Volume 23 No 2 July 2014 by WorldWeb Group

Transplant Journal of Australasia Volume 23 No 2 July 2014

Explore, Dream, Discover O f f i c i a l j o u r n a l o f t h e Tr a n s p l a n t N u r s e s â&#x20AC;&#x2122; A s s o c i a t i o n I n c .

Medicine, Miracles and Beyond Transplant Nurses’ Association 23rd National Conference 17-18th October 2014 | Mercure Hotel Irwin Street, Perth, Western Australia

For further information please visit the conference website at www.tna.asn.a Corina Jary on (08)9224 8793 email: corina.jary@health.wa.gov.au or Emily Toohey on (08) 9346 4415 emily. toohey@health.wa.gov.au

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For further information please visit the conference website at www.tna.asn.au Alternatively, contact Corina Jary P: (08) 9224 8793 E: corina.jary@health.wa.gov.au or Emily Toohey P: (08) 9346 4415 E: emily.toohey@health.wa.gov.au

TRANSPLANT JOURNAL OF AUSTRALASIA

CO NTE NTS Journal of the Transplant Nurses’ Association Inc. NATIONAL EXECUTIVE

TNA National Executive report

Guest editorial Transplant nursing: Changing scope of practice

President Claire West Tel: (02) 9515 7274 Fax: (02) 9515 3606 Email: president@tna.asn.au

Cynthia L Russell

Editorial 3

Secretary Libby John Tel: (08) 8204 5819 Fax: (08) 8204 6959 Email: secretary@tna.asn.au

Diary dates

Letter to the Editor

Editorial Board

Articles

‘One Stop Shop’ for all your travel needs Secretariat Shoma Mittra Tel: 0433 558 125 Email: secretariat@tna.asn.au

Barriers to becoming active on the renal transplant waiting list Emma van Hardeveld, Belinda Jones, Tim Hewitson, Stephen Holt and Peter Hughes

Treasurer Julie Pavlovic Tel: (03) 9496 3972 Fax: (03) 9496 3487 Email: treasurer@tna.asn.au

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A Quality Service Lung cancer after double-lung transplantation from a donor with a 25-year cancer-free period Competitive airfares and accommodation rates following curative colon cancer resection Editor A Visa Service Travel Insurance Teik E Oh, Michael T Musk, Andree J Gould, Marie A Tracey Mackay Schaumann, Geoffrey C Mullins and Bruce P Powell Email: TJAeditor@tna.asn.au Travelex Foreign Exchange Cash Passports Passport Photographs Attitudes to end-of-life issues and organ and ISSN 1323-5109 Published by the Transplant Nurses’ Association Inc. All correspondence to: Shoma Mittra, TNA Secretariat

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JOURNAL SUBMISSION DETAILS FOR 2 0 1 4 For 2014 the Transplant Journal of Australasia (TJA) will be produced in March, July and December. Papers are submitted to the Editorial Board, which provides feedback to the author prior to publishing. All papers will be sub-edited to journal style before publication — please refer to the Guidelines for Authors for more details on this and for detailed submission information.

Volume 23 Number 2 – July 2014

TRANSPLANT JOURNAL OF AUSTRALASIA

T N A N AT I O N A L E X E C U T I V E R E P O R T As we reach the midway mark for 2014, I’m sure many of you are wondering where the last six months have gone! It has been a busy year so far, for many transplant units, with record transplant numbers achieved already in many centres. It is wonderful to see donation and transplantation figures increasing, and let’s hope it can be sustained.

Website — websites are a fantastic way to communicate with our membership, but can be costly. We are working to ensure our website is as cost-efficient, user-friendly and informative as possible.

Transplant Library — this online transplant resource is a new initiative the TNA has provided to members. This database can be accessed free This edition of the TJA provides a bittersweet of charge by members via the TNA website and reflection on the wonderful skills and qualities allows members to search current research and Libby John of several of our long-term TNA members. It publications in all areas of transplantation. We was with sadness that we learned of the death are looking for feedback about use and relevance of a much-loved member, Kerry Murry, who passed away of the Transplant Library from our members, to inform our in Queensland in May. A tribute to her can be found in this decision about renewing this service for another 12 months. edition, and our thoughts are with her loved ones and the Scholarships — due to financial restraints we have had to Princes Alexandra Hospital Transplant Unit staff at this time. reduce the number of scholarship application rounds to one It is fitting, however, that we also celebrate the dedication per year until otherwise advised. This allows us to budget and passion that transplant nurses such as Kerry bring to more accurately and fairly for scholarship award expenditure. our profession, so we were absolutely delighted when we heard that theatre nurse Jenny Watson from the Australian I would also like to remind members that it is not just money National Liver Transplant Unit was awarded a Public Service that ensures the TNA works, it is the invaluable contribution Medal for outstanding public service to the Royal Prince from those who hold positions in state and national executive Alfred Hospital, particularly in the continued improvement of that make the TNA such a special association. Without these liver transplant surgery at the hospital, in this year’s Queen’s people donating their time and expertise, we would not be Birthday awards. Congratulations Jenny; an award well able to continue. As such, I would like to remind members deserved for many years of exemplary work and all those that recently an expression of interest was circulated for the sleepless nights! We are very proud of you. position of TJA Editor. While this may seem like a daunting We also recently became aware that our TJA Editor, Tracey Mackay, Nurse Donation Specialist at Royal Melbourne Hospital, and DonateLife volunteer, Leanne Campbell, received a Victorian Minister of Health Outstanding Volunteer Achievement Award for their voluntary participation as group leaders with The Compassionate Friends. Tracey and Leanne run a support group for bereaved parents and siblings of organ and tissue donors. Congratulations Tracey and Leanne, it is wonderful to have your passionate commitment to the care of donor families recognised by the state government.

role, it is in fact an incredibly rewarding position to undertake from a personal and professional point of view. Training and mentoring will be provided for the new TJA Editor, and current Editor Tracey Mackay or I would be more than happy to have a “no obligation” chat with anyone who would like to find out more about this position.

The National Executive continues to work hard at providing our members with as much educational and professional support as we can. This is becoming increasingly difficult in our economically challenged climate. The TNA has had a significant reduction in income this year, due to a reduction in sponsorship funding. However, we are constantly reviewing and revising the delivery of our key membership initiatives to ensure we can sustain and maintain what we see as vital services to our members. These services include:

The 2014 Annual Conference is fast approaching and everyone will be heading west to Perth, 17–18 October. The program and registration details are now available via the TNA website, so book your leave now! The 2014 TNA AGM will be held during the Perth conference, so please support our association by attending. Elections will be held at the AGM for the positions of TNA National Secretary and TNA National Treasurer. A call for nominations will be sent out in early August. Please seriously consider yourself or a colleague for one of these positions. Position descriptions can be found in the TNA Constitution on the TNA website, and any executive member is always available to talk to if you would like to obtain more information.

Annual Conference — the budget, format and organisational aspects of our national conference are currently under review, and recommendations will be put to members at the 2014 AGM.

“What is the recipe for successful achievement? To my mind there are just four essential ingredients: Choose a career you love, give it the best there is in you, seize your opportunities, and be a member of the team.” Benjamin F Fairless

TJA — all current editions are available online for members via the website, in e-reader format. Let us know if you’d like to cancel your hard copy and access the free, online version only.

Happy transplanting.

Libby John TNA National Secretary Volume 23 Number 2 – July 2014

TRANSPLANT JOURNAL OF AUSTRALASIA

EDITORIAL ‘Twenty years from now you will be more disappointed by the things that you didn’t do than by the ones you did do. So throw off the bowlines. Sail away from the safe harbor. Catch the trade winds in your sails. Explore. Dream. Discover’.

management and improve the patient’s suitability for assessment onto the waiting list.

Mainak Majumdar, Jodi Vuat, Kylie Lambert from Peninsula Health donation service, provided a research article, ‘Attitudes to end of life issues and organ and tissue donation amongst medical staff: a Mark Twain single centre survey’, in which they surveyed the Cynthia (Cindy) L. Russell, President, International medical staff of their hospital and discovered a lack Transplant Nursing Society and Professor, School of education and training in decision-making and of Nursing and Health Studies, University of communication skills regarding end of life care, Tracey Mackay Missouri has kindly provided the Guest Editorial. influenced the ability of these doctors to provide Her piece, ‘Transplant Nursing: Changing Scope informative, sensitive donation conversations of Practice’, discusses the five pillars that have developed routinely in end of life care discussions with families. and progressed transplant nursing into the specialty that In the article, ‘Lung cancer after double-lung transplantation we practice today. These pillars will change and progress from a donor with a 25-year cancer-free period following in the future, as more research is undertaken, as evidence is curative colon cancer resection’, Dr Teik E. Oh, et al., explore implemented into practice and transplant nursing emerges as the current knowledge surrounding carcinoma disease a recognized area, defined by the expert knowledge and skill transmission from donor to recipient and using a case of the specialty nurses. scenario, discusses the different possibilities of disease In this edition of the TJA, I have incorporated articles origin. addressing different areas of the donation and transplant For the first time, we have published a ‘Letter to the Editor’! sector, but each article relates to research and investigation carried out by enthusiastic, committed health professionals I thank Lesley Sheffield and Bronwyn Ludlum for their that strive to provide evidenced based, best practice care to willingness to share their views of the article ‘Thank you – their patients and families. How hard is it?’ (TNA Journal, Volume 23, No 1 – March In the first article, ‘Barriers to becoming active on the renal transplant waiting list’, Emma van Hardeveld and Belinda Jones from the Melbourne Health Kidney Care service, identified and explored the reasons that dialysis patients were not given access to transplantation. This retrospective study gave them insight into how they can influence patient

2014). I encourage all members to write to the Editor to give feedback on the articles that you read in the journal. I hope you enjoy this edition of the TJA. Tracey

DIARY DATES 2014 For more information, check out the links on the TNA website http://www.tna.asn.au 26-31 July 2014

25-27 August 2014

3-5 October 2014

17–18 October 2014

2014 World Transplant

Renal Society of Australasia

2014 European Organ

Transplant Nurses’

