OPEN LETTER TO ALL FEDERAL AND PROVINCIAL HEALTH MINISTERS
Dear Health Ministers: Canada urgently needs a national transplant policy
Fragmented, inconsistent policy across provinces leaves critically ill patients facing treatment inequality and death
A national transplant policy is the only solution to the pending crisis in Canada’s liver transplant system.
In August 2018, Ontario will become the only province in Canada to shelve the six-month wait for transplant imposed on patients whose liver failure is caused by alcohol use disorder. For the duration of the three-year pilot program, the rest of Canada will watch.
This change in Ontario creates an ethical dilemma for doctors in provinces without liver transplant centres of their own. They will soon face difficult choices, when it comes to patient treatment for liver failure caused by alcohol use disorder.
Do they continue to use their existing connections to liver transplant centres, which in many cases will result in their patients’ death? Or, do they turn away from established relationships and send their patients to Ontario, in order to save those lives?
The Hippocratic Oath would seem to make that decision a simple one. They are bound by their profession to put the needs of their patient first and thus send their patients to Ontario.
In doing so, doctors can only hope they are not bound by existing interprovincial agreements that affect funding of liver transplant procedures at centres they would not typically contact.
Only five Canadian provinces – British Columbia, Alberta, Ontario, Quebec and Nova Scotia – have liver transplant centres. All remaining provinces and territories send their patients out-of- province for transplant surgery.
If every patient suffering from alcohol use disorder in jurisdictions without liver transplant centres is sent to Ontario, Ontario’s liver transplant system will be forced to carry a disproportionate load. At the same time, patients in the rest of the provinces with liver transplant centres will continue to face a barrier that may cause their death.
Five Canadians die every day from alcohol-associated liver disease. (Stats Canada), most never assessed for liver transplant. If those were deaths from influenza, we would call it a public health emergency. How is avoidable death from alcohol use disorder any less important?
The issue is further complicated by our National Organ Waitlist, which links patients on waitlists across Canada with organs that become available. A patient would qualify to be listed for a liver transplant in one province, while not being eligible to receive that same organ under the criteria of another.
The concept of national transplant guidelines for patients with alcohol-associated liver failure is not new. In 2013, a group of doctors that included three liver transplant physicians from Ontario and British Columbia, published the results of a survey of Canadian liver transplant centres, reporting on waitlist requirements for patients with alcohol use disorder.
It noted the selection bias against persons with alcohol use disorder and called on the federal and provincial governments to create a national policy to “improve transparency, equality and accountability”. Their appeal for support was ignored. By you. By ALL of you.
This report was written by insiders – physicians who work in Canada’s liver transplant system. Two doctors, Dr. Paul Marotta and Dr. Roberto Hernandez-Alejandro were serving at the time on Trillium’s Liver-Small Bowel Working Group. In late 2012, this committee approved Trillium’s first waitlist criteria document, which included the 6-month wait. It would seem to me that there was lack of consensus at the boardroom table that day.
Another doctor who lent his name to the study, Dr. Eric Yoshida, is connected to the liver transplant program in British Columbia. Clearly support for the 6-month wait is neither unanimous in Ontario, nor its opposition confined to one province.
The complications of Ontario’s change were exemplified recently in the case of Eric Whitbread. Trapped in ICU in a Saskatoon hospital, his closest transplant centre is the University of Alberta.
Alberta’s policy includes a six months’ alcohol-free period and three weeks of inpatient rehabilitation. Eric is in ICU, on dialysis, so cannot meet the rehab requirement, But, he was already six months’ alcohol free, which meant he would qualify under Ontario’s existing waitlist standard.
In the United States, UNOS, the nonprofit that manages the American transplant system, rid itself of the potential liability of the six-month wait in the early 1990s. It leaves the decision of liver transplant waitlist criteria for patients with alcohol use disorder up to individual hospitals.
Over the past few years, more and more centres are ridding themselves of any wait for transplant, relying instead on compassionate criteria and post-transplant addiction care.
With multiple layers of health insurance coverage and programs, American with adequate coverage can choose a different transplant centre and/or a different state when the 6-month barrier is placed in front of them.
The question is, come this August, will Canadians have any choice at all? If they don’t, they may die.
Their lives, or their deaths, are in your hands.
Sincerely,
Debra Selkirk
Chief Advocacy Officer, Selkirk Liver Society
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