Psychiatric Assessment of Persons for Solid-Organ Transplant.

INTRODUCTION

Organ transplantation, a lifesaving procedure, has emerged as a ray of hope for individuals with acute or chronic organ failures.[12] Gradual advancements in the field of transplant medicine have increased the rates of transplantation worldwide and have incrementally improved the outcomes of the patients undergoing such transplant procedures. The first successful solid-organ transplant was conducted by Dr. Joseph Murray, who performed a kidney transplant on a patient with acute renal failure, with an organ donated by his identical twin brother. The use of immunosuppression to reduce the rates of rejection has led to a higher longevity of patients after transplantation. Refinement of patient selection, expertise, and training in transplant surgeries, dedicated teams for the conduct of transplantation and follow-up of patients, and advancements of immunosuppressant protocols have all resulted in better outcomes for patients, leading to many patients surviving decades after transplant. In India, there is a gradual rise in the number of patients undergoing organ transplantations.[3]

Organ transplantation can be classified in many ways.[4] Organ transplanted in the same individual is known as an autograft, while the transplantation of an organ from another individual is called an allograft. Allografts can be from a living donor or a deceased (cadaveric) donor. Solid-organ transplants typically include transplantation of kidneys, liver, heart, intestines, lungs, and pancreas. Among these transplants, kidney transplant is the most common solid-organ transplant conducted worldwide. Corneal transplants, skin transplants, and stem cell transplants are generally not included under solid-organ transplants. Transplantation can be carried out in a planned elective manner (in cases of chronic organ failure, for example, renal failure consequent to diabetic nephropathy) or on an emergency basis (in cases of acute organ failure, for example, liver failure after taking high doses of acetaminophen). The conduct of the transplant is contingent upon the availability of the organs. While the wait may be minimal for a live donor transplant (which can be done for kidney and liver transplants), the waiting times can be considerable for cadaveric transplants (like heart transplants). Many countries have registries that maintain a list of patients who require a transplant and are allocated the organs when organ donation occurs after the death of individuals who had pledged to give away their organs or when the family members agree for organ donation.

Organ transplantation is generally carried out in specialized centers with expertise in conducting such procedures. The team comprises surgeons, anesthetists, internists, critical care specialists, mental health professionals, trained nurses, perfusionists, dieticians, and other professionals involved in the care of the patients. The team approach helps in the proper assessment, conduct of transplantation, and after-care of patients. Solid-organ transplantation is a highly skilled surgical procedure, and dedicated centers help develop expertise and refine skills for the conduct of transplantations. Opportunities for specializations have been developed in this field, and training is offered to professionals who want to enhance their knowledge and skills in this area. A generic schematic of the solid-organ transplant workflow is presented in Figure 1.

Figure 1

Schematic representation of solid-organ transplantation process

Mental health professionals should be included in transplantation teams as varied mental health issues are faced by the recipients and donors. The skills of the mental health professionals complement those of the surgeons and other specialists of the team in dealing with the patient and improving the outcomes by recognizing various psychosocial issues, identifying diagnosable psychiatric disorders, highlighting and managing specific behavioral issues, and flagging pertinent ethical concerns.[56789] Involvement and importance of the mental health professionals in the transplant teams can be understood from the perspective that subspecialty of transplant psychiatry has been acknowledged. Thus, psychiatrists should be made a part of the hospital team that assesses the suitability of the candidates (both recipients and donors) for transplantation.

The present guidelines cover the mental health assessment of persons undergoing solid-organ transplants. These guidelines focus on the pretransplant assessments, assessments in the immediate peritransplant period, assessments after the transplantation and during follow-up. These guidelines also focus on the assessment of the donor and specific issues related to the donor and the relevant psychosocial issues. The relevant legal framework in India pertaining to solid-organ transplants is also discussed. These guidelines provide broad framework for the assessments pertaining to the solid-organ transplants. However, these guidelines are not a substitute for professional knowledge. The assessment procedures and management mentioned in the guidelines may be relevant to the ideal situation, where adequate manpower is available for carrying out such assessments. Across India, there is a wide variation in the availability and involvement of the mental health professionals as a part of the transplant teams. Hence, following these guidelines will be guided by the feasibility issues and the available manpower.

ROLE OF PSYCHIATRIC ASSESSMENTS

Psychiatrists have an important role in evaluating patient suitability for solid-organ transplantation.

There can be various phases related to transplantation, while inputs from the psychiatrists are called for [Table 1 and Figure 2]. The setting of evaluation, the profile of problems anticipated and encountered, and the expected interventions or suggestions vary. While pretransplant evaluation can be conducted in an office-based practice setting, evaluation of delirium or acute confusional state may need to be conducted in intensive care. A report mentioning suitability of the patient for undergoing transplantation may suffice for a planned transplantation procedure, with the patient evaluated on a single occasion. For a patient who manifests with delirium, the psychiatrist may need to closely align with the transplant team and initiate medications, as well as nonpharmacological interventions like reorientation cues, while the other members of the team attempt to identify and correct underlying causes like infection, anemia, or medication side effects. The psychiatrists can play an important part in the transplant team by facilitating effective communication with the patient and resolving ethical conundrums as well.

