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TRANSPLANT NURSING

Ethics and Professional Issues

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Ethics and Professional Issues

•  A professional is one who:


–  Is engaged in a practice that recognizes training or
education
–  Is characterized by or conforms to the technical and
ethical standards of a vocation

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Ethics and Professional Issues

Ø  Legal
Major professional Ø  Ethical
issues in transplant Ø  Evidence-based practice
Ø  Transplant research
nursing
Ø  Transplant education

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Ethics and Professional Issues

•  Who determines standard of care to be given by the


transplant nurse?
–  The Joint Commission on Accreditation of Healthcare
Organization (JCAHO)
–  UNOS: United Network for Organ Sharing
–  Independent medical facilities

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Ethics and Professional Issues

•  Standard of care:
–  Describes aspects of patient care that have undergone a review
process and are based on an agreed-upon and established level of
performance or excellence of care
–  May be established by usual and customary practice, legal
precedent, or guidelines promulgated by institutions or profession
associations
•  What is the purpose of standard of care?
–  To improve patient outcomes
–  May be specific to a nation (JACHO); a state; a community or
region (UNOS); a health care facility; or a unit within a health care
facility

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Ethics and Professional Issues

•  Which transplant certifications are available to nurses?


–  Certified Clinical Transplant Nurse (CCTN)
–  Certified Clinical Transplant Coordinator (CCTC)
–  Certified Procurement Transplant Coordinator (CPTC)

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Ethics and Professional Issues

•  What is the definition of death in


regards to organ transplantation?
–  Complete irreversible cessation of all
brain activity, including brain stem
–  Determination based on clinical
judgment supplemented if necessary
by a number of diagnostic aids
–  Varying definitions depending of
religious and cultural beliefs

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Ethics and Professional Issues

•  What is the World Medical Association’s declaration of death?


–  It must be determined there is “irreversible cessation of all
functions of the entire brain, including the brain stem”
–  If transplantation of organs are involved “two or more physicians
and the physicians determining the moment of death should in no
way be immediately concerned with performance of
transplantation

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Ethics and Professional Issues

•  When is death according to the uniform Determination of


Death Act?
–  Death is considered in a person with:
•  Irreversible cessation of circulatory and respiratory function
•  Irreversible cessation of all functions of the entire brain, including
the brain stem

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Ethics and Professional Issues

•  How does the health Information


Portability and Accountability Act
(HIPAA) establish health information
privacy relating to organ donation?
–  HIPAA ensures privacy of all personal,
protected health information
–  Organ donor and recipients must have
their identities protected at all stages
of transpalntation

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Ethics and Professional Issues

•  Privacy of individually identifiable health information: The


Privacy Rule
–  The office of civil rights is responsible for implementing and
enforcing this Rule
–  Protects all individually identifiable health information, held or
transmitted in any form or media: electronic, paper, or oral
•  This information is known as protected health information

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Ethics and Professional Issues

•  The term protected health information (PHI) relates to:


–  The identification of an individual donor or recipient
–  A person’s health status and treatments
–  Payment plans or insurance carriers

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Ethics and Professional Issues

•  Transplant Research is the systematic collection of information


in order to increase generalized knowledge
–  In U.S., the institutional review must be completed prior to
implementing a research study
–  The research protocol must meet the regulatory guidelines set forth by
the federal government and the local institutional review board

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Ethics and Professional Issues

•  Clinical ethics:
–  The systematic identificaion, analysis, and resolution of ethical
problems associated with the care of particular patients
–  Goals:
•  Facilitate clicical decision-making
•  Promotes participation of all relevant professionals
•  Enhances organizational commitment and cooperation

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Ethics and Professional Issues

•  Transplant research evolves around:


–  Systematic collection of information in
order to increase generalized
knowledge
–  Protection of human subjects
–  Informed consent
–  Transplant nurses’ responsibilities

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Ethics and Professional Issues

•  What is the transplant nurses role in transplantation research?