Congress

Annual Conference

Donation Congress 25th

Association

San Fransisco

Melbourne Convention and

EDTCO

23rd National Conference

USA

Exhibition Centre

Budapest

Mercure Hotel

Australia

Hungary

Irwin Street, Perth, WA, Australia

Volume 23 Number 2 – July 2014

TRANSPLANT JOURNAL OF AUSTRALASIA

LETTER TO THE EDITOR

addressing Tracey Mackay for Many thanks to eiving an donor families rec the importance of st-transplant. m the recipient po acknowledgement fro t Journal of rd is it?” (Transplan “Thanks — how ha 2014) clarified 23, No 1 — March Australasia, Volume Coordinator n Specialist Nursing for me — a Donatio r families who ing struggle of dono (DSNC) — the ongo ch as Rose meet at gatherings su speak to me when we Services of and Remembrance Planting Ceremonies no word of n. Nothing — no card, the void post-donatio d sometimes otion, frustration an thanks — the pure em derstood that ble. It is well un bitterness, is palpa ones’ organs donate their loved these families didn’t it somehow or thanks; however, expecting recognition ent and huge sense of bewilderm leaves them with a rrespondence en there is no co disappointment wh

l guilty when somehow I always fee their recipients, yet ilies ask me speak of and the fam there are no letters to why?

an data from ppen? South Australi So, why doesn’t it ha all recipients that only one-third of 2011–2013 showed s, and of this their donor familie corresponded with m our home ters were received fro group 75% of those let be explained view is that this can state. Our considered encourage nsplant units actively by the fact that SA tra rture a close ipients to write; we nu SA liver and renal rec nsplant units r liver and renal tra relationship with ou twice a week. face to face once or — seeing each other annual Rose ordinators attend the Also, Transplant Co mbrance and and Service of Reme Planting Ceremony emotions and nor families’ stories, are exposed to the do the future. recipients’ hopes for you to a family is t forget, a thank no ’s let , So whatsoever. ke a vital decision that they chose to ma on ati rm nfi co hy down, “W e s feelings of being let lives, a positive choic The family expresse umatic time in their tra st mo a at n ca ntly — dy. This is confirmed her, seemingly flippa ll share with everybo bother?” said one fat wi y the ich wh urs and his (not ’s telling his neighbo Survey 2010–2011 you imagine what he ent Donor Family rec the in ask me: t 60% of nor family members evidence suggests tha community? Often do yet published) where ing a letter from the nd comfort in receiv erything at the ev fou s ve ilie ga e fam W ? ite wr t “How could they no recipient. es.” worst time of our liv importance of the no doubt about the someone’s be n n thi ca wi ng ere ati Th be is heart “My 18-year-old son’s sue donation. It is iple of organ and tis a thank ) nc en pri c (ev t sti no rui d alt an es their liv tem is based chest; they are living irit upon which our sys the very powerful sp ver, for this you.” ly proud of it. Howe and we are justifiab o remember to know how uld be prudent to als itten? We just want spirit to endure it wo “Why haven’t they wr nothing. To ‘thank you’. It costs the power of a simple they are.” s. t of life, it is priceles those who give the gif families, that it’s to ate ter rei d an in As DSNCs we expla say thank recipients to write or Lesley Sheffield r SA not mandatory for the ar he Nursing Coordinato we en wh Donation Specialist her inadequate rat ms see all t tha t you, bu ir devastating antly recounting the donor families poign Also Bronwyn Ludlum losing a loved one. of e nc rie ications Officer SA pe ex ing life-alter Media and Commun or ni Se at wh me so l pretend we don’t fee we as DSNCs can’t messenger or r role being only as slighted, despite ou mmunication spondence. The co the conduit for corre unity and m the transplant comm pathway emanates fro

Volume 23 Number 2 – July 2014

TRANSPLANT JOURNAL OF AUSTRALASIA

GUEST EDITORIAL

Transplant nursing: Changing scope of practice Cynthia L Russell • PhD, RN, ACNS-BC-FAAN President, International Transplant Nursing Society and Professor School of Nursing and Health Studies University of Missouri, Kansas City, Missouri, USA

The field of transplantation is continuously advancing. With

The transplant nurse must remain current on these

the progression of chronic disease, the advancement of

challenging issues. These advances bring with them complex

technology and treatment options, and the limited numbers of

ethical and social issues7.

solid organs available for transplant, the scope of transplant nursing practice is rapidly changing. Transplant nurses must continually examine their abilities for ways to improve their knowledge, skills and experience. Being a transplant nurse requires an advanced level of nursing knowledge and a love of life-long learning. Together, these support transplant

Transplant nursing excellence is also challenged due to the worldwide shortage of transplant nurses. This shortage is anticipated to grow as our population ages. Additionally, in many countries, nurses in general, and transplant nurses more specifically, are sometimes not valued for their

nursing excellence.

contribution to patient, family, and community care. They are

Many pressures are placed on transplant nurses, challenging

knowledgeable, autonomous thinkers that they are.

nursing excellence. The number of older individuals and those living with chronic disease continues to grow, resulting in an increased demand for solid organ transplantation.

expected to follow medical orders, not to be the skilled and

Transplant nursing excellence is supported by our professional practice standards. Continuous practice improvement is the

Since solid organ donation has not met the need, technology

new expectation for transplantation and transplant nurses.

and treatment options have changed in an attempt to fill the

Transplant nurses are certified in their appropriate role to

gaps. For example:

establish a baseline level of transplant knowledge, skills, and experience. Experienced transplant nurses seek regular,

• Heart failure clinics support those waiting for a transplant. Left-ventricular assist devices support patients during longer waiting times and are more portable with fewer complications. • Technology is also improving organ preservation and recipient outcomes. Lungs and kidneys are now thermoregulated, oxygenated and perfused by machines during transport so that they are in optimal condition for transplantation. • The ability to transplant non-lifesaving, quality of lifeimproving tissues such as face and hands is now a reality1.

high-quality knowledge through educational programs and conferences. Increasingly, educational programs are more accessible through online venues, which keep costs low. Patient education focuses on providing the requisite knowledge and skills by the transplant nurse to patients, families and communities, thus encouraging optimal transplant outcomes. This includes self-management, support for safety and self-monitoring skills with available technology. All transplant nurses are required to review new research and practice guidelines for potential inclusion in their own practice. When practice changes are made, the impact of these changes on patient, family and community outcomes are monitored using quality and performance

• Creation of organs from stem cells is on the horizon.

improvement approaches.

• Tailoring transplant medications to the patient’s specific

Transplant nurses should participate in regular professional

genetic markers is being tested2. Transplant medications

practice evaluation, which includes both self, and peer

have been redesigned to decreasing dosing to once a

evaluations. Collegiality is maintained among the intra-

day instead of twice a day, which increases adherence to

professional team members with goal-focused transparent

these critical drugs3.

and open communication. Experienced transplant nurses

• Using nanotechnology to make transplant medications traceable within the patient’s body is possible4. • Patient self-monitoring of many important bodily functions via smart phones is occurring5,6.

Volume 23 Number 2 – July 2014

are encouraged to support and mentor new learners and seek leadership positions to move the team forward. Transplant nurses collaborate and communicate with the patient, their family and the community, encouraging links and resource provision for seamless care. 5

TRANSPLANT JOURNAL OF AUSTRALASIA

Integration of ethical principles in practice is an overarching requirement. Nurses are challenged as new technology creates uncharted territory with ethical dilemmas. With constraints on financial resources, questions develop about who should receive the limited organs available. This problem has led to organ trafficking and its associated care dilemmas.

Nursing Scope and Standards of Practice published by the American Nurses Association. The standards for transplant nursing and standards for professional practice are presented for the transplant nurse, the transplant nurse coordinator, and the advanced practice transplant nurse. Publishing this document established transplant nursing as a specialty practice.

Finally, leadership in professional organisations is an integral role for the transplant nurse. The worldwide transplant nursing community is involved in shaping the future of transplant nursing, which prevents others from dictating what our future will be.

Table 1: Transplant Nursing Standards and Professional Nursing Standards

Transplant nurses must look to five pillars to develop and maintain transplant nursing excellence. Transplant nursing and its scope of practice has emerged as a specialty, with five key pillars supporting transplant nursing excellence and improved patient and family outcomes. The first pillar was created in 1988, when the American Board for Transplant Certification (ABTC)8 was founded as an independent, not-for-profit organisation for the purpose of awarding a voluntary, non-governmental certification. The ABTC offers credentialling for the Certified Clinical Transplant Coordinator (CCTC), the Certified Procurement Transplant Coordinator (CPTC), and the Certified Clinical Transplant Nurse (CCTN). They have since added the Certified Transplant Preservationist (CTP) (“American Board of Transplant Certification”). These credentials are provided to qualified transplant professionals who have successfully passed the certification examination, which represents a standard of competence. The second pillar was developed in 2008, when Linda Ohler and Sandra Cupples published the Core Curriculum for Transplant Nurses9. This book provides a guide for the safe and effective care of solid organ transplant recipients. It is frequently and easily referred to for information on the unique issues related to heart, lung, kidney, liver, small intestine, and pancreas/islet cell transplantation — all covered in separate chapters. Other chapters address immunology, infections, pharmaceutical agents, patient education and discharge planning, and topics common to all organ transplants. The third pillar was established in 2009, when the International Transplant Nursing Society (ITNS) developed and published the Transplant Nursing: Scope and Standards of Practice10. This document describes transplant nursing and its development, characteristics of transplant nursing, educational requirements, globalisation, palliative care, ethics and informed decisions, advanced practice transplant nursing, specialty certification, and future considerations for transplant nursing (Table 1). Transplant Nursing: Scope and Standards of Practice is based upon three foundational nursing documents including: Nursing’s Social Policy Statement, the Code of Ethics for Nurses with Interpretive Statements, and 6

Transplant Nursing Standards Assessment Diagnosis Outcomes Identification Planning Implementation Evaluation Professional Nursing Standards Quality of Practice Education Professional Practice Evaluation Collegiality Collaboration Ethics Research Resource Utilisation Leadership The fourth pillar of transplant nursing excellence formed when the Introduction to Transplant Nursing: Core Competencies were developed and published by ITNS. This document describes the competencies relative to the 15 domains of transplant nursing practice for the transplant nurse, the transplant nurse coordinator, and the transplant advanced practice nurse. A nursing competency is a statement that describes skill, knowledge, or other characteristics required for nursing practice. These competencies are designed to guide the new transplant nurse, coordinator, or advanced practice nurse in developing foundational abilities for excellence in transplant nursing care. Currently, ITNS is developing the fifth pillar, a professional advancement scale for transplant nurses, transplant coordinators, and transplant nurses in advanced practice. These documents will describe the knowledge, skills and expertise needed for each level of transplant nursing practice — from novice, to competent, to expert. Advancement scales are needed to retain transplant nurses, especially transplant nurse coordinators11. Transplant nurses face many challenges to provide excellent nursing care. Fortunately, we are supported by professional practice standards. These pillars provide the foundation for

Volume 23 Number 2 – July 2014

TRANSPLANT JOURNAL OF AUSTRALASIA

transplant nurses to develop and excel for the best patient and family outcomes. Transplant nurses make up ‘One World of Caring’. Our patients, families and communities deserve our best — transplant nursing excellence.

