Liver Roulette:

Who Gets the Liver?

http://joannshrader.8m.com/index1.htm

John Elyard

Lynnette Lambert

Urie Salant

Debra Wood

NWABR

Ethics in the Science Classroom

July, 2003

Roulette Wheel: http://www.gamblersupply.com/Merchant2/merchant.mv?

Liver Roulette

(Who Gets the Liver?)

Liver Roulette is a unit in which students examine the procedures involved in organ transplants and the ethical issues surrounding organ donations.

Courses:

            Biology

            Anatomy/Physiology    

            Biotechnology

            Bioethics

Unit Background:

            Students will conduct an Internet “scavenger hunt” where they will learn about the biology of the liver and organ transplants.  Through a Jigsaw format they will examine several case studies of individuals who have been recipients of, or candidates for, liver transplants and will analyze and share the studies with the other members of their group.  After students have an understanding of organ transplants, they will be introduced to a GRASP (framework for the activity) where they will discuss, analyze and decide on who will be the recipient of a liver transplant.  They will present their findings to the “regional organ transplant center board” using a poster, PowerPoint, overhead or similar presentation.  The project will culminate with a reflective essay.

Objectives:

After completion of this unit, students will:

• Show understanding of liver function by completing an internet scavenger hunt
• Identify some of the conditions that cause liver failure through Jigsaw activity
• Understand that life-long restrictions are placed on recipients after transplantation
• Be able to explain the method by which livers are allocated
• Understand the current UNOS registry system
• Be able to explain ethical issues surrounding organ donation by completing an ethical-model worksheet

Washington State EALR’s:

Reading:

1.      The student understands and uses different skills and strategies to read.

1.1, 1.2, 1.3, 1.5

2.      The student understands the meaning of what is read.

2.1, 2.2, 2.3

3.      The student reads different materials for a variety of purposes.

3.1

Writing:

1.      The student writes clearly and effectively.

1.1, 1.2,1.3

 2.  The student writes in a variety of forms for different audiences and purposes.

           2.1, 2.2, 2.3

 3.  The student understands and uses the steps of the writing process.

           3.1, 3.2, 3.3, 3.4, 3.5           

Communication:

1.     The student uses listening and observation skills to gain understanding.

        1.1, 1.2, 1.3

2.         The student communicates ideas clearly and effectively.

2.1, 2.2, 2.3, 2.4, 2.5

3.     The student uses communication strategies and skills to work effectively with others.

        3.1, 3.2, 3.3

Science:

1.     The student understands and uses scientific concepts and principles.

        1.2

2.     The student knows and applies the skills and processes of science and technology.

        2.1, 2.2

3.    The student understands the nature and contexts of science and technology.

        3.1, 3.2

Liver Roulette

(Unit Timeline)

Additional teacher resources:

• “Organ Donation True or False”
• “Transplant Allocation” article
• Organ transplant hot line:  “Matchmaking at the heart of transplant process” (USA Today)
• Liver allocation criteria – UNOS
• Suggested background web sites

Hook Activities  Liver Roulette

1. Hand out 3 X 5 notecards sealed in envelopes with 3 labeled failing livers and the rest of the cards labeled  normal livers.  After opening the cards to determine who needs a liver, students need to go through a panel classroom discussion to decide who should get the liver and what criteria should be used for liver transplants.

2. Alternative to above:  Create anonymous student profiles depicting three students in the class.  Have students decide in an open classroom discussion which of the three receives the liver and on what criteria that liver was assigned.

3. Have students decide between a celebrity and a student willing to be a liver transplant “guinea pig.”

Internet Scavenger Hunt  Liver Roulette                                  Name ____________

Using the Web as the resource, answer the following questions.  For each question, indicate the web site at which the answer was found.

