Ethical dilemmas in psychiatric evaluations in patients with fulminant liver failure

Appel, Jacob M.; Vaidya, S.

doi:10.1097/mot.0000000000000060

Cited by 5 publications

(4 citation statements)

References 35 publications

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“…At our institution, we have a restrictive policy with regard to ICP monitoring and LT for patients with acetaminophen‐induced ALF. This is because of the potential for spontaneous recovery, the high prevalence of psychiatric conditions, and the unclear benefit of invasive ICP monitoring in this unique patient population . However, to date, few studies have reported detailed analyses of patient‐centered outcomes with standardized medical management of acetaminophen‐induced ALF in the absence of any surgical component to its management.…”

mentioning

confidence: 99%

Outcome of Acetaminophen‐Induced Acute Liver Failure Managed Without Intracranial Pressure Monitoring or Transplantation

Porteous¹,

Cioccari

Ancona³

et al. 2019

Liver Transpl

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Acetaminophen‐induced acute liver failure (ALF) may require emergency liver transplantation (LT) in the presence of specific criteria, and its management may also include intracranial pressure (ICP) monitoring in selected patients at high risk of cerebral edema. We aimed to test the hypothesis that management of such patients without ICP monitoring or LT would yield outcomes similar to those reported with conventional management. We interrogated a database of all patients treated in an intensive care unit for acetaminophen‐induced ALF between November 2010 and October 2016 and obtained relevant information from electronic medical records. We studied 64 patients (58 females) with a median age of 38 years. Such patients had a high prevalence of depression, substance abuse, or other psychiatric disorders and had ingested a median acetaminophen dose of 25 g. No patient received ICP monitoring or LT. Overall, 51 (79.7%) patients survived. Of the 42 patients who met King’s College Hospital (KCH) criteria, 29 (69.0%) survived without transplantation. There were 45 patients who developed severe hepatic encephalopathy, and 32 (71.1%) of these survived. Finally, compared with the KCH criteria, the current UK Registration Criteria for Super‐Urgent Liver Transplantation (UKRC) for super‐urgent LT had better sensitivity (92.3%) and specificity (80.4%) for hospital mortality. In conclusion, in a center applying a no ICP monitoring and no LT approach to the management of acetaminophen‐induced ALF, during a 6‐year period, overall survival was 79.7%, and for patients fulfilling KCH criteria, it was 69.0%, which were both higher than for equivalent patients treated with conventional management as reported in the literature. Finally, the current UKRC may be a better predictor of hospital mortality in this patient population.

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mentioning

confidence: 99%

Outcome of Acetaminophen‐Induced Acute Liver Failure Managed Without Intracranial Pressure Monitoring or Transplantation

Porteous¹,

Cioccari

Ancona³

et al. 2019

Liver Transpl

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“…The issues of physician attitudes toward patients can prove of particular importance in the unjust or inequitable allocation of scarce resources. 23,24 While perceived social worth is no longer considered an acceptable justification for favorable rationing decisions, implicit biases can shape allocation in a range of fields from transplant to novel therapeutics. 25 A provider may see a “beloved” patient as more capable of stewarding an organ than he actually is, for instance, even (as may be the case with an empathy-inducing patient) if he does not have the necessary caregiver support.…”

Section: Systemic Implicationsmentioning

confidence: 99%

Taking care of the beloved patient

Appel

2022

Clinical Ethics

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While the management of treating “hateful” patients has been the subject of considerable commentary, far less attention has been paid to the ethical challenges involved in the treatment of “beloved” patients. This essay offers a non-exhaustive taxonomy of “beloved” patients that includes relatable patients, inspiring patients, empathy-inducing patients, and joyful patients, and then discusses the potential pitfalls involved in the optimal care of each group. By drawing attention to these often overlooked and unwitting risks, the hope is to mitigate both their direct impact upon individual “beloved” patients and their residual impact upon those patients who are not viewed as “beloved” by their providers.

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“…In solid organ transplantation, an intentionally self-inflicted MOI is generally not sufficient to deny an individual a liver transplant, 81,82,83,84,85,86,87,88,89,90,91,92,93 nor does it serve as a criterion in liver allocation priority. 94,95,96,97,98 These conclusions are derived from data suggesting that long-term outcomes for those with intentional self-inflicted injury are comparable to those with non-self-inflicted injury, which supports ethical arguments that the circumstances creating the need for liver transplantation should not influence whether transplant will be offered as a treatment option.…”

Section: Recipient Considerationsmentioning

confidence: 99%

Self-Inflicted Gunshot Wound as a Consideration in the Patient Selection Process for Facial Transplantation

McQuinn¹,

Kimberly²,

Parent³

et al. 2019

Camb Q Healthc Ethics

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Abstract:Facial transplantation is emerging as a therapeutic option for self-inflicted gunshot wounds. The self-inflicted nature of this injury raises questions about the appropriate role of self-harm in determining patient eligibility. Potential candidates for facial transplantation undergo extensive psychosocial screening. The presence of a self-inflicted gunshot wound warrants special attention to ensure that a patient is prepared to undergo a demanding procedure that poses significant risk, as well as stringent lifelong management. Herein, we explore the ethics of considering mechanism of injury in the patient selection process, referring to the precedent set forth in solid organ transplantation. We also consider the available evidence regarding outcomes of individuals transplanted for self-inflicted mechanisms of injury in both solid organ and facial transplantation. We conclude that while the presence of a self-inflicted gunshot wound is significant in the overall evaluation of the candidate, it does not on its own warrant exclusion from consideration for a facial transplantation.

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Ethical dilemmas in psychiatric evaluations in patients with fulminant liver failure

Cited by 5 publications

References 35 publications

Outcome of Acetaminophen‐Induced Acute Liver Failure Managed Without Intracranial Pressure Monitoring or Transplantation

Outcome of Acetaminophen‐Induced Acute Liver Failure Managed Without Intracranial Pressure Monitoring or Transplantation

Taking care of the beloved patient

Self-Inflicted Gunshot Wound as a Consideration in the Patient Selection Process for Facial Transplantation

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