Crucial Communication in Organ Transplantation: Selection Conferences, Interprofessional Collaboration, Patient Advocacy, and Countertransference

Abstract: Solid organ transplantation (SOT) occupies a unique niche within health systems; aspects of transplant surgery and transplant medicine simply do not exist in other specialties. While less prominent than medical and surgical novelty, psychosocial elements of SOT are similarly distinctive. Chief among them are unique interpersonal dynamics and communication among the transplant center’s multidisciplinary clinicians but also with the patients and families they serve¹. These interpersonal factors are not just unique, however. They are among the most controversial and contentious matters that transplant clinicians encounter². They are also archetypes of the dual roles of all C-L psychiatrists, consulting and liaising, whose analysis can benefit any clinician, wherever they practice.

There are several reasons why communication in SOT is so noteworthy. First, the clinical stakes in SOT are high; donor organs, among society’s most precious resources, are in shortage and are allocated zero-sum by multidisciplinary selection committees to patients suffering with end-stage diseases. Second, end-stage disease activates patients’ and families’ survival instinct; they wish to avoid divulging anything alarming which could adversely affect transplant access. Third, transplant patients are rarely themselves seeking psychiatric treatment; evaluations are often required by SOT teams which stifles formation of rapport and therapeutic alliances. Fourth, end-stage diseases can be direct or indirect manifestations of severe psychiatric or addictive disorders (e.g., alcohol-related liver disease or cardiomyopathy, intentional drug overdoses, lithium-induced nephropathy, eating disorders, etc.) thus infusing complex biomedical clinical care with challenging psychosocial risks and hazards and the possibility of stigma toward already highly marginalized patient groups³. Finally, all this often occurs on hurried and compressed clinical timetables.

Dr. Winder will discuss (15 minutes) clinician communication and decision-making during selection conferences, including the importance of medical and surgical specialties perception of and communication to patients regarding psychosocial topics¹.

Dr. Andrews will present (15m) on clinician countertransference and biases which impact team communication and decisions during treatment and organ allocation decision-making.

Dr. Fipps will discuss (15m) the importance of psychosocial data (e.g., toxicology, medical adherence, psychometric screening tools) and their interpretation and use in determining patients' transplant candidacy; his remarks will include communication strategies for resolving discrepancies (e.g., positive toxicology in a patient reporting abstinence).

Dr Maldonado will teach (15m) about the unique therapeutic alliance which must form and be maintained in SOT and living donation between psychiatric clinicians and patients and families. He will also depict the careful balance of patient advocacy and donor organ stewardship, specifically its impact on clinical and team communication.

The remaining time (15m) will be spent for question-and-answer, case presentations, and panel discussion.

1. Winder GS, et al. The art of interprofessional psychosocial communication: optimizing patient interfaces with psychiatric specialists in liver transplantation. Transplantation Reviews. 2022 Dec 1;36(4):100728

2. Secunda K, et al. National survey of provider opinions on controversial characteristics of liver transplant candidates. Liver Transplantation. 2013 Apr;19(4):395-403

3. Wakeman SE, et al. Opioid use disorder, stigma, and transplantation: a call to action. Annals of İnternal Medicine. 2018 Aug 7;169(3):188-9

Learning Objectives:

• Define both common and unique elements of clinical communication in solid organ transplantation (SOT) which occur among multidisciplinary clinicians and with patients and families.
• Analyze the sizable impact of high clinical stakes of SOT, including allocation of rare and precious donor organs, on interactions with patients and families and among colleagues.
• Extrapolate communication principles and strategies from the presentation to one's own clinical work, regardless of venue or patient population.