Table 1

Reasons of psychiatric assessments for patients undergoing solid-organ transplantation

Pretransplant evaluation of the recipient

Pretransplant evaluation of the donor

Managing psychological issues and psychiatric condition before the transplantation

Managing apprehension of the patient before transplant surgery

Managing posttransplant delirium

Addressing psychological issues and psychiatric disorders if they emerge after the transplant

Managing issues of adherence to medications, dietary restrictions and other recommended behavioral changes

Providing guidance on ethical issues

Interpersonal issues between the patient/family and the member(s) of the treating team

Figure 2

Inputs from psychiatrists during various phases of the solid-organ transplant, IPR Interpersonal relationship

PRETRANSPLANT PSYCHIATRIC ASSESSMENT OF THE RECIPIENT

Assessment of the recipient is geared toward evaluating for the presence of preexisting psychiatric illnesses or vulnerabilities that are likely to significantly hamper the outcomes of the patients. It also aims to assess whether the patient is competent to comprehend the magnanimity of the decision to undergo the transplant and to confirm whether the patient is aware about the intricacies of undergoing the procedure and is willing to go through the process of transplantation. Such an evaluation is done during the preparatory phase when an individual is awaiting an organ transplant.

The issues to consider during the pretransplant assessment of the recipient are shown in Table 2 and Figure 3. It may be remarked that evaluation may need to be conducted on more than one occasion if specific issues are to be clarified. Such an assessment can be carried out at the outpatient setting or the bedside if the patient is admitted. Information from multiple informants would help get a clearer picture.

Table 2

Pretransplant assessment of the recipient

Note who all provided the information

Confirm the identity of the recipient

Assess the competence of the recipient

Assess the understanding of the patient of the pretransplant and the transplant procedure and the risks involved

Assess for the presence of any current psychiatric illness

Assess for the presence of any substance use disorder including the last intake, past history of efforts to abstain, lapses and relapses, etc.

Assess for the presence of any psychiatric illness in the past: Severity of symptoms, course of the symptoms, response to treatment, side effects of medications, adherence to medications, time to relapse in case the psychotropics are stopped

Assess for personality and coping mechanisms

Assess for family history of any psychiatric disorder

Past history of undergoing surgical procedures: Reaction of the patient to the hospitalization, adherence to the suggested recommendations, reaction to prolonged hospital stay, including the intensive care unit stay

Past history of transplant: In case the patient has undergone transplant in the pastreason for organ failure, time to failure, psychological reaction of the patient and the family to the failure

Medication history: Any psychiatric issues while receiving various medications (for example, past history of steroid associated psychiatric manifestations)

Social support

Patient’s understanding about the impact of organ transplant: Restrictions in the movements, dietary restrictions, regular medication intake, abstinence from the substance (s), following measures to prevent infection, etc.

Note the findings on the mental status examination including the level of cognitive functioning

Apply structured assessments/scales if required

Opine about suitability for transplantation

Figure 3

Pretransplant evaluation of the recipient

The assessment interview generally begins with developing rapport with the identified recipient and engaging in a conversation about the medical illness, which has necessitated the transplant. The psychiatrist can ascertain competence of the recipient during the process of the initial interview. It is helpful to know whether the patient understands what is going to happen prior to the transplant and during the transplantation, what kind of risks are anticipated, and what precautions or regimens would be required after the transplantation surgery is conducted. If the patient is unclear about the surgical procedure or the commitments required from his/her perspective, the patient may be referred to the surgeon for clarification. If the patient is found to be not competent, the legally accepted representative should be able to consent to the procedure (the same is applicable for minors). However, a challenge in such situations is to determine whether the legally acceptable representative or nominated representative truly represents the best interest of the patient and will continue to be responsible for the well-being of the transplant recipient after the surgical procedure is over.

The assessment needs to cover whether the patient is currently suffering from a psychiatric illness. The presence of psychiatric illness is not a contraindication for transplant per se but would need to be addressed before the transplant, if possible. Solid-organ transplants have been possible for patients with severe mental illnesses like schizophrenia.[10] Active alcohol use disorder in a patient with liver cirrhosis would make the potential recipient not suitable for a liver transplant, given the presumption that continued alcohol use after transplantation would be detrimental to the transplanted liver, leading to the futility of the entire transplant procedure. On the other hand, depression in a patient with progressive liver failure exacerbated due to the health condition might not be a contraindication to the transplant process. In fact, depression may resolve due to the improvement in the overall health of the recipient after the transplantation. Addressing patients with psychiatric illness during the waiting period may help improve outcomes subsequently.

