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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 3  |  Page : 221-224

Decision-making in complex clinical scenarios using an ethical framework: Kidney transplantation in a patient with severe left ventricular dysfunction


1 Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
4 Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission19-May-2019
Date of Decision06-Jun-2019
Date of Acceptance28-Aug-2019
Date of Web Publication17-Sep-2019

Correspondence Address:
Dr. Sreejith Parameswaran
#5348, Department of Nephrology, Super Speciality Block, Jawaharlal Institute of Postgraduate Medical Education and Research Campus, Dhanvantari Nagar P O, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_13_19

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  Abstract 


Complex medical scenarios such as organ transplantation often bring up complex ethical issues for the medical practitioner. Knowledge about evidence-based medical evaluation and management combined with adhering to fundamental principles of medical ethics will go a long way in protecting the interests of all the stakeholders. Here, we discuss a complex scenario faced by our kidney transplantation team about offering transplantation for a patient with severe left ventricular dysfunction and how we used a framework of ethical principles in clinical decision-making.

Keywords: End-stage renal disease, heart failure, medical ethics, transplantation


How to cite this article:
Parameswaran S, Lata S, Satheesh S, Ramanitharan M. Decision-making in complex clinical scenarios using an ethical framework: Kidney transplantation in a patient with severe left ventricular dysfunction. Indian J Transplant 2019;13:221-4

How to cite this URL:
Parameswaran S, Lata S, Satheesh S, Ramanitharan M. Decision-making in complex clinical scenarios using an ethical framework: Kidney transplantation in a patient with severe left ventricular dysfunction. Indian J Transplant [serial online] 2019 [cited 2019 Dec 9];13:221-4. Available from: http://www.ijtonline.in/text.asp?2019/13/3/221/266941




  Introduction Top


Medical practitioners face moral and ethical dilemmas on a day-to-day basis while caring for their patients. Complex clinical scenarios such as organ transplantation bring up complex ethical issues. The code of professional medical ethics provides a framework to address and resolve ethical challenges. Understanding and application of the ethical principles are important for all medical professionals. Here, we describe a complex situation faced by our kidney transplantation team and how the team successfully addressed the issue using a medical ethics framework.


  Case Report Top


A 37-year-old man was diagnosed with chronic kidney disease and end-stage renal disease and was initiated on maintenance hemodialysis at his hometown. His mother volunteered to donate her kidney, and the patient with his voluntary kidney donor (VKD) came to our hospital 6 months after he was initiated on dialysis. During pretransplant evaluation, he was found to have severe left ventricular (LV) dysfunction (LV ejection fraction [LVEF] 25%–30%). He had no history of any heart disease in the past; he was not a smoker. There was no history suggestive of coronary artery disease in the past. He was extensively evaluated in Cardiology department for the cause of LV dysfunction, including a coronary angiogram and stress myocardial perfusion imaging. No evidence of myocardial ischemia or structural heart disease could be identified. His functional status was good, and the perioperative risk assessment for cardiovascular events determined by “Revised Cardiac Risk Index” was 15% (Class IV risk).[1] After evaluation of the recipient and the VKD was completed, a kidney transplantation team meeting, comprising of representatives from Departments of Anesthesiology and Critical Care, Urology, and Nephrology was convened to discuss the treatment plan, in view of the severe LV dysfunction in the recipient and difference of opinion within the kidney transplantation team about the best way forward. A faculty from Cardiology Department also attended the meeting. The following issues came up for discussion at the meeting:

  1. Does the patient really know about the risks involved in the operation, or is he asking for the same from being ignorant of the potential complications?
  2. The patient may be willing to take the risk and give high-risk consent for the operation, but knowing the risks involved in the operation, can the medical team be “compelled” to proceed with the operation, just because the family accepts the risks involved, including perioperative mortality?
  3. Is it worthwhile doing kidney transplantation in a patient with heart failure, taking the additional risk of perioperative complications? What if the heart failure worsens after the kidney transplantation? The kidney is being donated by a living donor, who has to be subjected to unnecessary risk of a major operation and is this warranted if the transplantation operation may eventually turn out to be futile, in case the patient dies of heart failure soon after transplantation?
  4. There are other centers performing kidney transplantation operation in the patient's native state, why not refer the patient to such a center, instead of operating him in our hospital?


