Medard Hilhorst

Postmortal or living related donor: preferences of kidney patients

We studied the willingness and motives for accepting a living kidney donation in 61 kidney patients on the waiting list by a semistructured interview and a questionnaire on two occasions. Between both moments of measurement patients received general information on transplantation options. We tested whether demographic data, medical status data or quality of life correlated with treatment choice. Our results showed that 61% of the patients preferred living kidney donation to postmortal donation. Their main motivation for this choice was the better quality of the living kidney. The most often named reasons to choose postmortal donation were unwillingness to burden a loved one and fear of psychological problems in relation to the donor after transplantation. There was no statistical significant change of preference between both moments of measurement; however there seemed to be a tendency in favor of living kidney donation. Fewer years spent on renal replacement therapy correlated statistically significant with the choice for living kidney donation. These findings encourage the development of new strategies to facilitate the living kidney donation program, and confirm the need for the standard option of psychosocial support for patients.

Altruistic Donor Triggered Domino-Paired Kidney Donation for Unsuccessful Couples from the Kidney-Exchange Program

Between January 2000 and July 2009, 132 individuals inquired about altruistic kidney donation to strangers. These donors were willing to donate to genetically and emotionally unrelated patients. Some altruistic donors wished to donate to a specific person, but most wished to donate anonymously. In domino‐paired donation, the altruistic donor donates to the recipient of an incompatible couple; the donor of that couple (domino‐donor) donates to another couple or to the waiting list. In contrast to kidney‐exchange donation where bilateral matching of couples is required, recipient and donor matching are unlinked in domino‐paired donation. This facilitates matching for unsuccessful couples from the kidney‐exchange program where blood type O prevails in recipients and is under‐represented in donors. Fifty‐one altruistic donors (39%) donated their kidney and 35 domino‐donors were involved. There were 29 domino procedures, 24 with 1 altruistic donor and 1 domino‐donor, 5 with more domino‐donors. Eighty‐six transplantations were performed. Donor and recipient blood type distribution in the couples limited allocation to blood type non‐O waiting list patients. The success rate of domino‐paired donation is dependent on the composition of the pool of incompatible pairs, but it offers opportunities for difficult to match pairs that were unsuccessful in the kidney‐exchange program.

One donor, two transplants: willingness to participate in altruistically unbalanced exchange donation

Kidney exchange donation programs offer a good solution to help patients with a willing, but incompatible living kidney donor. Literature shows that blood type O patients are less likely to be selected for transplantation within a living exchange donation program. ‘Altruistically unbalanced donation’ could help these blood type O patients: one donor‐recipient pair is incompatible (e.g. A‐donoru2003>u2003O‐recipient) and the other pair is compatible, but not identical (e.g. O‐donoru2003>u2003A‐recipient). Exchanging these kidneys would result in two compatible living donor kidney transplants. We studied whether compatible pairs would be willing to participate in such procedure. We included 96 living kidney donors and recipients in our study. These donors and recipients could be divided into two groups: (i) donors and their direct recipients (nu2003=u200348), and (ii) paired exchange donors and their intended recipients (nu2003=u200348). All were asked whether they would be willing to participate in altruistically unbalanced exchange donation, as long as direct donation was also an option. We found no group differences. We found that one third of the donors and recipients are willing to participate in altruistically unbalanced kidney exchanges. Therefore this form of donation may be a feasible addition to already existing living kidney exchange programs.

Women's motives to opt for either implant or DIEP-flap breast reconstruction.

OBJECTIVEnUnderstanding womens motives concerning breast reconstructive surgery will contribute to a better counselling and care for the increasing number of women choosing post-mastectomy breast reconstruction (BR).nnnMETHODSnWe interviewed 31 women who opted for implant or deep inferior epigastric perforator (DIEP)-flap BR after therapeutic or prophylactic mastectomy. Motives for BR in general and for the selected type of BR were investigated following a phenomenological qualitative research approach.nnnRESULTSnWomen opting for implant BR were concerned with surgery-related issues, such as recovery time, number of scars and impact of surgery. They wanted to return to their daily life and restore their body image as soon as possible. Patients choosing DIEP-flap BR were more focussed on regaining a natural breast and wanted to benefit from the advantages of autologous tissue. Women scheduled for prophylactic mastectomy saw BR as an integral part of their treatment. Patients opting for BR after therapeutic mastectomy wanted to regain a complete body image with BR.nnnCONCLUSIONSnPatients motives for implant BR were primarily related to surgical issues, whereas women who chose DIEP-flap BR especially focussed on regaining a breast that resembles their own lost breast as well as possible. Clinical variables (such as therapeutic or prophylactic mastectomy, breast irradiation, and waiting lists) need to be taken into account when considering a certain type of BR, as these can be of great importance in the decision-making process.

The short-term psychological impact of complications after breast reconstruction.

Few studies have focused on the psychological impact of postoperative complications after breast reconstruction (BR). As postoperative complications after BR usually lead to a prolonged recovery time and sometimes require additional surgery, the short‐term impact on distress was investigated.

