The Geezer’s Dirty Dozen on Psychosocial Assessments for Organ Transplant

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This is another dirty dozen with video about the psychiatrist’s role in organ transplant. Organ transplant controversies can sometimes lead to major news stories, such as the recent controversy over the intellectually disabled girl being considered for kidney transplant, (see linkhttp://www.cbsnews.com/8301-504763_162-57369008-10391704/hospital-considers-kidney-transplant-for-previously-denied-disabled-girl/). A few years ago, conversely, the big story was about a young girl in the United Kingdom who refused a heart transplant (for the happy update on this see link http://www.dailymail.co.uk/news/article-2019241/Hannah-Jones-16-refused-lifesaving-heart-transplant-tells-U-turn.html). Neither of these stories mentioned the psychiatrist’s role specifically, though both imply that the role of mental health care specialists are probably important to help clarify the complicated emotional issues that can surround the selection or even de-selection of transplant candidates. It’s important to understand that the goal in organ transplant evaluation is not to exclude patients from transplant nor to compel them to undergo this difficult procedure, but to uphold the right of patients to be included while balancing the duty to the patient with the duties to other patients, society with respect to the scarce resource of organs available for transplant, and to the families of patients who are suffering from the burden of chronic or fulminant organ disease.

There will probably never be satisfactory answers to the complex transplant cases that grab the headlines. There is a process that all stakeholders including transplant teams, patients and their families, and hospitals can follow to help ensure that care is patient-centered and that the realities of organ scarcity are acknowledged, difficult as that balancing act is.

As usual, there are only a dozen slides with annotations and this can be only a very brief overview of the psychiatrist’s role in the preoperative evaluation. There are a great many issues I’m not able to cover in a short presentation of this nature, and of course, it should not substitute for guidance from one’s own personal physician.

Slide 3: This is a short historical overview of the history of organ transplant beginning with the first human kidney transplant in 1933 to the introduction of the immunosuppressant Cyclosporine in 1978. There’s also a link to the Organ Procurement and Transplantation Network at http://optn.transplant.hrsa.gov/.

Slide 4: This slide is about the emotional experience that the organ transplant experience is for all involved including the patient, his or her support group, and the transplant team. It’s critically important to view this as a team with the patient at the center. It’s all to easy to inadvertently send messages both verbal and nonverbal which may tend to overemphasize why the patient may need a transplant, for example alcoholic liver disease, which can unintentionally lead to stigma.

Slide 5: Candidate selection criteria are necessary because of the shortage of cadaver organs and the unfortunate downward trend in the number of voluntary donor registration. Because 18 persons die each day on organ transplant wait lists, it is vital to be both practical and supportive to patients and families. And because some patients may need more than one transplant  because graft survival rates tend to be lower than patient survival rates, we need to take the long view about the transplantation process and plan for what may need to be done or not done in the future according to the patient’s wishes and values.

Slide 6: Because more than 95% of transplant programs require a psychosocial evaluation as part of the candidate selection process, the professional performing them can be viewed as a gatekeeper. Thankfully, I believe it’s possible to evolve beyond this role and function as a collaborator. This means that the team adopts a culture of cooperation with the goal of identifying both medical and psychosocial challenges that may interfere with the suitability of the transplant candidate, and assembling the available resources  to maximize the chances of a successful post-transplant outcome.

Slide 7: This slide emphasizes again the role of collaborator the psychiatrist plays and there is a duty to understand and work with several stakeholders: the patient first and foremost, other patients on the wait list, living related donors if available, society in terms of husbanding the scarce resource of available organs for transplant and to the transplant program, which must sustain an acceptable patient survival rate in order to stay accredited., ensuring the ability to continue providing this vital life-saving service.

Another very important factor is the duty to those with disabilities. Under the Americans with Disabilities Act (ADA), we must not discriminate against those with disabilities by using eligibility criteria that would disproportionately affect that population. Further, transplant teams should take reasonable steps to compensate for the disability, taking into account available resources.

Slide 8: The preoperative psychosocial evaluation has several elements, and a suggested outline of one a psychiatrist would conduct can be found at link https://jajsamos.wordpress.com/2011/07/24/psychosocial-evaluations-for-organ-transplantation-according-to-the-practical-psychosomaticist/. The overall goals are are to identify any mental health issues that would interfere with the patient’s success after transplant and identifying available resources to cope with those challenges. The most common contraindications are untreated substance abuse or psychosis and a pattern of noncompliance with medical recommendations.

Slide 9: There is an extensive literature supporting the use of psychosocial evaluations and decision support tools in the assessment of candidates for transplant. The literature is inconclusive so far on whether primary psychiatric disorders per se are or are not associated with influences on survival or morbidity. Those with enduring maladaptive patterns for coping with illness or personality disorders usually have worse outcomes due to noncompliance. One decision support tool is the Psychosocial Assessment of Candidates for Transplantation, developed by M.E. Olbrisch and others in 1989. It’s copyrighted so obtain permission from Olbrisch in order to use it.

