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Ethical dilemmas in psychiatric evaluations in patients with fulminant liver failure

Appel, Jacoba; Vaidya, Swapnab

Current Opinion in Organ Transplantation: April 2014 - Volume 19 - Issue 2 - p 175–180
doi: 10.1097/MOT.0000000000000060
ETHICAL, LEGAL AND FINANCIAL CONSIDERATIONS: Edited by Kathy L. Coffman

Purpose of review: Fulminant hepatic failure (FHF) is one of the more dramatic and challenging syndromes in clinical medicine. Time constraints and the scarcity of organs complicate the evaluation process in the case of patients presenting with FHF, raising ethical questions related to fairness and justice. The challenges are compounded by an absence of standardized guidelines.

Recent findings: Acetaminophen overdose, often occurring in patients with histories of psychiatric illness and substance dependence, has emerged as the most common cause of FHF. The weak correlations between psychosocial factors and nonadherence, as per some studies, suggest that adherence may be influenced by systematic factors. Most research suggests that applying rigid ethical parameters in these patients, rather than allowing for case-dependent flexibility, can be problematic.

Summary: The decision to transplant in patients with FHF has to be made in a very narrow window of time. The time-constrained process is fraught with uncertainties and limitations, given the absence of patient interview, fluctuating medical eligibility, and limited data. Although standardized scales exist, their benefit in such settings appears limited. Predicting compliance with posttransplant medical regimens is difficult to assess and raises the question of prospective studies to monitor compliance.

aIcahn School of Medicine, New York, New York, USA

bMount Sinai St Luke's – Roosevelt Hospital, Assistant Professor Psychiatry, Icahn School of Medicine, New York, New York, USA

Correspondence to Swapna Vaidya, MD, Director Psychosomatic Medicine Fellowship St Lukes Roosevelt Hospital, Mount Sinai Health System Assistant Professor Psychiatry, Icahn School of Medicine Office location – 1090 Amsterdam avenue, 16th floor, New York, NY 10025, USA. Tel: +1 212 523 3763; fax: +1 212 523 2056; e-mail: svaidya@chpnet.org

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