Parents and clinicians underestimate distress and depression in children who had a transplant

The present study examined whether there are differences in reporting of depressive and post-traumatic stress symptoms between children who had a transplant and children who had other medical illnesses. We evaluated both the child's report about her/his symptoms and the parent or the clinician's report about these symptoms in the child. Scores on measures of depression (clinician rated vs. child rated) and post-traumatic stress (parent rated vs. child rated) were compared between medically ill children who have vs. have not had a solid organ transplant. The findings of a psychiatric evaluation are also reported. Children who have vs. have not received a solid organ transplant reported the same levels of depression and post-traumatic stress, while adults (their parents or clinicians who evaluated them) reported lower levels of depression and post-traumatic stress in the transplant group. The psychiatric evaluation revealed no differences between the groups. Children view their post-transplant course differently from adults caring for these children. Adults tend to underestimate the child's post-transplant emotional symptoms, possibly because they focus on the improved prognosis (whereas the children focus on the concrete experience of illness). The child's report of his or her emotional symptoms should be directly sought post-transplant.

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 und Explantation aus psychosomatischer Sicht

Auf den ersten Blick hat die Transplantationsmedizin wenig mit der Psychosomatik zu tun. In dieser Übersicht soll gezeigt werden, welchen Beitrag die Psychosomatik zu der Transplantationsmedizin zu leisten vermag. Ein besonderes Augenmerk liegt auf den Organspendern, die in den üblichen Beiträgen zur Transplantationsmedizin nicht die Aufmerksamkeit bekommen, die ihnen gebührt.

Medication non-adherence in the adolescent renal transplant recipient: a clinician's viewpoint

Recent advancements in immunosuppression and surgical techniques have significantly improved the outcome of kidney transplantation in the pediatric population. Adolescents enjoy the best 1-year graft survival of any age group. However, the long-term transplant outcome in adolescents is disappointing. Non-adherence with immunosuppressive medications is one of the most important contributing factors for graft rejection and loss in teenagers. The impact of non-adherence is perceived to be far more powerful in adolescent transplant recipients than in the transplant population as a whole. To better understand adolescent non-adherence, the process of transplantation must be placed in the context of adolescent development. Adolescents try to establish their identity and autonomy separately from the parents; however at the same time, adolescents with chronic illness require help, support and guidance from adults, including parents and medical personnel. Adolescents have limited ability to anticipate abstractly the long-term consequences of their immediate actions. This inconsistency can create frustration in both adolescents and in the supporting systems around them. Despite the significant consequences of adolescent non-adherence, research in this area is scarce. There are still no established definitions, standardized diagnostic methods and effective interventions to treat and prevent this problem. We propose the recommendations to approach the problems of adolescent transplant non-adherence from the transplant clinician's viewpoint. With early identification and appropriate interventions, significant improvement in adolescent graft survival is possible.

Organ donation and transplantation within the Zulu culture

Greater knowledge and technological advancement in the field of transplantation has increased the demand for organ donation beyond the supply of organs, especially among the black communities. This imbalance arises from the few sources of organs, limitations on the techniques of organ retrieval, disparities in the allocation of organs and socio-cultural factors. The aim of this study was to investigate the extent to which Zulu cultural norms and social structures influence an individual's decision to donate an organ or to undergo transplantation. A qualitative approach using an ethno-nursing method was selected. Semi-structured interviews were conducted with a transplant co-ordinator representing the professional sector, with traditional healers and religious leaders representing the folk sector, and with the general public representing the popular sector of the health care system. Both urban and rural settings were used. Conclusions arrived at showed that knowledge was lacking among Zulu speaking people about organ donation and transplantation and misconceptions about the topic were related to Zulu life patterns, beliefs about death, burial and life hereafter, and values and social structures. Recommendations with regard to the promotion of organ donation and transplantation among Zulu speaking people were made based on culture-sensitive and culture-congruent principles.