1. Name five organs which can be transplanted.

2. What is the shelf –life of

1. Liver

2. Kidney

3. Heart

3. How does the liver function?

4. List at least two complications that occur after transplant surgery?

5. What is the difference between end-stage kidney disease and end-stage liver disease?

6. What are the alternatives to transplants for the following organs:

1. Heart
2. Kidney
3. Liver

7. What conditions can lead to liver failure?

8. How are organs preserved until they are transplanted?

9. How many transplant regions exist in the United States?

10. What are some other considerations after the transplant occurs?

Internet Scavenger Hunt  Liver Roulette – With Answers

Using the Web Resources list, answer the following questions:

11. Name five organs which can be transplanted.

kidneys, livers, hearts, pancreases, intestine, lungs, and heart-lungs are now considered routine medical treatment.

12. What is the “shelf –life” of

1. Liver = 24 hours

2. Kidney = 24 hours

3. Heart = 4-6 hours

http://www.cdha.nshealth.ca/transplantservices/fAQ.html

13. How does the liver function?

The liver performs more than 400 functions each day to keep the body healthy. Some of its major jobs include:

• converting food into nutrients the body can use (for example, the liver produces bile to help break down fats)
• storing fats, sugars, iron, and vitamins for later use by the body
• making the proteins needed for normal blood clotting
• removing or chemically changing drugs, alcohol, and other substances that may be harmful or toxic to the body
• It aids in digestion by helping in the absorption of fat and certain vitamins, including vitamins A, D, E, and K.

14. List at least three complications that occur after transplant surgery?

http://www.clevelandclinic.org/health/health-info/docs/1800/1828.asp?index=8111

Rejection: Your immune system works to destroy foreign substances that invade your body. However, the immune system cannot distinguish between your transplanted liver and unwanted invaders, such as viruses and bacteria. Therefore, your immune system attempts to attack and destroy your new liver. This is called a rejection episode. About 70% of all liver transplant patients have some degree of rejection prior to discharge.

Infection: Because of the anti-rejection drugs that suppress your immune system, another complication of liver transplantation is infection. This problem diminishes as more time passes after surgery. Not all patients have problems with infections, and most infections can be treated successfully as they occur.

15. What are the alternatives  to transplants for  the following organs:

1. Heart – Ventricular Assist Device (accessory pump for the heart)
2. Kidney – Dialysis (Hemodialysis [the blood is dialyzed outside the body] and Peritoneal dialysis [where dialysis fluid is placed within the abcominal  cavity and reomoved several hours later)
3. Liver – NO CURRENT REPLACEMENT FOR TRANSPLANT! But some experimental ideas are under development: albumen dialysis / hepatocyte cell cultures, etc.

16. What conditions can lead to liver failure?

The most common causes of liver failure in adults are: chronic aggressive hepatitis, primary liver cancer and alcoholic cirrhosis.

17. How are organs preserved until they are transplanted?

Organ is washed; placed in saline;  and chilled for brief storage.

18. How many transplant regions exist in the United States?

11 regions in the United States.

19. What are some other considerations after the transplant occurs?

Issues would include: Patient compliance with the difficult post-operative care; Continuing expenses for drugs and follow-up medical care; Psychological issues of a transplant recipient.

                                                                                    Student Name_________________                           

Liver Roulette Jigsaw Questionnaire

1. Background of person:     

a.      Age

b.      Sex

c.       Profession

2. Why does this person need a liver transplant?

3. Wait time until liver received (if one was located)?

4. Did this person receive a liver?

5. Was the liver transplant successful?

Bibliography for article:

Members of Group:

Overall Score ____

Liver Donation Situation Assessment and Patient Status Reports

(Student Handouts for Presentation Assignment) 

Attention:   This packet is to be delivered immediately to all members of the local transplant council in order to determine allocation of the liver which became available due to Woody Carlson’s death.

Situation Status:   This morning at 3:15 Woody Carlson, 35 year-old healthy male died tragically in a motorcycle accident.  He indicated on his driver’s license that he wishes to be an organ donor in the event of his death. There are currently five patients that are suitable tissue matches.  Without a liver transplant, each patient will eventually die.  The local transplant committee needs to convene immediately to allocate the liver for transplant.  Members of the committee need to develop a point-based rubric which can be used to assign a rating for at least five different factors. The rubric will be used to determine a composite score for each patient in order to allocate the one liver.  Throughout this assessment, your committee will be interrupted from time to time to document the stage you have reached in the assessment process for legal purposes.  Prior to the actual liver transplant, you need to present your assessment rubric along with your decision on which patient receives the liver. 