Slide 10: I’m excited about the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) because I’ve been waiting for several years to see the finished product and to read about its successful implementation at Stanford University. It was developed by Dr. Jose Maldonado and colleagues it has excellent inter-rater reliability, it’s standardized, and identifies patients at risk for negative post-transplant outcomes. The recent study establishing this is currently at the time of this writing in press and is listed as a reference below. This tool is also under copyright and you should obtain permissions from Dr. Maldonado. However, the interested reader can view the SIPAT on the Stanford Psychosomatic Medicine web site at the link below:

PSGP – Education – Department of Psychiatry – Stanford University School of Medicine

Slide 11: This slide is a short overview of what I consider a landmark paper on the development of guidelines for the psychosocial evaluation of living unrelated donors in the U.S. by Dew et al (reference below). The issue of potential transplant recipients looking for an identifying potential donors on the internet is a hot button issue now and the meeting in Washington, DC was specifically to develop guidelines for the psychosocial evaluation of living unrelated donors. Two of the several essential components of the evaluation are the exploration of the motivation for volunteering to donate and knowledge of the short and long term risks.

Slide 12: This is a selected list of references and resources for the presentation.

Dew, M. A., C. L. Jacobs, et al. (2007). “Guidelines for the Psychosocial Evaluation of Living Unrelated Kidney Donors in the United States.” American Journal of Transplantation 7(5): 1047-1054.
Under the auspices of the United Network for Organ Sharing, the American Society of Transplant Surgeons and the American Society of Transplantation, a meeting was convened on May 25, 2006, in Washington, DC, to develop guidelines for the psychosocial evaluation of prospective living kidney donors who have neither a biologic nor longstanding emotional relationship with the transplant candidate. These ‘unrelated’ donors are increasingly often identified by transplant candidates via the Internet, print media and other public appeals. The expansion of living donor kidney transplantation to include significant numbers of donors with little to no preexisting relationship to the candidate has caused concern in the medical community regarding such psychosocial factors as donor psychological status, motivation, knowledge about donation and the potential for undue pressure to donate under some circumstances. Therefore, experts in mental health; psychosocial, behavioral and transplant medicine; and medical ethics met to specify (a) characteristics of unrelated donors that increase their risk for, or serve as protective factors against, poor donor psychosocial outcomes, (b) basic principles underlying informed consent and evaluation processes pertinent to these donors and (c) the process and content of the donor psychosocial evaluation. The meeting deliberations resulted in the recommendations made in this report.

Maldonado, J. R., M.D.,, H. Dubois, M.D.,, et al. (2012). “The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT): A New Tool for the Psychosocial Evaluation of Pre-Transplant Candidates.” Psychosomatics in press.
Background: While medical criteria have been well established for each end-organ system, psychosocial listing criteria are less standardized. To address this limitation, we developed and tested a new assessment tool: the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT). Methods: The SIPAT was developed from a comprehensive review of the literature on the psychosocial factors that impact transplant outcomes. Five examiners blindly applied the SIPAT to 102 randomly selected transplant cases, including liver, heart, and lung patients. After all subject’s files had been rated by the examiners, the respective transplant teams provided the research team with the patient’s outcome data. Results: Univariate logistic regression models were fit in order to predict the  transplant psychosocial outcome (positive or negative) using each rater’s SIPAT scores. These results show that SIPAT scores are highly predictive of the transplant psychosocial outcome (P<0.0001.) The instrument has excellent inter-rater reliability (Pearson’s correlation coefficient =0.853), even among novice raters. Conclusions: The SIPAT is a comprehensive screening tool to assist in the psychosocial assessment of organ transplant candidates. Its strengths includes the standardization of the evaluation process and it ability to identify subjects who are at risk for negative outcomes after the transplant, in order to allow for the development of interventions directed at improving the patient’s candidacy. Our goal is that the SIPAT, in addition to a set of agreed upon minimal psychosocial listing criteria, would be used in combination with organ specific medical listing criteria in order to establish standardized criteria for the selection of transplant recipients.

Marcangelo, M. and C. Crone (2010). Psychiatric aspects of organ transplantation. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D., and R. G. Robinson, M.D. New York, Cambridge University Press: 210-215.

