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