References 1. Siemionow M & Ozturk C. Face transplantation: outcomes, concerns, controversies, and future directions. Journal of Craniofacial Surgery 2012; 23(1):254–259. DOI: 10.1097/ SCS.0b013e318241b920 2. Cattaneo D, Perico N & Remuzzi G. From pharmacokinetics to pharmacogenomics: a new approach to tailor immunosuppressive therapy. American Journal of Transplantation 2004; 4(3):299– 310. DOI: 10.1111/j.1600-6143.2004.00312.x 3.

Kuypers DR, Peeters PC, Sennesael JJ et al. Improved adherence to tacrolimus once-daily formulation in renal recipients: a randomized controlled trial using electronic monitoring. Transplantation 2013; 95(2):333–340. DOI: 10.1097/ TP.0b013e3182725532

4. Wüthrich RP, Eisenberger U, Bock A et al. Towards a gold standard for adherence assessment in transplantation: high

accuracy of the proteus raisin system (PRS) combined with enteric-coated mycophenolate sodium (ECMPS) in stable kidney transplant recipients: 625. Transplantation 2012; 94(10S):245. 5.

Kugler C, Gottlieb J, Dierich M et al. Significance of patient selfmonitoring for long-term outcomes after lung transplantation. Clinical Transplantation 2010; 24(5):709–716. DOI: 10.1111/j.1399-0012.2009.01197.x

Miloh T, Annunziato R, Arnon R et al. Improved adherence and outcomes for pediatric liver transplant recipients by using text messaging. Pediatrics 2009; 124(5):e844–850. DOI: 10.1542/ peds.2009-0415

7. Abouna GM. Ethical issues in organ transplantation. Medical Principles and Practice 2003; 12(1):54–69. DOI: 68158 8. American Board of Transplant Certification (ABTC). Retrieved 13 May 2014 from: www.abtc.org 9. Ohler L & Cupples SA. Core Curriculum for Transplant Nurses. St Louis, Missouri: Mosby, 2008. 10. Transplant Nursing: Scope and Standards of Practice. Silver Springs, MD: American Nurses Association, 2009. 11. Russell CL & Van Gelder F. An international perspective: job satisfaction among transplant nurses. Progress in Transplantation 2008; 18(1):32–40.

TRANSPLANT LIBRARY AVAILABLE ONLINE TO ALL TNA MEMBERS NOW! What is the Transplant Library? The Transplant Library is an online resource providing high-quality, evidence-based information on all aspects of solid organ transplantation. The Transplant Library is updated every two weeks with new randomised controlled trials (RCTs) and every four weeks with new systematic reviews. Why should I access the Transplant Library? • Includes all RCTs, including congress abstracts. • Provides access to selected, good-quality systematic reviews. • RCTs published from 2004 have been given a methodological quality rating. • Selected RCTs have been reviewed by the Centre for Evidence in Transplantation (CET). • Main conclusions written by experts from the CET. • Trial registration information. • Direct access to free full-text articles. • All RCTs in solid organ transplantation. • Over 8,000 RCTs from 1970 (earliest record) to present. • Including over 4,000 congress abstracts. • Selected good-quality systematic reviews and meta-analyses from 2008 (over 315). • Includes records that are electronically published ahead of print updates. How do I access the Transplant Library? It’s easy! TNA members simply need to go to the TNA website www.tna.asn.au and log on with their email address and password. There is a Transplant Library direct link on the home page, or you can go to the “documents and resource” tab and click on “members links”. This will take you straight into the Transplant Library database … no need for any further user names or passwords. A Transplant Library search guide is also available on the TNA website “documents and resource” page.

Volume 23 Number 2 – July 2014

Novartis is very proud to support the Transplant Nurses Association

Long term commitment Designed by .com.au 1422/0414 Novartis Pharmaceuticals Australia Pty Ltd ABN 18 004 244 160 54 Waterloo Road North Ryde NSW 2113 TRA0067, First issued April 2014.

TRANSPLANT JOURNAL OF AUSTRALASIA

ARTICLE

Barriers to becoming active on the renal transplant waiting list Emma van Hardeveld *, Belinda Jones, Tim Hewitson, Stephen Holt and Peter Hughes RMH Kidney Care Service, Royal Melbourne Hospital, Melbourne Health, Melbourne, Vic, Australia * Corresponding author: Emma Van Hardeveld, RMH Kidney Care Service, Royal Melbourne Hospital, Melbourne Health, Parkville, Vic 3050, Australia Tel: +61 3 9342 3133 Fax: +61 3 9347 1420 Email: Emma.vanhardeveld@mh.org.au

Abstract Following a recent report showing that nationwide only 19% of dialysis patients less than 65 years of age are listed as active on the deceased donor renal transplant waiting list (ACTIVE), we set out to examine the barriers to listing. To explore this, we retrospectively queried our nephrology database (Nephworks) to analyse patients commencing dialysis between January 2010 and December 2011. In that time 143 new patients (<65 years) commenced renal replacement therapy (RRT) in our service. Of these, 24% (n=34) were transplanted, 4% (n=6) were referred for simultaneous kidney-pancreas transplantation (SPK), 8% (n=11) died, and a further 26% (n=38) were active on the transplant list by December 2011. The remaining 38% (n=54) were not listed and we explored the reasons for this. We identified nine categories that were problematic (with three patients falling into more than one category). Three of these categories accounted for 65% of this patient group — 26% were classified as obese, 20% were excluded due to extensive cardiovascular co-morbidity and 19% had simply failed to be referred for transplant assessment. Other categories included malignancy, irreversible airways disease, infectious disease, no access to Medicare, social (including patient refusal) and high-risk primary disease recurrence. In conclusion, nearly half (45%) of patients not listed for transplantation had potentially modifiable barriers to transplant listing (obesity, cardiac risk, lack of referral). A focus on patient referrals and active weight reduction strategies may significantly improve the number of patients activated onto transplant waiting lists.

Introduction Renal failure results from a diverse range of causes and continues to be a major health problem worldwide. Within Australia, 1 in 9 (1.7 million) adults have some degree of impaired kidney function, with approximately 10,000 of these currently receiving ongoing dialysis for end-stage kidney disease (ESKD)1. Kidney transplantation is widely accepted as the best treatment option for people with ESKD as it offers significant improvements in quantity and quality of life, when compared to contemporary renal replacement therapies2, and is considerably cheaper than dialysis therapies after one year. Patients deemed suitable for renal transplantation can either be transplanted pre-emptively (generally from a living donor) or listed on the deceased donor transplant waiting list, awaiting subsequent organ allocation. Assessment of suitability for transplantation is rigorous and multidisciplinary. Whilst there are sound clinical reasons for some patients not being suitable for transplantation, significant differences exist in the ‘acceptance’ criteria between institutions and there are no current Australian guidelines for transplant assessment and ultimate suitability. 10

A recent review by Pussell et al.3 of the 2010 ANZDATA registry data revealed that the proportion of dialysis patients across all age groups who were wait-listed for transplantation was alarmingly low. In the age group of 65 and under, Australia had the lowest percentage (18%) compared to France (49%)4, the UK (48%)5 and the US (33%)6. Although there are likely to be significant methodological differences of determining the percentage wait-listed in each country, the overwhelming message is that a substantial proportion of dialysis patients are not being offered the opportunity to receive a kidney transplant. The aim of this retrospective study was to determine the proportion of our incident dialysis patients <65 years that were on the deceased donor renal transplant waiting list, and further to define the reasons why the remainder were not achieving active status on the waiting list.

Methods Our comprehensive in-house nephrology database (Nephworks) was used to retrospectively examine data from all patients commencing dialysis in our major metropolitan

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Results

TRANSPLANT JOURNAL OF AUSTRALASIA

and regional dialysis service between January 2010 and December 20117. When considering our patient population for analysis, we were mindful that changes to clinical practice in recent years could impact on our data. Advances in transplant outcomes and safety, broadening acceptance criteria, and changes in general community expectations have been evident since 2009. Acknowledging this, we restricted our analysis to a two-year period post 2009. Patient outcomes were followed until July 2012. We examined the detailed records of those patients who did not achieve ACTIVE status.

Results We identified 143 new patients fitting our criteria who commenced renal replacement therapy We identified 143 new patients fitting our criteria who

RRT) during the study time period. The outcome thesethe patients is shown in figure 1. commenced renal replacement therapy (RRT)ofduring study time period. The outcome of these patients is shown in Figure 1.

Figure 2: Reasons for patients not being listed on the transplant waiting list

cardiovascular disease, thus restricting their suitability.

two ofwho these patients, each co-morbidity alone was risk a factors o ThoseInpatients, featured in more than one category, had both significant risk todisease preventthus transplantation. weightsufficiently and significant cardiovascular restricting their The suitability. In 2 body mass index (BMI) range of our patient group who

patients, each co-morbidity alone was a sufficiently significant risk to prevent transpla

were unable to access transplantation was 35.4–60.4, which

The Body Mass Index (BMI) range of our patient group who were unable to

covers the moderate to morbid obese profile8 (Table 1).

transplantation was 35.4 – 60.4, which covers the moderate to morbid obese pr (TableTable 1). 1: Patient BMI distribution and dialysis modality

Figure 1: Outcomes for all patients aged 65 years and under commencing dialysis between January 2010 and December 2011

Patient 1

Dialysis modality

BMI

HDx (Satellite)

60.4

Figure 1: Outcomes for all patients aged 65 years and under commencing dialysis between Patient 2 PD Between of RRT and July 2012, 34 of these anuary 2010 andcommencement December 2011. patients were transplanted, six were referred for simultaneous pancreas-kidney transplantation (SPK), 11 died and 38 were active on the deceased donor kidney transplant waiting list.

