Death after psychiatric contraindications to urgent liver transplant for paracetamol overdose.

Background: Paracetamol overdose (POD) is the most common cause of acute hepatic failure (AHF) in the United Kingdom. Without urgent orthotopic liver transplant (OLT), mortality is high. Psychiatric assessment for transplant is time-pressured and often undertaken by psychiatrists without transplant experience. Assessors may identify absolute psychiatric contraindications (APCIs) precluding transplant in otherwise medically suitable patients. It is unknown how often this occurs. The combination of high but unknown mortality, time pressure, and relative inexperience is likely to provoke anxiety in assessors. This study hypothesised that the proportion of POD patients assessed for OLT who die because psychiatric contraindications preclude transplant would be small but not negligible.

Aim: To determine the proportion of patients with paracetamol-induced AHF, for whom psychiatric contraindications preclude transplantation, and the consequent mortality.

Methods: This is an 18-year single-centre retrospective cohort study based in a national liver transplant centre. 524 participants were identified from a departmental database and included if they had AHF from suspected POD and received a psychiatric assessment for OLT. For those who died before discharge, records were reviewed for medical and psychiatric contraindications to transplant, alongside age, sex, and primary psychiatric diagnosis. We calculated the proportion of patients assessed for whom APCIs precluded transplant, resulting in death.

Results: Among 524 patients undergoing psychiatric assessment for OLT, there were 102 in-episode deaths (19.5%). APCIs were identified in 46 patients who were otherwise medically suitable for transplant and went on to die. This statistic represents 8.8% of the number of persons evaluated and 45% of the number of deaths. Within this subgroup, 27 (59%) were female, with a mean age of 44.6 years (ranging from 19-72 years). The most common primary psychiatric diagnosis was alcohol dependence syndrome, which accounted for 67% (n = 31).

Conclusion: 8.8% of medically suitable patients with AHF following POD died with APCIs to transplant. This indicates a need for ongoing assessor training and support, and (inter) national comparisons of practice.