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Organ Transplantation
Organ Transplantation DEALINGWITH TECHNOLOGY Valerie Poland
H
ealth professionals and policymakers are in a quandry. Technological advances making organ transplantation and artificial implantation more feasible are what put them there. Nurses. physicians, lawyers, educators, ethicists, and government representatives recently met to sort through the issues accompanying organ transplantation. The conference was sponsored by the University of Utah College of Nursing and Nursing Service department and was held in Salt Lake City. A thread running through the entire four-day seminar was how to best care for transplant patients and still obtain the research needed. What it boils down to is that we now have the technology to do more than we can afford and more than some think is ethical. This concern was evident in discussions about maintaining a patient to harvest the organs and determining who should receive organs.
T
he University of Utah’s research and accomplishments were recognized widely when its team implanted the first artificial heart in Barney Clark, DDS, approximately 18 months ago. While Dr Clark experienced many serious complications following the historic surgery, he died 112 days later from an infection unrelated to the artificial heart. Since Dr Clark’s death, many have criticized the attempt to implant a total artificial heart (TAH). William DeVries, MD, surgeon for Barney Clark, explained what was gained from the ex1026
perience. After years of implanting artificial hearts into animals at the University of Utah, Dr DeVries said it was time to progress. All that could be learned from animals had been achieved. He said, “We hadreached aplateau.” By applying the knowledge gained from animal research, it was learned that seizures may become a complication when cardiac output exceeds 1 1 L 0 patients autoregulate their heart rate and pulse patients need postoperative mobility. Dr DeVries said the impetus for devising a smaller drive system would not have been as strong without the Barney Clark experience. A system about the size of a woman’s handbag has now been made. At the conference, Dr DeVries announced that he planned to implant another TAH late this spring, probably in May. When deciding who will be a candidate for an implant, Utah physicians consider three groups of patients. They are patients who are unweanable from the cardiopulmonary bypass pump have cardiomyopathy 0 are in acute cardiogenic shock. Other criteria, which exclude 70% of the medically qualified candidates, include age, class of heart disease, physical and psychological status, family, and money. The candidate must be under 50 years old, medically compliant, emoValerie Poland, BS. is ti.ssocicctr cditor ofthe AORN Journal.
4 0R “10 V R N AL
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~~
M A Y 1984, VOL 39, NO 6
Seminar participants inspected various artificial organs that Willem Kolff, MD, PhD. brought. Dr Kolff invented the first artificial kidney in 1943. tionally stable, have class IV heart disease (as defined by the American Heart Association). and have family support. Because of the artificial heart’s size. only men and large-framed women can be considered. Care of the artificial heart recipient differs significantly from other cardiac surgery patients. Linda Gianelli, RN, and Debbie Pearce, RN, surgical intensive care unit nurses who cared for Dr Clark postoperatively. said the patients do not have an electrocardiogram, and they cannot have a cardiac arrest. The heart rate can be controlled precisely at all times. In the first 24 hours postoperatively, the patient must remain supine. Left and right cardiac output and diastolic filling pressures are monitored closely. Dr DeVries said the artificial heart may have widespread clinical applications, because approximately 1.000 people in the United States die of cardiac heart disease daily. There is an insufficient number of adequate donor organs for transplant. Using the TAH until a donor can be found is possible, but Dr DeVries said that does 1028
not resolve the problem of a lack of donated hearts.
The Gift of Lift) efining organ donation as the gift of life presents many ethical and cultural problems. These were explained by Judith Swazey, PhD, Boston University, and Joyceen Boyle, RN, PhD, University of Utah College of Nursing. Using the term gifr implies an indebtedness and a duty to accept. Swazey compared the feelings associated with receiving a dinner invitation or a birthday present with receiving an organ to show the depth of the social implications. When invited to a friend’s home for dinner, the feeling of needing to reciprocate usually follows. When given a birthday present, the receiver often returns a gift of similar worth. When offered a present, rarely is it refused. These social norms also apply when offered an organ, but the emotions are magnified because of the importance of the gift.
