An “Opting In” Paradigm for Kidney Transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors.

An “opting in” paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An “opting in” program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of “organ takers” who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who “opt in” would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive.

An “opting in” paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an “opting in” paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an “opting in” policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.     

肾源交换计划

肾源交换计划的目的是尽可能减少活体肾移植中配型不成功造成的肾源损失,缓解肾脏供求矛盾,使更多的患者得到合适的肾脏。该计划已在许多国家实施且颇具成效。本文主要介绍肾源交换计划的概念、分类和他国的实施经验,分析可能涉及的伦理问题,总结他国取得的成效,并就肾源交换计划在我国实施的可行性进行探讨。     

An "opting in" paradigm for kidney transplantation

Almost 60,000 people in the United States with end stage renal disease are waiting for a kidney transplant. Because of the scarcity of organs from deceased donors live kidney donors have become a critical source of organs; in 2001, for the first time in recent decades, the number of live kidney donors exceeded the number of deceased donors. The paradigm used to justify putting live kidney donors at risk includes the low risk to the donor, the favorable risk-benefit ratio, the psychological benefits to the donor, altruism, and autonomy coupled with informed consent; because each of these arguments is flawed we need to lessen our dependence on live kidney donors and increase the number of organs retrieved from deceased donors. An "opting in" paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An "opting in" program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of"organ takers"who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who "opt in" would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive. An "opting in" paradigm would simulate the reciprocal altruism observed in nature that sociobiologists believe enhances group survival. Although the allocation of organs based on factors other than need might be morally troubling, an "opting in" paradigm compares favorably with other methods of obtaining more organs and accepting the status quo of extreme organ scarcity. Although an "opting in" policy would be based on enlightened self-interest, by demonstrating the utilitarian value of mutual assistance, it would promote the attitude that self-interest sometimes requires the perception that we are all part of a common humanity.     

The experience of receiving a kidney transplant from a deceased donor: Implications for renal services

Objective: The study aimed to explore the psychological experiences of receiving a kidney transplant from a deceased donor and to examine resulting implications for renal services.

Design: A qualitative design was utilised within an interpretative phenomenological analysis (IPA) framework.

Main outcome measures: Semi-structured interviews were conducted with six adults (male = 5, mean age = 45 yrs) on their experiences of receiving a kidney transplant from a deceased donor. All participants had their transplant within the preceding 21 months. Data were analysed using IPA.

Results: The four elicited themes incorporate recipients’ positive feelings about receiving a transplant, mainly arising from the newfound freedom that this entails, in addition to strong feelings of gratitude towards their donors. They also capture challenges, such as the uncertainty of living with a transplanted kidney, and highlight the increased dependence on others throughout the transplant process.

Conclusion: The findings indicate a range of psychological, social and occupational experiences for participants. It is concluded that optimal care in renal services would incorporate a holistic approach to pre and post-transplant care; identifying and supporting the needs of transplant recipients. A biopsychosocial model of care may enhance service user well-being. Potential areas of future research are explored.     

The advantages and disadvantages of a brief intervention strategy in a community counseling service

Abstract

The Isis Centre, a long-established NHS open-access counselling facility in Oxford, experienced excessive demand for service. This placed strain on the capacity to deliver, and an unacceptably long waiting list resulted. A brief intervention strategy limited to four counselling sessions was shown to reduce the waiting time. This outcome study tests the hypothesis that the strategy was sufficiently clinically effective to warrant its continuing availability to those who wished to be seen more quickly, rather than waiting for an open-ended contract. Counsellors assessed outcome on clinical parameters and clients were retrospectively asked their views on the acceptability of the method and its usefulness.

There was a high level of correlation between clients' and counsellors' assessment. One-quarter of the study group had an experience classified as ‘useful and sufficient’. However, half felt the experience ‘useful but insufficient’, although this group also thought the intervention provided more than temporary relief. For one quarter, the experience was not helpful, but for some of these it prevented a long, unnecessary time on the waiting list.

While a brief intervention appears to be an effective strategy in delivering a counselling service, further work is necessary to target those most likely to benefit and those for whom a longer-term option should be sought from the start.     

Waiting Well: Tips for Navigating Painful Uncertainty

Waiting for uncertain news can be a source of anxiety and distraction. This paper explores the experience of waiting for news that is both uncertain and unchangeable and provides tips for waiting well under these circumstances. During difficult waiting periods people can mitigate anxiety, reduce disruptive rumination, and minimize later harm by (1) distracting themselves from their uncertainty, (2) managing their expectations, (3) looking for the silver lining in all outcomes, (4) keeping perspective regarding the news, and (5) planning ahead for the objective and psychological consequences of bad news.     

