CLINICAL
AND
RESEARCH
REPORTS
“couldn’t refuse.” It is interesting that, although the sample size is too small for accurate generalization, the donors whose recipients had died expressed more negative feelings and ambivalence about their donation.
We asked, Would you donate another kidney on a vital organ if you died?” All subjects were aware of the Gift of Life program, by which a person allows an organ to be taken if he or she dies suddenly, but only one carried a permission card. Six others answered “yes” but did not canny a permission card, and 3 donons said “no.” One noted, “No way. I paid my ticket. They did enough cutting on me.” The subjects were asked, as they had been in the original study, about their impressions of the decision making process. They found no fault at all. They felt that the physicians had been extremely considerate of them and suggested no changes in the process leading to their decision to donate. ‘ ‘
Discussion
In our original paper we pointed out that being asked to donate a kidney to a close relative who is in the tenminal stages of illness creates a crisis situation and a disequilibrium for the potential donor. We then postulated that the potential donor who decides to give a kidney discovers new sources of personal strength. The donor also reaps other rewards from his belief in the good he does by saving the recipient’s life, the positive relationship with his physicians, the positive emotional reinforcement from the recipient and family membens, and the considerable attention paid to him by friends, acquaintances, and news media. We further postulated that the combined impact of these forces was probably responsible for the postcnisis changes, including their more positive or beneficial self-image, reflecting a new equilibrium. Although most of the posi-
Effects BY
ofPayment
KENNETH
L.
DAVIS,
Mode
on
M.D.,
FLOYD
Clinic M.
Attendance ESTESS,
M.D.,
Psychotic patients who attend an aftencare treatment program are less likely to be readmitted to the hospital than those who drop out of such programs (1). The lower readmission rates may result from medication and/or sociotherapy (2). Given the relationship between rehospitalization and dropout rates, factors that Dr. Davis is Director, Comprehensive Care Clinic, Dr. Estess is Professor and Director, Psychiatry Clinics, and Dr. Gonda is Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, Calif. 94304. Ms. Simonton is Research Assistant, Veterans Administration Hospital, Palo
576
Alto,
Calif.
Am
,
where
Dr.
J Psychiatry
Davis
/34:5,
is also
May
Research
1977
Associate.
tive factors influencing subjects were substantially neduced on even absent after 9 years, the changes were still being reported; hence, they appear to be penmanent. Furthermore, the fact that all of our subjects used phrases very similar or identical to those they had used 9 years before might further indicate the stability of these changes.
On the other hand, forces acting in the opposite dinection were also discernible, particularly in those subjects who had experienced the actual loss, by death, of the close family member to whom they had donated. The crucial variable here appeared to be not the loss of the donated kidney but the loss ofthe family member. Undoubtedly we do not understand completely why people donate their organs to others: the reasons may be idiosyncratic. The ambivalence surrounding this issue was apparent only in those donors whose necipients had died. We are currently examining this aspect of donation in a larger donor group. It is clean that, at least among our group of subjects, the donation has had a considerable positive, long-lasting impact upon the donors’ lives. The idea that donors “lose a kidney but get nothing in return” is untenable. REFERENCES 1. 2. 3.
Fellner CH, Marshall JR: Twelve kidney donors. JAMA 206:2703-2707, 1968 Fellner CH, Marshall JR: Kidney donors-the myth of informed consent. Am J Psychiatry 126:1245-1251, 1970 Robertson JA: Organ donations by incompetents and the substi-
tutedjudgment 4. 5.
Fost Lewis
6.
Presented of Child Bernstein right
and SUSAN
doctrine.
NC: Children M: Kidney
Columbia
as renal donation
Law
Review
76:48-78,
donors (submitted for by a 7-year-old identical
at the 19th annual meeting of the American Psychiatry, New Orleans, La, Oct 1972 DM, Simmons RC: The adolescent kidney
to give.
Am
J Psychiatry
13 1 : 1338-1343,
1976
publication) twin child.
Academy donor:
the
1974
Rehospitalization C.
SIMONTON,
AND
THOMAS
A.
