To the Editor:

Living donor liver transplantation (LDLT) is a highly complex surgical procedure. Despite comprehensive efforts to ensure safety, LDLT inherently carries risks, including the possibility of recipient mortality [1]. Breaking bad news to a living donor about the recipient's death is particularly sensitive due to the donor's deep emotional and physical investment in the recipient's well-being. The donor may experience profound guilt or question the value of their sacrifice, despite not being responsible for the outcome. In contrast to other scenarios where bad news might be delivered to less emotionally involved individuals, the donor may also be dealing with distress related to their own surgical recovery, which can further complicate the situation [2].

When the recipient dies shortly after the surgery, the emotional impact on the donor can be profound. The manner in which the news is delivered is critical to how the donor processes the event and manages the emotional and psychological consequences. Ethical principles such as beneficence, nonmaleficence, respect for autonomy, and justice should guide the conversation [3]. Transparency in disclosing medical information, especially about adverse outcomes, is essential. Avoiding disclosure or delaying the news may lead to mistrust and potentially cause greater harm over time. However, it is also important to consider the donor’s emotional state and physical recovery from the surgery when deciding the timing of this conversation.

The psychological burden on the donor can be profound [4]. Therefore, it is essential to emphasize that the donor's act of generosity was not in vain and that they are not responsible for the recipient’s death. Posttraumatic stress disorder, depression, and anxiety are potential psychological consequences that require vigilant monitoring and prompt intervention. Currently, there is no specific approach recommended for breaking bad news to living donors when a recipient dies. The existing literature primarily focuses on delivering bad news in other medical contexts [5]. This highlights the need for tailored strategies to address the complex emotional and physical dynamics involved in communicating with living donors. Therefore, we recommend the following steps when breaking bad news to a living donor in the event of the recipient's death during or immediately after surgery: (1) assemble the right team: the donor must be informed by a well-prepared team. This team should include the transplant surgeon, anesthesiologist, and a mental health professional, such as a clinical psychologist or psychiatrist. Having these professionals present ensures that all medical and emotional aspects of the situation are thoroughly addressed. (2) Choose an appropriate setting: the donor should be in a private, quiet, and comfortable room, ensuring they are away from the hustle and stress of the hospital environment. The timing of the conversation should take into account the donor’s physical recovery post-surgery, but it should not be unnecessarily delayed. (3) Prepare the donor: initiate the conversation by ensuring the donor is physically comfortable and mentally prepared to receive the news. Acknowledge the complexity of the situation and reassure the donor that the medical team is available for support. Begin with statements such as, “We need to discuss some difficult news about the recipient's condition,” to emotionally prepare the donor for the seriousness of the information. (4) Deliver the news clearly and compassionately: the news should be conveyed in clear, simple language, avoiding medical jargon. A direct yet compassionate approach should be used. For example: “We are deeply sorry to inform you that, despite all efforts, the recipient of your liver did not survive the surgery. This is a devastating outcome, and we want you to know that every possible measure was taken to ensure their safety.” After delivering such news, it is important to pause, giving the donor time to absorb and process the initial shock. (5) Acknowledge the donor’s effort and sacrifice: reassuring the donor that their selfless contribution was invaluable, regardless of the outcome, can help provide some solace. A statement such as, "Your decision to donate was an incredible, selfless act, and this outcome does not diminish your generosity," can be very comforting. (6) Offer emotional support: after delivering the news, the donor is likely to experience a wide range of emotions, including shock, disbelief, guilt, anger, and grief. A mental health professional can provide immediate psychological support, assist the donor in processing their feelings, and offer ongoing counselling if needed. It is important to ensure that the donor understands these emotions are normal reactions to such a traumatic event. (7) Provide medical information and answer questions: the donor is likely to have numerous questions regarding what went wrong, whether alternative actions could have been taken, and the implications for their own health. It is crucial for the medical team to be ready to address these concerns in a manner that is both truthful and empathetic. Transparency is essential; the donor must be informed about the factors that contributed to the recipient’s death, but this should be done without overwhelming them with excessive technical details. (8) Involve the donor’s support system: if the donor has family or close friends present, involve them in the conversation at the donor's request. The presence of loved ones can offer immediate comfort and assist the donor in processing the information. (9) Ensure follow-up care: the process does not end with delivering the bad news. The donor should receive ongoing psychological support, which includes regular follow-up meetings with mental health professionals. It is crucial to provide access to grief counselling and other resources to help them cope with this traumatic experience. Additionally, close medical monitoring of the donor’s physical recovery is essential, as emotional distress could negatively affect their postoperative healing.

To conclude, breaking bad news to a living liver donor following the recipient's death is among the most emotionally taxing responsibilities in transplant medicine. It demands a careful balance of transparency, compassion, and ethical responsibility. Implementing a structured approach can assist donors in managing this traumatic event with care and sensitivity. It is crucial to honor the donor's altruistic act and prioritize their emotional well-being to support their recovery, both physically and mentally.