Assessment of the psychiatric illness in a patient who is planned for transplant may be made difficult due to the overlap of the symptoms of the medical illness and psychiatric disorder. Fatigue may be present in depression as well as could be due to heart failure. Similarly, autonomic symptoms may be present in anxiety disorder and also due to respiratory distress in patients who have respiratory failure and require lung transplantation. Discerning and differentiating symptoms may be challenging in such situations, and clinicians may need to rely on the temporality of onset, course over time, persistence of symptoms, context of exacerbations (fatigue worsening with effort more likely due to medical disorder, while the relief of fatigue with mood improvement would suggest the same to be a part of the psychiatric disorder).

Assessment of previous psychiatric illness is important as there can be the recurrence of mental illness which can impact the overall management of the patient. For example, a patient with bipolar disorder may be asymptomatic, but re-emergence of manic symptoms or occurrence of a manic episode around the time of transplantation may complicate the picture. The potential recipient is likely to sleep less at that point in time, which may precipitate an episode. Ascertaining previous psychiatric illnesses (including substance use disorders) would help optimize maintenance treatment and restart treatment when warranted. The treatment regimen of psychiatric illness also needs to be considered carefully, as some of the medications may need to be stopped during the peri-transplant period, and some of the medications may have interactions with the immunosuppressants after transplantation.

Family history of psychiatric illness would provide some information of genetic vulnerability to psychiatric illness. Assessment of personality and coping can help get an idea of how the individual would be able to deal with further stressors if they emerge. A detailed mental status examination should be performed, including higher mental functioning. Conditions like renal failure and liver failure which necessitate transplantation may be associated with neurocognitive impairments.

The assessment also provides a baseline for observing improvement or changes in cognitive profile, mood symptoms, and general adjustment to life circumstances. Whenever an opportunity arises, it might be prudent to get information from the transplant surgeon and other members of the team and discuss the findings of the assessment with them. A face-to-face discussion of the findings also gives an opportunity to clarify any doubts and provide more effective help to the transplant team. It is always better to have a conjoint session with the patient, their family, and the primary treating team members to facilitate communication between the patient and the treating team and also bridging the communication gap. Many a times, patients being referred to the mental health professionals are not aware that they are being referred for pretransplant evaluation, and also about the pretransplant precautions and measures, actual transplant procedure, the impact of the transplant procedure on their way of living, cost involved in the transplant, duration of hospitalization, etc., In such a scenario, the mental health professionals have an important role in making the primary treating team aware about the lack of knowledge of the patient/family, and they should be requested to provide adequate knowledge and address the queries of the patients/family. These can be done as part of the conjoint sessions.

Another situation encountered in clinical practice is evaluating a subgroup of patients who are referred for retransplantation, especially for renal transplant. In such a scenario, ascertainment of reasons for failure of the transplanted organ, time to failure, psychological reaction of the patient, and the family members for the transplant failure need to be considered. If the organ failure is an outcome of the lack of adherence of the patient to the suggested recommendations, for example, use of alcohol in a patient who has undergone liver transplant, it may raise ethical issues of using scarce resources.

Documentation of the findings of pretransplant evaluation is important. It provides a clear cross-sectional assessment of the patient’s condition and is useful for the transplant team. It can help determine (1) whether the potential recipient is suitable for transplant, (2) to understand if there are some psychiatric illnesses that may pose a challenge during the transplant process, and (3) to plan the medications and become cognizant of potential drug interactions. Nonpsychiatrists may not be very well aware of the psychiatric terminologies, and hence limited but rational use of jargon is preferred. For a potential transplant recipient, a typical final opinion, in case the potential recipient is found fit for transplantation, may read as “Currently, there is no contraindication from Psychiatric point of view to suggest that X cannot undergo transplantation. However, a repeat psychiatric assessment must be done just prior to transplant.”

Whether to use structured instruments for the assessment of the patient remains a prerogative of the evaluating psychiatrists. Some centers have devised their own processes of profiling patients and documenting their psychiatric status. Structured assessments can be a diagnostic instrument for making a psychiatric diagnosis, assess affective symptoms or general distress, neurocognitive functions, use of substances, assessment of personality and coping, and other instruments as deemed necessary. Table 3 presents some of the assessment instruments that can be used for the pretransplant assessment of patients. The use of these instruments should not be considered obligatory, and clinicians can choose the instruments that they would like to use in a particular patient depending on the need and the comfort of the clinicians in using the same.