Patient 3

Nocturnal HDx

35.4

Patient 4

HDx (Satellite)

44.8

Between commencement of RRT and July 2012, 34 of these patients were transplanted, 6 The remaining 54 patients were not active and these patients

38.1

HDx (Satellite)

45.5

were examined further. were referred for simultaneous pancreas-kidney transplantation (SPK), were Patients11 6 died and 38HDx (Satellite)

36.7

ctive on

Patients 5

The barriers preventing activation of these patients fell into Patient 7 the deceased donor kidney transplant waiting list. The remaining nine categories, with some overlap (Figure 2). The three

reasonspatients for not achieving ‘active’ status (65% of the ot active main and these were examined further. patients), included obesity (26%), extensive cardiovascular disease (20%), and failure to be referred for transplant assessment (19%). Other categories included malignancy,

54 patientsPD-HDx were (Satellite)

Patient 8

HDx (Satellite)

47.8

Patient 9

HDx (Satellite)

35.4

Patient 10

HDx (Satellite)

Patient 11

The barriers preventing activation these patients irreversible airways disease,ofinfectious disease, fell andinto no 9 categories, with some overlap access to Medicare, social (including patient refusal) and

Figure 2). The 3 main reasons for not achieving ‘active’ status (65% of the patients), high-risk primary disease recurrence. Males accounted for

37.2

Patient 12

HDx (Satellite)

38.6

65% (35)(26%), of this group. ncluded obesity extensive cardiovascular disease (20%),Patient and failure to be referred 13 HDx (Satellite)

42.9

Those patients, who featured in more than one category,

or transplant assessment (19%). Other categories included malignancy, Patient 14irreversible airways HDx (Satellite) had both risk factors of excess weight and significant

isease, infectious disease, and no access to Medicare, social (including patient refusal) and Volume 23 Number 2 – July 2014

igh-risk primary disease recurrence. Males accounted for 65% (35) of this group.

TRANSPLANT JOURNAL OF AUSTRALASIA

Of the 10 patients not referred for consideration of

We considered whether peritoneal dialysis as a modality

transplantation, nine were from regional areas. A regional

could have been a factor contributing to excess weight and

area is considered to be locations greater than 100 km from

central obesity. In agreement with previous data by Lievense

Melbourne as per the Department of Health9.

et al.14, this was not supported in the analysis (Table 1).

Discussion

It is well appreciated that diet and exercise form an

The recent review by Pussell, Bendorf and Kerridge3 of the 2010 ANZDATA registry revealed that nationwide only 19% of dialysis patients <65 years of age are active on the renal transplant waiting list. Whilst these figures seem better than the national average, there was a still a large proportion (38%) of patients failing to achieve ACTIVE status. Forty-five per cent of these had potentially modifiable (weight, cardiac risk and lack of referral) factors. The main objective of pre-transplant cardiac evaluation

important part of lifestyle changes needed to achieve and support sustained weight loss. Providing dietary counselling and improving patient motivation may assist patients in achieving weight loss. The motivation of a transplant may drive adherence to diet and exercise; however, for this to be successful, significant resource allocation may be required and may not be available or prioritised. To achieve the desired weight loss, more aggressive strategies — including referral for bariatric surgery — may be warranted, but this route is presently limited by cost and accessibility.

is to identify existing cardiac conditions amenable to risk

Most disappointingly, 19% of patients had not been referred

modification, and to exclude patients with poor short-term

for transplant assessment. Lack of referral was an identified

survival prospects.

issue for those patients who commenced RRT in local

There may be some ESKD patients, where early cardiac intervention can enable optimisation for transplantation, but there will always be patients in whom intervention will never improve the risk profile to allow for renal transplantation.

satellites/regional areas. This group of patients (nine out of the 10) had never been referred to or consulted with a physician at the major, affiliated metropolitan centre for the purposes of renal transplantation assessment.

Decisions regarding cardiac interventions may be influenced

The reasons for the lack of referral are likely to be

by the possibility of reducing the patient’s cardiac risk

multifactorial and include: the distances patients need to

and, thus, improving the patient’s likelihood of being listed

travel for testing; education and assessment; and local

as ‘active’ on the waiting list and eventually receiving a

physician practices. There did not appear to be any obvious

transplant.

demographic or medical differences in these patients compared to others commencing RRT in our unit. Presently,

There have been conflicting reports as to the short-term

one regional area has received access to biannual visiting

and long-term success of renal transplants in patients in

transplant assessment teams provided by our service —

extreme excess of their ideal body weight. Older reports

consisting of a nephrologist, transplant surgeon, a social

have concluded that transplantation in obese recipients is

worker and a transplant coordinator. This group of health

associated with increased patient mortality, diminished short-

professionals conduct clinics to assess transplant suitability

term and long-term graft survival, and increased surgical and

and provide education for informed transplant listing. Of

medical complications10,11. More recent studies have reported

note, this is an area of significant multiculturalism, inclusive

that obese patients have survival and complication rates

of a large Indigenous population. This service has had a

comparable to age-matched non-obese controls2,12,13.

positive impact on patients, promoting transplantation and

According to the World Health Organization classification, a BMI of 30–34.9 kg/m2 is defined as obese class I (mild),

facilitating assessment in their local area, while at the same time minimising impact on their social, working and financial lives. It may be beneficial for our service to consider the

35–39.9 kg/m2 as obese class II (moderate) and >40 kg/m2 as

implementation of this model in other regional areas as a

obese class III (morbid)8. While BMI is the most widely used

means of increasing local physician support, the promotion

marker of obesity, it is acknowledged that this is not always

of transplantation and a means to address the barriers we

a good indicator of fat-mass or central obesity.

have identified.

With this in mind, all patients are assessed individually by

The remaining metropolitan patient was not referred due to

the transplant team to assess weight distribution, degree of

misconceptions about transplant suitability from the patient

central adiposity in relation to height and surgical risk — so

perspective. Language difficulties may have contributed

no ‘cut-off’ for acceptance at our centre formally exists.

to this perception. Improvements in patient access to

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TRANSPLANT JOURNAL OF AUSTRALASIA

information in their primary language would be beneficial in this situation. Limitations of this study include the retrospective nature of the study design, the failure to account for co-morbidities and complications (for example, diabetic complications). Nevertheless, our single-centre experience may be helpful in defining the regional experience and may be applicable across other areas.

Conclusion While there are a number of unmodifiable reasons that some patients may not be deemed suitable for transplantation, we identified 45% of patients in our service that had potentially modifiable barriers to transplant listing (predominantly weight, cardiac risk and lack of referral). Promotion of the benefits of transplantation and early referral to transplant centres could potentially improve the percentage of patients listed for transplantation and ultimately improve patient outcomes if they are successfully transplanted.

References 1.

Kidney Health Australia. Key Chronic Kidney Disease Statistics in Australia. Available from: http://www.kidney.org.au (accessed 20 February 2013). 2. Tonelli M, Wiebe N, Knoll G et al. Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes. American Journal of Transplantation 2011; 11(10):2093–2109. 3. Pussel BA, Bendorf A, Kerridge IH. Access to the kidney transplant waiting list: a time for reflection. Internal Medicine Journal 2012; 42:360–363.

4. Agence de la biomedicine. Le rapport médical et scientiﬁque du prélèvement et de la greffe en France. http://www.agencebiomedecine.fr/annexes/bilan2010/donnees/organes/06-rein/ synthese.htm#t2France (accessed 18 November 2011). 5. Rommel R, O’Neill J, Webb L, Casula A & Johnson R. Centre variation in the access to renal transplantation in the UK (2004–2006). In: Feest T, Fogarty D eds. UK Renal Registry 13th Annual Report 2010; 13: 247–51. 6. Organ Procurement and Transplantation Network (OPTN) and Scientiﬁc Registry of Transplant Recipients (SRTR). OPTN/SRTR 2010 Annual Data Report. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, 2011. 7. Royal Melbourne Hospital Kidney Care Service, Nephworks Clinical Database, 2012. 8. World Health Organization. Global Database on Body Mass Index. Available from: http://apps.who.int/bmi/index. jsp?introPage=intro_3.html 9. Department of Health Victoria. Victorian Patient Transport Scheme (VPTAS), 2013. 10. Meier-Kriesche H, Arndorfer JA & Kaplan B. The impact of Body Mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation 2002; 73(1):70–74. 11. Espejo B, Torres A, Valentin M et al. Obesity favors surgical and infectious complications after renal transplantation. Transplantation Proceedings 2003; 35:1762–1763. 12. Massarweh N, Clayton JL, Mangum CA, Florman SS & Slakey DP. High body mass index and short and long-term renal allograft survival in adults. Transplantation 2005; 80(10):1430– 1434. 13. Gill JS, Lan J, Dong J et al. The survival benefit of kidney transplantation in obese patients. American Journal of Transplantation 2013; 13:2083–2090. 14. Lievense H, Kalantar-Zadeh K, Lukowsky LR et al. Relationship of body size and initial dialysis modality on subsequent transplantation, mortality and weight gain of ESRD patients. Nephrology Dialysis and Transplantation 2012;27(9):3631–8.

Editorial Board Michelle Harkess Heart/Lung Transplant Tracey Hughes Liver Transplant Tracey Mackay (Previous) Nurse Donation Specialist Tracy McConnell-Henry (Previous) Nurse Donation Specialist Nick Nuttall Eye Bank Catherine O’Driscoll CNC, Surgery Myra Sgorbini Donor Coordinator Shoma Mittra TNA Secretariat Bruce Maguire Social worker — Liver Transplant Yaprak Sarigo Liver Transplant Bronwyn Hayes Renal Transplant

Volume 23 Number 2 – July 2014

Member

NSW

mharkess@stvincents.com.au

Member

VIC

tracey.hughes@austin.org.au

Editor

VIC

TJAeditor@tna.asn.au

Member

VIC

tracy.mcconnell-henry@monash.edu

Member

QLD

nichalas_nuttall@health.qld.gov.au

Member

catherine.o’driscoll@health.wa.gov.au

Member

NSW

myra.sgorbini@sswahs.nsw.gov.au

Secretariat

secretariat@tna.asn.au

Member

Bruce.Maguire@health.wa.gov.au

Member

Turkey

yapraksarigol@gmail.com

Member

QLD

bronwynhayes@aapt.net.au

TRANSPLANT JOURNAL OF AUSTRALASIA

ARTICLE

Lung cancer after double-lung transplantation from a donor with a 25-year cancer-free period following curative colon cancer resection Teik E Oh • MBBS, MD, FRACP, FRCP, FANZCA, FCICM Emeritus Professor, University of Western Australia, Hospital Medical Director, DonateLife WA, Australia Michael T Musk • MBBS, FRACP Medical Director, WA Lung Transplant Unit, Royal Perth Hospital, Perth, WA, Australia Andree J Gould • BSc (Nursing), Assoc Dip Health Sci Clinical Nurse Consultant, DonateLife WA, Australia Marie A Schaumann • B Nursing, Cert Crit Care Donor Coordinator, DonateLife WA, Australia Geoffrey C Mullins • MBBS, FANZCA, FRCPC Hospital Medical Director, DonateLife WA, Australia Bruce P Powell • MBBS, MRCP, FRCA, FANZCA State Medical Director, DonateLife WA, Australia

Abstract Cancer in solid organ transplant recipients is an uncommon complication of organ transplantation. Lung cancer is the third most prevalent type of cancer in transplant recipients, after non-melanoma skin cancer and lymphomas1-3. The risk of cancer arising in a transplant recipient is attributed mainly to immunosuppression, but cancer can recur in the recipient or rarely occur de novo from donor transmission1-3. Differentiating a primary lung adenocarcinoma in a transplant recipient from a metastatic colorectal adenocarcinoma transmitted from the donor can be difficult. This paper describes the occurrence of lung cancer after double-lung transplantation from a donor with a 25-year cancer-free period following curative colon cancer resection. Potential organ donors need to be carefully evaluated for the risk of transmitting cancers, particularly the older age group and those with a past history of colorectal cancer, despite apparent long disease-free intervals.