Clinical decision-making in complex situations using an ethical framework

This situation highlights the importance of clear understanding and adherence to ethical principles of medical care in day-to-day practice, including the principles of patient autonomy, beneficence, and nonmaleficence. In addition, there was a difference of opinion among the members of the Kidney transplantation team about the best course of action.

The principle of respecting patient autonomy

Does the patient really know about the risks involved in the operation or is he asking for the same from being ignorant of the potential complications?

The patient was a graduate and was productively employed before he developed kidney failure. His wife was a paramedical professional (medical laboratory technician). The couple had consulted nephrologists and cardiologists elsewhere before approaching JIPMER for kidney transplantation operation. He was aware of the heart condition, its severity and its progressive nature. He was informed by the nephrologists he consulted that patients with such poor function of the heart had poor long-term survival on dialysis treatment. Since the patient did not have heart disease before he developed kidney disease and no obvious reason could be identified for the heart disease, he believed that it was related to the kidney failure and the heart function may improve after kidney Transplantation. The patient and his wife felt that his best chance of survival was to undergo kidney transplantation as soon as possible. He had inquired about the risks involved with the operation and after weighing the option of remaining on dialysis which is known to be associated with poor survival versus undergoing kidney transplantation operation, which is associated with significant risk of perioperative life-threatening complications but may offer better long-term survival, he had opted for the option of undergoing kidney transplantation. It was evident that the patient and his family had taken an informed decision about kidney transplantation.

Respecting patient “Autonomy” is one of the fundamental principles of medical ethics.[2],[3] Medical practitioners must respect the ability of the patient to make informed decisions about their personal matters, including medical matters, with freedom. “Paternalistic” attitude from medical practitioners is no longer considered acceptable, with values of the society evolving over time and significant emphasis being placed on assessing outcomes in line with expectations of the patients, their family, and their values and not that of the medical professionals. We are expected to not only respect patient autonomy but also to act always in a way to promote informed autonomous actions by patients. Hence, it was decided by the transplantation team that the patient and family's informed decision to pursue transplantation operation must be accepted.

The principles of nonmaleficence and beneficence

The patient may be willing to take the risk and give high-risk consent for the operation, but knowing the risks involved in the operation, can the medical team refuse to proceed with the operation, especially in view of the possibilities of a litigation at a later date which cannot be ruled out, if operation results in serious complications or mortality? Is it worth doing kidney transplantation in a patient with heart failure, taking the additional risk of perioperative complications? What if the heart failure worsens after the kidney transplantation?

“Primum nonnocere” or “Above all, do not harm” is considered one of the fundamental principles of medical ethics.[2],[3] It is well known that medical interventions may be associated with adverse effects, and even a beneficial treatment might be associated with serious adverse effects. It is possible that the medical practitioner may get carried away by the potential benefits of a treatment or might venture into therapeutic interventions swayed by emotional appeal or socioeconomic background of patients and may not evaluate or give attention to the possible harm patients may suffer from such treatment. Medical practitioners should weigh the potential benefits of the proposed treatment plan with all potential adverse effects and should pursue a treatment plan which will not ultimately harm the patient. It is more important to not cause harm than to do good to a patient.[2],[3]

The principle of beneficence in the context of medical practice implies that the medical practitioner's actions should always be aimed to serve the best interests of the patient and their families and this is considered a core ethical principle of medical practice.[2],[3]

The principles of nonmaleficence and beneficence may appear to be contradictory, as is evident in our case. The proposed treatment plan – kidney transplantation operation – is expected to significantly improve long-term survival and quality of life of the patient, if successful. However, the risks associated with the procedure are high, in view of the heart condition. When faced with a situation where the proposed treatment is expected to benefit the patient while at the same time expected to cause a known harm, the medical practitioner should weigh the expected benefits against the possible adverse effects and pursue a management plan where the benefit outweigh the harm; after ensuring that the patient and the family understand and accept possible risks and benefits.[3]

