Ethical Considerations in the Psychosocial Evaluation of Pediatric Organ Transplant Candidates, Recipients and Their Families

Addressing Substance Use in the Adolescent Transplant Population

Adolescence is a unique period of physical and psychosocial changes as youth transition, over many years, to adulthood. The psychosocial changes that accompany adolescence include emotional separation from parents, greater influence of peer groups, an interest in self-identification and autonomy, and increased risk-taking behaviors. Substance use is a common form of risk-taking behavior in the adolescent developmental stage. Alcohol, nicotine, and cannabis are the most common types of substances used in the United States. In the adolescent transplant population, rates of substance use appear to be at, or slightly below, their peer counterparts. Substance use can lead to deleterious health outcomes for adolescent transplant patients as a result of impaired decision-making, reduction in medication and clinic visit compliance, increases in mental health disorders, and risk for developing dependence and a substance use disorder. Given the close relationship that many pediatric transplant providers have with their patients and families, transplant care teams are in an excellent position to help their patients by addressing adolescent substance use. This narrative review describes how providers can use proactive standardized approaches to identify and intervene with substance use behavior.

Understanding Substance use Policies and Associated Ethical Concerns: A survey of Pediatric Transplant Centers

Psychosocial risk factors, such as substance use, have been linked to poor post-transplant outcomes for solid organ transplant patients, including poor medication adherence, increased risk for rejection, and even graft failure. Despite universal consensus that substance use is an increasing problem among youth, many pediatric transplant centers do not have policies in place to address substance use and no universal guidelines exist regarding assessment during the pre-transplant evaluation in this population. An online survey was administered via REDCap™ and directed toward medical leaders (ie, medical and surgical directors) of national heart, kidney, and liver transplant centers. Questions examined the following: perspectives on the need for a universal transplant center policy on pediatric substance use, abuse, and dependence; timing and frequency of evaluation for substance use; specific substances which would elicit respondents' concerns; and ethical concerns surrounding substance use. Data were analyzed using descriptive statistics. Data were collected from 52 respondents from 38 transplant centers, with the majority (n = 40; 77%) reporting no substance use policy in place for pediatric transplant patients. However, many endorsed concerns if a pediatric patient was found to be using specific substances. Our findings further highlight the need for a universal substance use policy across pediatric solid organ transplant centers. The results from the distributed survey will help to provide guidelines and best practices when establishing a universal policy for substance use.

Providers' perspectives on substance use among solid organ transplant candidates in a pediatric hospital

INTRODUCTION

Substance use is prevalent among youth and often leads to impairment in multiple domains. Additionally, substance use may pose adverse health issues post-transplant. Yet, practices related to substance use among pediatric patients who require organ transplant remain inconsistent. In this study, providers were surveyed for their perspectives on substance use among solid organ transplant candidates within a pediatric hospital.

METHODS

An online survey was administered to providers on the heart, kidney, and liver transplant teams at one tertiary pediatric care center located in the intermountain region of the United States (N = 50, 42% response rate). Providers answered questions about the need for a hospital-wide policy across heart, liver, and kidney transplant teams within this transplant center, timing of substance use evaluation, types of substances eliciting concerns based on organ, and recommended interventions. Data were analyzed using descriptive statistics.

RESULTS

Providers felt strongly about the need for a policy to guide recommendations for substance use among transplant candidates. Providers wanted a hospital-wide substance use policy (84%) and a standardized measure for assessing substance use (98%). Respondents (98%) indicated that substance use should be assessed during the pretransplant evaluation. Respondents expressed varied concerns based on substance and organ type, and recommended interventions for patients to cease substance use prior to transplant listing.

CONCLUSIONS

This study highlights the need for a clear, directive, hospital-wide policy and standardized procedure for evaluating substance use among adolescent solid organ transplant candidates nationally across pediatric transplant centers.