Introduction Organ transplantation has made remarkable progress over the past three decades, but is still a major undertaking with potential complications. Malignancy in the recipient is a recognised but uncommon complication. The risk of cancer in transplant recipients is attributed mainly to immunosuppression, but may recur in a recipient with preexisting disease or occur de novo1,2. Differentiating between a primary cancer and inadvertent transmission from the donor can present difficulties1-3.

Clinical report A 62-year-old female presented to a hospital in Perth in October 2010 after having collapsed at work. On examination, 14

she was comatose with a Glasgow Coma Scale 3 with fixed dilated pupils. Her past medical history included treatment for hypertension and an anterior resection for colon cancer in 1985. The cancer was ACPS A or T2N0M0 (confined to within bowel wall). She had three subsequent colonoscopies; in 2000, 2007 and June 2010, all showing benign polyps and no evidence of malignancy. Other events included a hysterectomy and bilateral salpingo-oophorectomy in 1990 for endometriosis and ovarian cysts, a cholecystectomy in 1996, and a basal cell carcinoma resection on her right leg in 2000, all without complication. A cranial CT examination showed a large perimesencephalic haemorrhage. She was admitted to the ICU, and the next day, after confirmation by brain death tests, was certified

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TRANSPLANT JOURNAL OF AUSTRALASIA

dead. DonateLife WA verified her consent for organ donation

lung cancer for lung recipients4. Non-melanoma skin cancer

with the Australian Organ Donation Registry. Following

(NMSC) and lymphomas are the most prevalent types of

a family conversation, consent for organ donation was

cancer reported, with lung cancer next1,2. Cancer occurrences

obtained from her senior next-of-kin. Her kidneys and lungs

are obviously affected by the type of cancer, its extent, time

were found to be suitable for donation and these organs were

since treatment, and the natural history of the cancer in the

retrieved shortly after death was certified. The kidneys were

normal population1-3.

transplanted into two middle-aged males.

The increased risk of cancer in transplant recipients is

Both lungs were transplanted into a 51-year-old male who

attributed to immunosuppression, but cancer may recur in a

had suffered idiopathic pulmonary fibrosis (IPF) for the

recipient with a history of pre-existing disease. Malignancy

previous two years, with a poor prognostic median survival

may also rarely occur de novo, due to inadvertent transmission

of three months. The transplanted lungs and the recipient’s

from a donor, a risk that has always been recognised1-3.

explanted lungs were examined during surgery. No signs

Protocols and guidelines exist to minimise this. Nonetheless,

suggestive of early malignancy were seen in either pair. The

isolated reports of tumour transmission continue to occur.

recipient’s clinical course was initially uneventful on an

In the UK, 0.05% of all transplant recipients had cancer

immunosuppressive regimen of tacrolimus, prednisolone,

transmitted from 0.09% of donors5. Donors aged 45 years

and mycophenolate mofetil. Cytology from bronchoalveolar

or more were nine times more likely to result in cancer

lavage (BAL) and lung biopsy specimens at three and six

transmission than younger donors5.

months post-transplantation, showed normal cells with no evidence of rejection. However, at 15 months posttransplantation, chest X-ray changes of a right lung pleural reaction with pleural effusion and basal atelectasis were

The standardised incidence ratio (SIR) denotes the risk relative to the cancer incidence in the general population. Lung transplant recipients have the greatest SIR for all

seen. He underwent a surgical repair of his sternal malunion

cancers except NMSC in Australian, UK and US reports1-3.

19 months post-transplantation. A chest CT examination at

Past reports of cancer occurrence did not differentiate

that time showed a right lower lobe mass with a small right

between single- and double-lung transplants. Most lung

pleural effusion. Cytology of the pleural effusion showed

cancers in single-lung transplant recipients were reported

no malignant cells. The right pleural effusion with basal

to arise in the remaining, often diseased native lung,

atelectasis persisted in chest X-ray examinations over the

although there are case reports of cancer developing in

next six months. Lung cancer was confirmed in November

the transplanted lung6. Our double-lung recipient had no

2012, 25 months post-transplantation, by cytology of

pre-existing cancer. His lung cancer may have arisen de

pleural fluid and a lung biopsy, which showed mucinous

novo from immunosuppression or by donor transmission.

adenocarcinoma. Immunohistochemical (IHC) staining

Increased lung cancer has been reported among patients

showed thyroid transcription factor-1 (TTF1)-ve, cytokeratin

with IPF7. Residual, undetected native cancer cells may have

20 (CK20)+ve and cytokeratin 7 (CK7)-ve for pleural fluid

given rise to the lung cancer post-transplantation. However,

but CK7+ve for the biopsy specimen. An endoscopy and

the removal of both native lungs makes this exceedingly

colonoscopy in November 2012 showed no gastrointestinal

unlikely, and any residual cancer would have manifested

malignancy. His immunosuppressive agents were reduced

earlier than 25 months after transplantation.

and he was started on chemotherapy, but his condition deteriorated. A cranial CT scan in February 2013 showed

Colon cancer recurrence

multiple intracranial metastases. He received palliative care

The donor had her colon carcinoma resected 25 years

and died in April 2013, 30 months after transplantation.

previously. Follow-up colonoscopy examinations, the last one only four months before her death, had not shown

Cancer in transplant patients

malignancy, although some polyps showed hyperplasia on

The main sources of information on cancer in transplant

histology. The prognosis of Australian Clinico-Pathological

recipients are studies of national cancer and transplant

Staging (ACPS) A colon cancer is good, with a five-year

registries and sporadic reports of cases . The incidence of

survival rate of over 90%8,9. If survival is extended to 15 years

cancer in post-transplant patients is 1–2%. Organ recipients

after resection, five-year conditional survival reached almost

have an overall risk more than twice that of the general

100%. However, ultra-late recurrences after curative primary

1-3

population in developing 32 different types of cancer .

resection have been reported, after an apparent cancer-

The incidence of specific cancers varies with the organs

free interval of 5–35 years10-12. Synchronous or interval

transplanted. In general, the risk of kidney cancer is greatest

adenomatous polyps were frequently seen11 and metastasis,

for kidney recipients, liver cancer for liver recipients, and

especially to lung, was frequently observed10. The risk of

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TRANSPLANT JOURNAL OF AUSTRALASIA

metachronous colorectal cancer may be lifelong13. A “tumour

A small percentage of certain cancers are due to a faulty gene

dormancy” hypothesis has been suggested, whereby cancer

acquired or inherited from a biological parent. BRAF is a

cells may be present after surgery but would remain dormant

human gene that makes a protein B-Raf which is involved in

for unknown reasons12. Many years later, cancer cells arise

directing cell growth. BRAF gene mutation is associated with

from cell changes to prompt cancer metastasis .

melanoma and to a lesser extent, non-Hodgkin’s lymphoma,

colorectal cancer, thyroid carcinoma, and lung non-small cell

Differentiation of primary from metastatic cancer

carcinoma and adenocarcinoma22. BRAF gene mutation was found in our recipient, but did not help identify the origin of

Differentiating primary lung adenocarcinoma from colorectal adenocarcinoma metastatic to the lung can be confounding, as histological appearances are similar14,15. IHC markers

the lung adenocarcinoma. He had no history of melanoma. Whether our recipient’s lung adenocarcinoma was primary

have been used for discriminating primary from metastatic

or metastatic remains inconclusive. A metastatic origin

pulmonary adenocarcinoma15,16. TTF1 is a nuclear protein

was suggested by the IHC staining studies, but not with

that regulates genes specific to lung, thyroid, and diencephalon

reasonable certainty. Chromosome, FISH, and gene mutation

tissues, and is a marker of the distal respiratory unit. Positive

studies were not helpful. Metastasis to donated lungs 25

TTF1 immunoreactivity has been identified in over 90% of

years after curative resection of early-stage colon cancer

primary lung adenocarcinomas

with a high sensitivity

in the donor (the “tumour dormancy” hypothesis), and

(91%) and specificity (98%)15. CK7, a marker of embryological

manifesting 25 months after transplantation, seems unlikely.

foregut derivation, has distribution in simple, stratified, ductal

On the other hand, it is also unlikely that the recipient

epithelium found in the breast, ovary, lung and uterus. CK7

developed primary lung adenocarcinoma de novo two years

expression is found in the majority of lung adenocarcinomas,

after his double-lung transplantation.

