Research on MI in Equipoise

The Case of Living Organ Donation

Allan Zuckoff, PhD & Mary Amanda Dew, PhD

University of Pittsburgh

Pittsburgh, PA USA

Second International Conference on Motivational InterviewingStockholm, Sweden

June 7-9, 2010

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

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?

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.

Donor Psychosocial Outcomes

Minority report negative outcomes 24% significant psychological distress 12% worse health, 25% worry about health 23% financial distress

Predict negative outcomes? Prevent negative outcomes?

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.

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

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

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.

Simmons Ambivalence Scale

Very hard

Somewhat hard

A little hard

Not at all hard

How hard a decision was it for you to donate?

Knew right away Thought it over

Did you know right away you would do it or did you think it over?

Simmons Ambivalence ScaleAgree a lot

Agree a little

Disagree a lot

Disagree a little

I sometimes feel unsure about donating.I sometimes wish the transplant patient were getting a cadaver organ instead of one from me.I would really want to donate myself even if someone else could do it.

Simmons Ambivalence Scale

Very dis-appointed

A little dis-appointed

A little relieved

Very relieved

How would you have felt if you found out that you couldn’t donate for some reason?

Yes No

Many donors have doubts and worries going into the transplant operation, even though they go through with it. Did you ever have doubts about donating?

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

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

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.

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.

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

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

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

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

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)

Session 2

Review Plan and Progress Values Card Sort

Three Pathways Planning Ending

Affirmation and looking forward

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

MI in Equipoise

Oxymoron or New Frontier?