Patient Assessments :  See attached sheet

*For the purpose of this activity, assume that all patients are a perfect tissue match for the available liver and that they all have sufficient medical coverage.

Patient #1

Firefighter John has been into sports his entire life. In his spare time he likes to hike, boat, and snow ski.  In high school he was an all-star athlete, and in college he was a lifeguard at Wild Waves.  John, who is 42, and his wife Mary have been married for 8 years now and live in Bellevue, Washington.  They have been trying to have children for about a year, but have so far been unsuccessful.  Presently John has liver failure caused by Hepatitis B, and he has less than a year to live.  He is unable to work fighting fires, but is still involved in teaching fire safety education to elementary school students.

Patient #2

Newly-engaged Jennifer grew up in a blue-collar family in Spokane, Washington.  She is now a household name, and Pop Star.  She has two platinum records and has been filming her second movie with her fiancé in Los Angeles.  When they are not filming, Jennifer and her fiancé like to go clubbing at the trendy LA hangouts.  A couple of days ago Jennifer overdosed on prescription painkillers and is now in Harborview Medical Center in Seattle, Washington with liver failure and will die in four days without a liver transplant.

Patient #3

Ken and Monica are wheat farmers in Cheney, Washington.  They have a 5-year-old daughter named Jodi, and a ten-year-old son named Will.  Will has congenital liver disease and can no longer attend school full time with his friends.  Ken and Monica make sure that Will takes his medication and sees his doctor regularly.  Currently Will is stable, but only has 18 months to live without a transplant.  The thing that Will misses most is playing football with his friends after school.

Patient #4

Since becoming a widow, Kim has worked as a waitress.  She is now 36 and has been living with her elderly mother and three children of her own in Ellensburg, Washington.  Ryan is 8, Alise is 5, and Erika is almost 16 months old.  She contracted Hepatitis C after getting her naval pierced when she was 16.  Kim cannot care for her mother or children very well right now because she is mostly bedridden, and needs frequent home care.  She was diagnosed with liver cancer after the birth of her last child and will die in six months without a liver transplant. 

Patient #5

Kevin has always dreamed about playing professional football in the NFL.  In high school, he was selected to the all-state football team, and received a full ride to the University of Washington.  In his classes, he does just well enough to stay eligible.  Kevin has Type I Diabetes, and has been a heavy drinker since he was a freshman in high school.  The combination of Diabetes and drinking has led to liver failure at the age of 22.  Right now Kevin is bedridden, in need of constant home care, and will be moved to a hospital within a month.  His parents George and Linda are caring for him at their home in Renton, Washington. 

Discussion Log - Be prepared to note down the key words for ideas and issues brought up during the discussion. You may use a key word more than once if you return to the same idea.

KNOWN: What facts are known?  What are the essential biological, ethical, economic, social or political considerations?  How do you know that the facts are significant, relevant, and accurate?

UNKNOWN: What additional facts, information, or evidence would be useful?

Liver Roulette Ethical Decision Making Model

Group_________________________________

I.                    Formulate the Facts

II. Consider the Controversy

Who are the candidates?   Identify the concerns and VALUES associated each candidate.

Liver Roulette 3-2-1 Reflection Essay                     Name

Write a “3-2-1”reflection which includes the following:

• 3 things brand new to you
• 2 things which presented conflict to you
• 1 - Would you agree to be an organ donor or to convince family members to become an organ donor?”

