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