With a dwindling number of organs available from brain-dead people, the trend now in Canada is to recruit live donors. Psychiatrists are increasingly involved in evaluating whether a transplant is in the best interests of these donors and recipients.

"Psychiatrists are uniquely trained to assess the psychosocial and medical implications of an organ transplant," said Susan Abbey, M.D., director of psychosocial services for the multiorgan transplant program at Toronto General Hospital. She was one of the speakers at a session on living organ donors at the annual meeting of the Canadian Psychiatric Association last month in Victoria, British Columbia. Abbey and three psychiatrists, three social workers and two psychiatric nurse clinicians make up the psychosocial services team of the multi-organ transplant program at Toronto General.

When the social worker or nephrologist has a particular concern, he or she usually calls for a psychiatric evaluation of the donor, said Brian Hodges, M.D, a psychiatrist in Abbey’s program.

"They may suspect that the donor’s decision is coerced or the donor has unrealistic expectations. I often ask the donor where the idea of donating his or her organ came from. Parents will sometimes demand that a sibling donate an organ to save another family member’s life. Or a potential recipient will mention that he or she is not doing well on dialysis and that a lot of people are doing well on transplants," said Hodges.

Abbey noted that a son or daughter who has been "the black sheep of the family" sometimes volunteers to donate an organ in the hope of gaining parental approval. "We let them know that this may not happen."

Hodges said that the donor may have a difficult family situation involving unemployment or being a caregiver for an elderly patient or a young child. "We remind donors that they will be incapacitated for several weeks and ask them if now is the right time to donate. If they seem quite reluctant, we reassure them that the transplant can usually wait, especially if it is a kidney," said Hodges.

Hodges also discusses the risk of transplant failure with the donor. "I ask the individual how he or she will feel if the recipient’s system rejects the organ and to consider the impact of that on their relationship. Or how the donor will feel if the recipient dies from complications," he said.

Hodges also evaluates the donor for a history of psychiatric illness. If a person is taking medication, "I mention that the transplant team likes donors to be off psychotropic drugs during surgery, which may cause them to relapse. I also ask about their pain tolerance and whether past surgeries have been difficult. I might recommend haloperidol to control delirium, which is a common side effect of steroids and immunosuppressants used during surgery."

Saul Marks, M.D., another psychiatrist on the organ transplant team, said at the CPA meeting that he meets with the recipient to assess his or her decision. "Sometimes family members will suggest an organ transplant because they are tired of bringing the patient in for kidney dialysis three times a week. However, the potential recipient might rather die gracefully."

Marks said he also reviews the transplant risks with recipients, including the potential for death or rejecting the organ. "I have to explain that receiving a healthy organ doesn’t guarantee good health. I point out that the recipient may have some good days or hours and take multiple medications for a while."

Marks also explains that the hospital requires recipients to live within an hour and a half of the hospital while they are on the waiting list for an organ donation. "I let them know that I will be supportive preoperatively and during surgery by giving advice to the team regarding medications to control side effects of the immunosuppressants. I also explain that my role postoperatively includes evaluating them for depression," said Marks.

Abbey commented that organ donations by nonrelatives are becoming more common. "Sometimes, strangers are motivated by their religious beliefs to donate an organ solely for altruistic reasons. Although I have reservations about a few such cases, the team approved the transplants, which worked out well for the donor and recipient," said Abbey.—C.L.