Background for FF #512: Solid organ transplantation has increased as has the chances of good outcomes (1). Nevertheless, patients who undergo solid organ transplantation still face significant risk, not only from the surgical procedure, but from organ rejection, prolonged immunocompromise, and infection which can occur long after the surgery (1). Palliative care (PC) considerations prior to transplantation include eliciting goals of care, understanding alternatives to organ transplantation (e.g., comfort focused care), advance care planning, exploring treatment limitations, and ensuring adequate understanding of the surgery and post-operative care (2,3). Many institutions routinely involve specialized PC interdisciplinary teams (IDTs) as part of the pre-transplantation process, but it is not always clear what these consultations should entail. This Fast Fact provides a framework based on expert opinion for pre-transplantation PC discussions that is applicable to all transplant care including heart, liver, lung, and bone marrow.

Timing: Involvement of a PC IDT in transplant preparedness should occur after discussion of procedural risks and benefits by the transplant team.

Relevant stakeholders: Ideally, patients and their caregivers participate in these PC conversations together, due to the complexity of care required following surgery. It may also be appropriate for the referring clinicians to participate in the discussion.

Key points to address during palliative care (PC) discussion: 

1. Hopes, desires, and worries related to the transplant and/or the wait for transplant.
2. Care preferences and desire for any treatment limitations if their transplantation is unsuccessful or if transplant is no longer offered.
3. Completion of advance directives (ADs), particularly designation of a surrogate decision-maker.
4. Social support system, including identification of a primary caregiver.
5. Alternative care plans besides transplant, including comfort-focused care (4).
6. Understanding the possibility of chronic symptom distress even after a successful transplant, this may include discussion of the importance of ongoing adherence with immunosuppression. Encourage the patient to discuss that risk with the relevant specialists if questions arise.
7. Awareness of major surgical risks such as infection, organ rejection, and prolonged ventilation. Encourage the patient to discuss these risks with the relevant specialists if needed (4). 

Explaining the role of PC: Pre-transplantation patients may question the involvement of PC as they may associate the term “palliative” with end-of-life or hospice care (4). The scope of the PC team’s involvement should be discussed with each transplantation team prior to patient contact to ensure consistency across teams. Many institutions request a routine PC consultation prior to transplant due to the significant, life-changing nature of the procedure; this care standard should be explained to the patient if applicable. In general, the role of specialized PC teams is to explain that transplantation is not mandatory and to provide education on other care options. Additional points that may be emphasized include: 1) the limited nature of PC involvement if transplantation goes well, 2) the benefits of familiarity with PC if support with symptom management, psychological distress, care resources, and/or difficult care decisions is needed in the future, and 3) the added support for patients and their families during the unpredictable time surrounding transplantation (6).

Explaining the role of advance directives (ADs): Normalizing discussions on goals of care helps to prepare transplant patients for healthcare decisions that may arise. Emphasis should be given to designating a surrogate decision maker, including completion of documentation that formally names a healthcare power of attorney. Discussing goals of care and quality of life preferences with the surrogate, both if they receive transplant or do not, is paramount to respecting the patient’s wishes. To avoid confusion, stress that ADs are used to prepare for worst-case post-transplant scenarios, such as if the patient loses the capacity to make medical decisions (5).

Continuing the conversation: Patients may bring up post-transplant concerns, such as lifelong pill burden, frequent clinic visits, and caregiver strain. PC clinicians can provide patients with support post-transplantation in collaboration with the transplant team. The transplant team and their IDT should be notified of any concerns. Transparent pre-operative conversations lay the foundation for a trusting clinician-patient relationship after surgery.

Summary: PC discussions for transplant candidates assist with clarifying goals of care, reviewing or completing ADs, and discussing the challenges that may arise in the peri-transplant period. The interdisciplinary model of PC including clinicians, social work, nursing, and chaplaincy can help to facilitate quality care for the transplant population.

References: 

1. Black CK, Termanini KM, Aguirre O, et al. Solid organ transplantation in the 21st century. Ann Transl Med. 2018 Oct;6(20):409. doi: 10.21037/atm.2018.09.68. PMID: 30498736; PMCID: PMC6230860.
2. Pawlow PC, Doherty CL, Blumenthal NP, et al. An Integrative Review of the Role of Palliative Care in Lung Transplantation. Progress in Transplantation. 2020;30(2):147-154. doi:10.1177/1526924820913512.
3. Pullen LC. Bringing palliative care to transplant. Am J Transplant. 2021 Jul;21(7):2315-2316. doi: 10.1111/ajt.16035. PMID: 34196485.
4. Rivet, Emily B. and others, ’Palliative Care in Transplantation’, in Anne C. Mosenthal, and Geoffrey P. Dunn (eds), Surgical Palliative Care, Integrating Palliative Care (New York, 2019; online edn, Oxford Academic, 1 Oct. 2019), https://doi.org/10.1093/med/9780190858360.003.0013, accessed 20 June 2023.
5. Wentlandt K, Dall’Osto A, Freeman N, et al. The Transplant Palliative Care Clinic: An early palliative care model for patients in a transplant program. Clin Transplant. 2016 Dec;30(12):1591-1596. doi: 10.1111/ctr.12838. Epub 2016 Nov 4. PMID: 27910190.
6. Wentlandt K, Weiss A, O’Connor E, et al. Palliative and end of life care in solid organ transplantation. Am J Transplant. 2017 Dec;17(12):3008-3019. doi: 10.1111/ajt.14522. Epub 2017 Nov 15. PMID: 28976070. 

Conflicts of Interest: None to disclose.
Author Affiliations: Mayo Clinic, Jacksonville FL.
Version History: Originally edited by Lara India MD; first electronically published in May 2025.