Organ transplants: Who should receive them?
Posted on Wednesday, January 9th, 2013 at 2:27 pm by Life Matters Media
The growing population of healthier older Americans is changing the way some medical centers choose recipients of organ donations. Debates are now brewing about who should receive vital organs and if age is a legitimate factor.
Many experts say these trends cannot be ignored. The graying population and revised policies determining who gets priority for donated organs have led to a rising proportion of older adults receiving transplants, The New York Times reports.
Joe Gammalo, 66, had been struggling with pulmonary fibrosis for more than a decade when he came to the Cleveland Clinic seeking a transplant four years ago. “It had gotten to the point where I was on oxygen all the time and in a wheelchair,” he told the Times‘ Paula Span. “I didn’t expect to live.”
Although lung transplants are difficult, often involving lifelong use of immunosuppressive drugs with high rates of side effects, the Clinic successfully performed the procedure. “It’s not like taking out an appendix,” said Dr. Marie Budev, the medical director of the Clinic’s lung transplant program.
Only about half of all lung recipients live for five years, she said, and most still die of their disease. The only treatment for pulmonary fibrosis, however, is a new set of lungs.
Some medical centers would have turned Gammalo away due to his age. Because survival rates are lower for the elderly, Span reports, “guidelines from the International Society for Heart and Lung Transplantation caution against lung transplants for those over 65, though they set no age limit.”
Still, the Society advises: “recognizing that advancing age alone in an otherwise acceptable candidate with few co-morbidities does not necessarily compromise successful transplant outcomes.”
Similarly, Judith Graham reported last April on the emerging trends associated with heart transplants. “Just a decade ago, people 65 and older were routinely rejected for heart transplants at all but a few institutions,” she wrote. But in 2006, the International Society for Heart and Lung Transplantation issued guidelines advising heart failure patients should be considered for transplants even up to age 70.
The new guidelines did not substantially increase the number of patients receiving heart transplants, however. Data from the Organ Procurement and Transplantation Network shows that in 2006, 243 patients ages 65 and older received new hearts. By 2011, there were 332 transplants.
Last year in the U.S., almost 16,000 kidney transplants, 6,000 liver transplants, 2,000 heart transplants and 2,000 lung transplants were performed. The majority going to individuals 50 to 64 years old. However, more than 1,500 individuals remained on the waiting list for lung transplants. Almost 3,000 adults were awaiting heart transplants.
So who should receive these rare organs? Some physicians, like Dr. Jeffrey Punch, chief of transplantation surgery at the University of Michigan, argue that the young should get priority.
“Personally, I think we should transplant 18 and younger and then address this issue of the young versus the old, taking care not to exclude older people but making sure that we put more emphasis on transplanting younger people,” he said.
Dr. Mandeep Mehra, executive director of the Center for Advanced Heart Disease at Brigham and Women’s Hospital, disagrees. ”Many of these older patients can transition to an even older age while maintaining a very good quality of life. Why would we deny someone that opportunity?”
Dr. Kevin Chan, transplant program medical director at the University of Michigan, posed this hypothetical: “What if there’s a 35-year-old on a ventilator who needs the lung just as much?” he asked. “Why should a 72-year-old possibly take away a lung from a 35-year-old?” But, he admits, “it’s easy to look at the statistics and say, ‘Give the lungs to younger patients.’ At the bedside, when you meet this patient and family, it’s a lot different.”
It is not as easy to receive an organ in the U.S. if you are 65 or older. Older individuals undergo physical and health screenings before being deemed eligible. They must have no chronic illness and the strength to complete post- surgery regimens. Then, they wait.
Differences between older and younger heart transplant patients are smaller when recipients are carefully chosen, according to researchers at Johns Hopkins University School of Medicine. After one year, 84 percent of heart transplant patients ages 60 and above survive, compared with 87 percent of younger patients. At five years, 69 percent of older patients survive, compared to the 75 percent of younger patients. The researchers suggest heart transplants not be restricted from patients based on age- so long as these encouraging statistics continue.
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Feeding tubes: Families struggle with the decision
Posted on Saturday, November 24th, 2012 at 3:12 pm by Life Matters Media
Many families caring for seniors with advanced neurological disease face this dilemma: prolong their loved one’s life by artificial means via a feeding tube or stop feeding them altogether. Lisa Krieger’s new feature for Mercury News focuses on the billion-dollar feeding tube business and why some families regret their decision to opt for artificial nutrition.
One-third of nursing home residents suffering from dementia receive tube feedings, contributing to the $1.64 billion industry. However, some families and physicians insist the value of feeding tubes is overrated, since they provide little medical benefit and increase pain for those suffering from progressive neurological disease.
“The number of nursing home residents with advanced dementia who get feeding tubes each year varies widely across states,” Krieger reports. The only comprehensive study on the matter found the average rate of use nationwide was 54 per 1,000 people.
Racial minorities are also more likely to opt for artificial tubes than whites. Life Matters Media previously reported that blacks are twice as likely than others to choose aggressive end of life treatments.
As medical costs continue to rise and the baby boomer population ages, views on artificial nutrition may be changing. “Decades after the tube achieved widespread use for people with irreversible dementia, some families are beginning to say no to them, as emerging research shows that artificial feeding prolongs, complicates and isolates dying,” Krieger writes.
For example, a 1999 study by Dr. Thomas Finucane of Johns Hopkins Medical Center found no evidence that feeding tubes prolong the lives of demented nursing home patients. They also didn’t prevent pneumonia or improve comfort.
Finucane’s analysis asserts: “We found no data to suggest that tube feeding improves any of these clinically important outcomes and some data to suggest that it does not… risks are substantial. The widespread practice of tube feeding should be carefully reconsidered…”
Most families, however, are accustomed to caring for their sick by feeding them, a reason why the decision to opt for or against artificial nutrition is especially emotional. “Food is how we comfort those we love; when all other forms of communication have vanished, feeding remains a final act of devotion,” Krieger writes.
Sometimes a terminally ill individual may not feel pain when a feeding tube is first inserted in the stomach. As the illness progresses and pain begins to get more intense, removing the tube becomes a moral debate. This quandary often comes as another surprise for families.
“It is amazing how long you can keep someone alive,” said Dr. Leslie Foote, medical director of Windsor Gardens Rehabilitation Center in California. “But we sure aren’t doing them any great favors.”
Despite some change in public opinion, families may not have the choice to reject feeding tubes. The fallout from the controversial 2005 Terri Schiavo case led the Catholic Church to order doctors at its hospitals to ignore patients’ advanced directives- even if they do not want artificial feeding. Catholic hospitals may mandate artificial nourishment.
In 2009, the U.S. Conference of Catholic Bishops issued the directive to more than 1,000 Catholic hospitals and nursing homes, as well as to all Catholic doctors.
“People with end stage dementia still possess human dignity. And that dignity must be respected,” said Vice- President of Corporate Ethics at Catholic Daughters of Charity Health System Gerald Coleman. Krieger insists that tube feeding constitutes ordinary care at Catholic hospitals.
Learn more about feeding tubes at WebMD.
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