Table 3

Instruments that can be considered during the pretransplant assessment of patients

Domain	Instruments
Diagnosis	MINI
General assessment	GHQ-12, K6 instrument
Depression	PHQ-9, HADS, BDI, HAMD
Anxiety	GAD Scale-7, HADS, HAMA
Substance use	ASSIST, AUDIT
Neurocognitive functioning	MMSE, HMSE, MoCA
Personality	EPI, MMPI, Iowa personality disorder screen
Coping	Brief COPE inventory
Social support	SSQ, Multidimensional Scale for Perceived Social Support

MINI – Mini-international neuropsychiatric interview; GHQ-12 – General health questionnaire-12; PHQ-9 – Patient health questionnaire-9; HADS – Hospital Anxiety and Depression Scale; BDI – Beck depression inventory; HAMD – Hamilton Depression Rating Scale; GAD – Generalized anxiety disorder; HAMA – Hamilton Anxiety Rating Scale; ASSIST – Alcohol, smoking, and substance involvement screening test; AUDIT – Alcohol use disorder identification test; MMSE – Mini-mental status examination; HMSE – Hindi mental status examination; MoCA – Montreal cognitive assessment; EPI – Eysenck personality inventory; MMPI – Minnesota multiphasic personality inventory; Brief COPE – Brief coping orientation to problems experienced; SSQ – Social support questionnaire

Pretransplant psychiatric assessment can be conducted on more than one occasion. In case the patient is suffering from a psychiatric illness that needs to be addressed prior to the transplant, appropriate treatment should be considered, especially if there is a reasonable gap between the initial assessment and the anticipated transplant procedure. In such a scenario, a reassessment can be scheduled after a period of time when the psychiatric illness has been addressed. Furthermore, gaps in information can be filled up in a reassessment.

TRANSPLANTATION RATING SCALES

Several rating scales have been developed for the assessment of candidates for solid-organ transplantation.

The transplant evaluation rating scale[11] is a clinician-rated instrument that looks at the adjustment of the patient on the basis of the evaluation of ten aspects of psychosocial functioning. The ten domains of psychosocial functioning are current or past mental disorders, personality disorder, substance use/abuse, compliance, health behaviors, quality of family and social support, history of coping, current coping with disease and treatment, quality of affect, and past and present mental/cognitive status. Each of these items is rated from 1 to 3 based on the level of impairment. The scale has been suggested to have good interrater reliability. It has been demonstrated to be a good instrument for the pretransplant assessment of patients undergoing a liver transplant, kidney transplant, and lung transplant.

The Psychosocial Assessment of Candidates for Transplantation[12] has 8 subscales, and each of them is rated on a 5-point Likert scale from 0 (poor candidate) to 4 (good candidate). The rating is clinician determined. The 8 subsections include 8 subsection items: family availability, family support, the risk for psychopathology, personality factors, ability to sustain change, medical adherence, drug and alcohol abuse, and relevant knowledge. This instrument has been used for several solid-organ transplant candidates and also has been utilized in pediatric transplant recipients.

Yet another commonly discussed instrument is the Stanford Integrated Psychosocial Assessment for Transplantation.[13] This instrument is also rated by the clinicians and has 28 items covering various issues such as understanding of the patient, treatment adherence, lifestyle-related factors, substance abuse, social support, psychological stability, and psychopathology. The questions are scored on Likert scales, and each of the questions has a different weight. Based on the total scores, the interpretation is provided, and the candidate is considered as an excellent candidate, good candidate, minimally acceptable candidate, poor candidate, or a high-risk candidate.

For pediatric transplant candidates, a separate instrument, pediatric transplant rating instrument, has been developed.[14] The instrument assesses 17 psychosocial factors divided into seven factors: illness factors, treatment adherence, patient or parental substance abuse, patient or parental psychiatric history, family environment, relation with medical team, and financial, logistical, and psychosocial support. The interrater reliability is higher for the preadolescent application of the scale rather than adolescent application.

PSYCHOSOCIAL ASSESSMENT

Several psychosocial issues affect the transplant procedure, and the psychiatrists are expected to be cognizant of the same.[515] Some of these psychosocial issues are presented in Table 4. These have a bearing on the management of the patient (including psychiatric management) and may lead to differences in outcome of transplant.

Table 4

Psychosocial issues with transplantation of relevance to the psychiatrist

Psychiatric disorders

Personality issues

Substance use

Adherence to medications

Financial stressors

Work and vocation

Familial concerns and social support

Psychiatric disorders can be present in the individual who is receiving the transplant, either before the surgery or afterward.[616] The profile of the psychiatric disorder can be varied, ranging from stress-related disorders to psychotic and mood disorders. The psychiatric evaluation is not aimed to exclude patients per se, but to help the patients as well through the treatment. Many of the psychiatric disorders can be treated effectively in patients who are supposed to undergo solid-organ transplantation.

