when is enough, enough? a case study in the ethical

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When Is Enough, Enough? A Case Study in the Ethical Considerations of Balancing Psychosocial Intervention and Patient Autonomy in Transplantation

Holly Brant, LISW-SMegan Homsy, LISW-S, CCTSW

2 ©T H E O H I O S TAT E U N I V E R S I T Y W E X N E R M E D I C A L C E N T E R

• We have no financial relationships to disclose

Financial Disclosure


After attending this CE event participants should be able to

• Understand how complications related to addiction issues resulted in a breakdown in communication and patient care

• Engage in thoughtful discussion about the balance between psychosocial interventions and patient autonomy

• Identify ethical challenges to transplant social workers when patients engage in self-destructive behaviors

• Articulate the importance of maintaining patient confidentiality and reporting inappropriate behaviors of other professionals


• This case study is a pertinent example of how despite our best efforts, if our priorities do not match up with those of the patient no matter the amount of work we put in, the treatment plan will not be successful.

• It is an examination of the balance between providing interventions and care and respecting patient autonomy.

• It is our hope that participants in this presentation also gain a renewed appreciation for the importance of maintaining boundaries.

• Our transplant team learned many lessons and matured considerably because of this case and this presentation seeks to share these with attendees.


Background InformationWhat’s at stake?

Here in the state of Ohio we have what is known as the Ohio Solid Organ Transplantation Consortium, which serves to oversee all transplants of livers, hearts, lungs, pancreas, and small bowels.

In order to qualify for a transplant, patients must meet one of three criteria:

No Diagnosis = No treatment required Patient has been abstinent from alcohol and/or substances

for a minimum of six months

Patient has completed a minimum of three months of

drug/alcohol treatment with a licensed provider

6 ©T H E O H I O S TAT E U N I V E R S I T Y W E X N E R M E D I C A L C E N T E R6

• Patient is a 44 year old Caucasian male • Being evaluated for a liver transplant with a diagnosis of HCV

• Originally diagnosed 11 years prior to transplant evaluation. • Patient met criteria for the following substance use diagnoses:

• Alcohol Use Disorder moderate in sustained remission, in a controlled environment

• Opioid Use Disorder, Severe, in sustained remission, on maintenance therapy, in a controlled environment

• Stimulant Use Disorder, Amphetamine-type, severe, in early remission, in a controlled environment

• Stimulant Use Disorder, Cocaine-type, severe in early remission, in a controlled environment.

The Patient: Marc O.Pre-Transplant Evaluation Phase


• Patient had been living in a sober living housing program for approximately 10 month prior to his social work evaluation.

• Previously diagnosed with Depression and Bipolar DO. • He had been linked with mental health services

intermittently and had participated in numerous detox and substance abuse programs over the last 10 years, with varying degrees of success.

• He was in dual diagnosis treatment through his Suboxone clinic

• Completing toxicology screenings on a biweekly basis



• After concluding the minimum three months of drug and alcohol treatment as set forth by the Ohio Solid Organ Transplantation Consortium, patient graduated from his sober living program, moved in with his sister and patient was listed for a liver transplant.



The Patient: Marc O.Transplantation Hospitalization • Admitted on 3/01/19, underwent Orthotopic Liver

transplant without any medical complexities

• Last Suboxone dose given the evening of 2/28/19(day before surgery), receiving methadone 5MG & 2MG IV dilaudid, intra & post operatively

• Acute Pain Service consulted to assist with pain management

• 3/05/19 Medication Assistance Treatment (MAT) team consulted to assist with resumption of Suboxone


The Patient: Marc O.Hospitalization

• Unable to start Suboxone until 3/13/19 due to pain medication dosing throughout course of hospitalization

• Relapsed on 3/16/19 – found with syringe in his arm and illicit substances in his belongings and bedside. OSU Security and Columbus Police were involved

• Planned discharge to his sister’s residency was subsequently no longer an option & SW consulted to assist with his disposition plan


The Patient: Marc O.Hospitalization Disposition Plan

• MAT SW, OP transplant SW, and IP transplant SW all assisting with disposition plan

• Contacting treatment programs on his behalf that could also assist with post transplant medical needs

• Arranging a 30 day treatment program that would provide transplant labs and Suboxone care, but this center required a discharge plan following completion of treatment.

