Nephrologists' perspectives on waitlisting and allocation of deceased donor kidneys for transplant

Allison Tong, Kirsten Howard, Germaine Wong, Alan Cass, Stephen Jan, Michelle Irving, J Craig

Research output: Contribution to journalArticleResearchpeer-review

Abstract

Background: Deceased donor kidneys are a scarce resource and there is debate about how to maximize the benefit from each donated kidney while ensuring equity of access to transplants. Allocation of kidneys to waitlisted patients is determined by a computer algorithm, but the decision to waitlist patients or accept the kidneys offered is largely at the discretion of nephrologists. This study aims to elicit nephrologists' perspectives on waitlisting patients for kidney transplant and the allocation of deceased kidneys.

Methods: We conducted semistructured face-to-face interviews with adult and pediatric nephrologists from 15 Australian nephrology or transplant centers. Transcripts were analyzed for descriptive and analytical themes.

Results: 25 nephrologists participated. 5 major themes on waitlisting and deceased donor kidney allocation were identified: patient advocacy (championing their own patients, empowering patients, giving hope, individualizing judgments, patient preferences, and limited autonomy), professional and moral integrity (transparency, avoiding value judgments, and eliminating bias), protecting center reputation (gatekeeping), achieving equity (uniformity, avoiding discrimination, and fairness for specific populations), and maximizing societal benefit (prioritizing best use of kidney, resource implications, favoring social contribution, and improving efficiency of the allocation process). In making individual patient assessments, estimates about outcomes for a patient had to be resolved with whether it was reasonable from a broader societal perspective.

Conclusion: Nephrologists expressed their primary responsibility in terms of giving their own patients access to a transplant and upholding professional integrity by maintaining transparency and avoiding value judgments and bias. However, nephrologists perceived an obligation to protect their center's reputation through the selection of “good” patients, and this caused some frustration. Despite having personal preferences for optimizing the balance between societal benefit and equity, nephrologists did not want direct responsibility for ensuring societal benefit in clinical practice. Rather, they placed the onus on policy makers and the community to reconcile such tensions and advocate for societal benefit.
Original languageEnglish
Pages (from-to)704-716
Number of pages13
JournalAmerican Journal of Kidney Diseases
Volume58
Issue number5
DOIs
Publication statusPublished - 2011

Fingerprint

Tissue Donors
Transplants
Kidney
Hope
Gatekeeping
Professional Autonomy
Patient Advocacy
Frustration
Nephrology
Nephrologists
Patient Preference
Administrative Personnel
Patient Selection
Interviews
Pediatrics
Population

Cite this

Tong, Allison ; Howard, Kirsten ; Wong, Germaine ; Cass, Alan ; Jan, Stephen ; Irving, Michelle ; Craig, J. / Nephrologists' perspectives on waitlisting and allocation of deceased donor kidneys for transplant. In: American Journal of Kidney Diseases. 2011 ; Vol. 58, No. 5. pp. 704-716.
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abstract = "Background: Deceased donor kidneys are a scarce resource and there is debate about how to maximize the benefit from each donated kidney while ensuring equity of access to transplants. Allocation of kidneys to waitlisted patients is determined by a computer algorithm, but the decision to waitlist patients or accept the kidneys offered is largely at the discretion of nephrologists. This study aims to elicit nephrologists' perspectives on waitlisting patients for kidney transplant and the allocation of deceased kidneys.Methods: We conducted semistructured face-to-face interviews with adult and pediatric nephrologists from 15 Australian nephrology or transplant centers. Transcripts were analyzed for descriptive and analytical themes.Results: 25 nephrologists participated. 5 major themes on waitlisting and deceased donor kidney allocation were identified: patient advocacy (championing their own patients, empowering patients, giving hope, individualizing judgments, patient preferences, and limited autonomy), professional and moral integrity (transparency, avoiding value judgments, and eliminating bias), protecting center reputation (gatekeeping), achieving equity (uniformity, avoiding discrimination, and fairness for specific populations), and maximizing societal benefit (prioritizing best use of kidney, resource implications, favoring social contribution, and improving efficiency of the allocation process). In making individual patient assessments, estimates about outcomes for a patient had to be resolved with whether it was reasonable from a broader societal perspective.Conclusion: Nephrologists expressed their primary responsibility in terms of giving their own patients access to a transplant and upholding professional integrity by maintaining transparency and avoiding value judgments and bias. However, nephrologists perceived an obligation to protect their center's reputation through the selection of “good” patients, and this caused some frustration. Despite having personal preferences for optimizing the balance between societal benefit and equity, nephrologists did not want direct responsibility for ensuring societal benefit in clinical practice. Rather, they placed the onus on policy makers and the community to reconcile such tensions and advocate for societal benefit.",
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Nephrologists' perspectives on waitlisting and allocation of deceased donor kidneys for transplant. / Tong, Allison; Howard, Kirsten; Wong, Germaine; Cass, Alan; Jan, Stephen; Irving, Michelle; Craig, J.