–  Explaining research protocols and obtaining informed consent
–  Collect research data as directed with proper documentation
–  Continuing research studies to advance the transplant nursing
practice

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Ethics and Professional Issues

•  Major ethical principles for nurses to abide by:


–  Autonomy: ability to make one’s own decisions independently
–  Beneficence: ability to provide beneficial care over harmful care
–  Justice: fair treatment to all individuals
–  Nonmaleficence: “do no harm”

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Ethics and Professional Issues

•  What ethics need to be involved with research to protect


human rights?
–  Confidentiality and privacy rights
–  Full disclosure of the purpose of all studies
–  Provide risks and benefits upfront
–  Offering of consent to participate
–  Names of all researchers
–  Anonymity where needed

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Ethics and Professional Issues

What are the two most controversial


ethical issues in organ transplantation?

1. Organ donation
from a living donor
versus salvage 2. Allocation of organs to
from the deceased needy patients in a non-
bias manner once they
have been procured

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Ethics and Professional Issues

•  What is the most “universally” agreed upon way of organ


allocation?
–  Different religions and cultures alike agree upon organs being
allocated fairly to those in need and equally among waiting
patients

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Ethics and Professional Issues

•  How are the national laws of


UNOS determined?
–  Delivering organs efficiently,
maximizing to opportunities
given by organ availability
–  Organ allocation within an
agreeable pattern or
distribution in the nation

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Ethics and Professional Issues

•  Organ Procurement and transplantation Network (OPTN):


–  Defines the ethical principles that provide the underpinning of the
regulations governing the organ allocation system
–  Utility, justice, and respect for persons are 3 foundational ethical
principles that create a framework for the equitable allocation of
scarce organs for transplantation

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Ethics and Professional Issues

•  Allocation policies and access to the waiting list:


–  Access to the waiting list for an organ transplant is the
fundamental prerequisite to organ allocation
–  Both geographic and socioeconomic challenges may impact referral
for transplantation
–  Listing practices and requirements may vary among institutions
and from one organ type to another
–  Allocation practices based on waitlist time need to be routinely
examined to assure that different waitlist practices do no
discriminate against certain groups of patients

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Ethics and Professional Issues

•  Where are organs allocated first utilizing


UNOS rules?
–  Local level
–  Regional level
•  Exception only with liver transplants that can go to a
person in the region more ill that a local individual
•  National level

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Ethics and Professional Issues

•  How are individual state organ procurement organizations


(OPO) involved in ethical debate?
–  Some believe that areas with higher death rates from crime or
accidents unfairly receive more organs opposed to rural, less-
populated areas simply because of the OPO regulating where
organs are allocated on the local levels first

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Ethics and Professional Issues

•  What type of documentation is


necessary following a patient
death in regards to a possibility of
organ donation?
–  Eligibility of organs or tissues
based upon cause of death
–  Donation requests of next of kin
and outcomes

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Ethics and Professional Issues

•  Why is documentation of family education important in the


donation request process?
–  Provides written documentation that the family has been given
proper information to make a decision on the option of transplant

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Ethics and Professional Issues

•  How is death determined with termination of heart or lung


function?
–  Irreversible cessation of cardiopulmonary functions
–  Death cannot be determined by a person involved with transplant
interests, persons within the family or anyone with special interest
in the patient and their demise

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Ethics and Professional Issues

•  What is the Uniform Anatomical Gift Act (1968)?


–  A consented document of a patients predetermined declaration to
donate their body or a portion there of for research, therapy or
future organ transplantation following their death

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Ethics and Professional Issues

•  How did the National Organ Transplant Act (1984) add


additional legislation?
–  Aimed to create a fair, uniform system of organ allocation
–  Prevent the creation of markets for living or deceased donor
organs while prohibiting payment for live organ donation

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Ethics and Professional Issues

•  How do organ markets create an ethical debate in the medical


community?
–  If potential organ donors or their families were compensated for
their organ donation, either living or after their death, the supply
of organs would increase to meet the demand of waiting recipients

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Ethics and Professional Issues

•  Why are there ethical arguments against an organ market


system?
–  Beliefs of inequality for individuals without insurance to pay for
transplantation
–  Poor individuals would donate living organs for monetary reasons
–  Only the wealthy could afford transplants by to purchasing organs
with market value

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Ethics and Professional Issues

•  What are other arguments against the organ market system?


–  Care of the critically ill may be suspended in order to cause
premature death with intention of organ harvest
–  Supply of organs may come from those with suboptimal health =
less healthy organs

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Ethics and Professional Issues

•  What is the idea of “presumed consent”?


