Psychosocial assessment of living organ donors: clinical and ethical considerations.

This article outlines psychosocial and ethical issues to be considered when evaluating potential living organ donors. Six types of living donors are described: genetically related, emotionally related, "Good Samaritan" (both directed and nondirected), vendors, and organ exchangers. The primary domains to be assessed in the psychosocial evaluation are informed consent, motivation for donating and the decision-making process, adequacy of support (financial and social), behavioral and psychological health, and the donor-recipient relationship. Obstacles to the evaluation process include impression management, overt deception, minimization of behavioral risk factors, and cultural and language differences between the donor and the evaluator. Ethical concerns, such as the right to donate, donor autonomy, freedom from coercion, nonmaleficence and beneficence in donor selection, conflicts of interest, "reasonable" risks to donors, and recipient decision making are also explored. To fully evaluate living organ donation, studying psychosocial as well as medical outcomes is crucial.

Selection and outcome of living donors for adult to adult right lobe transplantation.

BACKGROUND: The shortage of cadaveric livers has sparked an interest in adult-to-adult living donor transplantation. Right lobe donor hepatectomy is frequently required to obtain a graft of adequate size for adult recipients. Careful donor selection is necessary to minimize complications and assure a functional graft. METHODS: A four-step evaluation protocol was used for donor selection and satisfactory results of all tests in each step were required before proceeding to the next. Donors were selected based on a battery of laboratory studies chosen to exclude unrecognized infection, liver disease, metabolic disorders, and conditions representing undue surgical risk. Imaging studies included ultrasonography, angiography, magnetic resonance imaging, and intraoperative cholangiography and ultrasonography. The information obtained from liver biopsy was used to correct the estimated graft mass for the degree of steatosis. RESULTS: From March 1998 to August 1999, 126 candidates were evaluated for living donation. A total of 35 underwent donor right lobectomy with no significant complications. Forty percent of all donors that came to surgery were genetically unrelated to the recipient. A total of 69% of those evaluated were excluded. ABO incompatibility was the primary reason for exclusion after the first step (71%) and the presence of steatosis yielding an inadequate estimated graft mass after the second step (20%). CONCLUSIONS: Donor selection limits the application of living donor liver transplantation in the adult population. Unrelated individuals increase the size of the donor pool. Right lobe hepatectomy can be performed safely in healthy adult liver donors. Preoperative liver biopsy is an essential part of the evaluation protocol, particularly when the estimated graft mass is marginal.

Relapse prevention treatment for liver transplant patients.

This paper explores the utility of relapse prevention therapy (RPT) for transplant candidates with substance use disorders. Similarities and differences between this population and the general substance abuse patient population are discussed and suggestions are made for modifying the RPT treatment protocol. Major issues include the source and intensity of motivation for treatment, the nature of the therapeutic relationship, the type and severity of psychosocial consequences that may have been experienced as a result of substance use, and the patient's perception of the problem (addiction versus liver disease). Recommendations are made to provide empathy and support around medical concerns, motivate them for sobriety, and work to build collaborative relationships between team members and patients. Patients need to see the RP therapists as working to help them maintain sobriety and obtain a transplant, not as policing their drug use.

Rating scales for the psychosocial evaluation of organ transplant candidates. Comparison of the PACT and TERS with bone marrow transplant patients.

Two scaled formats for summarizing the results of psychosocial evaluations of transplant candidates have been published, the Psychosocial Assessment of Candidates for Transplantation (PACT) and the Transplant Evaluation Rating Scale (TERS). In this study, 40 consecutive candidates for bone marrow transplant were rated on the PACT and TERS. The PACT and TERS were comparable in interrater reliability. Similar conceptual items for each scale correlated fairly highly with one another. The PACT and TERS differ in several scale characteristics. The authors discuss the relationship between scale characteristics and clinical utility.

Psychosocial assessment of organ transplant candidates. Current status of methodological and philosophical issues.

Psychosocial assessments of candidates for organ transplant surgery are conducted to ascertain that potential patients are likely to benefit from the surgery through adequate coping, good compliance, and commitment to rehabilitation. Such assessments must be based on a realistic analysis of the behavioral demands of the transplant patient's role. Reliability of psychosocial assessments has been established within some programs, but wide discrepancies in the psychosocial criteria that are used exist among transplant centers. Validation studies are needed, with particular emphasis on outcomes for the patient and family as a whole, that go beyond the question of mere survival.

Psychosocial evaluation of organ transplant candidates. A comparative survey of process, criteria, and outcomes in heart, liver, and kidney transplantation.

Psychosocial selection criteria are widely used by transplant programs but have not been systematically described or compared within or across transplantation type. The authors surveyed all active cardiac, liver, and renal transplant programs in the United States about the existence of psychosocial selection criteria, how and by whom patients were evaluated, weight given to specific criteria, and how often patients were rejected for surgery on psychosocial grounds. The results document important differences in the process, criteria, and outcomes of pretransplant psychosocial evaluation within and across these programs. Cardiac programs are the most stringent, both in criteria and in rate of refusals.

Psychiatric aspects of heart transplantation.

This article, part of a series on organ transplantation, will review psychiatric aspects of heart transplantation, starting with a brief summary of medical aspects. The authors then review psychiatric symptoms and syndromes frequently encountered pre-, peri-, and posttransplantation; the selection of candidates; and treatment of psychopathology.

Psychosocial evaluation of heart transplant candidates: an international survey of process, criteria, and outcomes.

