← Back to January 2017

Nurse Practitioners and Patients with Prolonged Lung Transplant Hospitalizations

Tara Bolden, MN, NP

Susan Chernenko, MN, NP

Nikki Marks, MN, NP
Toronto General Hospital
Toronto, ON, Canada

We all know that the patient with a ten-day post-lung transplant hospital stay is nearing extinction. We sometimes refer to patients with rare conditions as Zebras, however, patients with short stays after lung transplant are now unicorns! All kidding aside, it is a reality that patients' length of stays is becoming increasingly long and more complex. There are a variety of reasons for this, mostly resulting from the success of lung transplantation, and in our program, successful experience with recipients with complex medical issues. Many of our patients are older, have multiple co-morbidities, and often have survived the use of life-sustaining treatments like ECLS either as a bridge to transplant, or bridge to recovery. For our patients, this results in what Frank calls "deep illness" (Frank, 1998), a state of illness that is "perceived as lasting, as affecting virtually all life choices and decisions, and as altering identity" (p. 197). This state of being results in significant physical compromise, and can also cause significant financial hardship, emotional stress and negative physical and psychological reactions for caregivers as well.

As Nurse Practitioners (NPs) in the Toronto Lung Transplant Program, we have developed expertise in helping patients and caregivers navigate "deep illness", all the while ensuring consistency in their complex medical care by working as members of a large interdisciplinary team. We help care for over 140 newly transplant recipients per year, and those who are re-admitted with complications in their post-transplant life. The NP role is well suited as part of an interdisciplinary transplant team as NP practice is grounded in nursing theory that emphasizes the development of the nurse-patient relationship over time. With extensive education and training in acute and long term complications of transplantation we are an embedded part of the interdisciplinary team that provides hands-on care for recipients.

As a result of complex care requirements, our practice combines both independent and collaborative practice. We maintain strong collaborative relationships with experts in associated fields in order to manage complications such as infection and rejection, as well as cardiac, neurologic, psychiatric or any other condition a patient may experience. We have strong professional relationships with key members of the interprofessional team and consult and liaise with medicine, pharmacy, physiotherapy, occupational therapy, speech language pathology, social work, spiritual care, and psychiatry to provide optimal care to our patients. At weekly interprofessional rounds, we find creative solutions to some very challenging patient issues whether it is further optimizing recovery, meeting unconventional patient and family wishes, or simply determining discharge disposition.

Patients and caregivers often experience overwhelming helplessness with so many experts involved in their care, especially during a long recovery. Having a consistent health provider as they recover from a lung transplant assures safe, high quality care as well as psychological reassurance. An important aspect of the NP role is the development of a nurse-patient relationship with patients and their caregivers. We try to maintain consistency in assignment to develop a trusting therapeutic relationship, as well as creating the opportunity for long-term planning and identification of health behavior patterns that may potentially result in future health issues.

As the post-transplant course ebbs and flows, sometimes in health, and sometimes in illness, the NP's relationship with patient and family can help in improving clinical care and outcomes. This continuity of care is not only highly valuable from a clinical perspective, it also provides the framework for a supportive structure for the patient and caregivers. Undergoing a highly-specialized procedure such as lung transplant can create intense levels of stress and anxiety. Having one identified health care provider, such as an NP to turn to throughout their complex clinical course can ease the patient's and support person's anxiety. The close partnership may also be effective in identifying and helping caregivers with higher than usual levels of caregiver stress or burnout.

As the patient's condition improves, goal setting with the family and the interdisciplinary team occurs. Often, the NPs clinical expertise is required to negotiate and plan the discharge disposition. Although our goal is to discharge home, sometimes an alternative end disposition location is required. In these situations, the strength in our position lies in the longitudinal nature of our knowledge and relationship with our patients and their caregivers, our expert knowledge of the healthcare system, and our close working ties to the interprofessional team. The best compromise for end disposition means having excellent communication amongst the various disciplines and other health care providers internally, as well as with those from other organizations. Excellent communication allows for seamless transition to rehabilitation hospitals, home or other institutions. After discharge or transfer, we continue to be involved through out-patient management of labs, medications and during clinic visits.

Ultimately, as technology evolves and we are able to provide lung transplantation to recipients who are older and have more complex medical issues, it is important that we strategize how to best provide ongoing care and support to patients and their caregivers. NPs are ideally suited health care professionals to help guide recipients and their caregivers through "deep illness" into their new health reality after lung transplantation. As part of the Toronto Lung transplant program, we feel fortunate to be part of a transplant program that is known for innovative and compassionate care, and that we can work with so many excellent colleagues from every discipline to help our sickest patients through their post-transplant course. ■

Disclosure Statement: The authors have no conflicts of interest to disclose.


  1. Frank, A. (1998). Just listening: narrative and deep illness. Families, Systems & Health (16), 197-212.

Share via:

links image    links image    links image    links image