Psychological Issues in Bone Marrow Transplantation

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Psychological

Issues

in Bone

Marrow

Transplantation

G. Gail Gardner, Ph.D., Charles S. August, M.D., and John Gfthens, M.D.

From the Departinents of Pediatrics and Psychiatry, University of Colorado School of Medicine, Denver

ABSTRACT. We studied the psychological and emotional problems experienced by seven children and their families who underwent bone marrow transplantation at the Univer-sity of Colorado Medical Center from 1973 to 1975. These problems included (1) anxiety and depression relating to isolation, fear of death, and painful procedures; (2) an overdependence associated with a feeling of helplessness; (3) anger directed toward both the staff and the parents; (4) a reduced tolerance for medical procedures; and (5) periodic refusal to cooperate. Initially we had been concerned that patients might become agitated, psychotic, or even suicidal. These did not occur. Severe anxiety over bodily changes was not a problem. We did not encounter prolonged refusal to cooperate, refusal to remain in isolation, or drug addiction.

Important aspects in management included an honest, straightforward, and direct discussion of all aspects of transplantation, including the potential complications and the risks of death from the underlying disease or from complications of transplantation. A firm but understanding approach to the patients appeared to be the most effective method to develop their continuing cooperation. The oppor-tunity for patients to express verbally their fears of procedures and of death was essential. The donors needed help in working through their feelings of guilt if a transplant was not successful. The parents needed continuing psycho-logical support for the many personal, social, and psycholog-ical difficulties which they had to face. Pediatrics 60:625-631, 1977, BONE MARROW TRANSPLANTATION, PSYCHOLOGICAL

PROBLEMS, ANXIETY, FEAR OF DEATH.

bone marrow transplantation at the University of

Colorado Medical Center had suggested that

severe psychological stress was associated with

this procedure. Therefore, in 1973 a psychologist

joined the pediatric bone marrow transplant

team, not only for diagnostic purposes, but also

for day-to-day support of the patients and their

families. This report describes some of the

psychological issues that have arisen in the last

three years.

PATIENTS AND METHODS

This study includes seven children who have

undergone bone marrow transplantation at our

center since 1973. The patients ranged in age

from 4 to 15 years, while the sibling donors

ranged in age from 7 to 19 years. The Table lists

them in detail with the diagnoses, lengths of

isolation and hospitalization, and outcomes. All of

the patients suffered from primary diseases that

were expected to cause death within one to six

months. The two leukemia patients (acute

lymphoblastic leukemia) who were in remission

had suffered previous relapses while receiving

multiple chemotherapy. Of the seven patients,

one survives. Patient 2 is healthy and lives a

normal life.

It is well established that organ transplantation

involves complex psychological problems. ‘

Many renal transplant programs identify and/or

treat psychological problems of the patient,

donor, family, and staff by working with a mental

health specialist who is either a consultant or an

active participant on the transplant team.813

In contrast to the abundant literature on

psychological aspects of renal transplantation,

similar issues in bone marrow transplantation

have not been described. Our early experience in

Received June 18; revision accepted for publication September 14, 1976.

Supported by U.S. Public Health Service grant RR-69 from the General Clinical Research Centers Program of the

Division of Research Resources.

Dr. August is now with The Children’s Hospital of Philadel-phia.

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BONE MAiuow TRANSPLANTATION

626 PSYCHOLOGICAL ISSUES IN TRANSPLANTATION

Pa

,--Age/Sex tients

J

-Diagnosis

Sibling Donors’ Age/Sex

Tr Before anspiant

During & After Transplant

Posttransplant Survival

Period (Days)

,-Duration of Illness

Number of Relapses

r-

-Days in Days in Isolation Hospital

13/M Congenital

hypoplastic anemia

15/F 13 yr No remission 40 70 55

13/F Aplastic anemia 17/M 36 mo 1 35 40 > 730

12/F ALL#{176}in remission 19/M 36 mo 4 38 41 35

15/M ALL in relapse 16/F 19 mo 2 72 75 110

7/M ALL in relapse 10/F 11 mo 2 44 57 206

4/M ALL in remission 8/M 15 mo 1 37 43 137

10/Mt ALL in relapse 7/F 32 mo 3 1, 45; 1, 58;

2,54 2,89

379

#{176}ALL= acute lymphoblastic leukemia.

tUnderwent second transplantation after first transplant relapsed.