–  Presuming that a person that is deceased would allow their
organs to be donated
–  In some European countries is policy as long as the individual
did not explicitly state their not agreeing to donation during
their life

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Ethics and Professional Issues

What are the types of organ donors


and how are they differentiated?

Non-heart beating Heart beating


organ donors: donors:

•  Donor has been declared •  Donor has been declared


brain dead and organ brain dead, pulmonary
procurement can begin function is mechanically
once declaration is made supported, cardiac
functioning remains

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Ethics and Professional Issues

•  How are living donors identified?


–  Altruistic donors
•  Donation of organ made by an individual for use by anyone
–  Living related/unrelated Donor
•  Donation of organ made by a person for a specific individuals use

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Ethics and Professional Issues

•  Live donors bring to light additional ethical questions…..


–  Should a healthy person be put at risk to save another human?
–  Do psychosocial factors contribute to the live donor feeling
obligated to help another person?

Ex: if I don’t do this, they will die without me

Copyright 2017. OnCourse Learning Corporation. All rights reserved.


Ethics and Professional Issues

•  What are two models of organ


procurement?
–  Gifted organs from live (living
related or unrelated) donors
–  Organ procurement or
“salvage” of organs from
deceased individuals

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Ethics and Professional Issues

•  What ethical theories need to be considered in organ


transplantation and procurement?
–  Religious beliefs
–  Cultural beliefs
–  Ability to gain consent for procurement not “presumed consent”

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Ethics and Professional Issues

•  What ethical questions can stem


from living donors volunteering for
organ procurement?
–  What consents, psychological
evaluations (if any) should be given?
–  What circumstances of the recipient
should allow procurement from a
living donor?

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Ethics and Professional Issues

•  How does the perfusion of an individuals organs prior to


consenting for organ donation controversial?
–  The patient is not officially “dead”
–  Some religions condemn the use of parts of a human life to
benefit another soul…what are the beliefs of this dying patient?

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Ethics and Professional Issues

•  What are thoughts about


administering medications to aid in
organ procurement prior to death?
–  Will anti-coagulants given before
death for the benefit of the future
organ procurement hasten death?
–  Should medications be given that
are not beneficial to the patient but
to the next recipient?

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Ethics and Professional Issues

•  What views are expressed by the American College of Critical


Care Medicine on this issue?
–  Beliefs that medications that will not harm the dying patient are
acceptable if consent has been given for future organ donation
after death, however, most important is the care of the dying
patient

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Ethics and Professional Issues

•  How would ethics be involved in an organ donation from


someone with a high risk lifestyle putting them (although
deceased) at risk for disease?
–  Standards of practice do not allow such individuals organs to be
transplanted with the potential of putting the organ recipient in
danger of developing illness (ex: HIV)
•  When would it be appropriate to transplant a patient with
multiple disease processes?
–  If multiple organs (liver/pancreas, heart/lung) are available with
matched requirements to the recipient

Copyright 2017. OnCourse Learning Corporation. All rights reserved.


Ethics and Professional Issues

•  What ethical dilemmas can occur with organ procurement


from infants or children?
–  Anencephalic infants: are they considered “living” or
“without life” with limited brain tissue
–  Children: are they able to give their own consent?

Copyright 2017. OnCourse Learning Corporation. All rights reserved.


Ethics and Professional Issues

•  Which ethical dilemmas are


specific to the female
transplant population?
–  Pregnancy post-transplant
–  Patients with potential
transplant needs becoming
pregnant
vs. termination

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Ethics and Professional Issues

•  Which ethical dilemmas are specific to the pediatric


population?
–  Children < 18 making decisions about their health and
transplantation with parental involvement
–  Infants with multiple anomalies receiving an organ or multiorgan
transplant

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Ethics and Professional Issues

•  Which ethical dilemmas are specific


to the elderly?
–  Whether they should receive organs
when they have a shorter life
expectancy with their increased age
–  Whether organs that are “older” with
the potential to have poorer medical
quality should be harvested for a
recipient

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Ethics and Professional Issues

•  What moral dilemmas arise with the idea of


xenotransplantation?
–  Should different biological organs from non-human species
be placed into humans?
–  What about contamination of illness only found in animals
transferring to a human?