AORN JOURNAL
M A Y 1984, VOL 39, NO 6 ~~
T ~ Good, P
the
Bad, the Ugly
C
Gerald Winslow. PhD. introduced Judith Swazey, PhD, Boston University. and her presentation on the social and cultural aspects of organ procurement and donation. Swazey said, *‘It is a very common belief that a donated organ is such an extraordinary gift both literally and symbolically that it is inherently unreciprocal. ’‘ The recipient may want to refuse the organ because he does not want to be indebted to the donor. Repaying the donor seems impossible, and even though the donor may not suggest that repayment is expected, the recipient is likely to have such feelings. When the donation is from a family member, the “black sheep syndrome” may come into play, according to Swazey. She said a donor may offer an organ to redeem himself. Or, the family may select the “black sheep” to punish him. Determining the donor‘s motivation is important. though difficult. Swazey argues for anonymity for the donor and recipient. This spares the donor from thinking the organ was wasted or inadequate if it is rejected or if the patient dies from other causes. 1030
yclosporine, often lauded as a miracle drug, is not the “magic bullet,” according to Byers W Shaw, Jr, MD, transplant surgeon at the University of Pittsburgh. It is still not known how cyclosporine works, but it is a potent immunosuppressant and has reduced the incidence of organ rejection. The advantage of cyclosporine as described by Dr Shaw is its potency as an immunosuppressor. Because of this characteristic, the organ rejection process, if it happens, is milder. There is less organ destruction and better graft function and survival. Lower steroids are needed when cyclosporine is used, which results in better healing and fewer and milder infections. The major disadvantage of the drug is its toxic effect. Renal complications and hypertension are also common risks. These complications, in addition to the side effects of fine tremors and seizures, make the drug less than ideal. There is also a risk of overimmunosuppression. When this occurs, patients get fungal and viral infections. A lymphoproliferative disorder is also possible, necessitating a reduction in the cyclosporine dosage. Lastly, cyclosporine is difficult to use because of its highly variable absorption rate. The drug is fat soluble, making absorption difficult in patients with liver disorders. The ugliness of cyclosporine is reflected in its cost, overuse, and misuse, according to Dr Shaw. A gram of cyclosporine costs $36, and total bill for the drug could range from $5,000 to $13,000 annually. A synthetic cyclosporine can be produced, but until production is simplified, it too is extremely costly.
Le~yisltrtionAffecting TI-tiiispltiiitcition
C
ost, more than any other factor, is why the federal government is responding to advances in transplantation and artificia1 organ implantation. David Sundwall, MD, physician advisor to chairman of the Labor & Human Resources Committee, Washington, DC, said the problem is that we cannot afford to
M A Y 1984, VOL 3 9 , NO 6
____._____ A O R N JOUR-NAA
which provides reimbursement for health care to retired and active military personnel and their dependents, liver transplants are reimbursed. Pediatric liver transplants for children with congenital defects have been taken out of the experimental category. This change allows for reimbursement .
Surgery Effective for Low Back Pain David Sundwall, MD, gave an overview of how several legislative and federal government bodies perceive organ transplantation.
do everything we can do for everyone. Now the government is interested in having input into its policies because no one wants total responsibility for rationing care. Dr Sundwall said that the cost of pediatric liver transplants could probably be absorbed because there are only about 3,000 patients who need this treatment. In comparison, there are approximately 66,000 people who need heart transplants. Reimbursing for heart transplants “would break an already shaky bank,” Dr Sundwall said. Rep Albert Gore (D-Tenn) has introduced a proposal that would create a major role for the federal government in transplants. It would also provide federal funding for national transplant centers and prohibit the sale of organs. Sen Orrin G Hatch (R-Utah) has made a similar proposal. It would call for creation of a task force to find the most appropriate reimbursement policy and a national registry network. Dr Sundwall does not believe that the reimbursement policy can be changed this year because of the costs and the charge to the Finance Committee to reduce spending. The Office of Management and Budget is resistant to transplants because of the reimbursement issue. Through the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS),
Laminectomy is an effective treatment for many patients who have tried conservative treatment without significant benefit, according to a report in the Dec 24 issue of The L w w r by Myfanwy Thomas, J Marshall. N Grant, and J Stevens, MDs. The physicians, all of the Institute of Neurology. National Hospitals for Nervous Diseases, London, compared 86 patients with low back pain who underwent laminectomy with 32 who did not. Of the patients who had surgery, 46 (53%) showed excellent results; 20 (23%) showed good results; and 10 (1 2%) showed both fair and poor results. The results for those patients not having surgery were excellent, 7 (22%); good, 9 (28%); fair 3 (9%), and poor 13 (41%). The criteria for surgical treatment were “more than one attack of low back pain and/or sciatica with loss of time from work and a filling defect on the myelogram,” the report stated. Women benefited less from the treatment, the one factor the report said reached statistical significance. The physicians recommend surgery be performed sooner rather than later (preferably within a year), as those patients showed the best result. They pointed out, however, that a long history does not “preclude an excellent result and, as the experience of this study has shown, surgery may be worthwhile even in patients who have had pain for ten years or more.”