16-18

with a negative or low positivity in colorectal cancer16. CK20 is an epithelial cytokeratin and a marker of embryological

Suitability of donors

hindgut derivation. Immunoreactivity is commonly positive

The question arises whether the donor’s organs were

in colorectal adenocarcinoma, transitional cell carcinomas,

suitable for transplantation. The US organ donation and

and Merkel cell carcinoma, but negative in lung cancer .

transplantation network regarded potential donors with

Dennis et al. found a 68% sensitivity and 91% specificity in

colon carcinoma at any stage as a high risk of transmitting

colorectal cancer . Primary lung adenocarcinoma is typically

cancer in transplants23, except for the patient in remission

TTF1+ve/CK7+ve/CK20-ve. Our recipient’s IHC staining

for more than 10 years. Benign tumours, such as polyps,

profile was TTF1-ve/CK20+ve. This profile is suggestive of

posed no significant risk. Australian guidelines recommend

the adenocarcinoma being of colorectal origin. Nonetheless,

absolute contraindications to organ donation if the donor

lack of TTF1 expression does not exclude a pulmonary origin

has HIV or Creutzfeldt-Jakob disease, active malignancy, or a

for a CK7+ve adenocarcinoma in the lung. Our recipient

history of melanoma or choriocarcinoma (malignancies with

was CK7-ve for pleural fluid but CK7+ve for the biopsy

a high risk for transmission, irrespective of the disease-free

specimen. A TTF1-ve/CK20+ve expression for primary lung

period)24. Patients with other past malignancies and a long

adenocarcinoma has been reported in tumours classified

cancer-free interval represent a small risk of transmission and

as mucinous adenocarcinoma16,17. This adenocarcinoma

should still be considered as potential donors24. Thus, organ

arises from bronchi (proximal respiratory tree) which may

donation from our donor complied with Australian and US

have a different IHC profile. Our recipient’s cytology showed

guidelines.

mucinous adenocarcinoma. Detecting the sex chromosomes in the tumour may differentiate whether its origin is female, that is, the donor. The cytogenetic technique, fluorescence in situ hybridisation (FISH)20, showed the presence of a single X-chromosome. This can arise either via a female losing an X-chromosome, or a male losing a Y-chromosome, and was unfortunately unhelpful to differentiate between primary (male recipient)

The use of genetic screening to detect genes associated with the development of cancer25 when evaluating the suitability of organ donors is impractical, in terms of unacceptable time delays, multiplicity of suspect genes, and high costs. To reject a potential donor on the basis of positive screening for a gene that increases the risk of, but may not eventuate in, cancer in the subject will only reduce the donor pool.

or metastatic (female donor). We did not have the facility of

The transplant teams were notified of the lung recipient’s

molecular genetic analysis using molecular probes to identify

cancer and they have closely followed up the two kidney

the origin of the tumour21.

recipients. To date, both are doing well.

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TRANSPLANT JOURNAL OF AUSTRALASIA

Conclusion

Harris JM, Johnston IDA, Rudd R et al. Cryptogenic fibrosing alveolitis and lung cancer: the BTS study. Thorax 2010; 65:70–76.

O’Connell JB, Maggard MA & Ko CY. Colon cancer survival rates with the new American Joint Committee on Cancer Sixth Edition Staging. Journal of the National Cancer Institute 2004; 96:1420–1425.

Australian Institute of Health and Welfare (AIHW). Cancer survival and prevalence in Australia: period estimates from 1982 to 2010. Cancer Series no. 69. Canberra: AIHW, 2012.

Cancer transmission from donor to recipient is a rare complication in organ transplantation1-3. With an increasing wait-list of patients for organ transplantation, there is a need to increase the pool of usable donor organs. The decision to use the organs of a patient with a past history of cancer depends on the donor age, tumour, histology, cancer stage, and the cancer-free survival26. Indeed, numerous organ transplant recipients have had successful outcomes from receiving organs from donors with a past history of treated benign intracranial tumours and small renal cell carcinoma2. The risk of transmitting colon cancer from a donor with a curative resection of colon cancer many years ago is unknown, but must be very rare. Overall, the very small risk of any tumour transmission needs to be balanced against the likely mortality for potential organ recipients at the top of the transplant wait-list. In our recipient, his risk of dying far exceeded any risk of acquiring cancer. Thus cases need to be assessed individually, to evaluate the transmission risk and potential recipients’ urgency for organs, including discussions with potential recipients on benefits and risks. Despite the very low incidence of colon cancer in lung transplant recipients (SIR 1.1)2, we recommend that potential donors with a past history of colon cancer should be considered an increased risk for cancer transmission, even though there may be a long cancer-free interval. The older-aged donor adds to the risk. Unexplained intracranial haemorrhage, as in the case of the donor, may need close consideration.

Acknowledgements We would like to thank A/Professor Bruce Latham, Pathologist, Royal Perth Hospital, for reviewing the manuscript and his helpful advice.

References

10. Cho YB, Chun HK, Yun HR et al. Clinical and pathologic evaluation of patients with recurrence of colorectal cancer five or more years after curative resection. Diseases of the Colon and Rectum 2007; 50:1204–1210. 11. Luchtefeld MA, Ross DS, Zander JD et al. Late development of metachronous colorectal cancer. Diseases of the Colon and Rectum 1987; 30:180–184. 12. Janssens JF, T’syen M, Verhaegen S et al. Ultra-late recurrences of gastro-intestinal carcinoma after primary resection: the mechanism of dormancy. Acta Gastro-enterologica Belgica 2012; 76:251–254. 13. Bouvier AM, Latournerie M, Jooste V et al. The lifelong risk of metachronous colorectal cancer justifies long-term colonoscopic follow-up. European Journal of Cancer 2008; 44:522–527. 14. Li HC, Schmidt L, Greenson JK et al. Primary pulmonary adenocarcinoma with intestinal differentiation mimicking metastatic colorectal carcinoma. The American Journal of Pathology 2009; 131:129–133. 15. Dennis JL, Hvidsten TR, Wit EC et al. Markers of adenocarcinoma characteristics of the site of origin: development of a diagnostic algorithm. Clinical Cancer Research 2005; 11:3766–3772. 16. Simsir A, Wei XJ, Yee H et al. Differential expression of cytokeratins 7 and 20 and thyroid transcription factor-1 in bronchioloalveolar carcinoma. American Journal of Clinical Pathology 2004; 121:350–357. 17. Moldvay J, Jackel M, Bogos K et al. The role of TTF-1 in differentiating primary and metastatic lung adenocarcinomas. Pathology Oncology Research 2004; 10:85–88. 18. Rekhtman N, Ang DC, Sima CS et al. Immunohistochemical algorithm for differentiation of lung adenocarcinoma and squamous cell carcinoma based on large series of whole-tissue sections with validation in small specimens. Modern Pathology 2011; 24:1348–1359. 19. Chu P, Wu E & Weiss LM. Cytokeratin 7 and cytokeratin 20 expression in epithelial neoplasms: a survey of 435 cases. Modern Pathology 2000; 13:962–972.

Collet D, Mumford L, Banner NR et al. Comparison of the incidence of malignancy in recipients of different types of organ: A UK Registry audit. American Journal of Transplantation 2010; 10:1889–1896.

Engels EA, Pfeiffer RM, Fraumeni JF et al. Spectrum of cancer risk among US solid organ transplant recipients. Journal of the American Medical Association 2011; 306:1891–1901.

21. De Soyza AG, Dark JH, Parums DV, Curtis A & Corris PA. Donor-acquired small cell lung cancer following pulmonary transplantation. Chest 2001; 120:1030–1031.

Chapman JR, Webster AC & Wong G. Cancer in the transplant recipient. Cold Spring Harbor Perspectives in Medicine 2013; 3pii:a015677.

22. Paik KP, Arcila ME, Fara M et al. Clinical characteristics of patients with lung adenocarcinoma harboring BRAF mutations. Journal of Clinical Oncology 2011; 29:2046–2051.

Hall EC, Pfeiffer RM, Segev DL & Engels EA. Cumulative incidence of cancer after solid organ transplantation. Cancer 2013; 119:2300–2308.

23. Nalesnik MA, Woodle ES, DiMaio JM et al. Donor-transmitted malignancies in organ transplantation: assessment of clinical risk. American Journal of Transplantation 2011; 11:1140–1147.

Neuberger J. Cancer in transplant recipients. In: Theme 6 — Organ donation and transplantation. NHS Blood and Transplant — Research and Development Triennial Report 2009–12. London: NHS, 2012, p. 48.

24. Australasian Transplant Coordinators Association ACTA. National Guidelines for Organ Donation. Australian Transplant Coordinator’s Association. 4th edn, 2008.

Abrahams NA, Meziane M, Ramalingam P et al. Incidence of primary neoplasms in explanted lungs: long term follow-up from 214 lung transplants. Transplantation Proceedings 2004; 36:2808–2811.

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20. National Human Genome Research Institute (NHGRI). Fluorescence in situ hybridization (FISH). Bethesda, MD: NHGRI, 2011.

25. Vogelstein B & Kinzler KW. Cancer genes and the pathways they control. Nature Medicine 2004; 10:789–799. 26. Orens JB, Boehler A, de Perrot M, et al. A review of lung transplant donor acceptability criteria. Journal of Heart and Lung Transplantation 2003; 22:1183–1200.

TRANSPLANT JOURNAL OF AUSTRALASIA

ARTICLE

Attitudes to end-of-life issues and organ and tissue donation amongst medical staff: a single-centre survey Mainak Majumdar * • MBBS, FJFICM Medical Donation Specialist, Peninsula Health, C/- Intensive Care Unit, Frankston Hospital, Hastings Road, Frankston, Vic 3199, Australia Tel: +61 3 9784 7777 Email:mmajumdar@phcn.vic.gov.au Jodi Vuat • RN Nurse Donation Specialist, Peninsula Health, Hastings Road, Frankston, Vic 3199, Australia Tel: +61 3 9784 7777 Email: jvuat@phcn.vic.gov.au Kylie Lambert • RN Nurse Donation Specialist, Peninsula Health, Hastings Road, Frankston, Vic 3199, Australia Tel: +61 3 9784 7777 Email: klambert@phcn.vic.gov.au * Corresponding author. No funding was received for this study. There are no conflicts of interest to declare.

Abstract Objective: Limited information is available on knowledge and attitudes of Australian health care workers on end-of-life issues including organ and tissue donation. We surveyed medical staff in a single Victorian metropolitan teaching hospital regarding their attitudes towards organ and tissue donation within the context of end-of-life care. Method: A written survey was distributed to a cross-section of medical staff at various educational forums within Peninsula Health. Information collected included current level of responsibility in the organisation, duration of experience as medical professionals, current exposure to patients potentially needing end-of-life care and experience in communicating end-of-life issues with patients and surrogates. Priorities in determination of decisions regarding end-of-life care were assessed and information was collected regarding prior training and experience in discussing organ and tissue donation in the context of end-of-life care. Results: Of 97 respondents, 78.6% were doctors with less than three years of clinical experience, 49.5% reported no previous education on end-of-life care issues and 49.5% reported no prior education on organ and tissue donation. Despite an appropriate matrix of rationales forming the basis for limitation or cessation of therapies, 32.65% would not routinely discuss organ and tissue donation with dying patients or their surrogate decision makers. Conclusion: Our survey revealed a lack of training in decision making and communication regarding end-of-life care issues. It highlighted the negative impact of not normalising donation conversations into routine end of life care discussions.

