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1
Jan Busschbach Psychologist
In cooperation with Willij Zuidema
Jan IJzermans
Willem Weimar
Jan Passchier
Leonieke Kranenburg
Medard Hilhorst
Settling Psychosocial Barriersin Living Donation
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Living donor transplantation: are the outcomes good enough?
Advantages Reduces the waiting list
Increases craft survival
Are the outcomes good enough? Should we pursue living donation?
Are the better outcomes worth the costs?
• Are the outcomes more valuable than the cost to overcome the barriers
From a descriptive point of view… The answer is might be no…
Living donation is not widely pursued
The effects do not outweighed the cost to overcome the barriers
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Barriers
What are the barriers? Sometimes hard medical issues… But most often soft issues
Legal
Cultural
Organizational
Psychological
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Psychological barriers
Negative emotions towards living donation Inappropriate emotions
Issues that related to inappropriate emotions …
Information Wrong information
Risk perception Wrong risk perception
Communication between patient and donor Blocked communication
* Kranenburg LW, Zuidema WC, Weimar W, Hilhorst MT, IJzermans JN, Passchier J, Busschbach JJ. Psychological barriers for living kidney donation: how to inform the potential donors? Transplantation. 2007 Oct 27;84(8):965-71
What can we do?
How can we change… Wrong information
Wrong risk perception
Blocked communication
Talking with the potential donor and patient
Rational
More and better information… Gives more appropriate emotions
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Information Interpretation Emotion
Not so rational,.. but reality
Better (more appropriate) emotion Better interpretation of information
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InformationInterpretationEmotion
Most likely model…
Need to work on both information and emotion Next question: how?
Talking with the patient and the potential donor
But there is not yet a ‘evidence based’ way…
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InformationInterpretation
EmotionInterpretation
Looking for the best psychotherapy..
Not much difference between psychotherapies Many very different therapies seem to work equally well
Research into non-specific factors Success factors in counseling
Most important non-specific factors Therapeutic alliance
Therapy adherence
System involvement
• Family
• Friends
Therapeutic alliance
Biggest generic success factor Sexton & Wiston (1992)
“…research has confirmed [that] the success of any therapeutic endeavor depends on the participants establishing an open, trusting, collaborative relationship or alliance.”
• http://personcentered.com/research.html
Control of emotion Safe environment
How do we establish such alliance Listening and talking…
Is it so simple?
Counter-transference
Our own ‘psychological schemes’ interfere Alternatively: Use theoretical scheme It does not matter much which…
Behavioral therapy
Cognitive therapy
Schema focus
Mentalisation
Reduces influence of own ‘psychological schemes’ Helps to build a “…open, trusting, collaborative
relationship or alliance.”
In order to control emotions
Treatment adherence
Treatment adherence is fatal It does not matter which therapy
As long as one use ONE therapy
Created a consistent… Framework
Language
In a confusing world
Thus consistency is important In time
Within the team
Protocols: adherence
Involve system
Patient part of ‘system’ System
Family
Friends
College's
Neighborhood
System is strong Involve system when necessary
In living donation, the system is important Obviously…the donor is part of the system
3 success factors
1. Therapeutic alliance
2. Adherence to ‘a’ therapy
3. Involve system
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What stops us?
Fear for pressure on the potential donor But we put pressure on patients on a routine basis
“If you don’t take the medicine you will become sick”
Not the medical domain The donor is not a patient
It is not ethical… to talk to the potential donor
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Not the medical domain?
Potential donor is not a patient Excludes caregivers
Exclude prevention
Suggests that patients are independent subjects, and not part of a system
The potential donor is in the medical domain
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Not ethical?
In spoken language: good or bad In science: consistent set of rules
Rules that are valid
Rules we agree on…
Is talking with the potential donor and patient ethical? Is there a consistent set of rules?
• Rules that are valid
• Rules we agree on…
That forbid or allow such interference
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Forbid interference
Non-directivity and value neutrality Talking with the potential donor is directive
But there is no such thing as non-directivity and value neutrality in counselling in general
• This rule can not applied validly anywhere
One should not change personal beliefs Assumes that beliefs are stable,… which they are not
• Personal beliefs have formed…
• There is no reason to believe they are completed
Assumes that beliefs are always right… which they are not
Assumes that it possible not to interfere…
No consistent sets of rules..
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Allow interference in beliefs
Stephen Toulmin Beliefs are a model of logical arguments Arguments are not fixed, but dynamic, Interferences can refine the model of arguments
Rawls Beliefs are a model of reflective equilibrium Beliefs represents a network of idea’s and facts Interferences can help to keep communication within the
network open
It is ethical to talk to the donor*
Ethics is a consistent set of rules Rules we would like to endorse
Set of rules that hold back interventions Seems to be inconsistent
Set of roles that allow interventions Consistent
Outcome in terms of process variables
* Hilhorst MT, Kranenburg LW, Busschbach JJ. Should health care professionals encourage living kidney donation? Med Health Care Philos. 2007;10(1):81-90
Existing interventions
Most standard Physician talks with patient
• Information
• Emotion regulation
Patient talks with potential donor
• Patients brings donor to the physician
More active towards donor…. (Rotterdam) Information meetings
For both patients and relatives (perhaps the donor)
“semi targeted” information towards donor
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Norwegian approach
Dr. Anders Hartmann The physician communicates directly with the
potential donor Physician discusses system with patient
Physician asks permission from patient
And calls the donor
No motivation of any refusal is given: “donor is not suitable”
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0
10
20
30
40
50
60
Patients "Donors"
Positive
Mixed
Negative
Norwegian approach will be appreciated
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James Rodrique
Activates communication in family (systems) “Very local” information meeting Especially in minorities RCT results:
Increase in knowledge
Willingness to discuss living donation
Decrease concerns
Outcome in terms of better model of arguments Toulmin, Ralws
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Rodrigue et al. Increasing live donor kidney transplantation: a randomized controlled trial of a home-based educational intervention. Am J Transplant 2007;7:394-401.
Illustration of a theoretical framework
MST: MultiSystemic Therapy Crime prevention in youth
Involving the whole system
Blueprint therapy evidence-based
Practical “Whatever it takes”
But what about Own psychological schemes?
Treatment adherence?
Treatment adherence MST
Conclusions
There are psychosocial barriers In living donation
It is ethical to interfere Outcomes define in process variable
These barriers can be overcome Building a constructive alliance
• Controlling emotions
Treatment adherences
Involve system
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