1031
H
ealth professionals and policymakers are in a quandry. Technological advances making organ transplantation and artificial implantation more feasible are what put them there. Nurses. physicians, lawyers, educators, ethicists, and government representatives recently met to sort through the issues accompanying organ transplantation. The conference was sponsored by the University of Utah College of Nursing and Nursing Service department and was held in Salt Lake City. A thread running through the entire four-day seminar was how to best care for transplant patients and still obtain the research needed. What it boils down to is that we now have the technology to do more than we can afford and more than some think is ethical. This concern was evident in discussions about maintaining a patient to harvest the organs and determining who should receive organs.
T
he University of Utah’s research and accomplishments were recognized widely when its team implanted the first artificial heart in Barney Clark, DDS, approximately 18 months ago. While Dr Clark experienced many serious complications following the historic surgery, he died 112 days later from an infection unrelated to the artificial heart. Since Dr Clark’s death, many have criticized the attempt to implant a total artificial heart (TAH). William DeVries, MD, surgeon for Barney Clark, explained what was gained from the ex1026
perience. After years of implanting artificial hearts into animals at the University of Utah, Dr DeVries said it was time to progress. All that could be learned from animals had been achieved. He said, “We hadreached aplateau.” By applying the knowledge gained from animal research, it was learned that seizures may become a complication when cardiac output exceeds 1 1 L 0 patients autoregulate their heart rate and pulse patients need postoperative mobility. Dr DeVries said the impetus for devising a smaller drive system would not have been as strong without the Barney Clark experience. A system about the size of a woman’s handbag has now been made. At the conference, Dr DeVries announced that he planned to implant another TAH late this spring, probably in May. When deciding who will be a candidate for an implant, Utah physicians consider three groups of patients. They are patients who are unweanable from the cardiopulmonary bypass pump have cardiomyopathy 0 are in acute cardiogenic shock. Other criteria, which exclude 70% of the medically qualified candidates, include age, class of heart disease, physical and psychological status, family, and money. The candidate must be under 50 years old, medically compliant, emoValerie Poland, BS. is ti.ssocicctr cditor ofthe AORN Journal.
4 0R “10 V R N AL
~
~
~~
M A Y 1984, VOL 39, NO 6
Seminar participants inspected various artificial organs that Willem Kolff, MD, PhD. brought. Dr Kolff invented the first artificial kidney in 1943. tionally stable, have class IV heart disease (as defined by the American Heart Association). and have family support. Because of the artificial heart’s size. only men and large-framed women can be considered. Care of the artificial heart recipient differs significantly from other cardiac surgery patients. Linda Gianelli, RN, and Debbie Pearce, RN, surgical intensive care unit nurses who cared for Dr Clark postoperatively. said the patients do not have an electrocardiogram, and they cannot have a cardiac arrest. The heart rate can be controlled precisely at all times. In the first 24 hours postoperatively, the patient must remain supine. Left and right cardiac output and diastolic filling pressures are monitored closely. Dr DeVries said the artificial heart may have widespread clinical applications, because approximately 1.000 people in the United States die of cardiac heart disease daily. There is an insufficient number of adequate donor organs for transplant. Using the TAH until a donor can be found is possible, but Dr DeVries said that does 1028
not resolve the problem of a lack of donated hearts.
The Gift of Lift) efining organ donation as the gift of life presents many ethical and cultural problems. These were explained by Judith Swazey, PhD, Boston University, and Joyceen Boyle, RN, PhD, University of Utah College of Nursing. Using the term gifr implies an indebtedness and a duty to accept. Swazey compared the feelings associated with receiving a dinner invitation or a birthday present with receiving an organ to show the depth of the social implications. When invited to a friend’s home for dinner, the feeling of needing to reciprocate usually follows. When given a birthday present, the receiver often returns a gift of similar worth. When offered a present, rarely is it refused. These social norms also apply when offered an organ, but the emotions are magnified because of the importance of the gift.
