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Racial Inequalities in the Organ Transplantation Selection Process – How Can C-L Psychiatrists Be Part of the Solution
Please join us for the live review of this session at 4:00 EST on Thu Nov 11:
https://clp21.secure-platform.com/a/solicitations/8/sessiongallery/schedule/items/126
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Transplantation offers a chance for patients with end-stage organ failure to prolong and improve the quality of their lives. Transplant is not a cure, but a chance to live with a chronic medical condition and its many potential complications. Along with a medical and surgical evaluation, a psychosocial evaluation has been found to be an important part of the pre-transplant assessment and a predictor of post-transplant outcomes. The transplant psychiatrist plays an important role in this process to support the patients and strengthen their candidacy, but they also have the challenging role of identifying psychosocially high-risk candidates (e.g., limited support system, history of treatment non-adherence, untreated severe mental illness or active substance abuse). An outcome might be that patients are declined due to medical or psychosocial reasons thought to outweigh the actual benefit of transplant to the patient. However, especially in the current US climate of increased awareness of racial and ethnic inequality in multiple spheres of life, it behooves us to reflect on how racial and ethnic inequality influences the transplant selection process. Emerging evidence does raise important questions. Even after controlling for other variables, Black patients with end-stage liver disease were less likely to be listed for a liver transplant list (Jesse et al, 2019). For lung transplant recipients, it took longer for non-white patients to make it to the list, even though both groups eventually had similar outcomes (Mooney et al, 2018). Race and ethnicity are intertwined with other psychosocial variables (e.g. stigma towards mental health diagnoses, socioeconomic status, social support availability, history of “treatment non-adherence” due to insurance or logistical problems). These inequalities will thus translate into the final outcomes of our psychosocial evaluation. Until now, not much emphasis has been placed on how the psychosocial pre-transplant evaluation might assess for factors emanating from decades of discrimination and inequality, or how it might further perpetuate the discrimination and inequality by labeling patients high risk based on these factors. This workshop is a first attempt at discussing how race and ethnicity as well as other factors (gender, sexual orientation, and socioeconomic status) might interplay with the process and outcome of transplantation by using didactics and illustrative cases to highlight these challenges in transplant evaluation. Jose Maldonado will critically evaluate the evidence for suggested domains of transplant psychosocial evaluation. Yelizaveta Sher will discuss the influence of race and ethnicity in the transplantation referral, transplantation evaluation, and transplant outcomes. Sheila Lahijani will discuss special considerations in bone marrow transplant populations. Filza Hussain will moderate a discussion as to how transplant and C-L psychiatrists can advocate for marginalized patients throughout the various stages of the transplant process.
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Transplantation offers a chance for patients with end-stage organ failure to prolong and improve the quality of their lives. Transplant is not a cure, but a chance to live with a chronic medical condition and its many potential complications. Along with a medical and surgical evaluation, a psychosocial evaluation has been found to be an important part of the pre-transplant assessment and a predictor of post-transplant outcomes. The transplant psychiatrist plays an important role in this process to support the patients and strengthen their candidacy, but they also have the challenging role of identifying psychosocially high-risk candidates (e.g., limited support system, history of treatment non-adherence, untreated severe mental illness or active substance abuse). An outcome might be that patients are declined due to medical or psychosocial reasons thought to outweigh the actual benefit of transplant to the patient. However, especially in the current US climate of increased awareness of racial and ethnic inequality in multiple spheres of life, it behooves us to reflect on how racial and ethnic inequality influences the transplant selection process. Emerging evidence does raise important questions. Even after controlling for other variables, Black patients with end-stage liver disease were less likely to be listed for a liver transplant list (Jesse et al, 2019). For lung transplant recipients, it took longer for non-white patients to make it to the list, even though both groups eventually had similar outcomes (Mooney et al, 2018). Race and ethnicity are intertwined with other psychosocial variables (e.g. stigma towards mental health diagnoses, socioeconomic status, social support availability, history of “treatment non-adherence” due to insurance or logistical problems). These inequalities will thus translate into the final outcomes of our psychosocial evaluation. Until now, not much emphasis has been placed on how the psychosocial pre-transplant evaluation might assess for factors emanating from decades of discrimination and inequality, or how it might further perpetuate the discrimination and inequality by labeling patients high risk based on these factors. This workshop is a first attempt at discussing how race and ethnicity as well as other factors (gender, sexual orientation, and socioeconomic status) might interplay with the process and outcome of transplantation by using didactics and illustrative cases to highlight these challenges in transplant evaluation. Jose Maldonado will critically evaluate the evidence for suggested domains of transplant psychosocial evaluation. Yelizaveta Sher will discuss the influence of race and ethnicity in the transplantation referral, transplantation evaluation, and transplant outcomes. Sheila Lahijani will discuss special considerations in bone marrow transplant populations. Filza Hussain will moderate a discussion as to how transplant and C-L psychiatrists can advocate for marginalized patients throughout the various stages of the transplant process.