The implementation of a kidney exchange program does not induce a need for additional psychosocial support

The Dutch kidney exchange donation program started in January 2004. A literature review has shown that several factors of the exchange program could influence the psychological well being of participants, such as the loss of the possibility of a ‘medical excuse’ for unwilling donors and the issue of anonymity. However, these factors have not been the subject of empirical study yet. We therefore studied these factors to determine whether additional psychosocial support is necessary for donors and recipients in the Dutch kidney exchange program. We used structured interviews for all 48 donors and recipients that had undergone exchange donation/transplantation in 2004. A psychologist interviewed the participants before and 3u2003months after transplantation. We included a comparison group of 48 donors and recipients participating in the regular living kidney donation program. Donors did not experience additional pressure to donate due to the exchange donation. Most participants (69%) preferred anonymity between the couples. Ten percentage needed additional emotional support. In this respect the exchange group did not differ from the comparison group. We conclude that the psychosocial support offered to exchange couples can be comparable with the support normally offered to participants in the regular living kidney donation program.

Barriers in the Uptake and Delivery of Preconception Care: Exploring the Views of Care Providers

Objectives To examine health care professionals’ views of their role and responsibilities in providing preconception care and identify barriers that affect the delivery and uptake of preconception care. Methods Twenty health care professionals who provide preconception care on a regular basis were interviewed using semi-structured interviews. Results We interviewed twelve community midwives, three General Practitioners, three obstetricians, one cardiologist specialized in congenital heart diseases and one gastroenterologist.We identified four barriers affecting the uptake and delivery of preconception care (PCC): (1) lack of a comprehensive preconception care program; (2) limited awareness of most future parents about the benefits of preconception care, hesitance of GP’s about the necessity and effectiveness of PCC; (3) poor coordination and organization of preconception care; (4) conflicting views of health care professionals on pregnancy, reproductive autonomy of patients and professional responsibility. Conclusion We have identified four barriers in the uptake and delivery of preconception care. Our findings support the timely implementation of a comprehensive program of PCC (already advocated by the Health Council of the Netherlands) and increasing awareness and knowledge of PCC from care providers and future parents. We emphasize the need for further research on how organizational barriers lead to suboptimal PCC and how interdisciplinary collaboration and referral can lead to optimally tailored intervention approaches.

Information-seeking behaviour and coping style of women opting for either implant or DIEP-flap breast reconstruction

BACKGROUNDnHigh satisfaction rates have been reported after autologous breast reconstruction. Yet, most mastectomy patients receive implant reconstructions (ImBR). Independent and active decision makers have shown mainly to choose for autologous reconstructions, such as the Deep inferior epigastric perforator (DIEP) flap (DiepBR). To further explore the decision making to opt for either ImBR or DiepBR, we investigated patient knowledge, informational resources used, effect of plastic surgeons advice, coping style and personal independence.nnnMETHODSnA total of 153 women, who were planned for DiepBR or ImBR preoperatively, completed a study-specific and standardised validated psychological questionnaire. Analyses were aimed at information-seeking behaviour, personal independence and coping styles associated with autonomous decision making regarding reconstruction.nnnRESULTSnDiepBR women reported different informational resources to be very important and they were more active information seekers, compared with ImBR women. ImBR women found their physicians advice to be more important in their decision making than DiepBR women. Actively seeking for information regarding BR was positively correlated with active coping, sensitivity to others and the decision for DIEP-flap BR.nnnCONCLUSIONSnWomen opting for DIEP-flap BR were more active and independent in their decision making regarding the type of BR. Women opting for implant BR seemed less well-informed and more dependent on their physician in their decision compared with women opting for DIEP-flap BR. To undergo a complex type of BR, active and independent information seeking may be required. However, clinical and logistic characteristics need to be considered, as some patients were limited in their reconstruction options.

“Living apart together”: moral frictions between two coexisting organ transplantation schemes

Cadaveric transplantation and living transplantation exist side by side. Both practices help to alleviate organ need. They provide us with two separate moral schemes. Is it rational to keep them apart? The cadaveric system is organised along strict, impartial lines, while the living system is inherently partial and local. The ethical justification for this partial scheme seems to be that it merely supplements the cadaveric scheme: partial transplants do not come at the expense of cadaveric impartiality, but in fact significantly reduce the waiting time for patients on the list for a cadaveric transplant. This seemingly peaceful coexistence is challenged by new initiatives, among them living donation list exchange, and also the LifeSharers initiative, leading to practices that undermine cadaveric impartiality. Should we bemoan this fact, or should we move on towards a new balance in the relationship between cadaveric and living transplantation practices, towards a new moral weighing of impartial and partial values? I argue, against the background of a rapid growth of living donations, that we have good, ethical reasons—not only utilitarian ones—for giving the value of partiality a more prominent place in our policies.

Nudge me, help my baby: on other-regarding nudges

There is an increasing interest in the possibility of using nudges to promote peoples health. Following the advances in developmental biology and epigenetics, it is clear that ones health is not always the result of ones own choices. In the period surrounding pregnancy, maternal choice behaviour has a significant influence on perinatal morbidity and mortality as well as the development of chronic diseases later in life. Ones health is thus a matter of ones own as well as ones maternal choices. Therefore, self-regarding and other-regarding nudges should be considered as viable strategies to promote health. In this article, we introduce the concept of other-regarding nudges. We use the harm principle and the principle of beneficence to justify these other-regarding nudges. We conclude by stressing the importance of a fair assessment of expectations towards the nudgee, when determining whether a nudge is aimed at preventing harm or promoting a good.