Dealing with Difficult Scenarios in Transplantation

While the evaluation and post-surgical management of transplant patients primarily occur in the outpatient setting, there are scenarios in which challenging psychosocial issues will occur in the inpatient setting. Some of these situations include fulminant/acute organ failure, nonadherence leading to hospitalization for organ rejection, and patients experiencing decompensation in their mental health after transplant. Each of these scenarios presents a challenge to the transplant team, and psychosocial providers are likely to be called to the bedside to assist with these issues. When patients present with acute organ failure, the standard psychosocial evaluation is expedited and the patient may not be alert and oriented to interview. This leads to logistical and assessment challenges when trying to make a determination about a patient’s suitability for transplant. These scenarios can lead to tension among transplant team members, as there can be little time to come to an agreement about a patient’s candidacy. After transplant, up to 50% of patients report not always taking their immunosuppression medication as prescribed. This places patients at high risk for organ rejection. When patients are hospitalized for a rejection episode, the transplant team often relies on the expertise of psychiatrists to provide intervention and help patients alter their behavior. In the case of graft failure, this might include opining on a patient’s suitability for re-transplant. Finally, the prevalence of psychiatric disorders in transplant candidates and recipients is substantially higher than in the general population. Most transplant teams encourage mental health issues to be well-controlled prior to transplant; however, transplant surgery and the post-transplant medical regimen can exacerbate pre-existing psychiatric issues or contribute to the onset of new ones. In some situations, this may lead to difficulty in patient management, requiring intervention from psychiatry. In this workshop, provided by members of the Transplant Psychiatry SIG, a review of these concerns will be presented. In addition, cases will be presented to illustrate particular challenges and to provide guidance for addressing them.

Dr Sheila Jowsey-Gregoire will moderate and introduce the session (5-10 minutes), providing a brief overview of the content of the workshop. Next, Dr Stephan Weinland will discuss acute organ failure and the challenges of having to expedite an inpatient transplant evaluation (25 minutes). Dr Kristin Kuntz will discuss nonadherence in transplant patients and opportunities to identify and intervene on adherence barriers. Considerations regarding re-transplant in patients with a history of nonadherence will be discussed (25 minutes). Dr Sarah Andrews will present information on psychiatric illness in transplant patients and ways in which psychiatric illness can be exacerbated in the setting of solid organ transplant. She will provide guidance on treatment and communication with the transplant team (25 minutes). Case examples will be provided by all speakers.