Introduction

packages including e-learning programs, targeted theoretical

Transplantation is an accepted therapeutic option to save or improve the quality of life in selected patients with end-stage organ disease.

and practical training, and international professional training programs in the field are described3,4. Preclinical exposure to organ and tissue donation improves both knowledge and attitudes to organ donation of medical students5. Community

There is consensus that the most important problem in

attitudes towards organ and tissue donation in Australia are

transplantation is the scarcity of donors and, consequently,

generally positive6. The majority of Australians are willing

a shortage of organs for the number of potential recipients1.

to become organ (80%) and tissue (78%) donors7. Despite

All efforts in donation are now focused on increasing the

such community support, Australia compares poorly with

donation rate of each country . Best practice measures include

many countries in the western world in terms of actual donor

training of health care students and professionals. Training

numbers (Figure 1).

Volume 23 Number 2 – July 2014

Medical staff attitudes to end of life issues and organ and tissue donation

! ! ! ! !

Medical staff attitudes to end of life issues and organ and tissue donation ! (Figure 2). Seventy (71.5%) identified themselves as interns,

International Donor Statistics 2011

residents andclinical hospital medical officers (HMOs). Fifty-eight Postgraduate experience (yrs) from medical respondents !

Donors PMP 35.9

33.5

TRANSPLANT JOURNAL OF AUSTRALASIA

28.5

Postgraduate clinical experience (years) from medical respondents

25.9

23.2

20.0

17.4

14.9

14.7

13.2 8.6

<12 months ain

a ati Cro

rt Po

tri

s Au

tvi La

ech Cz

li tra

s Au

y an

erl

th Ne

Source: IRODaT (International Registry of Organ Donation and Transplantation

! !

1-3 years

Figure 1

4-6 years 7-10 years

>10 years

Methods

Figure 2

Between December 2009 and February 2011, all members of medical staff (interns, residents, registrars and consultants) attending education sessions on organ and tissue donation at our metropolitan teaching hospital were invited to fill

! (59.8%) reported being exposed to the care of critically

in a form surveying their attitudes to end-of-life care and organ donation. The surveys were distributed as printed

unwell patients in an acute setting less than five times a week

(Figure 3).Medical staff attitudes to end of life issues and organ and tissue donation !

Medical respondents exposure to the care of critically unwell patients in an acute setting

hard copies and respondents returned completed surveys by hospital internal mail or directly to the medical or nurse donation specialist for the hospital.

<2 per week 2-5 per week

This was a descriptive study to assess existing levels of

6-10 per week

knowledge and attitudes to death, dying and organ and

>10 per week

tissue donation amongst medical staff employed in our organisation. All respondents were voluntary attendees at designated hospital education sessions on organ and tissue donation. All responses to the survey were also voluntary. Thus, specific institutional ethical approval was not sought. Data was entered into Excel spreadsheets (Microsoft Office for Mac 2008, Microsoft Corp, Redmond, Washington, USA)

Figure 3

Eighty-eight (91.65%) characterised their experience of

Medical respondents exposure to the care of critically unwell patients in an acute ! setting having discussions with patients and next of kin regarding

wishes around the end of life, including ICU admission,

CPR, initiation of life support and organ and tissue donation (Figure 4) as “Sometimes”, “Not Often” and “Rarely”.

and statistical analysis was done using GraphPad Prism 6 (GraphPad Software Inc, La Jolla, CA, USA). Frequency distribution tables were made. Nonparametric matched sets of data were compared using Friedman test. Nonparametric

Medical respondents experience of having discussions with patients and next of kin regarding wishes around end of life, including ICU admission, CPR, initiation of life support and organ and tissue donation

data sets were examined for correlation by calculating Spearman’s r coefficient.

Nearly always Often

Results

Sometimes

One hundred and two responses were received. Five were

Not often

incomplete or incorrectly filled. Ninety-seven responses were

Rarely

analysed. Of these, the section on prioritising rationales for limiting therapies (question 6 in the survey questionnaire)

Figure 4

was incorrectly or incompletely completed by 19 respondents

! Forty-eight (49.5%) had either no prior exposure to formal

and only the 79 usable responses were analysed for that

Medical respondents experience of having discussions with patients and next of kin

Seventy-seven (78.6%) of the responses were from doctors

regarding wishes around end ofissues life, including ICU admission, initiation teaching on end-of-life or were unsure CPR, (Figure 5). of life support and organ and tissue donation! We did not find significant correlation either with clinical

with postgraduate clinical experience of three years or less

(r=0.033, P=0.75).

section.

Volume 23 Number 2 – July 2014

experience (r=-0.040, P=0.69) or hospital designation

TRANSPLANT JOURNAL OF AUSTRALASIA

Medical respondent’s prior exposure to formal teaching on organ and tissue donation

Medical respondents prior exposure to formal teaching on end of life issues! 50

50 45 40 35 30 25 20 15 10 5 0

45 40 35 30 25 20 15 10 5 0

Yes

Unsure

Inadequate

Figure 7

Figurerespondents 5 Medical prior exposure to formal teaching on end of life issues!

When asked to prioritise indications for limiting care in

Medical respondent’s felt that they should routinely discuss organ and tissue donation in conversations with dying patients or their next of kin

patients, the response patterns largely corresponded to current anecdotal accounts of Australasian medical practice

(Figure 6).

60 50

Medical respondents prioritise indications for limiting cares in patients!

40 30

'"!

&#!

&"!

%#! $#! "!

Yes

Maybe

2nd priority

$"!

Most significant

%"!

Figure 8

3rd priority 4th priority

e Ag Co

iti

b or

ilit

sib

r ve Re

f yo

th Pa

’s nt

tie Pa

e pr

to en xt

ish

io ys Ph

t en

e ng

a er

e Pr

ity

l ua

e Lif

ish W

t ex fN

Discussion

5th priority 6th priority

Limited information is available on knowledge and attitudes

Least significant

of Australian health care professionals towards end-of-life issues including organ and tissue donation.

Figure 6

Medical respondents prioritize indications for limiting cares in patients!

Death is often not culturally acceptable and a taboo subject8. There is a perceived culture of death denial in medical

The majority of respondents felt that routine discussions

education9. Certainly, specialist trainees rate the overall

on end-of-life care with patients or their surrogates should

quality of fellowship teaching to be higher than specific

include conversations on ICU admission (94.9%), CPR

training in end-of-life care10.

(96.9%) and invasive procedures (90.8%). A significantly different number felt organ and tissue donation (72.4%) should also be included in this conversation (Friedman’s test, P<0.0001).

Our survey highlights that while junior medical staff at our centre would determine limits on a patient’s care in a way consistent with current Australian medical practice, they are significantly hampered by both a lack of theoretical

In our sample, 48 (49.5%) reported inadequate or no prior

training and practical experience. Inadequate exposure

exposure to formal teaching on organ and tissue donation

to participation in the care of critically unwell patients

(Figure 7). We did not find significant correlation either with

combined with self-reported gaps in specific training on

clinical experience (r=0.030, P=0.77) or hospital designation

end-of-life care issues may limit their ability to meaningfully

(r=0.065, P=0.53).

communicate decisions on the end of life to patients and

Only 32 (32.65%) indicated that they felt they should

their surrogate decision makers.

routinely discuss organ and tissue donation in conversations

This lack of specific education appears to extend to cadaveric

with dying patients or their next of kin (Figure 8).

organ and tissue donation. As an index of awareness in acute care settings, the Australasian College of Emergency Medicine

Volume 23 Number 2 – July 2014

TRANSPLANT JOURNAL OF AUSTRALASIA

surveyed a cross-section of medical and nursing staff working

Swedish critical care nurses reported an absence of leadership

in Australasian emergency departments. In Australasian

and lack of an organisational structure as barriers to organ

emergency departments, 29.2% of the medical staff and

donation25. Lack of knowledge about organ donation and

23.8% of the nursing staff reported having no education

brain death has been reported from Italy26 and Poland27. Poor

regarding organ and tissue donation. Despite broad support

knowledge and attitudes to donation among medical staff

for organ and tissue donation, many were uncertain of their

have been reported in Malaysia28 and Qatar29.

role in facilitating donation11. Only 67.7% of emergency department medical and nursing staff felt they had the

Limitations

necessary competence and knowledge to identify a potential

This study was done at a single metropolitan teaching

donor. Of note, 71% had never referred a potential donor12.

hospital in Victoria. While it is reasonable to expect the

Only 60.4% of emergency department staff demonstrated

junior medical workforce at one centre is representative of

sufficient knowledge of brain death. Of concern, 52.5% of the

that of other similar hospitals in the state, our results may not

respondents who failed to demonstrate adequate knowledge

be generalisable to knowledge and attitudes to death, dying

of brain death reported they felt competent and comfortable

and organ and tissue donation amongst junior medical staff

explaining brain death to families of patients. Of those who

working in other states or, indeed, even other health services

had recent experience of discussing brain death with next of

in the same state.

kin, 34.2% were unable to demonstrate sufficient knowledge of brain death and 13.3% did not accept brain death13. Older clinicians, male clinicians and clinicians of certain religious and cultural backgrounds were identified as having less positive beliefs and attitudes towards donation14.

There was limited response from registrars, specialists and junior medical staff with more than five years’ clinical experience. The survey has not attempted to explore why this is the case. Since responders were voluntarily attending designated hospital education forums on organ and tissue

Transplantation in Australia relies heavily on organ and

donation, the attitudes of non-attendees towards death, dying

tissue retrieved from deceased donors. Lack of specific

patients and organ and tissue donation remains unknown.

education on organ and tissue donation may result in failure to identify potential donors, overestimation of contraindications to donation, non-integration of organ and tissue donation requests from appropriate potential donors into routine holistic end-of-life care practice and difficulties in donation conversations with surrogate decision makers. Previous education on donation was significantly related to attitudes and willingness to participate in donationrelated tasks11. Health care providers’ success in obtaining donation consents is optimised when they themselves have a favourable outlook towards donation15. Significant deficiencies in medical education on organ and tissue donation have been reported in other health systems. A needs assessment of medical and nursing education in the US found a significant proportion of schools failed to provide instruction on donation, definitions of brain and

It is uncertain to what extent the results of our survey are skewed by the evident response bias. However, members of junior medical staff with less than five years’ clinical experience at present would be expected to gain in seniority and eventually become the opinion leaders in medicine in the future. Regardless of the attitudes of the current generation of registrars and specialists, the absence of education on death, dying and organ and tissue donation at the formative stages of their careers is likely to have significant impact on the clinical leaders of tomorrow.