Some personality issues can be of relevance in patients who are undergoing transplants. Cluster A and anxious-avoidant personality traits may interfere with treatment-seeking, and patients may not engage with the treatment providers. Patients with paranoid personality may be suspicious of treatment providers and may check the treatment regimen carefully. Patients with dependent personalities may depend on the family members or treatment providers for making the decisions for them and may not effectively participate in the decision-making. Patients with antisocial or narcissistic traits may have difficulty following suggestions of the transplant team. Thus, understanding the personality of the potential recipients is important.

Many individuals consume substances in a nondependent pattern. Active substance use (particularly alcohol and tobacco) is generally seen as a contraindication for being considered for transplant surgery. Smoking can result in delayed wound healing and reduced efficacy of medications. While individuals consuming substances can be helped with treatment, many potential transplant recipients may not disclose their consumption status, thinking that they may be rejected from transplant lists. Occasional consumption of substances is not a contraindication to transplant, and transplantation has been carried out on individuals who have been using substances in the past.[17] However, the ethical consideration of justice implores that scarce human organs should be judiciously used. In general, for patients with alcohol dependence syndrome, abstinence from alcohol for 3–6 months is required for being considered for the organ transplantation, with the exception of the life-threatening conditions.

Posttransplant, patients need to adhere to the medications so that graft rejections do not occur. Advances in immunogenetics and pharmacotherapy have led to the use of immunosuppressants with minimal side effects. Yet, the patients are required to take these medications on a long-term basis. Lack of adherence to these medications can be due to various reasons, including increasing age, a higher number of comorbidities, lower social support and employment, lower education, forgetting to take at the correct time, manifestation of depression, rebellious behavior, intolerance of side effects, poor rapport with the treatment time, and others.[1819] In the Indian context, financial issues may also be one of the contributing factors for poor medication adherence. The role of the psychiatric assessment may also be to understand the reasons for such nonadherence and guide further measures to address it.

The process of organ transplantation and consequent medications can be quite draining for the patient and the family members. This is often a concern and a source of stress to the individual. This may not be very explicitly expressed but may play a role during the decision-making process of consideration of transplant, around the period of surgery and subsequently as well.

After the transplantation, the patient may not be able to resume the previous vocation in the manner he/she used to do before the surgery took place. The patient may need to curtail the exertion and social interaction during the course of the recovery. This may lead to issues in rehabilitation or resumption of vocation. Purposeful engagement, which may help in rebuilding resilience, may thus be affected due to the constraints after the transplant procedure.

Family support plays an important role in the entire process of transplantation. During and after the transplant, the individual becomes dependent on others to some extent. Identification of familial and other social supports for such a time is always helpful. The family and social support help in providing care, pragmatic support, and also humane touch that helps an individual to cope with difficult situations.

ASSESSMENT OF THE DONOR

Assessment of the live donor is also an important component of the pretransplant evaluation. Live donors are applicable for liver and kidney transplantation among solid-organ transplantations. In general, live donors are the immediate family members of the recipient. Swap donors are also permitted wherein two or more sets of donors and recipients swap organs in view of ABO compatibility. Many donors consider organ donation a satisfying experience that gives them a sense of purpose.

The pretransplant assessment of the donor shares many of the characteristics of the assessment of the recipient [Table 5 and Figure 4]. The identity of the donor can be checked by looking at the identification cards issued by various government agencies (Aadhar Card, Voter ID, Driving license, Passport, etc.), marriage certificate (in the case of spouse), and past photographs of the donor with the potential recipient. The intake interview, after confirming the identity and noting the informants, encompasses needs to elicit what the potential donor knows about the transplant procedure and the risks involved in it. The competence of the potential donor needs to be checked. One of the major aims is to assess whether there is any coercion involved, and if so, what is the degree of coercion if it is applicable. Coercion may be manifest or subtle, and some degree of influence does occur in the decision-making. Whether the influence is to the degree that constrains autonomy has to be judged on case to case-to-case basis. The reasons/motivation for becoming the donor should also be discussed. Often, multiple family members are considered for donation, and the selection of the final donor has some degree of pressure or a feeling of obligation to volunteer for organ donation. Sometimes, family dynamics play a role in deciding who would become the donor, and it may not be clear whether the potential donor is coerced or wants to donate out of compassion. A ‘black sheep syndrome’ has been described wherein a rather disrespectful family member attempts to get recognition and admiration of the family by becoming the donor. Further, many a times, there could be financial disparity between the different family members, especially the siblings. In such a scenario, it is important to assess the aspect of any financial transaction or obligation on the part of the donor toward the family of the recipient. Another aspect to note in the Indian scenario is donation of the solid organs by the female spouse to her husband. In majority of the solid-organ transplantations in India, females are the donors. Hence, while evaluating the spouse, it is important to assess the association of the onset of the physical illness with the duration of marriage, overall duration of marriage, number of children, and pressure from the other family members on the spouse to donate the organ. It is often useful to inform the spouse that he/she is not obliged to donate the organ, if he/she does not wish to do so.