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Ethics and Professional Issues

•  What ethical dilemmas may occur with individuals receiving


repeat transplants?
–  Belief that one person is more important than another individual
life
–  Organ failure or rejection in one person that was already given
an organ and another “chance” shouldn’t get priority over an
individual still awaiting one transplant

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Ethics and Professional Issues

•  Why are patients with chronic illness receiving organ


transplants sometimes viewed as less acceptable morally
than an individual with an acquired illness or congenital
anomaly?
–  Example: Alcoholic patient with cirrhosis receiving a liver
transplant over a person with hepatitis they acquired through
a transfusion

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Ethics and Professional Issues

•  Why does this add to controversy over a centralized data


base for organ donors?
–  Confidentiality of personal information
–  Sharing medical information between those willing to donate and
organ recipients
–  Creating centralized data banks by driver license numbers in
each state

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Ethics and Professional Issues

•  Transplant nurses are responsible for


confidentiality of what areas of
transplantation?
–  The nature of death of the donor
allowing organs to be available
–  Privacy of donor and recipient medical
information
–  Identity of donor/donor family

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Ethics and Professional Issues

•  Where did the Nuremberg Code originate?


–  In Germany when human subjects were experimented on,
body parts taken from the deceased, without consent if
thought to be for the “good of people”
•  Why is the Nuremberg Code important in organ
transplantation?
–  It states “voluntary consent of human subjects is essential”
•  Therefore, a person should make the choice for organ donation prior to
death and organ procurement

Copyright 2017. OnCourse Learning Corporation. All rights reserved.


Ethics and Professional Issues

•  The American Nursing


Association (ANA) Standards
of Clinical Practice include
research as:
–  Nurses use research findings
in practice and use their
research data in the creation
of care plans and specified
interventions

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Ethics and Professional Issues

•  What are barriers to individuals committing to become organ


donors?
–  Lack of information
–  Misunderstanding about the term “brain death”
–  Lack of communication with family members about decision to
become a donor

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Ethics and Professional Issues

•  Should condemned prisoners be organ donors?


–  The UNOS Ethics Committee has raised a small number of the
many issues regarding organ donation from condemned prisoners
–  One proposal suggested that prisoners be given the option of
donating organs upon their death, another suggests that
condemned prisoners be offered the option of trading a kidney or
their bone marrow in exchange for a commuted sentence of life in
prison without parole
–  It’s beyond the scope of the committee to examine the morality
and ethical issues encompassing the death penalty, it is worth
noting that this topic is both ethically and judicially controversial

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Ethics and Professional Issues

•  Should convicted criminal status be considered in evaluating


individuals for organ transplantation?
–  Punitive attitudes that completely exclude those convicted of
crimes from receiving medical treatment, including an organ
transplant are not ethically legitimate

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Ethics and Professional Issues

•  Should the status of a convicted criminal be a factor in


reaching a decision regarding who should be eligible to obtain
an organ transplant?
–  Convicted criminal status should be a irrelevant in the evaluation
for candidacy as a potential transplant recipient
–  It assumes the convicted criminal have been sentenced only to a
specific punishment but have not been sentenced by society to an
individual punishment of it inability to receive consideration for
medical services

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Ethics and Professional Issues

•  General considerations in assessment for transplant


candidacy?
–  Life expectancy
–  Organ failure caused by behavior
•  Alcoholism
•  Drug abuse
•  Smoking
•  Eating disorder
–  Compliance/Adherence
–  Repeat transplantation

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Bibliography

•  Administration, H.R. Organ Procurement and Transplantation Network.


(n.d.). Retrieved 2/14/2017 from U.S> Department of Health &
Human Services.
https://optn.transplant.hrsa.gov/governance/policies/
•  Anderson-Shaw, Lisa. Ethical issues in liver transplantation. In R.
Brown (Ed.); 2017. Retrieved from:
http://www.uptodate.com/home/index.html
•  DuBois JM, Delmonico FL, D’Alessandro AM. When organ donors are
still patients” is premortem use of heparin ethically acceptable? Am J
Crit Care. 2007;16(4):396-400.
•  Mohamed RY, Verheijde JL. “Non-heart-beating,” or “cardiac death,”
organ donation: why we should care. J Hosp Med. 2007;2(5):324-334.
•  Ohler L, Cupples S. Core Curriculum for Transplant Nurses. Second Ed.
St. Louis, MO: Mosby; 2016.

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