4. Clinical Guidelines for Liver Transplantation (PDF) - British ...

Guidebook for the Solid Organ Transplant Programme Chapter 4
Appendix O
CONTRACT FOR ABSTINENCE
The policy of BC Transplant is that no patient with an ongoing substance abuse problem be accepted
for liver transplantation. In order to be considered a possible liver transplant candidate, patients with
a history of alcohol or drug abuse will have to demonstrate at least six continuous months of
abstinence.
In order to do everything to ensure a successful outcome to transplantation,
I, _________________________________________, AGREE TO COMPLETELY ABSTAIN FROM ALCOHOL,
ILLICIT DRUGS AND OTHER ABUSABLE SUBSTANCES FOR THE REST OF MY LIFE. In addition, I will refrain
from abusing any prescription medications.
I may also be required to avail myself of the services of an alcohol and drug (A&D) treatment program to
help ensure relapse prevention and I will adhere to the recommendations of the A&D counsellor. In addition,
I will allow random testing of my blood, breath and urine as evidence of my abstinence.
I give permission to have family members, significant others and relevant health care providers be contacted
to help verify my continuing abstinence and for purposes of ongoing transplant assessment.
Following completion of the initial required period of abstinence, I will be re-assessed by the Transplant
Team to determine my status regarding transplantation. I UNDERSTAND THAT VIOLATING THIS AGREEMENT
WILL RESULT IN MY FORFEITING MY TRANSPLANT CANDIDACY STATUS.
I further understand that lifelong abstinence from all abusable substances is an important part of my
ability to maintain my health and the health of the transplanted liver following surgery.
Resuming substance use any time following acceptance into the transplant program will result in my
being removed from the transplant waiting list.
If I relapse after surgery, I agree to enter a substance abuse program chosen for me by the Transplant Team. I
ALSO UNDERSTAND THAT IF I RELAPSE TO SUBSTANCE USE FOLLOWING TRANSPLANTATION, I WILL NOT
BE OFFERED A SECOND TRANSPLANT SHOULD ONE BECOME NECESSARY.
I have read the above and agree to the conditions set forth and I have a copy of this contract for my records.
____________________________________
Patient Signature
__________________________________
Signature of Witness
____________________________________
Date and Place
___________________________________
Print Name and Relationship to Patient
Chapter 4 – Clinical Guidelines for Liver Transplantation – July, 2010 Page 60
See Page 1 for disclaimer