Assessment Sheet Liver Roulette

1. Participation in initial ‘decision’ activity.                                     _________

2. Score from Presentation Rubric (weighted per teacher)            _________

3. Participation grade from jigsaw activity                                      _________

4. Score from Internet Scavenger Hunt                                          _________

5. 3-2-1 Reflection Sheet                                                                _________

                  Averaged Total             __________

 Web Resources     Liver and Organ Transplants

Links to student resources:

University of Southern California

            Liver Transplant Program and Center for Liver Disease

            http://www.surgery.usc.edu/divisions/hep/

Patient Guide

http://www.livertransplant.org/patientguide/

A slide show of medical concerns and the actual surgery itself! http://www.livertransplant.org/patientguide/livertransplanttour.html

Virtual Hospital (Children’s Hospital of Iowa)

Evaluation of Candidates for Liver Transplant

http://www.vh.org/adult/patient/surgery/livertransplant/

An outline of the real process of candidate selection for UNOS:

(Note: after the candidates are approved by a committee and placed on a waiting list with UNOS, The historical allocation scheme has been that the sickest patient who has waited the longest receives the next available liver.)

http://www-med.stanford.edu/shs/txp/livertxp/HTML/selection.adult.html

Links to teacher resources that may be useful:

UNOS (United Network for Organ Sharing)

Organ center overview:

http://www.unos.org/whatWeDo/organCenter.asp

            UNOS Memo on “MELD” Scoring for Liver Transplant – 

for patients and their families.

http://archive.mail-list.com/hbv_research/msg03335.html

Allocation of the liver: VERY TECHNICAL! 

See policy 3.6. “Organ Distribution: Allocation of Livers”

Model for End-Stage Liver Disease (MELD) Scoring System

Medical criteria explained -

http://www.unos.org/policiesandbylaws/policies.asp?resources=true

Laura Bishop

Media Resource Personnel for Bioethics

Georgetown University

Resource for video: LifeCenter Northwest Kidney Foundation for patient waiting for transplants.  Deanna Clark Executive Director   Also has a speaker’s bureau.

Patty Wood 253-631-3734  Kidney Transplant 30-year Survivor.  Willing to be a speaker and has video.

3.0    ORGAN DISTRIBUTION

The following policies apply to the allocation of organs for transplantation.

3.6    ALLOCATION OF LIVERS.  Unless otherwise approved according to Policies 3.1.7 (Local and Alternative Local Unit), 3.1.8 (Sharing Arrangement and Sharing Agreement), 3.1.9 (Alternate Point Assignments (Variances), and Policy 3.4.6 (Application, Review, Dissolution and Modification Processes for Alternative Organ Distribution or Allocation Systems) and Policy 3.9.3 (Organ Allocation to Multiple Organ Transplant Candidates), the allocation of livers according to the following system is mandatory.  For the purpose of enabling physicians to apply their consensus medical judgement for the benefit of liver transplant candidates as a group, each patient will be assigned a status code or probability of pre-transplant death derived from a mortality risk score corresponding to the degree of medical urgency as described in Policy 3.6.4 below.  Mortality risk scores shall be determined by the prognostic factors specified in Tables 1 and 2 and calculated in accordance with the Model for End-Stage Liver Disease (MELD) Scoring System and Pediatric End Stage Liver Disease (PELD) Scoring System described in Policy 3.6.4.1 and 3.6.4.2, respectively. Patients will be stratified within MELD or PELD score by blood type similarity as described in Policy 3.6.2.  No individual or property rights are conferred by this system of liver allocation. 

3.7      

NOTE:   The amendment too Policy 3.6 (Allocation of Livers) shall be implemented following programming on the UNOS Computer System.

                        Livers will be offered to patients with an assigned Status of 1 in descending point sequence with the patient having the highest number of points receiving the highest priority before being offered for patients listed in other categories within distribution areas as noted below.  Following Status 1, livers will be offered to patients based upon their probability of pre-transplant death derived from assigned MELD or PELD scores, as applicable, in descending point sequence with the patient having the highest probability ranking receiving the highest priority before being offered to patients having lower probability rankings.