Speakers
Yelizaveta Sher
Clinical Associate Professor of Psychiatry | Stanford University School of Medicine
Dr. Sher is a Clinical Associate Professor of Psychiatry at Stanford. She works closely with patients with cystic fibrosis as well as patients before and after lung transplantation. She is a co-editor of Facing COVID-19, Facing Transplantation, Facing Cystic Fibrosis, and Psychosocial Care of End-Stage Organ Disease and Transplant Patients.
Jose Maldonado
Professor - Associate Division Chief Adult Psychiatry, Consultation Psychiatry | Stanford University
Dr. Maldonado is the Associate Division Chief of Adult Psychiatry for Psychosomatic Medicine and Consultation-Liaison Psychiatry at Stanford University Medical Center. He is board certified in Adult Psychiatry, Psychosomatic Medicine, Forensic Psychiatry, Addiction Medicine, and Forensic Medicine.
His research lab developed the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) a tool created to assess the psychosocial candidacy of organ transplant and ventricular assisted devices (VADs) candidates. In addition, his research has led the field of Psychosomatic Medicine with the development of tools for the prediction and assessment of various neuropsychiatric disorders; including the development of a new tool for the timely and accurate diagnosis of delirium: the Stanford Proxy Test of Delirium (S-PTD); the Stanford Algorithm for Predicting Delirium (SAPD), a tool to help predict patients at risk for developing delirium; and the Prediction of Alcohol Withdrawal Severity Scale (PAWSS). He has developed management protocols and algorithms for the prevention and treatment of delirium; as well as novel pharmacological techniques (benzodiazepine-sparing protocol) for the prophylaxis and treatment of complicated alcohol withdrawal syndromes.
Dr Maldonado has been the recipient of multiple awards and recognitions, the most recent includle: the 2017 – Franz-Köhler-Inflammation-Award from the German Society of Anesthesiology and Intensive Care Medicine (DGAI) for extraordinary achievements in research on inflammation and its relationship to the pathophysiology of delirium; and the 2018 – Eleanor and Thomas P. Hackett Memorial Award by the Academy of Consultation-Liaison Psychiatry, the Academy’s highest honor, for distinctive achievements in CLP training, research, clinical practice, and leadership.
His research lab developed the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) a tool created to assess the psychosocial candidacy of organ transplant and ventricular assisted devices (VADs) candidates. In addition, his research has led the field of Psychosomatic Medicine with the development of tools for the prediction and assessment of various neuropsychiatric disorders; including the development of a new tool for the timely and accurate diagnosis of delirium: the Stanford Proxy Test of Delirium (S-PTD); the Stanford Algorithm for Predicting Delirium (SAPD), a tool to help predict patients at risk for developing delirium; and the Prediction of Alcohol Withdrawal Severity Scale (PAWSS). He has developed management protocols and algorithms for the prevention and treatment of delirium; as well as novel pharmacological techniques (benzodiazepine-sparing protocol) for the prophylaxis and treatment of complicated alcohol withdrawal syndromes.
Dr Maldonado has been the recipient of multiple awards and recognitions, the most recent includle: the 2017 – Franz-Köhler-Inflammation-Award from the German Society of Anesthesiology and Intensive Care Medicine (DGAI) for extraordinary achievements in research on inflammation and its relationship to the pathophysiology of delirium; and the 2018 – Eleanor and Thomas P. Hackett Memorial Award by the Academy of Consultation-Liaison Psychiatry, the Academy’s highest honor, for distinctive achievements in CLP training, research, clinical practice, and leadership.
Filza Hussain
Clinical Assistant Professor | Stanford University
Filza Hussain MD is a Clinical Assistant Professor of Psychiatry at Stanford University School of Medicine. She is an Aga Khan University, Pakistan, alumnus and completed her residency training at the Mayo Clinic, Minnesota and a CL fellowship at Columbia University in New York. Her clinical focus is transplant psychiatry and she serves as the liaison to the Liver and Kidney transplant programs at Stanford. Other areas of clinical/research interests include Personality disorders, Suicidology, Cultural Psychiatry, and medical pedagogy.
Sheila Lahijani
Clinical Associate Professor | Stanford University School of Medicine
Dr. Lahijani is a CL Psychiatrist at Stanford Hospital and Clinics. She is the Medical Director of the Stanford Cancer Center Psychosocial Oncology Program where she serves as a psycho-oncologist and oversees program development and operations. She teaches psychiatry, medicine, and neurology trainees. Dr. Lahijani collaborates closely with advanced practice providers and social workers at the Cancer Center. Her clinical and scholarly interests interests include psychotherapy for the medically ill, psychopharmacology, and neuropsychiatric sequelae of cancer therapy.
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