GONDA,
M.D.
contribute to patients dropping out of aftencane clinics deserve scrutiny. Previous reports indicating connelations between dropout rates and such variables as thenapists’ experience and age, race, and socioeconomic class of patients have been questioned in recent investigations (3-5). This study attempted to isolate factors that might discriminate between patients who are likely to remain in treatment and those who have a high risk of dropping out. The
Clinic
The
Population
Comprehensive
Cane
Clinic
ofthe
Stanford
Uni-
CLINICAL
versity Department of Psychiatry and Behavioral Sciences serves psychotic on borderline patients who have had one on more psychiatric hospitalizations. Patients meet weekly and attend 1#{189} hours of group therapy, 20 minutes of individual therapy, on both. Over 80% of the clinic population receive both mdividual and group therapy, as well as pharmacotherapy. A high level of attendance is encouraged, but patients are informed that they may attend infrequently if they desire. Psychiatric services are supplied by psychiatric residents, medical students, and social workers. A total of I 15 patients attended the clinic at least once between July 1974 and July 1976. Characteristics of the clinic population are presented in table 1 Virtually all patients were taking a psychopharmacologic medication at the time of the initial clinic visit. Patients were also classified according to payment mode, defined as follows: “private” means that the patient pays the full fee, although the fee is always based on ability to pay. The fee for these patients averages slightly more than $15 pen visit. “Assistance” means that some part ofthe fee is paid by a third party, private or public. In oven 90% of assistance cases, the aid comes from the county, state, or federal govern.
ment.
Clinic patients were designated as brief, irregular, on regular attenders according to the following criteria: brief, fewer than four meetings; irregular, less than 75% offour or more meetings; regular, 75% or more of four or more meetings. Dropouts were defined as all patients who had no contact with the clinic for at least eight consecutive meetings. Results
Almost half (49.6%) of the entire population dropped out of treatment at some point during the 24 months of study; 13% of all patients dropped out after their first meeting and 46% ofall dropouts occurred before the fourth meeting. Chi-squane tests were penformed to determine how the variables of sex, age, diagnosis, and payment mode were related to continuing treatment or dropping out of therapy. Private patients are more likely to drop out (25 of57, or 43.9%) than patients receiving assistance (15 of 58, or 25.9%) (x24.lO dfl, p
AND
RESEARCH
REPORTS
“couldn’t refuse.” It is interesting that, although the sample size is too small for accurate generalization, the donors whose recipients had died expressed more negative feelings and ambivalence about their donation.
We asked, Would you donate another kidney on a vital organ if you died?” All subjects were aware of the Gift of Life program, by which a person allows an organ to be taken if he or she dies suddenly, but only one carried a permission card. Six others answered “yes” but did not canny a permission card, and 3 donons said “no.” One noted, “No way. I paid my ticket. They did enough cutting on me.” The subjects were asked, as they had been in the original study, about their impressions of the decision making process. They found no fault at all. They felt that the physicians had been extremely considerate of them and suggested no changes in the process leading to their decision to donate. ‘ ‘
Discussion
In our original paper we pointed out that being asked to donate a kidney to a close relative who is in the tenminal stages of illness creates a crisis situation and a disequilibrium for the potential donor. We then postulated that the potential donor who decides to give a kidney discovers new sources of personal strength. The donor also reaps other rewards from his belief in the good he does by saving the recipient’s life, the positive relationship with his physicians, the positive emotional reinforcement from the recipient and family membens, and the considerable attention paid to him by friends, acquaintances, and news media. We further postulated that the combined impact of these forces was probably responsible for the postcnisis changes, including their more positive or beneficial self-image, reflecting a new equilibrium. Although most of the posi-
Effects BY
ofPayment
KENNETH
L.
DAVIS,
Mode
on
M.D.,
FLOYD
Clinic M.
Attendance ESTESS,
M.D.,
Psychotic patients who attend an aftencare treatment program are less likely to be readmitted to the hospital than those who drop out of such programs (1). The lower readmission rates may result from medication and/or sociotherapy (2). Given the relationship between rehospitalization and dropout rates, factors that Dr. Davis is Director, Comprehensive Care Clinic, Dr. Estess is Professor and Director, Psychiatry Clinics, and Dr. Gonda is Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, Calif. 94304. Ms. Simonton is Research Assistant, Veterans Administration Hospital, Palo
576
Alto,
Calif.
