Development of the University of Pittsburgh Medical Center policy for the care of terminally ill patients who may become organ donors after death following the removal of life support

In the mid 1980s it was apparent that the need for organ donors exceeded those willing to donate. Some University of Pittsburgh Medical Center (UPMC) physicians initiated discussion of possible new organ donor categories including individuals pronounced dead by traditional cardiac criteria. However, they reached no conclusion and dropped the discussion. In the late 1980s and the early 1990s, four cases arose in which dying patients or their families requested organ donation following the elective removal of mechanical ventilation. Controversy surrounding these cases precipitated open discussion of the use of organ donors pronounced dead on the basis of cardiac criteria. Prolonged deliberations by many committees in the absence of precedent ultimately resulted in what is, to our knowledge, the country's first policy for organ donation following elective removal of life support. The policy is intricate and conservative. Care was taken to include as many interested parties as possible in an effort to achieve representative and broad based support. This paper describes the development of the UPMC policy on non-heart-beating organ donation.     

The dead donor rule: should we stretch it, bend it, or abandon it?

The dead donor rule--that persons must be dead before their organs are taken--is a central part of the moral framework underlying organ procurement. Efforts to increase the pool of transplantable organs have been forced either to redefine death (e.g., anencephaly) or take advantage of ambiguities in the current definition of death (e.g., the Pittsburgh protocol). Society's growing acceptance of circumstances in which health care professionals can hasten a patient's death also may weaken the symbolic importance of the dead donor rule. We consider the implications of these efforts to continually revise the line between life and death and ask whether it would be preferable to abandon the dead donor rule and rely entirely on informed consent as a safeguard against abuse.     

Child and adolescent services research at the national institute of mental health: Research opportunities in an emerging field

This article describes an important new area of research on services for children and adolescents with mental disorders at the National Institute of Mental Health, the parameters of mental health services research for youth, and the opportunities that are available for grant-funded investigations in this area.     

Nonsuicidal physically self-damaging acts in adolescents

To determine the frequency and correlates of nonsuicidal physically self-damaging acts in 12–14 year olds, a two stage epidemiologic survey with a self-administered questionnaire (N=3283) followed by a psychiatric interview of a subsample of the adolescents and their parents (N=444) was used. Prevalence estimates of interview validated nonsuicidal physically self-damaging acts were 2.46% in males and 2.79% in females. Significant relationships were found between nonsuicidal physically self-damaging acts and suicidal ideation, major depression and undesirable life events. Data suggest that physically self-damaging acts occur at substantial rates during early adolescence. The strong correlation between nonsuicidal self-destructive acts and both suicidal ideation and major depression clarifies prior conflicting reports in the literature and suggests that a history of self-damaging acts should be taken into consideration when evaluating for possible depression and suicide risk.     

The aggression-coercion cycle: Use of seclusion and restraint in a child psychiatric hospital

The widespread use of seclusion and restraint in child psychiatric hospitals to manage aggression and noncompliance is based on the assumption that coercive consequences reduce the frequency of undesirable behaviors exhibited by the patients. We report a study of the use of seclusion and restraint in a public child psychiatric hospital during a 3-year period. Twenty-eight percent of the patients had been secluded or restrained a total of 1670 times. About 25% of these patients had been secluded more than five times during their hospitalization, and 32% had been placed in restraints more than once. Behaviors that typically resulted in repeated seclusion included physical aggression toward staff, verbal aggression toward peers, non-compliant or oppositional behavior, and self-harm. Variables that predicted patients most at risk for repeated seclusion included age, gender, and psychiatric diagnosis. The predictor variables for those most at risk for repeated restraint included age, property destruction, and self-harm. The high rates of use of seclusion and restraint suggest that these methods for controlling the behavior of children and adolescents in this child psychiatric hospital may not have been therapeutic. We suggest that staff in such hospitals engage in a pattern of behavior characterized by an aggression-coercion cycle, in which increasingly aggressive and coercive behaviors are exhibited by both patients and staff.     

The effects of exposure to different sources of sexual information on sexual behavior: Comparing a “sex-expert system” to other educational material

Sexpert, an expert computer program designed to counsel couples on their sexual relationships, was evaluated. Eighty-one heterosexual couples were assigned to one of three experimental manipulations (Sexpert, video, and self-help book) or a control condition. Daily sexual behavior monitoring forms and structured retrospective reports served as measures of baseline and post-manipulation behavior. Daily monitoring of sexual behavior failed to show significant changes occurring after the manipulations. However, retrospective data concerning the postmanipulation period show that compared with the control, the Sexpert, video, and book manipulations had a significant positive impact on couples’ sexual behavior, communication, and learning about sexuality. Sexpert, video, and book were similarly evaluated, except that Sexpert was evaluated as more engaging. In addition, subjects retrospectively reported positive changes in communication, relationship satisfaction, and sexual behavior during the baseline period. This suggests that daily behavioral monitoring is intrusive and may confound the variables measured by it.     

Visual influences on auditory pluck and bow judgments

In the McGurk effect, visual information specifying a speaker’s articulatory movements can influence auditory judgments of speech. In the present study, we attempted to find an analogue of the McGurk effect by using nonspeech stimuli—the discrepant audiovisual tokens of plucks and bows on a cello. The results of an initial experiment revealed that subjects’ auditory judgments were influenced significantly by the visual pluck and bow stimuli. However, a second experiment in which speech syllables were used demonstrated that the visual influence on consonants was significantly greater than the visual influence observed for pluck-bow stimuli. This result could be interpreted to suggest that the nonspeech visual influence was not a true McGurk effect. In a third experiment, visual stimuli consisting of the wordspluck andbow were found to have no influence over auditory pluck and bow judgments. This result could suggest that the nonspeech effects found in Experiment 1 were based on the audio and visual information’s having an ostensive lawful relation to the specified event. These results are discussed in terms of motor-theory, ecological, and FLMP approaches to speech perception.     

Shape from stereo: A systematic approach using quadratic surfaces

We used quadratic shapes in several psychophysical shape-from-stereo tasks. The shapes were elegantly represented in a 2-D parameter space by the scale-independentshape index and the scale-dependentcurvedness. Using random-dot stereograms to depict the surfaces, we found that the shape of hyperbolic surfaces is slightly more difficult to recognize than the shape of elliptic surfaces. We found that curvedness (and indirectly, scale) has little or no influence on shape recognition.     

Infant use of relative motion as information for form: Evidence for spatiotemporal integration of complex motion displays

Previous studies of infants’ ability to integrate and to utilize relative motion as information for form in the absence of structural cues have primarily involved motions that are uniform in rate, direction, and path within the form to be constructed. In the present study, we examined infants’ ability to integrate relative motion information from motions that are nonuniform along these dimensions, and from this integrative process to construct a coherently rotating two-dimensional form. Infants’ ability to integrate nonuniform motion was measured with regard to their ability to discriminate the rotating form from a noncoherent control display containing the same absolute motions. The results showed that discrimination of the coherent and incoherent displays was not demonstrated until 7 months of age. Two additional experiments were conducted to rule out the possibility that this discrimination was based on the detection of local regions of coherence, rather than the perception of the global rotating form. In both experiments, the results did not support discrimination based exclusively on local cues alone. From the combined results of all three experiments, we conclude that infants demonstrate the capacity to integrate the information contained within nonuniform trajectories into a coherent structure by 7 months of age.