Table 5

Pretransplant assessment of the donor

Note who all provided the information

Confirm the identity of the donor, and the relationship with the recipient

Assess the competence of the donor

Assess the understanding of the transplant procedure and the risks involved

Assess for the presence of any current psychiatric illness, including substance use disorder

Assess for the past history of psychiatric illness, including the substance use disorder

Assess for the motivation of organ donation

Note the findings on the mental status examination

Apply structured assessments/scales if required (rarely)

Opine about suitability for transplantation

Figure 4

Pretransplant assessment of donor

The assessment of the donor should evaluate for the presence of a psychiatric disorder or substance use disorder. The presence of a psychiatric disorder by itself is not a contraindication for organ donation, provided competence is established. However, if time permits, addressing the psychiatric disorder to the extent possible would be helpful in such a situation. In general, persons with intellectual disability are not considered for becoming a donor. The findings of the mental status examination should be noted, especially cognitive assessment. For persons having minimal cognitive impairment, mental competence to consent for the surgery is important. If the potential donor is found to be competent, he/she should be considered for transplantation. Structured assessment of symptoms of anxiety, depression, and distress is rarely necessary for the potential donors. Table 3 presents some of the questionnaires that can be used for the assessment of the donors as well. The final impression of the suitability for being a donor should be opined about. Should we have both table and figure with same content?

ETHICAL CONSIDERATIONS FOR PSYCHIATRISTS

Organ transplantation raises some ethical issues as well.[202122] One of them is autonomy. The principle of autonomy mandates that the prospective patient must have a free choice to decide whether he or she would like to get a transplant. Some degree of coercion or influence may be there as the person with the failing organ may be suggested by family members and friends to undergo the transplant. However, the final decision whether to undergo the transplant or not resides with the patient. If the patient is incompetent or a minor, the guardian or legal representative can decide for the person undergoing the solid-organ transplant. The principle of autonomy also applies to a considerable degree for the donor as well. The donation of organs is a voluntary choice, and the treating psychiatrist should clearly mention when he/she finds that the donor may not be having an autonomous choice.

A major ethical issue in the field of organ transplantation pertains to the facet of justice. When organs for transplant are scarce, the tenet of justice calls for equitable distribution of the organs without favor. This particularly applies to cadaveric donors. The window of opportunity for transplant is short, and the organ has to be quickly transported, sometimes across cities, to reach the recipient who undergoes the transplant procedure immediately. Many countries have national lists of potential organ recipients, and the organs recipients are identified on the basis of such lists. India does not have such a consolidated list as of now. Another aspect of justice is deciding whether to transplant organs, where the prognosis is relatively poor, vis-à-vis where the prognosis is expected to be better.

The ethical principles of beneficence and nonmaleficence apply as in any other case. The psychiatrists and transplant team members act in the best interest of the patients who are to receive the transplant. Such a principle of beneficence extends on to the donors as well, and their health also needs to be taken care of appropriately. The practice of nonmaleficence suggests physicians do no harm, i.e., avoid transplantation in situations that may worsen the quality of life without actually benefitting the patient in terms of longevity.

THE LEGAL FRAMEWORK OF TRANSPLANTATION IN INDIA

In India, the transplantation of solid organs is governed under the Transplantation of Human Organs and Tissues Act (1994). The Act was further amended in 2011.[232425] The Rules alongside the Act came in 1995 and were further revised as Transplantation of Human Organs and Tissues Rules, 2014. The Act has been promulgated to streamline the process of organ donation and transplant activities. The introduction of the Act in 1994 led to the acceptance of brain death as a form of death. The Act also prohibited the sale of organs for transplantation [Table 6].

Table 6

Basic facts about Transplantation of Human Organs and Tissues Act (1994)

Who can donate: Father, mother, brothers, sisters, daughter, son, spouse, and grandparents

What if the first-degree relatives are not available: Recipient and donor are required to seek special permission from the government-appointed authorization committee. It needs to be ascertained that there is no coercion and financial exchange for the transplant (in such a scenario, the mental health professional may have to ascertain that the donor is doing so altruistically, and the same may have to be ascertained)

What about cadaveric donor: Two certifications are required 6 h apart by two different doctors nominated by the appropriate authority, and at least one of them should be an expert in the field of neurology to ascertain brain death. The cadaveric donation can be considered if the person has pledged for the same before death or if the legal guardians consent for the organ donation