AORN JOURNAL
M A Y 1984, VOL 39, NO 6 ~~
T ~ Good, P
the
Bad, the Ugly
C
Gerald Winslow. PhD. introduced Judith Swazey, PhD, Boston University. and her presentation on the social and cultural aspects of organ procurement and donation. Swazey said, *‘It is a very common belief that a donated organ is such an extraordinary gift both literally and symbolically that it is inherently unreciprocal. ’‘ The recipient may want to refuse the organ because he does not want to be indebted to the donor. Repaying the donor seems impossible, and even though the donor may not suggest that repayment is expected, the recipient is likely to have such feelings. When the donation is from a family member, the “black sheep syndrome” may come into play, according to Swazey. She said a donor may offer an organ to redeem himself. Or, the family may select the “black sheep” to punish him. Determining the donor‘s motivation is important. though difficult. Swazey argues for anonymity for the donor and recipient. This spares the donor from thinking the organ was wasted or inadequate if it is rejected or if the patient dies from other causes. 1030
yclosporine, often lauded as a miracle drug, is not the “magic bullet,” according to Byers W Shaw, Jr, MD, transplant surgeon at the University of Pittsburgh. It is still not known how cyclosporine works, but it is a potent immunosuppressant and has reduced the incidence of organ rejection. The advantage of cyclosporine as described by Dr Shaw is its potency as an immunosuppressor. Because of this characteristic, the organ rejection process, if it happens, is milder. There is less organ destruction and better graft function and survival. Lower steroids are needed when cyclosporine is used, which results in better healing and fewer and milder infections. The major disadvantage of the drug is its toxic effect. Renal complications and hypertension are also common risks. These complications, in addition to the side effects of fine tremors and seizures, make the drug less than ideal. There is also a risk of overimmunosuppression. When this occurs, patients get fungal and viral infections. A lymphoproliferative disorder is also possible, necessitating a reduction in the cyclosporine dosage. Lastly, cyclosporine is difficult to use because of its highly variable absorption rate. The drug is fat soluble, making absorption difficult in patients with liver disorders. The ugliness of cyclosporine is reflected in its cost, overuse, and misuse, according to Dr Shaw. A gram of cyclosporine costs $36, and total bill for the drug could range from $5,000 to $13,000 annually. A synthetic cyclosporine can be produced, but until production is simplified, it too is extremely costly.
Le~yisltrtionAffecting TI-tiiispltiiitcition
C
ost, more than any other factor, is why the federal government is responding to advances in transplantation and artificia1 organ implantation. David Sundwall, MD, physician advisor to chairman of the Labor & Human Resources Committee, Washington, DC, said the problem is that we cannot afford to
M A Y 1984, VOL 3 9 , NO 6
____._____ A O R N JOUR-NAA
which provides reimbursement for health care to retired and active military personnel and their dependents, liver transplants are reimbursed. Pediatric liver transplants for children with congenital defects have been taken out of the experimental category. This change allows for reimbursement .
Surgery Effective for Low Back Pain David Sundwall, MD, gave an overview of how several legislative and federal government bodies perceive organ transplantation.
do everything we can do for everyone. Now the government is interested in having input into its policies because no one wants total responsibility for rationing care. Dr Sundwall said that the cost of pediatric liver transplants could probably be absorbed because there are only about 3,000 patients who need this treatment. In comparison, there are approximately 66,000 people who need heart transplants. Reimbursing for heart transplants “would break an already shaky bank,” Dr Sundwall said. Rep Albert Gore (D-Tenn) has introduced a proposal that would create a major role for the federal government in transplants. It would also provide federal funding for national transplant centers and prohibit the sale of organs. Sen Orrin G Hatch (R-Utah) has made a similar proposal. It would call for creation of a task force to find the most appropriate reimbursement policy and a national registry network. Dr Sundwall does not believe that the reimbursement policy can be changed this year because of the costs and the charge to the Finance Committee to reduce spending. The Office of Management and Budget is resistant to transplants because of the reimbursement issue. Through the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS),
Laminectomy is an effective treatment for many patients who have tried conservative treatment without significant benefit, according to a report in the Dec 24 issue of The L w w r by Myfanwy Thomas, J Marshall. N Grant, and J Stevens, MDs. The physicians, all of the Institute of Neurology. National Hospitals for Nervous Diseases, London, compared 86 patients with low back pain who underwent laminectomy with 32 who did not. Of the patients who had surgery, 46 (53%) showed excellent results; 20 (23%) showed good results; and 10 (1 2%) showed both fair and poor results. The results for those patients not having surgery were excellent, 7 (22%); good, 9 (28%); fair 3 (9%), and poor 13 (41%). The criteria for surgical treatment were “more than one attack of low back pain and/or sciatica with loss of time from work and a filling defect on the myelogram,” the report stated. Women benefited less from the treatment, the one factor the report said reached statistical significance. The physicians recommend surgery be performed sooner rather than later (preferably within a year), as those patients showed the best result. They pointed out, however, that a long history does not “preclude an excellent result and, as the experience of this study has shown, surgery may be worthwhile even in patients who have had pain for ten years or more.”
1031