Am
,
where
Dr.
J Psychiatry
Davis
/34:5,
is also
May
Research
1977
Associate.
tive factors influencing subjects were substantially neduced on even absent after 9 years, the changes were still being reported; hence, they appear to be penmanent. Furthermore, the fact that all of our subjects used phrases very similar or identical to those they had used 9 years before might further indicate the stability of these changes.
On the other hand, forces acting in the opposite dinection were also discernible, particularly in those subjects who had experienced the actual loss, by death, of the close family member to whom they had donated. The crucial variable here appeared to be not the loss of the donated kidney but the loss ofthe family member. Undoubtedly we do not understand completely why people donate their organs to others: the reasons may be idiosyncratic. The ambivalence surrounding this issue was apparent only in those donors whose necipients had died. We are currently examining this aspect of donation in a larger donor group. It is clean that, at least among our group of subjects, the donation has had a considerable positive, long-lasting impact upon the donors’ lives. The idea that donors “lose a kidney but get nothing in return” is untenable. REFERENCES 1. 2. 3.
Fellner CH, Marshall JR: Twelve kidney donors. JAMA 206:2703-2707, 1968 Fellner CH, Marshall JR: Kidney donors-the myth of informed consent. Am J Psychiatry 126:1245-1251, 1970 Robertson JA: Organ donations by incompetents and the substi-
tutedjudgment 4. 5.
Fost Lewis
6.
Presented of Child Bernstein right
and SUSAN
doctrine.
NC: Children M: Kidney
Columbia
as renal donation
Law
Review
76:48-78,
donors (submitted for by a 7-year-old identical
at the 19th annual meeting of the American Psychiatry, New Orleans, La, Oct 1972 DM, Simmons RC: The adolescent kidney
to give.
Am
J Psychiatry
13 1 : 1338-1343,
1976
publication) twin child.
Academy donor:
the
1974
Rehospitalization C.
SIMONTON,
AND
THOMAS
A.
GONDA,
M.D.
contribute to patients dropping out of aftencane clinics deserve scrutiny. Previous reports indicating connelations between dropout rates and such variables as thenapists’ experience and age, race, and socioeconomic class of patients have been questioned in recent investigations (3-5). This study attempted to isolate factors that might discriminate between patients who are likely to remain in treatment and those who have a high risk of dropping out. The
Clinic
The
Population
Comprehensive
Cane
Clinic
ofthe
Stanford
Uni-
CLINICAL
versity Department of Psychiatry and Behavioral Sciences serves psychotic on borderline patients who have had one on more psychiatric hospitalizations. Patients meet weekly and attend 1#{189} hours of group therapy, 20 minutes of individual therapy, on both. Over 80% of the clinic population receive both mdividual and group therapy, as well as pharmacotherapy. A high level of attendance is encouraged, but patients are informed that they may attend infrequently if they desire. Psychiatric services are supplied by psychiatric residents, medical students, and social workers. A total of I 15 patients attended the clinic at least once between July 1974 and July 1976. Characteristics of the clinic population are presented in table 1 Virtually all patients were taking a psychopharmacologic medication at the time of the initial clinic visit. Patients were also classified according to payment mode, defined as follows: “private” means that the patient pays the full fee, although the fee is always based on ability to pay. The fee for these patients averages slightly more than $15 pen visit. “Assistance” means that some part ofthe fee is paid by a third party, private or public. In oven 90% of assistance cases, the aid comes from the county, state, or federal govern.
ment.
Clinic patients were designated as brief, irregular, on regular attenders according to the following criteria: brief, fewer than four meetings; irregular, less than 75% offour or more meetings; regular, 75% or more of four or more meetings. Dropouts were defined as all patients who had no contact with the clinic for at least eight consecutive meetings. Results
Almost half (49.6%) of the entire population dropped out of treatment at some point during the 24 months of study; 13% of all patients dropped out after their first meeting and 46% ofall dropouts occurred before the fourth meeting. Chi-squane tests were penformed to determine how the variables of sex, age, diagnosis, and payment mode were related to continuing treatment or dropping out of therapy. Private patients are more likely to drop out (25 of57, or 43.9%) than patients receiving assistance (15 of 58, or 25.9%) (x24.lO dfl, p