• Sober living residence if bed became available, friends/family, or homeless shelter


The Patient: Marc O.Areas For Improvement

• Multiple teams involved in care plan: Acute Pain Service, MAT, Transplant Surgery, and Hepatology

• Communication to team members and patient

• Discontinuing his Suboxone and not re-starting until post-op day 13

• Patient accountability and follow through with his sobriety and treatment plan since his relapse

• Respecting patient autonomy even if it is not in line with transplant teams expectations

• Setting and maintaining professional boundaries

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The Patient: Marc O. Post-Transplant Phase

During his first year post-transplant, social work attempted several forms of intervention – some at the request of the patient, others as consulted by the medical team these included • To arrange various treatment programs for the patient (most of which he did not

follow through with)• To find housing for the patient (as he had been forced to leave his sister’s home

after his relapse during his hospitalization)• Patient was eventually incarcerated on drug related charges.

Numerous times patient missed labs and appointments, did not refill his IS medications, and for lengthy periods of time was unreachable by the transplant care team resulting in social worker and other team members calling patient’s support, other providers and the police for safety checks.

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When Is Enough, Enough? A Case Study in the Ethical Considerations of Balancing Psychosocial Intervention and Patient Autonomy in Transplantation

Holly Brant, LISW-SMegan Homsy, LISW-S, CCTSW

• Given then sensational nature of this patient’s case, much conversation was generated

• It became apparent that personnel within transplant, though not involved in patient care, were inappropriately discussing this patient’s case and engaging in unprofessional behavior

• We were placed in the unenviable position having to report this behavior to hospital management and legal teams in order to protect a vulnerable patient

• Eventually, a member of the transplant psychosocial team was terminated from their position due to violating HIPPA

The Aftermath:What were the consequences?


The Aftermath:What did we learn?

• In the aftermath of these issues our transplant center had to reckon with the realization that we had failed the patient.

• As a team our transplant center created a task force to review this case and what can be done in the future to prevent such breakdowns in patient care.

• Protocols on how to manage patients who are on MAT at the time of transplant was established.

• Staff across the multi-disciplinary team attended trainings regarding addiction, management of pain and best practices for MAT services.

• Additionally, our transplant center collaborated with our hospital’s addiction treatment program for a streamlined referral process for transplant patients to addiction services.


Ethic PrinciplesWhat forces shape patient care?

• Autonomy

• Beneficence

• Health maximization

• Non-maleficence


• In principle when a patient with capacity to make their own medical decisions refuses recommended treatment, that refusal must be respected by the medical team.

• Conversely, one could argue that patients under the duress of addiction, be it active use or withdrawal symptoms, have inadvertently surrendered some components of their autonomy.

• Does the clinician’s responsibility to help the patient ever override the patient’s freedom of choice?

• What about medical holds or involuntary psychiatric hospitalizations?

• The problem faced by clinicians in cases like this is how to perform their ethical responsibility to the patient when it is being challenged or impeded by the patient’s willful behavior that poses a serious risk to their health or to the safety of others.

Ethic PrinciplesWhat forces shape patient care?

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Present Day Update


Questions?


Fleming JN, Lai JC, Te HS, Said A, Spengler EK, Rogal SS. Opioid and opioid substitution therapy in liver transplant candidates: A survey of center policies and practices. Clin Transplant. 2017 Dec;31(12):10.1111/ctr.13119. doi: 10.1111/ctr.13119. Epub 2017 Nov 27. PMID: 28941292; PMCID: PMC6392463.

Kanchana TP, Kaul V, Manzarbeitia C, Reich DJ, Hails KC, Munoz SJ, Rothstein KD. Liver transplantation for patients on methadone maintenance. Liver Transpl. 2002 Sep;8(9):778-82. doi: 10.1053/jlts.2002.33976. PMID: 12200777.

Majumder P, Sarkar S. A Review of the Prevalence of Illicit Substance Use in Solid-Organ Transplant Candidates and the Effects of Illicit Substance Use on Solid-Organ Transplant Treatment Outcomes. Cureus. 2020 Jul 3;12(7):e8986. doi: 10.7759/cureus.8986. PMID: 32775068; PMCID: PMC7402423.

Stowe J, Kotz M. Addiction medicine in organ tansplantation. Prog Transplant. 2001 Mar;11(1):50-7. doi: 10.7182/prtr.11.1.n86031643h5n248p. PMID: 11357557.

Weinrieb RM, Barnett R, Lynch KG, DePiano M, Atanda A, Olthoff KM. A matched comparison study of medical and psychiatric complications and anesthesia and analgesia requirements in methadone-maintained liver transplant recipients. Liver Transpl. 2004 Jan;10(1):97-106. doi: 10.1002/lt.20003. PMID: 14755785.

Weinrieb RM, O'Brien CP. A case report of naltrexone for alcoholism in a liver transplant recipient: side effects and safety. Am J Addict. 2004 Oct-Dec;13(5):495-7. doi: 10.1080/10550490490512870. PMID: 15764427.

References:


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when is enough, enough? a case study in the ethical

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