A National Study of Burnout Among American Transplant Surgeons

This study examines burnout in a national sample of transplant surgeons. Data analyses were conducted on a sample of 209 actively practicing transplant surgeons. Measures included the Maslach Burnout Inventory, a demographic survey, and the Surgeon Coping Inventory. Burnout was reflected in 38% of surgeons scoring high on the Emotional Exhaustion dimension, whereas 27% showed high levels of Depersonalization, and 16% had low levels of Personal Accomplishment. Several significant predictors of emotional exhaustion were identified and included questioning one's career choice, giving up activities, and perceiving oneself as having limited control over the delivery of medical services (R2= 0.43). Those who perceived themselves as having a higher ability to control delivery of medical services and who felt more appreciated by patients had lower levels of depersonalization and were less likely to question their career choice (R2= 0.16). Surgeons with high personal accomplishment experienced greater professional growth opportunities, perceived their institution as supportive, felt more appreciated by patients, and were less likely to question their career (R2= 0.24). The prioritization of goals to reflect both professional and personal values accounted for a significant amount of the variance in predicting both emotional exhaustion and personal accomplishment in separate regression equations. Recommendations to decrease burnout would include greater institutional support, increased opportunities for professional growth, and greater surgeon control over important services to facilitate efficient work. Coping strategies to moderate stress and burnout are also beneficial and should include prioritizing goals to reflect both professional and personal values.

Influence of Socioeconomic and Ethical Factors on People's Behaviour Regarding the Use of Cadaveric Organs

An organ donation is based on feelings of human solidarity and altruism. This approach, however, has not improved the organ shortage problem. The following suggestions might help to dismantle the persistent barrier linked to organ donation. (1) Society should be aware that during our lifetime we might be as much potential organ recipients as organ donors. (2) Educational campaigns should integrate the notion that cadaver organs are an irreplaceable source of health for every member of society. (3) Communication campaigns should illustrate that in allowing the use of our organs after death, we are, in fact, sharing a chance to prolong health for everybody, including perhaps ourselves. Furthermore, people need to acknowledge that using body parts is acceptable, and part of a tacit agreement between all members of society. Making a live organ donation to which the donor is emotionally related is a pressure-free decision. On the contrary, the donation of cadaver organs is influenced by negative factors. Conversely, self-interest and resistance to offering the body of a loved one to a stranger may make donation much more difficult if the current message is not modified. In an international survey of 242 transplantation professionals, with a 57% response rate, 70% to 83% agreed with this proposal. An international public survey has recently been finished, showing some results about the public's knowledge about religious opinions concerning transplantation, suggesting that religious institutions should assume a leadership role to give information about their positions. On the other hand, partial results concerning public attitudes regarding economic support to organ donation indicate that final data may be of interest. The creation of a Task Force with representatives from the World Health Organization, UNESCO, churches, and leaders of the global transplantation community may be key to joint efforts as a means to modify negative attitudes, to develop a new philosophy, and to deliver a new message to society.

Face transplantation: Part II-an ethical perspective

In May 2004, researchers at the University of Louisville Medical Center in Kentucky submitted a 30-page detailed document to the University's Institutional Review Board (IRB) that outlines their plan for the first face transplant. Despite the fact that both the Royal College of Surgeons in England in 2003 and France's Comite Consultatif National d'Ethique in 2004 issued reports saying that the risks of this surgery far outweigh the benefits tojustify it at the present time, the IRB at the University of Louisville is presently studying the proposal. Even though the microsurgical skills and anatomical knowledge is well established, face transplantation is more than a matter of technical achievement. The psychological impact on recipients and donor families as well as the long-term risks of a lifetime of immunosuppressant drugs must also be considered. More time is needed to perfect this surgery so that the rejection rate can be lowered and the patient's immune system can be taught to permanently tolerate the transplanted face. An ethical analysis will show that more time is needed to perfect this surgery so that the rejection rate can be lowered and the patient's immune system can be taught to permanently tolerate the transplanted face. To permit this surgery now, when there are so many unknown, life-threatening dangers would be medically irresponsible and ethically objectionable.

