Second International Conference on Motivational Interviewing<br />Stockholm, Sweden<br />June 7-9, 2010<br />Research on M...
Living Organ Donation<br />Donation of an organ (kidney, liver lobe) while alive to someone who needs it<br />Not enough c...
Concern for the Donor<br />Unique medical situation<br />Major surgery with associated risks<br />Person who undergoes it ...
Donor Psychosocial Outcomes<br />Most donors report positive outcomes*<br />> 95% would donate again<br />72% report posit...
Donor Psychosocial Outcomes<br />Minority report negative outcomes<br />24% significant psychological distress<br />12% wo...
The Decision to Donate an Organ*<br />Major, high-stakes life decision<br />Irreversible<br />Outcome is not assured <br /...
Pre-Donation Ambivalence<br />Fear of the surgery<br />Anticipated effects of the recovery period<br />Pain<br />Financial...
Pre-Donation Ambivalence<br />Family pressure<br />Overt demands<br />Subtle situational pressure <br />Perceived family o...
Making the Decision*<br />Instantaneous Choice <br />No deliberation (“knew right away”)<br />Deliberation <br />Collect r...
Simmons Ambivalence Scale<br />
Simmons Ambivalence Scale<br />
Simmons Ambivalence Scale<br />
Ambivalence and Outcomes<br />Residual pre-donation ambivalence is the only consistent risk factor for poor psychosocial o...
Ambivalence and Outcomes<br />Residual pre-donation ambivalence is the only consistent risk factor for poor psychosocial o...
Initial Finding <br />Simmons, et al. (1977)<br />130 pre-surgery kidney donors <br />Assessed prior to physical qualifica...
More Recent Findings<br />Switzer, Simmons, & Dew (1996)<br />343 anonymous bone marrow donors<br />Residual ambivalence w...
MI with Living Donors<br />Prevent negative psychological outcomes by resolving ambivalence<br />Equipoise<br />Recommitme...
Structure of the Intervention<br />Two sessions, 30-45 minutes each<br />Conducted by telephone<br />Take place after Pote...
Session 1<br />Structuring<br />Confidentiality from recipient, family, and transplant evaluation team<br />No effect on w...
Session 1<br />Story of the decision to donate<br />DARN for donating<br />Potential sources of ambivalence<br />Feedback<...
Session 1<br />Three Pathways<br />Residual ambivalence<br />Treat  lingering concerns as obstacles to whole-hearted commi...
Session 2<br />Review Plan and Progress<br />Values Card Sort<br />Three Pathways<br />Planning <br />Ending <br />Affirma...
Next Steps<br />Completed initial development cases<br />Trained interventionists<br />Initiated preliminary RCT<br />MI v...
MI in Equipoise<br />Oxymoron or New Frontier?<br />
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Zuckoff icmi equipoise_livingdonor

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  • Zuckoff icmi equipoise_livingdonor

