I have the distinct pleasure of introducing today’s guest blogger, Dr. Stephen Potts, a consulting transplant psychiatrist in Edinburgh, United Kingdom. I sent a request out over a transplant list serve I happen to be a member of because I occasionally do consult in this capacity, though rarely these days. I mentioned a dearth of posts about transplant psychiatry and Dr. Potts volunteered immediately–and I’m sure every reader will be thrilled he did. Thanks, Stephen–The Geezer
Dr. Stephen Potts FRCPsych,
Department of Psychological Medicine,
( Hon Senior Clinical Lecturer, University of Edinburgh)
Royal Infirmary of Edinburgh
I’m a psychiatrist, currently watching a kidney being transplanted from father to son – both of whom I have seen as patients – in one of the operating rooms at the Royal Infirmary of Edinburgh (RIE). I’ve not set foot in an OR (except as a patient or imminent father-to-be) since my days as a surgical intern 25 years ago. What am I doing here now?
Transplant psychiatry is a small but growing field, in the UK as in the US. The RIE houses the liver and pancreas transplant units for the whole of Scotland (pop. 6 million), as well as one of its two kidney transplant units. Heart and lung transplants go west to Glasgow or south to Newcastle: we don’t venture north of the diaphragm.
We’ve just celebrated the 1000th kidney and 1000th liver transplant since the unit was established in its current form in 1992 – an event marked by the announcement of an ambitious expansion in the liver programme.
The role of psychiatry has been recognised from the outset, and one-third of the senior psychiatry time in my small liaison psychiatry department is now funded directly by the transplant service: a level due to increase further. My colleague Roger Smyth does the liver work: I do kidney and pancreas, and we cross-cover.
The work of a psychiatrist in a transplant unit divides various ways. There are elements in common with other areas of surgical practice: the preoperative preparation of psychiatrically vulnerable patients; the early post-operative management of delirium and psychiatric reactions to steroids and immunosuppressants; and the later management of reactions such as depression after graft failure and other complications.
Beyond this, a large and growing proportion of our work is devoted to more contentious and transplant-specific questions of selection of recipients, and more recently of living donors.
For liver transplant in particular, the underlying liver disease often has a psychiatric origin, such as alcoholic liver disease, hepatitis arising from intravenous drug misuse, or, most acutely, fulminant hepatic failure arising from overdose of paracetamol/acetaminophen .
Scotland is drowning in a flood of alcohol, and our rates of alcohol related problems are all trending in the wrong direction: chillingly so for alcoholic liver disease, where patients are getting younger and more commonly female. We are regularly asked to give views about likelihood of relapse to harmful levels of drinking after transplant, and some patients are turned down for listing as a result.
We assess for urgent liver transplant 40 or more paracetamol/acetaminophen overdose patients per year, from all over Scotland and occasionally Northern Ireland. Reactions from colleagues elsewhere (“You must have misplaced the decimal point: surely you mean 4?”) suggest this is again a peculiarly Scottish phenomenon, at least at this level of frequency. We are asked, usually in the middle of the night, with limited information, and little or no ability to interview the patient (because of encephalopathy), to assess them against an agreed set of absolute and relative psychosocial contraindications to listing for urgent liver transplant. The stakes could not be higher: if they reach medical criteria for transplant, are listed, and get an organ, their 1-year survival rate is 95%. If they do not get a transplant, either because none becomes available, or they are not listed, their mortality is 95%.
Kidney transplant does not offer such stark dilemmas, and fewer people develop kidney disease because of psychiatric problems (bipolar patients who develop renal failure after long term lithium use do present, but not commonly). However we are regularly asked to see current dialysis patients to assist as questions of capacity, compliance, mood disorder and substance misuse arise. The fall-back treatment of dialysis allows more time for interventions and probationary periods, but again some assessments result in patients being suspended or removed from transplant lists.
Appropriately selected recipients in all these categories do well, but there is a risk that without psychiatric sifting inappropriate recipients are transplanted who then go on to relapse into substance misuse, take further overdoses, or fail to adhere to the demanding post- transplant regime, thereby threatening their own survival and that of their grafts. Donated organs are a scarce resource, available because of the generosity of the public, and there are not enough to go round. Three people in the UK die every day on transplant lists, because demand still exceeds supply – and by a widening margin, despite our successful efforts to increase donation rates. The transplant team as a whole, and those psychiatrists who work within it, therefore have a responsibility to ensure the best outcome for the organs that become available: and this implies turning down some potential recipients on psychiatric grounds.
