & Schulte Am Esch, J.. (1994). Living donor for liver

transplantation. Hepatology, 20 (1), 495-555. Ganley, P. P.. (1995). Living

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Nursing, 21 (6), 523-525. Heffron, T. G.. (1993). Living-Related pediatric liver

transplantation. Seminars in Pediatric Surgery, 2 (4), 248-253. Jones, J.,

Payne, W. D., & Matas, A.. J.. (1993). The living donors- Risks, benefits,

and related concerns. Transplantation Reviews, 7 (3), 115-128. Lynch, S. V.,

Strong, R. W., & Ong, T. H.. (1992). Reduced-size liver transplantation in

children. Transplantation Reviews, 6 (89), 115-128. Singer, P. A., Siegler, M.,

Whitington, P. F., Lantos, J. D., Emond, J. C., Thistlewaite, J. R., &

Broelsch, C. E.. (1989). Ethics of liver transplantation with living donors. The

New England Journal of Medicine, 321 (9), 620-621. Smith, S. L. . (1993). The

cutting edge in organ transplantation. Critical Care Nurse, supp. June, 10-30.

Wise, B. V. . (1994). Advances in pediatric solid organ transplantation. Nursing

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