Public opinion and organ donation suggestions for overcoming barriers

Getting organs for transplantation depends on people's decision; thus, public opinion is essential to finding a solution to this problem. Efforts to improve organ shortage focus on: 1) Living, unrelated donation, 2) increasing marginal donors and 3) proposing economic support for donors. Paradoxically, no initiative has been suggested to modify public opinion towards cadaver donors. Several reasons explain the resistance to donating cadaver organs: Lack of awareness, religious uncertainties, distrust of medicine, hostility to new ideas, and misinformation. Education should be used to reshape public opinion about the use of organs for transplantation. Society should accept that "using" body parts is moral and offers a source of health for everybody. The concept that using cadaver organs implies sharing a source of health might be a social agreement between all members of Society. Suggestions for improving organ shortage include: 1) Society should understand that during one's life one may be just as easily a potential organ receiver as one is an organ donor. 2) Cadaver organs are an irreplaceable source of health. 3) As self-interest is one obstacle to donating cadaver organs, the "concept that allowing the use of our organs after death represents a chance of sharing health for everybody" may be useful for a change of attitude. Even though a poll among transplant professionals supported this suggestion, an international public survey should be carried out to evaluate people's reaction to this message.

Role of patient-support groups in the Thailand transplant program

Thailand started kidney transplantation in 1972 when vascular and nonvascular transplant programs were first established. Presently, we have 27 kidney, 6 liver, and 6 intrathoracic private or governmental transplantation centers, all approved and members of the Organ Donation Centres Thai Red Cross Society (ODC). They also provide organ procurement teams to the ODC. The Thai Medical Council has issued and supervised the criterion of brain death and ethical rules of transplantation to all practicing physicians since 1989. All recipients must register at these selected transplantation centers and at the ODC. When the potential donor arrives from any hospital in Thailand, the donor hospital notifies the ODC and organ procurement teams are sent out to harvest organs and transfer them to the recipient transplantation centers. The ODC computerizes and shares organs according to ABO, HLA typing, and crossmatching results. After transplantation all patients register with the Thai Transplantation Society (TTS) and the ODC. The TTS, the Thai Transplant Coordinator Society, and the ODC are responsible for the education of surgeons, physicians, nurses, patients, the public, and mass media to improve our transplant program. Bone marrow transplantation has separate regulations. Pooled, nonrelated bone marrow donors are registered at the blood-bank of the Thai Red Cross Society to provide donors for bone marrow transplantation. Financially, government support recipients only if they are state enterprise workers or civil servants. Public fund support through the ODC for organ procurement and the Kidney Foundation of Thailand is available for kidney transplantation. The ODC and the transplantation centers are the main patient-support groups for transplant programs in Thailand.

Pediatric cardiothoracic domino transplantation: the psychological costs and benefits

The first domino transplants were carried out in the UK in 1987, since which time 52 such procedures have been carried out involving patients within the paediatric cardiothoracic transplant programmes of Harefield and Great Ormond Street Hospitals. Although there are medical advantages in using domino organs--such as the ability for preoperative cross-matching, the heart not being subjected to the biochemical changes of brain death and less post-transplant coronary artery disease in the recipients of domino hearts compared with the recipients of hearts from cadaveric donors--the psychological sequelae for both donor and recipient have not been previously studied. The objective of this study was to identify the main psychological themes for patients involved in the domino programmes at the two hospitals, focusing on those situations where both patients were cared for in the same tertiary centre. Patients and their families were interviewed during routine outpatient clinic visits. Negative themes identified by patients included anxiety, guilt, resentment and anger if either patient had a poor outcome or suffered significant complications, disappointment and low self-esteem for potential donors whose heart was not used and recipient awareness of donor characteristics. Positive themes included gratefulness, comfort for the recipient that someone had not had to die for them directly and the benefit to the donor of giving their heart to another patient. In conclusion, domino transplantation has many medical advantages but there are significant negative psychological concomitants which need to be addressed within the multi-disciplinary management of these patients.