In: American Journal of Kidney Diseases, Vol. 58, No. 5, 2011, p. 704-716.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Nephrologists' perspectives on waitlisting and allocation of deceased donor kidneys for transplant

AU - Tong, Allison

AU - Howard, Kirsten

AU - Wong, Germaine

AU - Cass, Alan

AU - Jan, Stephen

AU - Irving, Michelle

AU - Craig, J

PY - 2011

Y1 - 2011

N2 - Background: Deceased donor kidneys are a scarce resource and there is debate about how to maximize the benefit from each donated kidney while ensuring equity of access to transplants. Allocation of kidneys to waitlisted patients is determined by a computer algorithm, but the decision to waitlist patients or accept the kidneys offered is largely at the discretion of nephrologists. This study aims to elicit nephrologists' perspectives on waitlisting patients for kidney transplant and the allocation of deceased kidneys.Methods: We conducted semistructured face-to-face interviews with adult and pediatric nephrologists from 15 Australian nephrology or transplant centers. Transcripts were analyzed for descriptive and analytical themes.Results: 25 nephrologists participated. 5 major themes on waitlisting and deceased donor kidney allocation were identified: patient advocacy (championing their own patients, empowering patients, giving hope, individualizing judgments, patient preferences, and limited autonomy), professional and moral integrity (transparency, avoiding value judgments, and eliminating bias), protecting center reputation (gatekeeping), achieving equity (uniformity, avoiding discrimination, and fairness for specific populations), and maximizing societal benefit (prioritizing best use of kidney, resource implications, favoring social contribution, and improving efficiency of the allocation process). In making individual patient assessments, estimates about outcomes for a patient had to be resolved with whether it was reasonable from a broader societal perspective.Conclusion: Nephrologists expressed their primary responsibility in terms of giving their own patients access to a transplant and upholding professional integrity by maintaining transparency and avoiding value judgments and bias. However, nephrologists perceived an obligation to protect their center's reputation through the selection of “good” patients, and this caused some frustration. Despite having personal preferences for optimizing the balance between societal benefit and equity, nephrologists did not want direct responsibility for ensuring societal benefit in clinical practice. Rather, they placed the onus on policy makers and the community to reconcile such tensions and advocate for societal benefit.

AB - Background: Deceased donor kidneys are a scarce resource and there is debate about how to maximize the benefit from each donated kidney while ensuring equity of access to transplants. Allocation of kidneys to waitlisted patients is determined by a computer algorithm, but the decision to waitlist patients or accept the kidneys offered is largely at the discretion of nephrologists. This study aims to elicit nephrologists' perspectives on waitlisting patients for kidney transplant and the allocation of deceased kidneys.Methods: We conducted semistructured face-to-face interviews with adult and pediatric nephrologists from 15 Australian nephrology or transplant centers. Transcripts were analyzed for descriptive and analytical themes.Results: 25 nephrologists participated. 5 major themes on waitlisting and deceased donor kidney allocation were identified: patient advocacy (championing their own patients, empowering patients, giving hope, individualizing judgments, patient preferences, and limited autonomy), professional and moral integrity (transparency, avoiding value judgments, and eliminating bias), protecting center reputation (gatekeeping), achieving equity (uniformity, avoiding discrimination, and fairness for specific populations), and maximizing societal benefit (prioritizing best use of kidney, resource implications, favoring social contribution, and improving efficiency of the allocation process). In making individual patient assessments, estimates about outcomes for a patient had to be resolved with whether it was reasonable from a broader societal perspective.Conclusion: Nephrologists expressed their primary responsibility in terms of giving their own patients access to a transplant and upholding professional integrity by maintaining transparency and avoiding value judgments and bias. However, nephrologists perceived an obligation to protect their center's reputation through the selection of “good” patients, and this caused some frustration. Despite having personal preferences for optimizing the balance between societal benefit and equity, nephrologists did not want direct responsibility for ensuring societal benefit in clinical practice. Rather, they placed the onus on policy makers and the community to reconcile such tensions and advocate for societal benefit.

U2 - 10.1053/j.ajkd.2011.05.029

DO - 10.1053/j.ajkd.2011.05.029

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VL - 58

SP - 704

EP - 716

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JF - American Journal of Kidney Diseases

SN - 0272-6386

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ER -