Our procedure for bone marrow

transplanta-tion involved an initial evaluation during which

time informed consent was obtained from the

parents and whenever possible from the patient

and donors themselves. A series of conferences

was held in which one of the senior staff

attempted to explain the rationale for

under-taking marrow transplantation, the elements of

transplantation biology, and the potential

bene-fits and risks of the procedure. The conferences

were illustrated with color slides showing the

course of patient 4.

Written consent was obtained from the

parents. The consent form described every

possible complication and all side effects in detail.

The chances of remission or possible cure were

estimated with a figure of 10% for leukemia and

50% for aplastic anemia. The complications and

risks as well as the possible benefits were

discussed in detail with all patients 10 years of age

or older (as well as with the parents) and the

child’s verbal consent was required. The second

transplant in patient 7 was based solely on the

10-year-old child’s request (with parental consent). A

modified and less-detailed discussion was carried

out with the 4- and 7-year-old patients, and the

responsibility for consent was necessarily more

dependent upon the decision of the parents. The

staff attempted to present the facts objectively

and did not attempt to encourage patients or

families to participate. If a child had been

reluc-tant to undergo transplantation or had been

considered to be psychologically unsuitable, the

staff would have refused the procedure at our

center. The patients had every opportunity to

withdraw from the protocol up until the

adminis-tration of the x-ray or the cyclophosphamide

therapy. All patients and families to whom

trans-plantation was proposed elected to have the

procedure, and two additional patients from our

services were transplanted at other centers

because our facilities were in use.

Several parents said they felt they could not

refuse another chance, however small, to have

their child survive when they knew certain death

was the alternative. Yet other parents, for whose

child there was no possible donor, said they were

glad not to have to make the decision of whether

or not to put their child through the ordeal of

transplantation. Thus, for the transplant group,

the hope of survival was a most powerful force,

the parents asking only that suffering not be

prolonged if the situation later became

hope-less.

The children were then placed in total

protec-tive isolation with sterilization of everything that

entered their room (including food) and

adminis-tration of topical and oral antibiotics to suppress

the growth of all microbial flora.’4 The period of

isolation generally lasted five to six weeks. Three

patients had elective central venous

hyperalimen-tation. Cyclophosphamide at near lethal doses

(200 mg/kg) was given to patients with aplastic

anemia. Total body irradiation at lethal doses

(1,000 rads) and cyclophosphamide (120 mg/kg)

combined at times with other chemotherapeutic

agents were given to children with leukemia.’5

During and after this therapy the patients

experi-enced periods of profound pancytopenia.

Trans-fusions of RBCs and platelets were required

regularly, and the danger of bacterial or fungal

infections was great. In addition, the patients

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temporarily developed severe mucositis of their

mouth and gastrointestinal tract, developed

diar-rhea, lost all their hair, and experienced cycles of

reddening and desquamation of their skin. Some

children lost substantial amounts of weight.

The donors underwent general anesthesia while

the marrow was removed by needle aspiration

from both iliac crests. The marrow was then

filtered to create a single cell suspension and

administered to the recipients intravenously or

intraperitoneally.

Psychological evaluation of and support for

patients began prior to transplantation and

included observation and interview of all patients

and formal testing for some. The goals were to

establish (1) the level of intelligence, (2) the

degrees and kinds of emotional problems, and (3)

the characteristic coping mechanisms. By this

means we sought to anticipate emotional

difficul-ties and initiate psychological support strategies.

We also tried to determine how these children

perceived their illnesses and what their attitudes

were about the transplantation procedure. Five

patients took tests selected from the following:

the appropriate Wechsler intelligence scale,

Rorschach test, thematic apperception test,

Minnesota multiphasic personality inventory,

figure drawings, and sentence completions.

RESULTS Patients

Though the interviews (verbal and play) clearly

yielded the most clear and reliable information,

the tests-especially the IQ test, thematic

apper-ception test, and sentence completions-provided

clarification and validation of hypotheses based

on interviews that were semistructured and

designed to cover all major psychological issues as

mentioned above. At their initial psychological

assessment, all patients were found to be

intelli-gent and none had severe emotional problems. All

understood that they had life-threatening diseases

and that they might die in spite of or because of

their transplantation. Thus, one boy commented,

“When I grow up I want to be an astronaut . . . if

I do grow up.” Even the youngest patient, 4 years

old, described his leukemia as “a bad sickness and

you could die from it.” He added that death

meant “you just lie there and never wake up.”