We have evolved an approach to recipient selection which is robust, as firmly based on evidence as we can make it, and applied consistently. And it needs to be: in liver transplant especially these are quite literally life or death decisions, and regularly subject to scrutiny by our courts and regulatory bodies.
Selection among living donors, and the part played by psychiatry within it, is a newer and still evolving area. UK legislation changed in 2006, allowing an expanded range of transplants from living donors. As well as the customary donors who were related closely to the recipients by genetics or emotion (generally siblings, parents or spouses) it is now legally possible to undertake transplants between donor-recipient pairs where the connection is more distant. The law requires that all such relationship require scrutiny, and the more distant the relationship the greater the level of scrutiny expected, and the more likely psychiatrists are to be involved.
Simultaneously living donor liver transplant programmes were established in Britain (including one in Edinburgh). Drawing on US experience, and awareness of the enhanced mortality and morbidity as compared with kidney donation, the units involved set up Donor Advocate Teams, which assess all cases of potential live liver lobe donation. The Edinburgh team includes a psychiatrist (me!). We have assessed 13 potential donors to date and declined several on psychiatric grounds.
The 2006 law also made possible, for the first time in Britain, so-called “altruistic”donations where a donor comes forward wishing to give an organ to an unspecified recipient, much as one might give blood to a blood bank. Across the UK there have been more than 80 such transplants since 2006, all of them kidneys. The law making them possible mandates a psychiatric assessment at an early stage (before invasive investigations). I’ve assessed 16 such cases, one of whom sighed when I asked him what he thought of the requirement to see a psychiatrist. “What does it say about our society that the first thing that happens when you want to give a kidney is you’re sent to a shrink?”
He went on to donate successfully with no problems: but I was convinced of the need for the provision after four of the first five altruistic donors we assessed were excluded on psychiatric grounds. Since then we saw a string of donors who went on to donate successfully, generating the impression that there is a bimodal distribution. I’ve now begun to doubt that too, seeing a number of potential donors recently where I am genuinely unsure whether psychiatric factors exclude them or not.
There was uneasiness in Britain about altruistic donation when the legislation changed; but the practice has now been generally accepted, which is unsurprising, given that it has been well established in the US and elsewhere for some time.
The next development to trouble clinicians and regulators was unanticipated by UK lawmakers: organ donation for altruistic reasons, directed towards a specific recipient who had no previous connection to the donor by genetics or emotion.
This has emerged because of the ease with which potential donors and recipients can contact each other via websites, Facebook pages and the like. National media recently reported a high-profile case whereby a London recipient has contacted an American donor previously unknown to her, via a US website http://www.thefloodsisterskidneyfoundation.org/. The donor appears to be acting altruistically, but it is disputed whether the current UK code of practice would allow such a donation. Potential solutions are working through the regulatory bodies right now, and are likely to establish further roles and responsibilities for psychiatrists working alongside transplant units, though it is not yet clear what those will be.
I was thinking about this over Christmas/Hannukah/Diwali: a season associated with gifts and giving. Such acts divide into the giving of presents to family members and other close contacts; and more general deeds of charity to unspecified recipients. The former are personally directed, and usually motivated by natural interpersonal connections of love and devotion: the latter are impersonal, undirected, and usually arise from laudable (but not universal) motives of generalised benevolence (Peace on Earth: goodwill to all men, etc). The London case cited above is intermediate between the two.
We do not generally question the sanity of family members who wish to donate kidneys to each other, but where the risks of donation are high (as for liver transplant) we do require a psychiatric review. Nor do we generally question the sanity those who give to charity: but where the gift involved is a part of one’s own living body we do, even for the lower level of risk involved in kidney transplant. Psychiatric assessment has a role in both cases in excluding people whose motivation to donate arises from mental disorder.
There is however a tendency for regulatory bodies to expect more of a psychiatric assessment than it can deliver, and because the regulators don’t yet know how to deal with donations which are intermediate between presents and acts of charity there is the risk that psychiatrists are expected to answer such questions as: “How likely is concealed payment or duress?”
So long as we recognise the limits of what we can (or can be expected to) do, psychiatrists have much to offer our colleagues in transplant medicine and surgery – and the field has much to offer us. As I watched a father’s kidney produce its first few precious drops of urine, shortly before being plumbed into his son’s bladder, I was left in no doubt about the true nature of giving, and the much prized role of a transplant team in facilitating it.