Uncertainty avoidance moderates the link between faith and subjective well-being around the world

Theorists have suggested that faith in God can play an important role in the relief of anxiety associated with uncertainty. Yet little is known about the impact of national differences in uncertainty avoidance – the degree to which uncertainty is threatening to members of a culture – on the relationship between faith and subjective well-being. In the present study, we investigated faith’s relationships with psychological well-being in the World and European Values Surveys for nearly 240,000 people in 92 countries, and the role national uncertainty avoidance plays in modifying these relationships. We found that faith was positively related to subjective well-being around the world overall, but this relationship was moderated by uncertainty avoidance. In particular, the relationship between faith and well-being was strongest in nations characterized by the highest levels of uncertainty avoidance. Our results suggest that cultural norms of uncertainty avoidance play a role in determining faith’s role in psychological functioning.     

Letter to a genetic counselor

The author describes her personal experience terminating a pregnancy after receiving an abnormal amniocentesis result: While still waiting for the results, she and her husband attempted to deny the importance of the pregnancy, an approach which they subsequently regretted. When they received the abnormal result, they found themselves able to make necessary decisions quickly, despite being in shock. It then took some time before they realized what a major loss they had actually suffered. The painful aftermath included accepting emotional responsibility for their decision to abort, as well as explaining that difficult decision to their older children. Thoughts of a possible subsequent pregnancy could not be faced at once. Over time, the author found the support of friends and colleagues, and even of a support group, to be invaluable. All in all, the entire experience was more painful than she would have predicted, and she hopes that this account will prove helpful both to genetic counselors and to other patients who receive abnormal results from prenatal diagnosis. A list of suggested readings is appended.Rose Green is a pseudonym.     

Training of conversational skills with institutionalized elderly: a preliminary study

16 residents in a Residential Care Home for elderly people volunteered and were trained in a social skills program aimed at increasing conversational skills. Subjects were assigned randomly to three groups, one experimental and two control groups (placebo and waiting list). The techniques used in the experimental group were behavior rehearsal, feedback, modeling, discriminative reinforcement, verbal instructions, and homework. Relative to control groups, experimental subjects showed significant increases in conversational skills, such as receiving information, speaking-up, and giving information. They also showed a significant decrease in their scores on Zung's Self-rating Scale of Depression compared with the two control groups. They showed an increase in assertive responses and a decrease in aggressive and inhibited responses. These changes remained when follow-up was made 3 mo. later, suggesting the potential utility of this training program with elderly persons residing in old people's homes.     

The psychological cost of waiting

The study of any problem involving waiting situations invariably assumes that people dislike having to wait. The analysis of queueing problems usually prescribes that some costs should be associated with the time people spend waiting to be served. These are usually considered to be of an economic nature, though the existence of other costs of a psychological nature is accepted. It is generally accepted that after having to wait for a certain amount of time, anxiety and stress start to build up in an individual, due both to the sense of waste and the uncertainty involved in a waiting situation. This work provides a theoretical basis for analysing this building up process as it occurs during the waiting period. It is proved that, under very general conditions, the resulting psychological stress accumulated during the process is a marginal increasing function of the waiting time, and some strategies to minimise it are developed. The results obtained give theoretical support to the usual assumptions underlying the development of systems to provide “real time” information to people in waiting situations. This is especially important in the operation of public transportation systems. The results also provide theoretical support to the “convex” treatment usually given to the waiting cost function in queueing problems.     

Different to ‘dust collectors’? The giving and receiving of experience gifts

• Gift giving theory has evolved around the giving and receiving of physical goods, yet experiences as gifts are increasingly important in modern Western economies. This research generating data from consumer informants focuses exclusively on experiences. The donor, recipient, occasion and gift, and the three gift giving process stages provide a synthesising framework for the findings. The concepts of donor sacrifice of time and effort, alongside gift surprise emerge as especially pertinent to experience gift giving, and notions of sharing, suspense and recipient sacrifice reinforce the proposition that experience gifts are deserving of researcher effort to better understand the phenomenon. Copyright © 2006 John Wiley & Sons, Ltd.

     

Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial

Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Within the last few years, several adaptations to specific settings have been developed. This study aims to evaluate a three-month DBT inpatient treatment program. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment (i.e. four weeks after discharge for the DBT group). Pre-post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson's criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features. Stability of the recovery after one month following discharge, however, was not evaluated and requires further study.     

Between the idea and the reality: A study of the counselling experiences of bereaved people who sense the presence of the deceased

There have been many theories of the process of loss and bereavement, from Freud, to the present day. Early theories of bereavement described a process which, following various stages and associated tasks, ended at the relinquishment of the bond to the deceased. In more recent years theories have taken different directions, identifying how bereaved people re‐learn life, recreate biographies, and continue relationships to the deceased. Some research studies of bereavement have investigated the counsellors’ perspective, but there are very few studies of the client's experience and most studies have focussed on outcomes of counselling. This qualitative study, using semi‐structured interviews, provides an insight into the bereaved client's perspective on the content and process of their counselling experiences. Taking as its focus the client's sense of the presence of the deceased, this study aimed to identify whether or how counsellors facilitate exploration of this experience and which theories they use in client work. The main finding is that 80% of the counsellors were not perceived by participants to have worked with them satisfactorily in relation to their sense of presence of the deceased or in relation to the story of the death itself.     

