Hearing that a transplant program has unexpectedly low graft or patient survival rates brings the assumption that the program's staff must be unqualified or inexperienced (not doing enough), or uncaring or incompetent (not trying hard enough). But what if the problem is actually that they're doing too much and trying too hard?
At the end of the year, the Los Angeles Times reported on the unexpectedly high death rate of patients in the liver transplant program at the University of Southern California (USC). They told the stories of several individual patients who were extremely sick, who would likely die with or without a liver transplant, who may have received marginal donor organs, but ultimately were transplanted at USC when other programs had turned them down. The available data support the notion that USC has a very high-risk patient population: the "expected" survival rate for USC was lower than the national average, and USC patients had a higher risk of dying before a transplant, not just afterwards. There were also systems problems within the program, as detailed both by the LA Times and the USC Daily Trojan student newspaper--these should be corrected, and plans to do so are in place. But the USC dilemma generates the more vexing question of who is an appropriate transplant candidate and who is "too sick" to receive a treatment designed for "end-stage" presumably fatal disease.
Much of the response to this story was defensive, with letters to the editor in defense of both the field of liver transplantation and the USC program in particular. For a field founded on treating otherwise untreatable diseases, and that has made untreatable diseases treatable, this defense is perfectly understandable. Also, the line between acceptable and untenable transplant candidates is a moving target that has generally become more permissive over time. Personally, I can't imagine the despair of being "too sick to transplant" and can fully understand why patients would seek out any program that would offer them a chance, and why a program would strive to give them that chance.
Yet the fact remains that the outcomes of patients treated at USC are poor by national standards, and as insightfully stated by Dr. David Mulligan, chairman of transplant surgery at Mayo Clinic Hospital in Phoenix: "They're pushing it as hard as they can and having the results that you'd expect to see." Beyond the "push" for individual patients, though, is a "push" on much larger systems:
- The staff is devoting its considerable training and talents to some patients who stand little chance of benefitting from them.
- USC is dedicating resources to a program that may ultimately harm it more than help it as an institution.
- Organizations such as OneLegacy (the organ procurement organization serving Southern California) and UNOS are spending their time and energy matching donors and recipients who may have very little chance of success.
- Medicare, Medicaid, or private insurers are paying for an expensive treatment that has less chance of succeeding than it may under more normal circumstances.
The follow-up to this story indicates that, however good the intentions of USC's previous practices, they are changing. It will take time to see if these changes improve their survival rates and repair their reputation. But the patients who are too sick to transplant are still out there, and someday treating them successfully is a challenge to the field of transplantation and medicine in general.