patient and their carers should be educated and provide consent. For those deemed not legally competent, the appointed guardian should be educated and asked to provide consent. 1.4 Assessment and wait-listing The referral of individuals with organ failure to a transplant unit for assessment of transplant eligibility should be initiated and completed in a timely manner to maximise the chances of successful transplantation. The transplant eligibility assessment should include: Patient education regarding treatment options: treatment options include transplantation versus no transplantation, or living donor versus deceased donor transplantation for those with kidney failure (and for some patients with liver failure). Patients should be educated regarding likely risks, estimated benefits, and expected outcomes of transplantation. Patients should also be educated about the range of donor characteristics and the potential risks and benefits of accepting a higher-risk organ. Medical assessment: both physical and psychological assessment is required to identify possible issues or contraindications to transplantation, and to enable an estimation of the risks and benefits of transplantation for each individual. This assessment should include clinical review by members of the transplanting team, including (at a minimum) a suitably experienced transplant surgeon and a suitably experienced transplant physician, plus any other clinicians deemed necessary. Assessment will include screening tests designed to ensure medical suitability for transplantation, as directed by the transplant team. The time required to complete medical assessment is variable, determined largely by case complexity. Listing for deceased donor organ transplantation: this should be done by the transplant team following completion of the assessment to their satisfaction. Criteria for listing vary from organ to organ, and are detailed in each organ-specific chapter within this document. If the transplant team believe transplantation is either contraindicated or that the patient does not meet the criteria for listing—either due to the absence of an indication for transplantation or an unfavourable projected risk-benefit scenario if transplantation were to be attempted—then the patient and their referring clinician should be informed and advised as to the reasoning behind this decision. In some cases, where additional information is required, a listing decision may be deferred until such information becomes available. Every reasonable effort should be made to obtain the necessary information within a reasonable timeframe, and the referring clinician should be kept adequately informed regarding information requirements and timelines. 1.5 Appeals Patients in Australia who are either (i) not referred for transplant assessment, or (ii) assessed by a transplant unit and deemed unsuitable for listing, have a right to appeal such decisions (see the NHMRC Ethical Guidelines15). The appropriate pathway for patients in scenario (i) who disagree with their assessment is to seek a second opinion from a specialist within the field. Potential outcomes of seeking a second opinion are: (a) the specialist from whom the second opinion is sought believes that referral for transplant is not indicated, in which case this should be explained to the patient; or (b) the second opinion is that referral is indicated, and that specialist refers the patient to a transplant service for assessment. In the case of scenario (ii), where the decision not to list a patient is appealed, the local unit will first review the clinical information to determine whether there are any factors that might lead to a change in the original decision. If the unit uphold their decision that the patient is not eligible for listing, however the patient, their family or other advocates still disagree with this assessment, then the appropriate pathway is to seek—via the patient’s specialist, and with the impartial assistance of the local April 2021 version 1.5 4 unit—referral to a second transplant unit within the patient’s jurisdiction; an inter-state opinion may, if required, be sought by negotiation between the units and with the patient’s consent. In the case of heart transplantation, given the logistical challenges and costs related to patient transport, the second unit should first conduct a data review, followed by a face-to-face review only if warranted. In all cases, the local unit should assist patients and families in pursuing a second opinion by providing clinical data to the second unit so that the patient does not have to undergo repeat investigations. Potential outcomes of referral to a second transplant unit are: (a) the second transplant unit agrees that the patient is not suitable for transplant listing, and this is explained to the patient; or (b) the second unit believes that the patient should be waitlisted, which should then be performed at either the primary or the secondary unit following discussion involving all parties. In the case of intestinal transplantation and vascularised composite allotransplantation, for which only single transplant units currently exist, there is not the option of referral to a second unit within Australia or New Zealand if a patient appeals the decision of the transplant unit not to list. For intestinal transplantation, an understanding exists with the United Kingdom to refer cases for second opinion to the UK