Factors influencing the willingness to donate body parts for transplantation

Three hundred and thirty-six people representing three ethnic groups (White, Asian, and Afro-Caribbean) were asked to rank their preferences concerning various incentives that might induce them to agree to the posthumous donation of their body parts. A conjoint analysis of the responses suggested that 'self centred' options (notably upfront cash payments and priority on waiting lists) were generally more popular than 'altruistic' alternatives. Members of the sample already possessing donor cards were more knowledgeable about the issue of organ transplantation than others, were less squeamish, and had relatives who favoured organ donation. The strength of a person's desire to donate body parts was related positively to self-respect and whether the individual was 'religious'; and negatively to (i) squeamishness and (ii) having relatives who objected to transplantation. Altruistic preferences vis-à-vis organ donation were associated with knowledgeability, self-esteem, family background, low levels of squeamishness, and the extent to which a person experienced 'helper's high.' People who were financially well-off were the most self-centred in the organ donation context. Overall the results imply substantial disparities between public policy and contemporary public opinion regarding transplant donation incentives.

Life and death decisions: using school-based health education to facilitate family discussion about organ and tissue donation

Public education that encourages family discussions about organ and tissue donation can enhance understanding, facilitate a donor's wishes and increase the numbers of donations. Action research methods were used to explore the impact of a student-initiated family discussion about donation. Most discussions were positive; only 7% middle school and 4% high school participants described them as "terrible." "Getting it started" was the most difficult. High school students felt "very" or "somewhat" prepared, whereas middle school students only felt "somewhat prepared". Guided family discussions ensure that families have accurate information about donation and an opportunity to talk about end-of-life choices in a non-crisis situation.

???Don???t Know Enough about It!???: Awareness and Attitudes Toward Organ Donation and Transplantation among the Black Caribbean and Black African Population in Lambeth, Southwark, and Lewisham, United Kingdom

BACKGROUND

The current demand for transplant organs, particularly kidneys, far outweighs the supply in the United Kingdom. This problem is particularly severe for the black African and black Caribbean population, who have been shown to have a disproportionately greater presentation on kidney transplant waiting lists in some regions of the United Kingdom. The situation is clear: There is an urgent need to address the number of black African and black Caribbean patients requiring a kidney transplant, otherwise the human and economic costs will be high.

METHODS

An exploratory study was undertaken to assess the current awareness of organ donation and transplantation and to explore attitudes toward these issues in a cross-section of the black African and black Caribbean population in Lambeth, Southwark, and Lewisham.

RESULTS

It was found that there was a lack of available information for the black African and black Caribbean communities. This precipitated low levels of awareness about organ donation and transplantation issues.

CONCLUSIONS

In an effort to redress this, effective methods for targeting black African and black Caribbean groups are required. From this study, there are indications that appeals for organ donors may be more effectively communicated by using a grass-roots, community-network approach. For this reason, consideration should be given to language and cultural needs, and to the provision of culturally sensitive material and information.

Evolutionary ethics: can values change

The hypothesis that values change and evolve is examined by this paper. The discussion is based on a series of examples where, over a period of a few decades, new ethical issues have arisen and values have changed. From this analysis it is suggested that there are a series of core values around which most people would agree. These are unlikely to change over long time periods. There are then a series of secondary or derived values around which there is much more controversy and within which differences of view occur. Such changes need to be documented if we are to understand the process involved in the evolution of differences in ethical views.

