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LAST MONTH’S CLINICAL CHALLENGE

 

When a related family member donor is seen at your institution for assessment and counseling prior to allogeneic transplantation, who evaluates and counsels the donor?  (If a nurse or physician’s assistant does the primary evaluation and counseling, please indicate the physician overseeing the evaluation.)


YOUR RESPONSES

 
  • The same transplant doctor who is managing the transplant recipient – 50% 

  • A different transplant doctor than the one managing the transplant recipient – 44%

  • A physician not associated with the transplant practice – 3%
  • A physician from outside the transplant institution – 3%
       

 

Commentary Provided by Stella Davies, MD
Cincinnati Children's Hospital Medical Center

 

Most respondents reported that physicians within their own teams evaluate stem cell donors prior to transplantation.  Programs are almost equally divided between those in which the patient’s physician also evaluates the donor, and those in which a different physician evaluates the donor.  In our own pediatric practice, donors are commonly seen by the recipient’s physician.

 

Historically, there has been considerable concern about minimizing risks to donors, including physical risks and the possibility of coercion.  Evaluation of the adult donor by independent physicians was advocated in the 1970s to minimize these risks.  For minors, court review of the appropriateness of consent was sometimes required1.  More than 30 years of experience of stem cell collection has reduced concerns about physical risks, since the risk of morbidity is quantifiable and small, and risk of death is extremely low. 

 

Concerns about risks of coercion remain.  For related donors, the most powerful coercive force is likely family expectations; an adult declining to donate to an ill sibling is placed in a difficult position.  Our survey suggests that most centers believe that team physicians, even those caring for the recipient, can supply sufficient objectivity to perform an adequate physical and psychosocial assessment and obtain informed consent.

 

The issue of donor risk and of informed consent is more troubling when the donor is not legally competent to give consent.  There is an inherent conflict of interest in a parent giving consent for the collection of marrow from a healthy child for donation to a sick sibling, and in the early days of transplantation this was frequently addressed by seeking a court order.  The courts almost uniformly granted permission for collection of bone marrow, on the basis that there was significant psychological benefit to the donor if a sick sibling’s life could be saved2.  Court review is rarely required now.  However, clear documentation and quantification of psychological benefit to minor donors is lacking and may be dependent on a successful transplant, an outcome that is unknown when the decision to donate is made. 

 

Very few programs use a physician not associated with the transplant program, although this is probably the best way to ensure the donor receives an unbiased evaluation and consent session.  Such an approach is used by the National Marrow Donor Program, which has facilitated more than 25,000 volunteer stem cell donations to anonymous recipients.  It would be unthinkable to have a patient’s physician also evaluate a potential unrelated donor.  While logistics probably have the greatest influence over who evaluates and consents related donors, it is important to acknowledge the potential conflicts involved and to have systems in place to ensure the welfare of donors. 

 

 

References

 

1.       Nolan JG. Anatomical transplants between family members – the problems facing court and counsel.  The Family Law Reporter; 1975; 1; 4035.

2.       Robbennolt JK, Weisz V, Lawson CM. Advancing the rights of children and adolescents to be altruistic: bone marrow donation by minors. Journal of Law and Health, 1994-95. 213-245.