1. Psychological Issues in Living Liver Donation Mary Ellen Olbrisch, Ph.D. Medical College of Virginia of Virginia Commonwealth University

2. Acknowledgements Sharon M. Benedict, Ph.D. Robert A. Fisher, M.D. Deborah L. Haller, Ph.D. James L. Levenson, M.D. Marc Posner, M.D. Amadeo Marcos, M.D. (University of Rochester) Galen Switzer, Ph.D., Mary Amanda Dew, Ph.D. (University of Pittsburgh)

3. Psychological Issues in Living Liver Donation: Much Ado About Nothing?

4. “What if we were to look at people who want to be living donors as philanthropists?” - Jimmy Light, M.D.

5. “Do you really believe that every living donor should have a psychological evaluation?” - Various M.D.’s

6. What happens in a typical psychological evaluation? Structured interview and mental status examination Collateral interviews If necessary, objective and projective personality testing

7. And what does not happen? Trance induction or hypnosis Dream analysis Psychoanalytic interpretations Uncovering secret personal knowledge

8. “How in the world can I prove to this psychologist that I am sane?” - Joyce Roush, R.N., Good Samaritan Kidney Donor

9. Purposes of Psychological Evaluation of Living Liver Donors Informed consent Behavioral health / substance abuse Somatization Psychological health Freedom from coercion, ambivalence and fear Physical, financial and social support Motivation Diversity Issues Acceptance of recipient boundary conditions

10. Benefits of Psychological Evaluation for the Donor Reflection and mindfulness Consideration of potential outcomes Exposure of pressure or coercion Working through ambivalence Health behavior counseling

11. Benefits of Psychological Evaluation for the Transplant Program Assess donor’s psychological resources and ability to manage stress Assess health behaviors which may place both donor and recipient at risk Identify character pathology

12. Costs… of evaluating of not evaluating Costs… of evaluating of not evaluating Evaluation anxiety Privacy concerns Patient / donor time $ - $$$ Undiagnosed psychopathology Unidentified substance abuse Undetected coercion Unresolved ambivalence Inadequate support Prolonged disability Risk to the recipient Donor dissatisfaction

13. “I thank God every day that my sister was not able to donate her liver to me.” - Cadaver Liver Recipient

14. Recipient Issues Donor-recipient relationship Refusal to consider living donation Denial / postponement

15. Research Priorities Outcomes Risk and protective factors Decision-making and motivation Donor-recipient relationships Recipient resistance

16. Methodological Issues Reduce self-report bias Multiple approaches to measurement Standardize preoperative assessment protocols Include non-donors in comparison groups Develop protocols for Good Samaritan donation Issues of generalizability

17. Summary: Much To Do, Not Much Ado… Living liver donation is neither psychologically healthy nor pathological per se. Psychological evaluations are necessary components of research to detect risk factors for poor outcome. Transient and lasting psychological and social benefits and detriments may develop and should be assessed.

18. Summary -continued Summary -continued Empirical data is needed to guide clinical decision-making. Research to study methods to increase recipient receptiveness to living donation may be a valuable contribution to liver transplantation. Careful study of the Good Samaritan phenomenon is warranted.

19. DONOR ≠ DONOR =