Telephone-administered cognitive behavior therapy for obsessive-compulsive disorder

Exposure with response prevention and cognitive behavior therapy are widely recognized as effective treatments for obsessive-compulsive disorder. Unfortunately, many people with obsessive-compulsive disorder--particularly those living in rural areas--do not have access to therapists providing these treatments. Accordingly, we investigated the efficacy of telephone-administered cognitive behavior therapy for obsessive-compulsive disorder. Two open trials are reported, for a total of 33 people with obsessive-compulsive disorder (without major depression). The first trial consisted of 12 weeks on a waiting list followed by 12 weeks of treatment (delayed treatment). The second trial consisted of 12 weeks of immediate treatment. Obsessive-compulsive symptoms did not change during the waiting period. Symptoms declined from pre- to post-treatment, with gains maintained at 12-week follow-up. For the pooled sample our pre-to-post-treatment effect size was as large or larger than those obtained in other studies of reduced contact treatment, and similar to those of face-to-face exposure with response prevention. Our proportion of treatment dropouts tended to be lower than those of other reduced contact interventions. The results suggest that telephone-administered cognitive behavior therapy is effective and well-tolerated, at least for people with obsessive-compulsive disorder without major depression. It remains to be seen whether this treatment is safe and effective when comorbid major depression is present.     

活体肝移植与供体安全

等候移植的病人增多和可用器官短缺,是我们目前所面临的主要问题。为降低等候期间的死亡率,活体肝移植(LDLT)是一种不错的选择,但其前提是要确保供体的安全。尽管活体肝移植术对供体而言是安全可行的,然而供体所发生的严重并发症、甚至死亡则是我们所不应忽视和低估的。     

Counselling adolescents of immigrant parents: A transcultural approach

Adolescence is a difficult time for most children, but even more complex for the adolescents coming from immigrant families. Immigrant is a vague, broad concept and is difficult to define. Not all immigrants experience financial, psychological and social adjustment in the same way. In this paper it refers to the ones who experience ‘cultural misunderstanding’ characterized by social isolation, social confusion and deep general uncertainty. The paper focuses on some of the general aspects of the lack of appropriate support that the offspring of immigrant parents experience. A brief outline is given to show the attempt made by the Intercultural Therapy Centre (NAFSIYAT) to provide a transcultural therapeutic milieu for the adolescents from immigrant parents.     

Measuring Spirituality as a Universal Human Experience: A Review of Spirituality Questionnaires

Spirituality is an important theme in health research, since a spiritual orientation can help people to cope with the consequences of a serious disease. Knowledge on the role of spirituality is, however, limited, as most research is based on measures of religiosity rather than spirituality. A questionnaire that transcends specific beliefs is a prerequisite for quantifying the importance of spirituality among people who adhere to a religion or none at all. In this review, we discuss ten questionnaires that address spirituality as a universal human experience. Questionnaires are evaluated with regard to psychometric properties, item formulation and confusion with well-being and distress. Although none of the questionnaires fulfilled all the criteria, the multidimensional Spiritual Well-Being Questionnaire is promising.     

A near-death experience among the Mapuche people

This paper describes a possible near-death experience (NDE) among the Mapuche people of Chile. The individual reporting the experience was in a cataleptic-like state for two days, the experience itself occurring at the end of this period. Some common features of NDEs, such as encounters with deceased people and being sent back, are present, together with clear evidence that past and present cultural environment shape in part the content of mental experiences.This work was funded in part by the University of Chile (DTI Project Q-3064).The author thanks Editorial Andrés Bello for permissionto translate the near death account into English.     

Improving Communication of Uncertainty in the Reports of the Intergovernmental Panel on Climate Change

ABSTRACT— The Intergovernmental Panel on Climate Change (IPCC) assesses information relevant to the understanding of climate change and explores options for adaptation and mitigation. The IPCC reports communicate uncertainty by using a set of probability terms accompanied by global interpretational guidelines. The judgment literature indicates that there are large differences in the way people understand such phrases, and that their use may lead to confusion and errors in communication. We conducted an experiment in which subjects read sentences from the 2007 IPCC report and assigned numerical values to the probability terms. The respondents' judgments deviated significantly from the IPCC guidelines, even when the respondents had access to these guidelines. These results suggest that the method used by the IPCC is likely to convey levels of imprecision that are too high. We propose an alternative form of communicating uncertainty, illustrate its effectiveness, and suggest several additional ways to improve the communication of uncertainty.     

Effect of family environment and donor source on patient quality of life following renal transplantation.

The authors examined the degree to which the supportiveness of a patient's family environment predicts change in quality of life following renal transplantation. The sample consisted of 95 patients receiving renal grafts from either a living donor or a cadaveric donor. Patients were initially assessed prior to transplantation with follow-up assessment occurring an average of 5.5 months after transplantation. Among patients receiving a living-donor kidney, those reporting a more supportive family environment exhibited reduced depression, improved mobility, and improved social functioning. However, those living-donor recipients reporting less family support exhibited increased depression and diminished mobility and social functioning after transplantation. Patients receiving a kidney from a cadaveric donor showed modest improvements in quality of life regardless of the degree of family support.