    1. 1. Second International Conference on Motivational Interviewing<br />Stockholm, Sweden<br />June 7-9, 2010<br />Research on MI in Equipoise<br />The Case of Living Organ Donation<br />Allan Zuckoff, PhD & Mary Amanda Dew, PhD<br />University of Pittsburgh<br />Pittsburgh, PA USA<br />
    2. 2. Living Organ Donation<br />Donation of an organ (kidney, liver lobe) while alive to someone who needs it<br />Not enough cadaver organs to meet need<br />Superior long-term outcomes for recipient compared to cadaver donation<br />More likely to be alive years post-transplant<br />Less likely to have rejected the organ<br />Higher quality of life<br />
    3. 3. Concern for the Donor<br />Unique medical situation<br />Major surgery with associated risks<br />Person who undergoes it is healthy<br />No possible medical benefit to the donor, and potential for harm<br />“First do no harm”?<br />Should living donation be permitted?<br />
    4. 4. Donor Psychosocial Outcomes<br />Most donors report positive outcomes*<br />> 95% would donate again<br />72% report positive feelings from donation (self-esteem, better person, life more worthwhile)<br />Perceptions of physical functioning, psychological well-being, social well-being equivalent to or better than the general population<br />* Dew, M.A., Switzer, G.E., DiMartini, A.F., Myaskovsky, L., & Crowley-Matoka, M. (2007). Psychosocial aspects of living organ donation. In H.P. Tan, A. Marcos, & R. Shapiro (eds.), Living donor transplantation. New York: Informa Healthcare USA, Inc.<br />
    5. 5. Donor Psychosocial Outcomes<br />Minority report negative outcomes<br />24% significant psychological distress<br />12% worse health, 25% worry about health<br />23% financial distress<br />Predict negative outcomes?<br />Prevent negative outcomes?<br />
    6. 6. The Decision to Donate an Organ*<br />Major, high-stakes life decision<br />Irreversible<br />Outcome is not assured <br />Affects donor’s most central relationships<br />Crisis situation with implicit time deadline<br />Unfamiliar, with unclear norms<br />Altruistic<br />* Simmons, R.G., Marine, S.K., & Simmons, R.L. (1987). Gift of life: The effect of organ transplantation on individual, family, and societal dynamics. New Brunswick, NJ: Transaction, Inc. <br />
    7. 7. Pre-Donation Ambivalence<br />Fear of the surgery<br />Anticipated effects of the recovery period<br />Pain<br />Financial effects<br />Conflicts with other family obligations<br />Worry about long-term health effects <br />
    8. 8. Pre-Donation Ambivalence<br />Family pressure<br />Overt demands<br />Subtle situational pressure <br />Perceived family obligation to donate<br />“Black sheep” donors<br />Recipient issues<br />Prognosis<br />Response to the donor’s gift<br />
    9. 9. Making the Decision*<br />Instantaneous Choice <br />No deliberation (“knew right away”)<br />Deliberation <br />Collect relevant information<br />Identify and evaluate alternatives (pros and cons)<br />Make and implement decision<br />Postponement / Evasion <br />Never experience self as making a decision<br />Exploratory steps led to being “locked in”<br />* Simmons, R.G., Marine, S.K., & Simmons, R.L. (1987). Gift of life: The effect of organ transplantation on individual, family, and societal dynamics. New Brunswick, NJ: Transaction, Inc. <br />
    10. 10. Simmons Ambivalence Scale<br />
    11. 11. Simmons Ambivalence Scale<br />
    12. 12. Simmons Ambivalence Scale<br />
    13. 13. Ambivalence and Outcomes<br />Residual pre-donation ambivalence is the only consistent risk factor for poor psychosocial outcomes<br />In contrast with<br />Age, gender, education, marital status<br />Pre-donation psychological distress<br />Relationship to recipient or family<br />Type of surgery<br />Post-surgery medical complications<br />Success of transplant<br />
    14. 14. Ambivalence and Outcomes<br />Residual pre-donation ambivalence is the only consistent risk factor for poor psychosocial outcomes<br />Acute ambivalence<br />Results in disqualification from donation or decision not to donate in most cases<br />Residual ambivalence <br />Uncertainty following commitment and co-existing with intention to donate<br />
    15. 15. Initial Finding <br />Simmons, et al. (1977)<br />130 pre-surgery kidney donors <br />Assessed prior to physical qualification<br />Correlation of pre-donation ambivalence and negative attitudes (regret) about donation 1 year post-donation<br />r = .31 (p = .001)<br />* Simmons, R.G., Marine, S.K., & Simmons, R.L. (1987). Gift of life: The effect of organ transplantation on individual, family, and societal dynamics. New Brunswick, NJ: Transaction, Inc. <br />
    16. 16. More Recent Findings<br />Switzer, Simmons, & Dew (1996)<br />343 anonymous bone marrow donors<br />Residual ambivalence was common<br />62% SAS > 0, 12% SAS ≥ 5<br />R.A. predicted poor outcomes <br />Physical difficulty with donation<br />Psychological reactions post-surgery and 1 year post-donation (controlling for post-surgery reactions)<br />Switzer, G.E., Simmons, R.G., & Dew, M.A. (1996). Helping unrelated strangers: Physical and psychological reactions to the bone marrow donation process among anonymous donors. Journal of Applied Social Psychology, 26, 469-490.<br />
    17. 17. MI with Living Donors<br />Prevent negative psychological outcomes by resolving ambivalence<br />Equipoise<br />Recommitment to the decision to donate or resolute decision not to donate are equally preferred outcomes<br />Effectiveness defined in terms of reduction in measured ambivalence<br />
    18. 18. Structure of the Intervention<br />Two sessions, 30-45 minutes each<br />Conducted by telephone<br />Take place after Potential Donor (PD) has been medically and psychologically cleared to donate<br />“Cooling off” period<br />
    19. 19. Session 1<br />Structuring<br />Confidentiality from recipient, family, and transplant evaluation team<br />No effect on whether or not PD can donate<br />Goal: help PD feel “settled,” “at peace” with the decision<br />Emphasis on personal choice and control<br />
    20. 20. Session 1<br />Story of the decision to donate<br />DARN for donating<br />Potential sources of ambivalence<br />Feedback<br />Review of positive SAS items <br />Planning (E/P/E)<br />Concrete problem-solving<br />Shifting perspective<br />
    21. 21. Session 1<br />Three Pathways<br />Residual ambivalence<br />Treat lingering concerns as obstacles to whole-hearted commitment (end equipoise)<br />Change of heart<br />Strengthen resolve not to donate (end equipoise)<br />Acute ambivalence<br />Serious doubts about going forward triggers focus on decisional balance (equipoise)<br />
    22. 22. Session 2<br />Review Plan and Progress<br />Values Card Sort<br />Three Pathways<br />Planning <br />Ending <br />Affirmation and looking forward<br />
    23. 23. Next Steps<br />Completed initial development cases<br />Trained interventionists<br />Initiated preliminary RCT<br />MI vs. Enhanced Standard Care <br />Education on healthy lifestyles after donation<br />Follow-up at 6 weeks and 3 months<br />Ambivalence pre and post-donation<br />Physical and psychosocial outcomes<br />
    24. 24. MI in Equipoise<br />Oxymoron or New Frontier?<br />

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