A formal perioperative risk assessment for cardiovascular events was performed on the patient, using accepted guidelines.[1] In addition to routine cardiovascular evaluation, the patient also underwent a coronary angiogram and a stress myocardial perfusion imaging, both of which were normal, there was no evidence of myocardial ischemia. His functional status was good, and he did not have symptoms of heart failure such as peripheral edema, exertional breathlessness, or pulmonary crackles. However, low LVEF, even in the absence of symptomatic heart failure, is known to be associated with poor outcomes after noncardiac surgery. Patients with LVEF ≤29% have significantly poorer survival compared to those with LVEF >29%.[1] After optimization of dialysis dose, correction of anemia, control of secondary hyperparathyroidism, and ensuring euvolemic status using bioimpedance technique (Body Composition Monitor, Fresenius Medical Care, Germany)-guided assessment of dry weight and initiating and titrating beta-blocker (carvedilol) to the maximum tolerated dose, his LV function showed marginal improvement. The cardiologist opined that the cardiac status did not warrant heart transplantation at that point of time. The anesthesiology team assessed that the perioperative risk was high but was not unacceptable.

Literature review revealed that in patients with LVEF <40% prior to kidney transplantation operation, 86% of patients showed at least 5% improvement in LVEF after transplantation operation and 70% had an LVEF of >50% after transplantation.[4] The only risk factor for failure of improvement in LVEF after transplantation operation was the duration of time the patient had spent on dialysis prior to transplantation.

It was assessed that there was a significant chance of improvement of LV function after a successful kidney transplantation operation and this, in turn, may offer a significant survival advantage to him compared to remaining on dialysis. The quality of life was expected to be significantly better after kidney transplantation, compared to dialysis. Thus, there was definite and significant benefit from performing the kidney transplantation operation in him. At the same time, the perioperative cardiovascular risk was not prohibitively high. The kidney transplantation team arrived at a consensus that the expected benefits of the operation outweighed the potential adverse effects, and it was also evident that the patient and his family fully understood the risks and benefits. The team decided to proceed with the transplantation operation after obtaining informed consent from the patient and family.

There are other centers performing kidney transplantation operation in the patient's native state and why not refer the patient to such a center, instead of operating him in our hospital?

One of the primary reasons the patient approached JIPMER for the transplantation operation was the accessibility of the program (operation performed free of cost); he was unable to raise enough money for undergoing kidney transplantation at the next nearest kidney transplantation center, which was 150 km away. Refusing to accept him for the operation at our center will force his family to go to another center where the treatment may be more expensive. If the family fails to raise funds for the operation elsewhere, he may end up not undergoing transplantation. It is also possible that the operation may be delayed, even if the family succeeds in raising funds. The team also agreed that our hospital already had almost all infrastructures to perform the operation and to deal with any complications that may arise following the operation. The team decided that it was not in the best interest of the patient to refer him elsewhere for operation.

The management of the patient and follow-up information

Once an informed consent was obtained, the patient was taken up for kidney transplantation with his mother as the VKD. The operation and postoperative period were uneventful and there were no adverse cardiovascular events or prolonged ventilatory requirement. The kidney graft function was excellent, and he was discharged from the hospital with a baseline creatinine of 1.2 mg/dl on postoperative day 12. He remains asymptomatic on follow-up and an echocardiogram done 3 months after kidney transplantation operation revealed LVEF of 45% (LVEF was 25% prior to transplantation).


  Conclusions Top


Systematic, evidence-based clinical assessment and using an ethical framework for decision-making in complex medical scenarios will help medical practitioners in making clinical decisions in the best interest of all stakeholders. All medical practitioners should have a clear understanding and should be able to apply principles of medical ethics in day-to-day clinical decision-making.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: A report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol 2014;64:e77-137.  Back to cited text no. 1
    
2.
Lo B, Grady C. Ethical issues in clinical medicine. In: Harrison's Principles of Internal Medicine. 20th ed., Ch. 8. McGraw-Hill Education. United States of America.  Back to cited text no. 2
    
3.
McCormick TR, Principles of Bioethics. Bioethics Tossssols, University of Washington School of Medicine. Available from: https://depts.washington.edu/bioethx/tools/princpl.html.  Back to cited text no. 3
    
4.
Wali RK, Wang GS, Gottlieb SS, Bellumkonda L, Hansalia R, Ramos E, et al. Effect of kidney transplantation on left ventricular systolic dysfunction and congestive heart failure in patients with end-stage renal disease. J Am Coll Cardiol 2005;45:1051-60.  Back to cited text no. 4
    




 

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