Healthcare Essay, Research Paper

Holistic CareAre we Treating the Patient or the Condition?

Alesha M. Johnson, R.N.

Jewish Hospital College of Nursing

and Allied Health

Nursing 4600

Conceptual Approach to Acute Care

October 8, 1996

Holistic CareAre we Treating the Patient or the Condition?

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.

References

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, 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 related liver transplantation (LRLT) in childrenFocus

on issues. Pediatric 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 Clinics

of North America, 29 (4), 615-629.