Conclusions Our survey highlights significant deficits in the current Australian medical education curriculum on the topics of both end-of-life care and organ and tissue donation.

cardiac death and the discussion of organ donation during

It was reassuring to note that the framework for decision

routine health care visits . Among undergraduate medical

making in the ethical care of dying, critically unwell patients

students, lack of knowledge despite positive attitudes has

was consistent with current Australasian practice.

been described around the world

. Furthermore, standard

17–22

medical curricula in themselves do not appear to alter attitudes to organ donation over the course of undergraduate training23.

It was concerning that junior medical professionals in a First-world metropolitan teaching hospital could not make the link between dying patients in critical care settings and the opportunity to approach their surrogates for consent for

Poor knowledge and attitudes to organ donation are not

organ and tissue donation. Lack of awareness of processes

unique to Australia. In Belgium, critical care nurses reported

and time frames around organ and tissue retrieval and

a significant need for training in caring for potential donors24.

a lack of clarity in the important role played by medical

Volume 23 Number 2 – July 2014

TRANSPLANT JOURNAL OF AUSTRALASIA

professionals in the process may have influenced this. The fact that organ and tissue donation is not routinely considered part of holistic end-of-life care in current Australian practice may be an issue. It was concerning that a significant proportion of junior medical staff would not routinely discuss organ and tissue donation with dying patients or their surrogates. Given that most of the responders were within five years of graduation from medical school, this may represent a significant gap in the content of medical education currently on offer in Australia. A bigger survey to confirm these findings from a single centre would be appropriate. It would be of interest to assess what content, if any, constitutes education on organ and tissue donation across medical schools in Australia and also what significance it carries in the overall medical curriculum and assessment in current Australian medical education.

References

12. Neate et al. Australian emergency clinicians’ perceptions and use of the GIVE clinical trigger for identification of potential organ and tissue donors. Emergency Medicine Australasia 2012; 24:501–9. 13. Marck et al. Australian emergency doctors’ and nurses’ acceptance and knowledge regarding brain death: a national survey. Clinical Transplantation 2012; 26:E254–E260. 14. Marck et al. Personal attitudes and beliefs regarding organ and tissue donation: a cross-sectional survey of Australian emergency department clinicians. Progress in Transplantation 2012; 22(3):317–22. 15. Siminoff et al. Health care professional attitudes toward donation: effect on practice and procurement. Journal of Trauma 1995; 39(3):553–559. 16. Anker et al. Teaching organ and tissue donation in medical and nursing education: a needs assessment. Progress in Transplantation 2009; 19(4):343–8. 17. Sonmez et al. Attitude and behaviour related to organ donation and affecting factors: a study of last-term students at a university. Transplantation Proceedings 2010;42:1449–52 18. Sobnach et al. Medical students’ knowledge about organ transplantation: a South African perspective. Transplantation Proceedings 2010; 42:3368–71. 19. Peron et al. Organ donation and transplantation in Brazil: university students’ awareness and opinions. Transplantation Proceedings 2004; 36:811–13.

The Declaration of Istanbul on Organ Trafficking and Transplant Tourism. Available from: http://www.declarationofistanbul.org

20. Akgun et al. Attitudes and behaviour related to organ donation and transplantation: a survey of university students. Transplantation Proceedings 2002; 34:2009–11.

Manyalich et al. IRODaT: The International Online Registry for Organ Donation and Transplantation 2007. Transplantation Proceedings 2009; 41:2030–34.

21. Okoye et al. What does the medical student know about eye donation/corneal transplant? The University of Nigeria scenario. West Indian Medical Journal 2010; 59(1):41–4.

Paez et al. Training of health care students and professionals: a pivotal element in the process of optimal organ donation awareness. Transplantation Proceedings 2009; 41:2025–29.

22. Chung et al. Attitudes, knowledge and actions with regard to organ donation among Hong Kong medical students. Hong Kong Medical Journal 2008; 14:278–85.

The PIERDUB Project: International Project on Education and Research in Donation at University of Barcelona: Training university students about donation and transplantation. Transplantation Proceedings 2010; 42:117–120.

Zheng et al. Impact of preclinical exposure to organ donation on knowledge and attitudes of medical students. Progress in Transplantation 2012; 22(1):79–85.

Irving et al. Community attitudes to Deceased Organ Donation: A focus group study. Transplantation 2012; 93(10):1064–69.

DonateLife Australia. Available from: http://www.donatelife.gov. au/discover/facts-a-statistics

Riley. A strategy for end of life care in the UK. British Medical Journal 2008; 337:e943.

Tucker. Culture of death denial: relevant or rhetoric in medical education? Journal of Palliative Medicine 2009; 12(12):1105–8.

10. Buss et al. Hematology/oncology fellows’ training in palliative care. Cancer 2011; 117:4304–11. 11. Jelinek et al. Organ and tissue donation-related attitudes, education and practices of emergency department clinicians in Australia. Emergency Medicine Australasia 2012; 24:244–250.

23. Burra et al. Changing attitude to organ donation and transplantation in university students during the years of medical school in Italy. Transplantation Proceedings 2005; 37:547–550. 24. Pelleriaux et al. An analysis of critical care staff’s attitudes to donation in a country with presumed-consent legislation. Progress in Transplantation 2008; 18(3):173–8. 25. Floden et al. ICU nurses’ perceptions of responsibilities and organization in relation to organ donation — A phenomenographic study. Intensive and Critical Care Nursing 2011; 27:305–316. 26. Zampieron et al. Undergraduate nursing students’ attitudes towards organ donation: a survey in an Italian university. International Nursing Review 2010; 57(3):370–376. 27. Kubler et al. Attitudes to brain death and organ procurement among university students and critical care physicians in Poland. Transplantation Proceedings 2009; 41:1473–76. 28. Abidin et al. Are health professionals responsible for the shortage of organs from deceased donors in Malaysia? Transplantation International 2013; 26:187–194. 29. Alsaied et al. Knowledge and attitudes of health care professionals toward organ donation and transplantation. Saudi Journal of Kidney Diseases and Transplantation 2012; 23(6):1304–1310.

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TRANSPLANT JOURNAL OF AUSTRALASIA

Obituary: Kerry Murry Written by Cathy Martin

Kerry Murry

Kerry Murry, a long-time member of the Transplant Nurses’ Association (Queensland), died on 17 May 2014, from cancer, diagnosed several months prior. Kerry’s family and the Transplant Unit at the Princess Alexandra (PA) Hospital have been deeply saddened by her passing. A large number of nurses, doctors and staff attended her funeral, reflecting their deepest respect, sorrow and somewhat disbelief. After completing her nursing training at PA Hospital in 1979, Kerry nursed and travelled overseas, before starting in the PA Transplant Unit in 1986, where she continued working until late 2013. Kerry was our most loved, respected and valued colleague and friend. As a senior clinical nurse, Kerry consistently displayed the highest standards of integrity and care, as she mentored, guided and educated many nurses and trainee doctors, who being new to the transplant area benefited from her astute observations and thorough clinical and procedural knowledge. And, flowing on from this, thousands of patients who in having received either a liver or a kidney transplant, were likewise the direct and fortunate beneficiaries of Kerry’s superb skill and compassion. Kerry was a one-person quality control team who was not afraid to set and demand a truly professional tone. Kerry’s excellent memory for people and events was notable. Kerry lived “true caring”, and in her conversations she would always recall every detail about a person’s family members when asking after them. Kerry provided an amazing balance of care, perception, perspective and compassion whilst being able in a no-nonsense way, to encourage frightened and overwhelmed patients to put one foot in front of another, achieving great results. Kerry was not one to tolerate fools or slackers and got on with the job honestly. Her questioning, sharp and assertive intelligence was notable, as were her warmth, loyalty and sense of humour. Kerry’s standards were as high for herself as they were of others. As people reflected upon Kerry’s great qualities in the days after her death, consistent themes

Volume 23 Number 2 – July 2014

emerged: “so pragmatic and logical” … “could really see things for what they were” … “so down to earth” … “known for not beating around the bush” … “sensible” … “one of the good ones”… “Kerry actually “got it” and was “true to herself”. Whilst not at work to make friends, it was no small irony that some of Kerry’s closest and most enduring friendships arose from her training days and the workplace, and that these friendship circles continue strongly today. Kerry is deeply missed, but her legacy is well carved and will live on in more ways than she might ever have imagined. We are hugely grateful that Kerry chose transplant nursing as we and thousands of others, are all the better for it. The Transplant Nurses Association conveys deepest condolences to Kerry’s family, especially her 15-year-old daughter, Emily. To laugh often and love much; To win the respect of intelligent persons And the affection of children; To earn the approbation of honest critics And to endure the betrayal of false friends; To appreciate beauty; To find the best in others; To give of one’s self; To leave the world a little better, Whether by a healthy child, A garden patch Or a redeemed social condition; To have played and laughed with enthusiasm And sung with exultation; To know that even one life has breathed easier Because you have lived — This is to have succeeded. Ralph Waldo Emerson

TRANSPLANT JOURNAL OF AUSTRALASIA

Mrs Katherine Jennifer (Jenny) WATSON Public Service Medal in Queen’s Birthday Awards for outstanding public service to the Royal Prince Alfred Hospital, particularly in the continued improvement of liver transplant surgery at the hospital Mrs Watson played a vital role in the creation

improve organ retrieval and liver transplant

and development of the liver transplant team at

surgery to ensure the best possible outcomes

the Royal Prince Alfred Hospital assisting with

for transplant patients.

animal research to perfect the technique before

Mrs Watson was involved in the first ever

clinical work commenced, and was involved in

combined liver and lung transplant in New

surgical trials, surgical equipment design and

South Wales in 2013, which was carried out

manufacturing.

at St Vincent’s Hospital, involving teams from

In 1986, Mrs Watson assisted with the first liver

both hospitals. She managed the logistics of the

transplant performed at the hospital: one of the

case, including the organisation of all staff and

first transplants ever performed in Australia. To

equipment required to ensure the operation

date, she has overseen the transplantation of 1,417 livers and personally trained more than 100 nurses in the skills required to assist in transplant surgery. She has scrubbed in and assisted with approximately 1,100 transplants.

was a success. Mrs Watson is also a volunteer member of the NSWFB community fire unit at Menai, and a founding member of the Transplant Nurses Association, which provides assistance

During her 37 years’ distinguished service at the Royal Prince

in the education and professional development of nurses

Alfred Hospital, Mrs Watson has assisted in the creation

in Australia. Mrs Watson has dedicated her professional

and development of policy surrounding liver transplantation

life to the development and continual improvement of liver

and organ retrieval processes. She has worked tirelessly to

transplant surgery.

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Transplant Nurses’ Association Inc. Your opportunity to contribute significantly to standards of care for donors, recipients and their families.

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