University of Michigan, University of Michigan Health System, Ann Arbor, USA.
Ann Intern Med. 2011 Oct 18;155(8):503-8. doi: 10.7326/0003-4819-155-8-201110180-00006.
To receive a liver transplant, patients must first be placed on a waiting list-a decision made at most transplant centers by a multidisciplinary committee. The function of these committees has never been studied.
To describe decision making in liver transplant committees and identify opportunities for process improvement.
Observational multicenter study.
4 liver transplant centers in the United States.
68 members of liver transplant committees across the 4 centers.
63 meetings were observed, and 50 committee members were interviewed. Recorded transcripts and field notes were analyzed by using standard qualitative sociologic methods.
Although the structure of the meetings varied by center, the process was uniform and primarily involved inductive reasoning to review possible reasons for patient exclusion. Patients were excluded if they were too well, too sick (in the setting of advanced liver disease), or too old or had nonhepatic comorbid conditions, substance abuse problems, or other psychosocial barriers. Dominant themes in the discussions included member angst over deciding who lived or died, a high correlation between psychosocial barriers to transplantation and the patient's socioeconomic status, and the influence of external forces on decision making. Unwritten center policies and confusion regarding advocacy versus stewardship roles were consistently identified as barriers to effective group decision making.
The use of qualitative methods provides broad understanding but limits specific inferences. The 4 centers may not reflect the practices of every transplant center nationwide.
The difficult decisions made by liver transplant committees are reasonably consistent and well-intentioned, but the process might be improved by having more explicit written policies and clarifying roles. This may inform resource allocation in other areas of medicine.
The Greenwall Foundation and the National Institutes of Health.
患者必须先被列入等候名单，才能接受肝移植，这一决定由大多数移植中心的多学科委员会做出。这些委员会的运作情况从未得到过研究。
描述肝移植委员会的决策过程，并确定改进流程的机会。
观察性多中心研究。
美国 4 家肝移植中心。
4 家中心的 68 名肝移植委员会成员。
观察了 63 次会议，并对 50 名委员会成员进行了访谈。使用标准的定性社会学方法对记录的转录本和现场记录进行分析。
尽管会议的结构因中心而异，但过程是统一的，主要涉及归纳推理，以审查排除患者的可能原因。如果患者状况良好、病情过重（晚期肝病）、年龄过大或存在非肝脏合并症、药物滥用问题或其他心理社会障碍，就会被排除在外。讨论中的主要主题包括成员对决定谁生谁死的焦虑，移植的心理社会障碍与患者社会经济地位之间的高度相关性，以及外部力量对决策的影响。未成文的中心政策和对倡导与管理角色的混淆一直被认为是有效集体决策的障碍。
定性方法的使用提供了广泛的理解，但限制了具体的推断。这 4 家中心可能无法反映全国每个移植中心的实践情况。
肝移植委员会做出的艰难决策是合理一致且出于善意的，但通过制定更明确的书面政策和澄清角色，决策过程可能会得到改善。这可能为其他医学领域的资源分配提供信息。
格林沃尔基金会和美国国立卫生研究院。
