Title: Balancing Urgency, Life expectancy and Quality of Life in Organ Allocation Decisions: A survey

Authors: James Stahl, Angela C Tramontano, Brian Cohen

Purpose: Describe public attitudes towards Urgency, Life expectancy and Quality of Life in Organ Allocation Decisions

Background: Allocating livers for transplant requires making difficult choices between eligible recipients.  The US Task Force on Organ Transplantation recommended that considerations of justice, autonomy and medical outcome be part of this choice.  Justice may be modeled as a function of 3 types of need related to clinical urgency, quality of life and years lived.  Currently, priority for livers is based on clinical urgency alone as measured by the MELD/PELD score, a score based on lab values.  In this study we explore the trade-offs inherent in the decision to allocate scarce resources between clinical urgency, age, quality of life and life expectancy before and after transplant.

Methods: We conducted a web-based survey where respondents were presented with questions related to demographics, hypothesized influences on organ allocation decisions, and trade-off questions. The trade-offs were between pairs of the following: clinical urgency (time to death under 1 yr), age, current quality of life, post-transplant quality of life, current life-expectancy, post transplant life expectancy

Results:  1600 persons were notified via email about the survey, of these 623 (39%) people completed it. Of these 75% were women, 53% attended college, average family income was between $25-50 K (36.2%). In the figures we present 2 trade-offs: clinical urgency (months left to live <1yr) vs age and clinical urgency vs current quality of life.  In figure 1, if 2 patients are the same age the first patient needs to be 1-2 months more urgent than the other to receive the organ.  Older patients need to be relatively more urgent to be given priority for an organ (~ 1.3 months/ 10 yrs age difference). In figure 2, the patient with the worse initial QOL needs to be more urgent to be given priority for transplant (-.4 mos/ QOL level)

Conclusion:  People are prepared and able to answer difficult ethical trade-off questions via survey.  It appears that urgency is only one of many factors (Age, Quality of life, Expected outcome, etc.) that influence how allocation decisions are made.