Psychological problems are infrequent after donation and most donors experience increased self-esteem, whilst donor and recipient relationships are enhanced. The majority of donors express no regrets after donation (11). However, it is essential to identify pre-existing or potential mental health issues that might arise for the prospective donor, to ensure that these are appropriately addressed. An opportunity to explore any concerns in confidence should be offered as an integral part of the assessment process, including aspects related to the donor assessment process, family relationships and decision-making. The purpose of such an assessment is to identify the level of support or intervention that may be required so that appropriate arrangements can be made, including referral to a mental health professional if necessary. A full psychological or psychiatric assessment should be sought if there is concern about the suitability of a donor on mental health grounds; for example, if there is evidence of previous or current mental illness, active substance abuse, dependence on prescribed medication, self- harming behaviour, or significantly dysfunctional family relationships, particularly between recipient and donor. Such an assessment is valuable in establishing when it is unsuitable to proceed to donation on these grounds (12).
Support may be provided by a variety of healthcare professionals who have the necessary knowledge and skills to deal with a range of psychological and social needs. Most transplant centres have designated personnel (usually a transplant co-coordinator or nurse specialist) who play a key role in organising the assessment and surgery for donor and/or recipient. Such individuals generally become closely acquainted with the patients and their families and may be best placed to provide the necessary support, even in the context of adverse events prior to or following transplantation. Other centres have dedicated social workers, counsellors, psychologists and psychiatrists, or access to such colleagues, to whom patients can be referred for specialist intervention and additional support. The development of peer support/patient befriending programmes, in which
39 patients who have experienced living donor transplantation offer support and guidance to donors and recipients who are considering this option, has also become an established and effective part of clinical practice in some centres, providing a complementary approach to that of healthcare professionals (13).
Current HTA policy requires all non-directed altruistic donors to undergo a mandatory mental health assessment (14). This is because the circumstances are unique, due to the lack of proximity with the recipient. Not all genetically and/or emotionally related donors and recipients will require referral to a mental health professional but a clear, stratified framework for psychological care must be in place to ensure that needs are accurately identified and appropriately met and that there is access to a range of specialist services for patients who may need to be referred. A „tiered approach‟ to delivering support and psychological services is an appropriate model in the context of living kidney donation (15).
There is some evidence to suggest that, by merely presenting the option of living donation, the potential donor is immediately placed under an unwarranted moral burden and may feel in a „no win‟ situation (16). While this may be true for some people and it may not be possible for the donor to avoid these pressures completely, a supportive environment which encourages discussion can relieve the strain and facilitate decision- making.
Sibling decision-making has been reported as one of the most complex areas (15). Motivational factors such as altruism, manipulation of familial relationships, coercion and covert pressure are reported (see Chapter 3). Donor advocacy is essential in these situations to ensure that donors feel supported to make the right decision for them (see section 4.4).
Psychological problems have been reported after donation, of which both donor and recipient should be made aware (17). These usually focus around the gift exchange elements of donation: recipients suffer psychological distress from feelings of indebtedness, which they can never repay; and donors exhibit proprietary interest in the health, work, and private life of the recipient that can damage relationships. Such issues should be raised prior to surgery to pre-empt difficulties that might arise at a later date. In terms of psychological care, the impact of living donor transplantation for donor and
40 recipient should be considered within the context of the wider family network to ensure effective support and intervention.
4.6.1 Death
Death is a rare complication of transplant surgery, but can occur (see Chapters 6 &11). Studies show that there is a need for immediate bereavement support to help with the feelings of guilt, loss, anger and depression expressed by both the survivor and members of the family. Bereavement support in these cases should be provided by qualified, independent counsellors and should continue in the community for as long as required.
4.6.2 Transplant Failure
Early graft failure will result in feelings of profound loss for many donors and recipients. Emotional support is essential at this time but studies show that with appropriate help the majority of donors and recipients recover from this disappointment without psychological morbidity (10). Support must be accessible to all patients and their families, up to and including referral to a mental health professional.
Living donor kidney transplantation is increasingly considered the treatment of choice for recipients with increased baseline comorbidity. An increased risk of post-operative co- morbidity, transplant failure and death is likely and the appropriate management of expectations is an essential part of the pre-transplant preparation for all parties concerned.