In stage 3, individuals are referred to the pre-transplant service for extensive tests to determine transplant qualification. The protocol varies by facility, however all are focused on 1) the need for the transplant, 2) the likelihood of surviving the surgery, 3) the availability of social and psychological ‘fitness’, 4) the likelihood of adherence with medication and caring for the transplanted organ, and 5) the ability to pay the bills; the ‘pocketbook’ test.

Others start to fear the seriousness of the disease and ask why.  There may be denial, fear and difficulty with acceptance. Denial may persist in others especially when the person does not look ill. Members of social groups may notice withdrawal and lack of social participation. There is a gap in patient participation and the expectations of others which can result in conflicts as the individual fails to meet obligations of established roles. Frustrations often increase with inability to engage in interests as evaluations, appointments, and procedures are now central to the individual’s allocation of time.

This can be a time of high levels of anxiety as the individual and supportive others are torn between hope that the serious step of transplantation is not needed, and hope that transplantation holds a solution to their deteriorating physical condition. An important event is attendance at pre-transplant educational sessions where the team presents transplantation as a serious undertaking. The obvious exception is fulminate liver failure where the person either has a short wait, or goes directly to Stage 5, the transplant.

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