Opinions on renal transplantation and organ donation in high school students in two large northern (Torino) and southern (Napoli) Italian cities

Organ shortage for transplantation has focused attention on educational interventions. Italy is a nonhomogenous country whose cultural and economic differences are reflected in the health-care system: dialysis is mainly public in the north versus private in the south; and transplantation rates display a wide range from 3.4 to 37.8 per million people in 2002. The aim of the present study was to analyze the opinions of population of high school students (last two years) in two large cities: northern (Torino) and southern (Napoli) Italy, as a knowledge base for a randomized controlled trial on the efficacy of educational interventions on renal replacement therapy and organ donation, targeted to high school students.

METHODS

This preliminary study included eight public high schools that completed a first and anonymous semistructured questionnaire. Five hundred and eighty nine questionnaires were retrieved in Torino and 539 in Napoli. In both cities most students answered that they would give a kidney to a brother, sister, or partner needing dialysis (Torino: yes 80.6%; no 2.2%, uncertain-blank 17.2%; Napoli: yes 86.1%, no 1.1%; uncertain-blank 12.8%). Only 36.3% of the students in Torino and 37.7% in Napoli answered that they would consent to organ donation, if they had to choose for a strict relative with brain death. Opposition was 28% in Torino and 23.7% in Napoli; 35.7% in Torino and 38.6% in Napoli were blank-uncertain. These data underline the need for detailed information on the opinions of the overall population as basis for tailored educational campaigns.

To give or to receive? opinions of teenagers on kidney donation

BACKGROUND

The attitude toward living donation varies widely in the world, for economic and cultural reasons. In Italy, as in other Mediterranean settings, the role of living kidney donation is minor.

AIM

To analyze the reasons for this attitude, we gathered data in a general population sample of high school students in a large northern Italian industrial city (Torino, about 900,000 inhabitants).

METHODS

Semistructured questionnaires (n = 1676), gathered in 2001 to 2002 in 14 high schools, in the context of an educational program on dialysis, renal transplantation, and organ donation, were analyzed presumably reflecting opinions gathered before the educational intervention.

RESULTS

Most students, in the case of a close relative or partner needing dialysis, answer that they would donate a kidney (yes: 78.2%, no: 2.9%, uncertain-blank: 18.9%); receiving a living donor kidney is felt as disturbing: only 57.5% of the students would accept it (no: 5.9%, uncertain-blank: 36.6%), mainly because of fear of long-term problems for the donor. Donation from an older to a younger person is seen more positively than vice versa.

CONCLUSION

In our settings, the attitude of the teenagers on living donation is positive; however, while "giving" is positively seen, the presence of unresolved fears is witnessed by the lower acceptance of the idea of "taking." These data suggest to focus on the risks of kidney donation in educational campaigns and in patient-physician information. The positive attitude shared by the teenagers supports the working hypothesis that lack of information is one of the determinants of the low living donor transplantation rate in our area.

Commodification and exploitation: arguments in favour of compensated organ donation

This paper takes the view that compensated donation and altruism are not incompatible. In particular, it holds that the arguments against giving compensation stand on weak rational grounds: (1) the charge that compensation fosters "commodification" has neither been specific enough to account for different types of monetary transactions nor sufficiently grounded in reality to be rationally convincing; (2) although altruism is commendable, organ donors should not be compelled to act purely on the basis of altruistic motivations, especially if there are good reasons to believe that significantly more lives can be saved and enhanced if incentives are put in place, and (3) offering compensation for organs does not necessarily lead to exploitation-on the contrary, it may be regarded as a necessity in efforts to minimise the level of exploitation that already exists in current organ procurement systems.

Avoiding steroids in solid organ transplantation

The excellent results obtained today in solid-organ transplantation allow the envisaging of an improvement in long-term quality of life with a functioning graft. One way for this to be achieved is by the reduction, or even better, the avoidance, of steroid-based immunosuppression. Avoidance of steroids is indeed known to enhance the physical and psychological well being of the allograft recipient. This paper reviews the current status of steroid-free immunosuppression in renal, pancreatic, hepatic, intestinal, and cardiac transplantation.