Ethical considerations in the early composite tissue allograft experience: a review of the Louisville Ethics Program.

This paper reviews the formulation and evolution of the ethical component in one of the earliest clinical composite tissue allograft (CTA) programs, the hand transplantation program in Louisville, Kentucky, USA. The purpose was to derive lessons and define principles to give guidance for future programs and introduction of new CTA. We reviewed the initial ethical considerations, including input from respected ethical scholars, guidelines for innovative procedures transparency in public and professional scrutiny, and compliance with human studies regulations (IRB approval). We found the initial focus on ethics, scholarly input, guidelines for innovative procedures, and human studies protection regulations to be valid. Moreover, we noted the effect of autonomy in subjective, quality-of-life benefits on equipoise and effective risk-benefit analysis in effective informed consent. We found that psychiatric screening and support to be exceptionally valuable in protecting autonomy, suitability for participation, assessing personality organization, and determining compliance ability. We conclude that the program ethical principles were validated. For future CTA programs and procedures, we recommend an ethical emphasis with adherence to high standards and transpire to independence to scrutiny and oversight. We recommend protection of autonomy judgments in equipoise judgment and informed consent. We recommend skilled psychiatric screening and support. We endorse scholarship, scientific accuracy, and data sharing.

Transplantation psychoneuroimmunology: building hypotheses.

The research findings of psychoneuroimmunology have not yet been fully applied to the field of transplantation psychiatry. Though much study has been devoted to the impact of psychiatric disease on the immunosuppressed state and disease progression in HIV-related illness, little has yet been written on the immunology implications of psychiatric disturbances in the immunosuppressed post-transplant patient. Utilizing Medline literature searches to review relevant research data in psychoneuroimmunology and transplantation immunology, the author formulates and examines four transplantation psychoneuroimmunology hypotheses involving the potential impact of depression on post-transplant organ rejection, cancer, coronary artery disease, and infections. The author concludes that though major questions remain, it appears reasonable to include the impact of depression, and possibly other psychological states, among factors that may affect the net state of immunosuppression in transplant patients.

Psychiatric assessment of candidates for hand transplantation.

An important part of the pretransplant evaluation of candidates for hand transplantation is a psychiatric assessment to formulate psychological benefits and risks of transplantation and determine any appropriate psychosocial interventions to optimize the patient's candidacy for the procedure and prevent psychiatric morbidity. Screening data are presented from 213 individuals who contacted a national referral center for hand surgery regarding hand transplantation, and from the subsequent detailed psychiatric assessments of 9 individuals considering the procedure. Most of the nine patients undergoing intensive psychiatric assessment were assessed as demonstrating an overall favorable profile of psychological benefits and risks. In addition to providing information regarding the psychological experience of patients with amputations and their motivation for hand transplantation, it is hoped this information, as compared with posttransplant outcome data, will help further refine the assessment of candidates for this procedure and possibly other forms of composite tissue allotransplantation.

The role of the psychiatrist in organ transplantation.

The psychiatrist has multiple roles on the transplant team, beginning with the transplantation psychiatry consultation (TPC). It addresses such issues as risks of exacerbation or recurrence of a psychiatric illness, pharmacokinetic and pharmacodynamic considerations due to organ failure, potential drug interactions involving psychotropic and immunosuppressant medications, adequacy of support system, history of medical compliance, emotional and cognitive preparedness for transplantation, mental status findings supplemented by standardized cognitive testing and psychosocial rating instruments, and decision-making capacity. The consultation concludes with an overall assessment of the patient's psychosocial strengths and limitations, and recommended interventions to optimize his or her candidacy for transplantation. The consultation findings aid the psychiatrist and the transplant team in striving for fairness and the ideal of "neutrality" in an effort to serve the needs of the patient, other transplant candidates, and society with regard to optimal organ stewardship.

Electroconvulsive therapy consultation: an update.

In the past, a pre-electroconvulsive therapy (ECT) psychiatric evaluation focused on the question, "Does the patient have an ECT-responsive condition?" Technological advances, a broadening experience base with psychiatric patients with concomitant severe medical illness, and advances in ECT technique have led to the need for a more extensive pre-ECT assessment of the patient's psychiatric and medical status, including concomitant medications. A specific "ECT consultation" has evolved that builds on the basic components of the standard psychiatric consultation and extends to recommendations designed to maximize the safety and efficacy of ECT for each individual patient. This article briefly reviews the key components of the ECT consultation and provides an extensive update on important considerations in the use of combined ECT and psychotropic medications.