The Act clarifies who can donate the organs. For living donation, father, mother, brothers, sisters, daughter, son, spouse, and grandparents can donate, provided they are able to show the proof of relationship by genetic testing and/or by legal documents. If there are no eligible first-degree relatives, and if there is a donor who is willing to donate the organ, the recipient and donor are required to seek special permission from the government-appointed authorization committee. They are subsequently asked to appear for an interview in front of the committee. The committee evaluates that the motive of donation is altruism or affection and not a financial inducement or other types of coercion. A mental health professional may have to ascertain the level of altruism for the donor, by reviewing his personality traits. For brain dead donors, the Act mandates that two certifications are required 6 h apart by two different doctors nominated by the appropriate authority, and at least one of them should be an expert in the field of neurology. For dead donors, organ transplantation is possible if the person had authorized removal of organs from the body after the death signed in front of two witnesses on a prescribed form. If the donation has not been committed prior to death, the legal guardians of the person can provide consent for organ donation of the person being who has become brain dead. For brainstem dead individuals, transplantation is carried out after a certificate is signed by all members of the Board of Medical Experts, and when the individual is <18 years of age, additional signed consent of the parents is needed. Approval of the authorization committee is required when considering transplantation when either donor or recipient is a foreign national.

Authorization committees are formed under the Mandate of the Transplantation of Human Organs and Tissues Act. They are six-member teams and can be hospital-based (where transplantations are carried out) or state or district-level committees. The medical practitioners in the authorization committees are not part of the transplant teams. The authorization committees examine the request for organ transplantation and then decide upon whether the transplantation should be allowed in a particular case or not.

The psychiatric assessment may be required by the authorization committee when unrelated donors and recipients are being planned for organ transplantation. This may be more applicable in cases of a donor/recipient being a foreign national.

PSYCHIATRIC ASSESSMENT IN IMMEDIATE PERITRANSPLANT PERIOD

In the immediate peritransplant period, the psychiatric assessment may be catering to several issues: (1) whether the potential recipient is still competent for transplant, (2) whether there are any immediate psychiatric problems that need to be addressed, (3) addressing posttransplant delirium, and (4) addressing immediate posttransplant psychological reactions.

The psychiatrist may be called in if the patient is apprehensive about the transplant procedure. The psychiatrist may be able to comment on whether the patient is still competent for the intended surgery. Furthermore, any anxiety or apprehension of the patient can be attended to during such a psychiatric consult. In case the patient rejects the transplant outright, again, competency should be checked, and the transplantation be withheld till the patient consents to the procedure. If the patient becomes incompetent, and in the presence of explicit instructions of the patient for the conduct of surgery prior to him/her becoming incompetent, the surgery should be undertaken.

Delirium or acute confusional state may occur in the patient prior to the transplant or subsequent to the transplant. The reasons for such delirium can be many, including failure of the organ, medication adverse effects or interactions, dyselectrolytemia, and infections. Often, multiple etiologies interact to produce delirium. Assessment in such situations focuses upon the clinical diagnosis of delirium. Confusion Assessment Method (CAM) or Confusional Assessment Method for intensive care unit (CAM-ICU) are quick bedside assessment instrument for delirium. Instruments like Delirium Rating Scale-Revised 98 version (DRS-R98), full version of the CAM, or CAM-ICU can be used to quantify the extent of delirium. Delirium can be hyperactive, hypoactive, or mixed. Often, hypoactive delirium is missed clinically as the patient is not disruptive. Yet, such a delirium should also be addressed. Management of delirium focuses on the identification of the cause of delirium and addressing the cause as promptly as possible. Antipsychotics can be helpful in reducing the aggression associated with delirium. Benzodiazepines are generally avoided as they lead to prolongation of confusion. Nonpharmacological measures like reorienting, placing the patient near the window, having a clock in intensive care, and meeting with family members may all help reduce the symptoms of delirium and make the patient more amenable. The psychiatrist needs to consider carefully the drug interaction between medications given for the symptoms of delirium and the medical condition/other medications being given to the patient. For example, hepatically metabolized antipsychotics like risperidone and haloperidol need to be carefully given in patients with hepatic failure. Renally excreted antipsychotics like amisulpride would need to be carefully considered in a patient with renal failure awaiting transplant.

In the immediate posttransplant period, the patient may feel overwhelmed, leading to symptoms of acute stress reaction, adjustment disorder, or depression. Assessment for such a patient may include evaluation for depression and clarifying the presence of cognitive deficits. Such an assessment also provides an opportunity to provide supportive therapy to the patient and nudging the patient to focus on problem-solving and using his/her strengths in dealing with the challenging situation.

POSTTRANSPLANT PSYCHIATRIC ASSESSMENT

In the posttransplant period, psychiatric assessments are generally initiated, when the transplant team suspects that there may be a comorbid psychiatric disorder hindering the improvement of the patient, or when the patient fails to maintain adherence to the treatment provided (mainly the immunosuppressants), or when hostilities emerge between the patient and the treatment providers.