Heart transplant programs were surveyed regarding psychosocial evaluation process, criteria, and outcomes. There was considerable disagreement among programs when a patient is rejected on psychosocial grounds with regard to the use of second opinions and how often patients are informed of the reasons. Wide discrepancies in criteria used and rates of patients refused on psychosocial grounds were discovered. More than 70% of all programs excluded patients for transplantation on the grounds of dementia, active schizophrenia, current suicidal ideation, history of multiple suicide attempts, severe mental retardation, current heavy alcohol use, and current use of addictive drugs. Lack of consensus was found for some exclusion criteria (cigarette smoking, obesity, noncompliance, recent alcohol or drug abuse, criminality, personality disorder, mild mental retardation, controlled schizophrenia, and affective disorder). The proportion of patients rejected for transplantation on psychosocial grounds ranged from 0% to 37%, with an average rate of 5.6% in the United States and 2.5% in non-U.S. programs. This survey thus supports the need for research on the validity and reliability of psychosocial selection criteria.

Symptom correlates of blood pressure: a replication and reanalysis.

Although normative studies have traditionally found that blood pressure (BP) fluctuations are asymptomatic, recent research by Pennebaker et al. [(1982). Psychophysiology 19: 201-210] has suggested that systolic blood pressure (SBP) changes are, in fact, highly correlated with idiosyncratic patterns of symptoms within individuals. The present study was designed as a conceptual replication of those findings and as an initial attempt to develop a standardized clinical procedure for assessing symptom-BP relationships. Eleven normotensive male subjects participated in a series of 16 brief tasks. The first eight tasks were "mental" stressors (e.g., WAIS-R subtests), while the second eight were "physical" stressors (e.g., breath-holding, running in place). Following each task or baseline, blood pressure was measured and subjects rated the degree to which they were experiencing each of nine symptoms (e.g., racing heart, sweaty hands). For each subject, simple symptom-BP correlations were computed across the 16 measurement periods. High symptom-SBP correlations were obtained only for the physical task period. It is argued that the magnitudes of the correlations reported by Pennebaker et al. (1982) were spuriously inflated by the inclusion of strenuous physical exercise, and a reanalysis of the data from that study supports this contention. The clinical value of assessing idiosyncratic symptom-blood pressure relationships seems doubtful.

The contribution of a cultural perspective in understanding and evaluating client satisfaction.

Increasing attention is being given to including measures of client satisfaction as a component in the evaluation of health care services. An understanding of cultural factors that may influence attitudes and behaviors in the health care situation can contribute to the theory and measurement of client satisfaction. Through an examination of some of the cross-cultural literature, this paper delineates dimensions of the health care situation in which clients have been shown to have distinctive preferences, behavioral patterns, attitudes, and treatment expectations. A knowledge of the beliefs and attitudes concerning health and illness that are espoused by a particular cultural group can be a valuable asset in understanding how members of that group will evaluate the delivery of health care services. The examination of how cultural and ethnic differences may affect client satisfaction outcomes points to the necessity of avoiding a global measure of client satisfaction without first examining those particular aspects of health care delivery and of the measurement context that may have a predictable influence on client satisfaction ratings.

Psychological adjustment and patient information in inflammatory bowel disease: development of two assessment instruments.

Research on the psychological adjustments that patients must make in living with inflammatory bowel disease, symptomatic and life-disrupting chronic illnesses, has been difficult to interpret because no standard measurement instruments of known reliability and validity have been available. Two studies are presented on the construction, validation and cross-validation of the two instruments measuring patient information and psychological adjustment in inflammatory bowel disease. Both scales were shown to be reliable on the basis of internal consistency. Convergent validity of the psychological adjustment scale with measures of self-esteem and social competence and with a measure of public self-consciousness was demonstrated, as was discriminant validity along the dimension of social desirability. Assumptions underlying the scales are discussed, and research and clinical applications are suggested.

Psychological adjustment to inflammatory bowel disease: informational control and private self-consciousness.

Until recently the psychological and social factors related to inflammatory bowel disease have been studied as causes rather than as consequences of this condition. This study looks at the impact of these diseases by investigating correlates of psychological adjustment to inflammatory bowel disease. A curvilinear hypothesis predicted that patient adjustment to living with the disease would be related to the amount of information possessed about the disease, and that this relationship would be mediated by the patient's degree of private self-consciousness. Questionnaire returned by 143 members of the Houston Chapter of the National Foundation for Ileitis and Colitis were analyzed. Results indicate that a patient's general level of self-esteem and social competence is the best predictor of disease-related adjustment. Information and adjustment were inversely related for patients with a high degree of private self-consciousness, and unrelated at lower levels of this variable. Perception of control through information predicted adjustment better than information per se.

Evaluation of a stress management program for high utilizers of a prepaid university health service.

This study examined the effectiveness of a brief educational intervention with high utilizers of a prepaid university health service. Each of 165 participants was assigned to one of three groups; health screening plus health education, health screening control, or no contact comparison. The treatment consisted of a 1-hour educational session designed to make participants aware of psychological and social factors that make people prone to illness and to inappropriate use of health resources. The treatment appeared to be responsible for reducing utilization of the university health center for a short period of time, with this effect dissipating over time. There were no significant differences between groups on other outcome measures. The findings for this treatment are compared with the results of other studies indicating the psychotherapy may have some effect in reducing inappropriate high medical care utilization.