Orentlicher, D. (1996). “Psychosocial assessment of organ transplant candidates and the Americans with Disabilities Act.” General Hospital Psychiatry 18(6 Suppl): 5S-12S.
The use of psychosocial criteria to assess candidates for organ transplantation may violate the Americans with Disabilities Act (ADA). The ADA prohibits discrimination on the basis of disability or on the basis of eligibility criteria that disproportionately affect persons with disabilities. When organ programs deny access to a person because of schizophrenia, they are denying an organ on the basis of disability. When organ programs deny access to a noncompliant person, they are denying an organ on the basis of an eligibility criterion that is more common in persons with coexisting disabilities like mental illness. Accordingly, both of these denials may violate the ADA. However, the ADA recognizes that it often is appropriate to take a person’s disability into account when allocating organs for transplantation. There is a legitimate social interest in allocating organs in a way that maximizes medical benefit, and a person’s disability may compromise the benefit that the person will receive from a transplant. It is likely that courts will interpret the ADA to permit denials of organs or lower waiting list priorities for persons with disabilities as long as predictions of diminished benefit are based on scientifically valid criteria, the assessment of candidates is individualized and not based entirely on generalized predictors, and the transplant program undertakes reasonable steps like psychological counseling to compensate for an organ candidate’s coexisting disability.

Olbrisch, M. E., J. L. Levenson, et al. (1989). “The PACT: A rating scale for the study of clinical decision making in psychosocial screening of organ transplant candidates.” Clin Transplantation 3: 164-169.

Presberg, B. A., J. L. Levenson, et al. (1995). “Rating scales for the psychosocial evaluation of organ transplant candidates. Comparison of the PACT and TERS with bone marrow transplant patients.” Psychosomatics 36(5): 458-461.
Two scaled formats for summarizing the results of psychosocial evaluations of transplant candidates have been published, the Psychosocial Assessment of Candidates for Transplantation (PACT) and the Transplant Evaluation Rating Scale (TERS). In this study, 40 consecutive candidates for bone marrow transplant were rated on the PACT and TERS. The PACT and TERS were comparable in interrater reliability. Similar conceptual items for each scale correlated fairly highly with one another. The PACT and TERS differ in several scale characteristics. The authors discuss the relationship between scale characteristics and clinical utility.

Rosenberger, E. M., M. A. Dew, et al. (2012). “Psychiatric disorders as risk factors for adverse medical outcomes after solid organ transplantation.” Current opinion in organ transplantation.
PURPOSE OF REVIEW: Given that the prevalence of psychiatric disorders in transplant candidates and recipients is substantially higher than in the general population, and that linkages between psychiatric disorders and medical outcomes for nontransplant-related diseases have been established, it is important to determine whether psychiatric disorders predict posttransplant medical outcomes. RECENT FINDINGS: Most research has focused on the association between depression (both pretransplant and posttransplant) and posttransplant mortality. Some research has examined transplant-related morbidity outcomes, such as graft rejection, posttransplant malignancies, and infection. However, methodological limitations make it difficult to compare existing studies in this literature directly. Overall, the studies presented in this review indicate that psychiatric distress occurring in the early transplant aftermath bears a stronger relationship to morbidity and mortality outcomes than psychiatric distress occurring before transplant. SUMMARY: The literature on the impact of psychiatric conditions on the morbidity and mortality of solid organ transplant recipients remains inconclusive. More research is needed in order to investigate these associations among a broader range of psychiatric predictors, morbidity outcomes, and recipient populations. Until evidence suggests otherwise, we recommend frequent monitoring of psychiatric symptoms during the first year after transplantation to aid in early identification and treatment during this critical period of adjustment.

Transplant Psychiatry in the United Kingdom: Special Thanks to Guest Blogger Dr. Stephen Potts of Edinburgh, UK « The Practical Psychosomaticist: James Amos, M.D

Quiz on Psychosocial Assessments for Organ Transplantation:

1. The organization that facilitates organ matching and collects data about transplants in the U.S. is the Organ Procurement and Transplantation Network (OPTN)

A. True

B. False

2. The reasons why carefully crafted selection criteria are needed to find optimal transplant candidates are:

A. Graft survival rates are lower than patient survival rates

B. Annually 10% to 15% of liver, heart, lung transplant candidates will die while on the wait list

C. Many patients will need more than one transplant

D. The number of persons needing transplant far exceeds the number of available organs

E. All of the above

3. The role of the transplant psychiatrist doing psychosocial assessments is to weed people out who have mental disorders

A. True

B. False

4. The transplant psychiatrist has a duty to which stakeholders?

A. Transplant service

B. Other patients on the wait list

C. Norman U. Senchbau

D. A and B

5. The goals of the preoperative psychosocial evaluation of transplant candidate are:

A. Identify resources to enhance the suitability of the candidate

B. Assess the candidate’s mental status and decisional capacity

C. Assess the psychosocial function of the candidate and his/her support group

D. All of the above

Quiz Answer Key

1. A

2. E

3. B

4. D

5. D

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