After the transplantation, there can be a recurrence of a psychiatric problem or the emergence of a new psychiatric diagnosis. It has been seen that depression may affect up to 60% of the solid-organ recipients and is associated with increased rates of mortality and development of neoplasms in the posttransplant period. Addressing psychiatric disorders that occur after transplantation is thus important to improve the outcomes of the patients. Several challenges are present when the patients with transplantation present with symptoms of psychiatric disorder: (1) whether the symptoms are severe enough and are causing impairment to be considered as a disorder, (2) whether the symptoms are due to the psychological reaction of the patient or are due to the ongoing medications, (3) whether to wait for spontaneous resolution of the symptoms (especially if they are related to temporary adverse medical outcomes) or start treatment immediately, (4) what kind of treatment(s) to offer (psychotherapy versus pharmacotherapy), (5) how to avoid or minimize the drug interactions, (6) what would be the impact of the addition of psychotropics on the physical health of the patient (for example, risk of hyponatremia and bleeding while using selective serotonin reuptake inhibitors (SSRIs) and risk of QTc prolongation while using psychotropic with other medications or in patients with hypokalemia), and (7) other medication-associated side effects which can impact the quality of life of the patient. It might be difficult to establish the diagnostic threshold, especially the impairment criteria. This is because the patient might have had social or occupational impairment already imposed by the medical condition that led to the transplant. Yet, a decrease in social interactions or work productivity in an individual who had regained many of these functions may hint toward a psychiatric diagnosis. Patients who have undergone transplantation may be frail, limited in mobility, or otherwise unwilling to travel. Regular sessions of office-based psychotherapy may not be suitable for the same. Online psychotherapy may be considered favorably in such cases. Medications, when offered, should be started in lower doses, and dose escalation should be done cautiously with appropriate monitoring (for example, reviewing the serum electrolytes while using SSRIs). Among the antidepressants, escitalopram and sertraline are preferred as they are less frequently associated with drug interactions. For cases of alcohol use disorder where even nondependent use of alcohol during the posttransplant phase occurs, it might be important to act early and prevent further drinking to avoid injury to the transplanted liver.

Apart from psychiatric disorders, psychiatrists may be required to evaluate in cases when the patient refuses treatment. Poor adherence to the medication regimen (immunosuppressants, antibiotics, etc.) may lead to graft rejection. Hence, enhancing the motivation of the patient to continue with the medication in appropriate doses would be helpful. Assessment by the psychiatrists focuses on the reasons for nonadherence to medications, critically examining for the presence of depressive disorders (hopelessness and wish to die), psychosis (suspiciousness toward the treating team and the medications), neurocognitive impairment (forgetting medication regimen or getting confused about the medicines), and substance use disorders. In case any psychiatric disorder is identified, the patient can be suitably managed. The psychiatrist can also suggest measures such as reminders, positive reinforcement by appreciating the efforts of the patient, and paying attention to the patients’ concerns, which may help address the issue of adherence.

Psychiatrists may also be called in during the posttransplant period when there are communication issues or explicit hostilities between the patient and the treatment team. Personality differences and individual circumstances can result in a rift between the patient and the treatment providers. An aggressive (even verbal) stance of the unsatisfied patient results in doubts in the minds of the treatment provider whether the patient is suffering from a psychiatric illness. In such a situation, the assessment by the psychiatrist should focus on ascertaining the presence of a psychiatric illness (like psychotic disorder, mania, delirium, dementia, or personality disorder). If a psychiatric disorder seems to be contributory to the situation, it should be addressed. In case a diagnosable psychiatric disorder is not present, but personality traits are identified, further management would focus on improving communication and engagement with the transplant team. The psychiatrist may like to understand the point of view of the patient and the treatment providers and attempt to improve the communication between the two. The psychiatrist may be able to guide the patients about what is expected of him/her during the treatment process. The psychiatrist may also be able to help the treatment providers understand the patient’s point of view and what measures would result in fewer conflicts in patients with certain personality traits.

CONCLUSION

Psychiatric assessment of potential recipients and donors (when applicable) is an important step in the pretransplant evaluation. The pretransplant assessment encompasses the recipient’s understanding of the transplant, any known psychiatric illness, relevant family history, and current mental status examination. Similarly, the donors should be assessed for their understanding of the procedure and risks involved, motivation for organ donation, psychiatric history, and current mental status examination. Psychiatric assessments can also be requested immediately after the transplant surgery, primarily for delirium. During the subsequent follow-up period, the assessment may need to focus on the issues of adherence, the emergence of psychiatric illness or substance use, or any interpersonal relationship issues. The psychiatric assessment also needs to consider the psychological, social, cultural, and economic attributes of the patient. Assessments should be documented and discussed with the transplant colleagues when an opportunity arises.

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Conflicts of interest

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