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period of the patient's strengths and weaknesses and their coping mechanisms. A patient may fail this test, such as a patient who relapses to alcohol or drugs or patients who become grossly noncompliant with medical care. Although these situations may make transplant doubtful, we need to determine what is going on and respond in a therapeutic way. For the relapsing alcoholic, it may be referral for rehabilitation with the possibility of being active on transplant list post rehabilitation. For patients who are noncompliant, a referral to another transplant center might be appropriate. However, for the vast majority of "transgressions" by patients we want to understand issues from the patient's perspective, maintain clear expectations and help identify and support patient positive coping mechanisms.

Table 15.1. outlines the general psychosocial evaluation format for all solid organ transplants. Several visits may be necessary before a thorough evaluation can be completed. The patient's energy level, mental status and the presence or lack of presence of family may play an important factor. In general, it is always preferable to have patients bring family members with them for psychosocial evaluations. Family members often provide information that the patient cannot and can collaborate important information such as recent substance use. Their presence at the meeting also provides an important opportunity to observe family dynamics. It is equally important in certain instances to interview patients and families separately to allow them to express any concerns or questions they may have. Family members may be reluctant to say anything that jeopardizes transplant candidacy. Potential donors may have ambivalence about donation or organ recipients may express a feeling of pressure to undergo a procedure they do not want. Even the timeliness of scheduling appointments can be instructive as to motivation or ability to follow through. Some patients and families are fairly sophisticated regarding medical issues. This apparent sophistication may belie underlying psychosocial difficulties in the family. On the other hand, some patients and families present so chaotically initially that it seems they will not make it through the procedure, but they do. Medical personal should be careful not to make unalterable judgments of people based on initial presentation, personnel bias or third party information. It is the practice of many transplant centers to

Table 15.1. Essentials of psychosocial evaluation for tranplant

— Clear introduction

— Review of medical history and patient's perspective of illness

— General medical history

— General psychiatric history

— Family history

— Drug and alcohol history

— Social history

— Current living situation and support

— Insurance and pertinent financial concerns

— Meet with family together or separately

— Assess patient motivation and sophistication

— Listen for patient concerns

— Urine toxicology as necessary

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