At each level of distribution, adult livers (i.e., greater than or equal to 18 years old) will be allocated in the following sequence (adult donor liver allocation algorithm):

Adult Donor Liver Allocation Algorithm

Local

                1.             Status 1 patients in descending point order

Regional

                2.             Status 1 patients in descending point order

                Local

                            3.           All other patients in descending order of mortality risk scores (probability of pre-transplant death)

                Regional

              4.           All other patients in descending order of mortality risk scores (probability of pre-transplant death)

National

                5.             Status 1 patients in descending point order

              6.            All other patients in descending order of mortality risk scores (probability of pre-transplant death)

                                        Within liver Status 1 and the organ distribution system defined in this policy for adult donor livers, a liver recovered from a pediatric organ donor shall be allocated to a pediatric liver candidate before the liver is allocated to an adult candidate (according to the pediatric donor liver allocation algorithm set forth below); provided, however, that the recipient transplant program cannot use only part of the liver in a single patient without offering the remaining portion(s) for transplantation:

(i)                   in sequence, as determined by the adult donor liver allocation algorithm set forth above and defining “local” based upon the Host OPO’s local area, to the highest-ranking patient on the waiting list of candidates; provided, however, that the Host OPO places the liver segment(s) by the time the donor organ procurement procedure has started, or

                                (ii)           into patients listed with the recipient program or any medically appropriate candidate on the UNOS Patient Waiting List, if, after reasonable attempts by the Host OPO to place the remaining portion(s) of the donor liver, the liver segment(s) is not placed by the time the donor organ procurement procedure has started.

                                        In the event that the transplant program receiving the liver offer declines to transplant the whole organ into the designated candidate or to transplant a part of the organ into the designated candidate, offering the remaining portion(s) for transplantation as described earlier in this paragraph, then the donor liver shall be allocated to the next candidate on the waiting list, in the sequence outlined below (i.e., the pediatric donor liver allocation algorithm).  For purpose of Policy 3.6, pediatric patients and organ donors are defined as less than 18 years of age.

                        Pediatric Donor Liver Allocation Algorithm

                                Local

1.                    Pediatric Status 1 patients in descending point order

2.                    Adult Status 1 patients in descending point order

                                Regional

3.                    Pediatric Status 1 patients in descending point order

4.                    Adult Status 1 patients in descending point order

                                Local

5.                    All other pediatric patients with a PELD score at or above a 50% risk of 3-month pre-transplant mortality in descending order of mortality risk scores (probability of pre-transplant death)

6.                    All other adult patients with a MELD score at or above a 50% risk of 3-month pre-transplant mortality in descending order of mortality risk scores (probability of pre-transplant death)

7.                    All remaining pediatric patients in descending order of mortality risk scores (probability of pre-transplant death)

8.                    All remaining adult patients in descending order of mortality risk scores (probability of pre-transplant death)

                                Regional

9.                    All other pediatric patients with a PELD score at or above a 50% risk of 3-month pre-transplant mortality in descending order of mortality risk scores (probability of pre-transplant death)

10.                 All other adult patients with a MELD score at or above a 50% risk of 3-month pre-transplant mortality in descending order of mortality risk scores (probability of pre-transplant death)

11.                 All remaining pediatric patients in descending order of mortality risk scores (probability of pre-transplant death)

12.                 All remaining adult patients in descending order of mortality risk scores (probability of pre-transplant death)

                                National

13.                 Pediatric Status 1 patients in descending point order

14.                 Adult Status 1 patients in descending point order

15.                 All other pediatric patients with a PELD score at or above a 50% risk of 3-month pre-transplant mortality in descending order of mortality risk scores (probability of pre-transplant death)

16.                 All other adult patients with a MELD score at or above a 50% risk of 3-month pre-transplant mortality in descending order of mortality risk scores (probability of pre-transplant death)

17.                 All remaining pediatric patients in descending order of mortality risk scores (probability of pre-transplant death)

18.                 All remaining adult patients in descending order of mortality risk scores (probability of pre-transplant death)

                                        The liver must be transplanted into the original designee or be released back to the Host OPO or to the UNOS Organ Center for distribution.  If a liver is offered to a patient who is unavailable to receive the transplant at his/her listing transplant center in the organ allocation unit to which the liver is being distributed, then the liver shall be released back to the Host OPO or to the UNOS Organ Center for allocation to other liver transplant candidates in accordance with UNOS Policy 3.6.  The final decision whether to use the liver will remain the prerogative of the transplant surgeon and/or physician responsible for the care of that patient.  This will allow physicians and surgeons to exercise judgement about the suitability of the liver being offered for their specific patient; to be faithful to their personal and programmatic philosophy about such controversial matters as the importance of cold ischemia and anatomic anomalies; and to give their best assessment of the prospective recipient's medical condition at the moment.  If a liver is declined for a patient, a notation of the reason for the decision not to accept the liver for that patient must be made on the appropriate UNOS form and promptly submitted to UNOS.

