VCU Transplant Center among busiest, most innovative, clinically successful
Medical, social, family issues make this 'a whole different realm of nursing'
By Joan Tupponce

The 130 patients on the liver transplant list at the VCU Hume-Lee Transplant Center in VCU Medical Center are anxiously waiting to hear if they will be the recipient of a liver transplant. When they do hear, April Ashworth will be there to help.

"Liver transplant patients are very challenging because the liver is very complicated," observes Ashworth, liver transplant coordinator at VCU Medical Center. "The liver is a very vital organ in the body. A lot of people don't realize how important it is."

VCU's Hume-Lee Transplant Center is one of the oldest, continuously active transplant programs in the United States and consistently is ranked among the busiest, most innovative and clinically successful programs in the nation. The Medical College of Virginia Hospitals (now VCU Medical Center) started its transplant program in 1962.

Hume-Lee was one of the pioneering centers in the United States to perform an adult-to-adult living donor liver transplant. The Center now handles liver, kidney and pancreas transplants as well as living donor liver transplantation. Hume- Lee also works with liver cancer patients.

All liver disease patients receive a physical to make sure they need a liver transplant and can withstand the procedure before they are added to the transplant waiting list. The process is governed by the United Network for Organ Sharing. "UNOS has specifi c criteria that people have to meet to be put on the list," Ashworth explains. "Patients are put through a transplant evaluation. We look at the systems in the body. We want to make sure their heart and other organs are healthy enough to go through a transplant."

Hume-Lee performs 50 to 60 liver transplants a year, including living donor transplants. "That's a whole different specialty," Ashworth says. "A person donates a portion of his or her liver to another person. You have to be a match to the recipient."

Patients come from around the country. "Anyone can come here from anywhere they live," Ashworth says. "The Hunter Holmes McGuire Richmond VA Medical Center is part of our liver transplant program and veterans can come from all over. We also transplant infants and children."

Ashworth and the nurses in the Center start working with a patient when the patient is deemed ready to go through the transplant process. "We have a set of patients we follow," she explains. "We work with them at the Center and when they come back to the clinic to meet with the surgeon after their transplant. We work with the surgeons and the hepatologists."

Liver disease is a very complex disease because it affects so many systems in the body. "Liver patients don't have options," Ashworth says. "Their only option is a transplant or they will die." People have a false impression of what causes liver disease, she adds. "It doesn't just come from alcoholism or Hepatitis C, although Hepatitis C is a huge portion of patients we transplant. We also have patients who have autoimmune or metabolic diseases that they were born with."

Unfortunately, the availability of organs is not increasing at the same rate as the need for transplants. That is why living donors are so important. "The reason the living donor program started is the shortage of organ availability," Ashworth says. "They have been doing living donor transplants in Europe for years because of their culture. They don't use deceased donors. Living donation gives the patient another option."

Patients have to be on the donor transplant list before they can get a living donor - someone with liver disease who already has a living donor cannot get the transplant if he or she is not on the list. "You have to go through evaluation and testing in order to qualify," Ashworth says. "The donor could be related to the patient, unrelated or a good Samaritan donor if the person meets the criteria."

Living donors usually spend fi ve to six days in the hospital. "The liver regenerates in two to four weeks," Ashworth explains. "Those donors are usually back to normal activities in four to six weeks."

More and more people are signing up to be living donors, she adds. "Over the last two years we have had more people interested because they have been educated about the program."

Ashworth admits that working on the specialty fl oor can be challenging. "Anytime you have a patient as complex as a liver or kidney transplant there are hurdles you have to get over like infections or kidney failure," she says. "As a nurse, you have to be a little more cautious."

It's not just the medical issues that can be problematic. Transplant patients also have social issues to deal with. "Families can get very upset," Ashworth says. "This is a whole different realm of nursing." Clinical social worker Sheila Bullock understands the stress that these families are facing. Bullock works with the liver transplant team. "I have a support group for patients and families, and we put a lot of emphasis on social support," Bullock says. "When we do psychosocial assessments, we include the caregiver."

The problems that face patients and families are multi-layered. Many are dealing with role reversals in their family because the member of the family that everyone depended on now has a chronic illness. "There's also the stress of seeing your loved one who was very healthy and high functioning decline in health," Bullock says. "We see a lot of anxiety because people are dealing with the unknown. They don't know what to anticipate."

Families go through fi nancial losses, as well. "I tell them they have to look at their life and prioritize," Bullock says. "This is a time when they need to reassess their fi nances."

Some families become stronger while others fall apart. Regardless, Bullock is there to help. "Transplant is a specialized service," she says. "Once they come on the transplant list, they are my patients until they die."

Bullock knows that nurses on the unit also need comforting at times. "My heart goes out to the nursing staff because this is a tough population we are dealing with," she says. "Transplant patients come to us with higher MELD (Model for End Stage Liver Disease) scores, which means they are sicker and their needs become greater. They require a lot from us."

The staff is like a family, she adds. "We deal with tough issues, families in turmoil. We do have to turn to each other and talk. That's our support system."