Allocation Sequence for Patients with PELD or MELD Scores Less Than or Equal to 6  (All Donor Livers). 

Adult patients with a MELD score of 6 will be considered together with all pediatric patients with a PELD score less than or equal to 6.  These patients will be initially ranked based upon waiting time. Those waiting list positions assigned to pediatric candidates based on this initial ranking (e.g., if the 3^rd and 5^th on the ranked list are held by pediatric patients) will then be re-distributed amongst the pediatric group based on PELD score, with the patient with the highest PELD score receiving the highest available pediatric ranking position.  The next available pediatric ranking position will be assigned to the pediatric candidate with the next highest PELD score.  Re-distribution of pediatric candidates continues until the pediatric candidate with the lowest PELD score is assigned the last pediatric ranking position. 

                                3.6.1       Preliminary Stratification.  For every potential liver recipient, the acceptable donor size must be determined by the responsible surgeon.  The UNOS Match System will consider only potential liver recipients who are an acceptable size for that particular donor liver.

3.6.2           Blood Type Similarity Stratification/Points.  For Status 1 transplant candidates, patients with the same ABO type as the liver donor shall receive 10 points.  Candidates with compatible but not identical ABO types shall receive 5 points, and candidates with incompatible types shall receive 0 points.  Blood type O candidates who will accept a liver from an A₂ blood type donor shall receive 5 points for ABO incompatible matching. Within each MELD/PELD score, donor livers shall be offered to transplant candidates who are ABO-identical with the donor first, then to candidates who are ABO-compatible, followed by candidates who are ABO-incompatible with the donor.

                                3.6.2.1    Allocation of Blood Type O Donors.  With the Exception of Status 1 patients, blood type O donors may only be allocated to blood type O patients, or B patients with a MELD or PELD score greater than or equal to 20.

                                3.6.2.2    Liver Allocation to Candidates Willing to Accept an Incompatible Blood Type. For Status 1 candidates, or candidates with a MELD or PELD score of 25 and greater, centers may specify on the waiting list those patients who will accept a liver from a donor of any blood type. 

                                3.6.3       Time Waiting.  Transplant candidates on the UNOS patient waiting list shall accrue waiting time within Status 1 or any assigned MELD or PELD score; however, waiting time accrued while listed at a lower MELD/PELD score will not be counted toward liver allocation if the patient is upgraded to a higher MELD/PELD score. Stratification of patients within a particular MELD/PELD score shall be based on total waiting time currently and previously accrued at that score on the same waiting list registration added to waiting time accrued at any higher MELD/PELD score. For example, if there are 2 persons with a MELD score of 30 who were both of identical blood type with the donor, the patient with the longest accrued waiting time in MELD score 30 or higher would receive the first offer. Waiting time will not be accrued by patients awaiting a liver transplant while they are registered on the UNOS Patient Waiting List as inactive.

                Patients in Status 1 will receive waiting time points based on their waiting time in Status

                                1.             Ten points will be accrued by the patient waiting for the longest period for a liver transplant and proportionately fewer points will be accrued by those patients with shorter tenure.  For example, if there were 75 persons of O blood type waiting who were of a size compatible with a blood group O donor, the person waiting the longest would accrue 10 points (75/75 x 10).  A person whose rank order was 60 would accrue 2 points.  ((75-60)/75 x 10 = 2).

              3.6.4         Degree of Medical Urgency.  Each patient is assigned a status code or mortality risk score (probability of pre-transplant death) which corresponds to how medically urgent it is that the patient receive a transplant. 

                                3.6.4.1    Adult Patient Status<