The results of the initial psychological evaluation

revealed the patients’ primary emotional

prob-lems to be (1) anxiety related to illness and death,

(2) feeling of being burdens to their families, (3)

low seff-esteem, and (4) feeling of helplessness and

vulnerability.

The major emotional problems encountered

during transplantation in these patients were

anxiety, depression, overdependence and

regres-sion, anger with reduced tolerance for

pro-cedures, and periodic refusal to cooperate.

All patients had high levels of anxiety due

primarily to fear of death and fear of procedures.

Fear of death was communicated in different

ways including humorous signs with captions such

as “I’d sure hate it if I weren’t around,” or “This

place is condemned.” The children expressed

more concern when complications arose. Before

the transplant, one child frequently discussed her

fear of death. Another child intellectualized his

fears until he developed fever and respiratory

problems at which time he was able to express his

fear of death and asked for all possible efforts to

save him. Like many gravely ill children, he

requested that he not be left alone. Three hours

later he suffered a cardiac arrest from which he

did not recover. A third child expressed his fears

nonverbally by reaching for his religious medal

whenever he was told of a setback. After multiple

complications, he wept and discussed his fears of

blindness and death with the psychologist.

Anxiety regarding procedures and strict

isola-tion was a universal reaction. It reduced the

tolerance for further procedures and for

remain-ing in isolation. Although patients sometimes

wished the transplant had not been done and

wanted to die, hope usually predominated.

All patients except the 4-year-old child

experi-enced short periods of significant depression.

They were invariably precipitated and

aggra-vated by the development of complications, by

the knowledge that a procedure such as a bone

marrow biopsy or an arterial puncture was to be

performed, or by the very real threat of death.

The children’s depression was generally

charac-terized by an attempt to withdraw from the

nurses and physicians or by uncharacteristic

qui-etude and inactivity. In more severe periods of

depression, children refused to talk or hid under

the sheets.

Paradoxically, the patients were sometimes

depressed when the staff felt optimistic. The

different reactions seemed due to the fact that the

staff were responding to clinical and laboratory

data, such as vital signs, platelet or leukocyte

counts, while the patients were responding to

their pain from procedures, nausea, lassitude, or a

lack of appetite.

Surviving patients were depressed even after

discharge, sometimes for several months. This was

related to anxiety over continuing procedures and

to restrictions on activity. One patient’s diary

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628 PSYCHOLOGICAL ISSUES IN TRANSPLANTATION

from being home all the time and not having any

hair . . . I want to be able to walk into stores with

all the rest of the people . . . why can’t I have a

normal life like everybody in the family? God

help me . . . sometimes I wish I had never had it

done . . . God, why do things happen to me?

Why?”

Patients’ feelings of helplessness and

vulnera-bility prior to transplantation became heightened

during the transplant itself, with total isolation

and 24-hour special-duty nursing care, creating

an environment of marked dependence upon

others. All persons entering the room wore caps,

masks, gowns, gloves, and boots. The sterile food,

frequent bathing, and culturing added to the

seemingly endless series of indignities. At times,

regression alternated with pseudomaturity. The

children all understood the need for strict

routines and hypervigilance, which also served as

defenses against feelings of vulnerability. One

child said his family treated him “like an

egg . . . very carefully; they’re afraid I’m going to

break if I touch anything.” Patients lost their

desire and willingness to eat and drink even after

the gastrointestinal tract had healed, probably in

part because of their dependence on the

intrave-nous hyperalimentation that was carried out for

approximately three weeks, and, in part, as an

expression of control, albeit passive and negative.

All patients became increasingly dependent upon

their parents and behaved in ways characteristic

of children considerably younger than their

chronological ages.

Having to submit passively to so many routines

and procedures, the patients struggled to gain

some sense of being the masters of their lives. One

boy became angry and belligerent at the nurses,

maintaining this behavior for several weeks.

Another patient frequently blamed his parents for

his suffering. Thus, the children’s ways of coping

with stress were sometimes troublesome. Parents

tended to take these and other rebellious

behav-iors in stride, having been told in advance that the

children might act this way.

All patients accepted the frequent procedures

surprisingly well, but as the weeks passed, their

tolerance clearly decreased. Patients who at first

had required only local anesthesia for bone

marrow aspirates later insisted on heavy sedation.

Although no patient truly refused necessary

treat-ment or study, delaying tactics were frequent.

Patients at all age levels manifested their

reduced tolerance for procedures by developing

pseudostoical attitudes. That is, they denied

symptoms, especially to the medical staff whom

they knew might immediately initiate studies

involving further pain and suffering. Fortunately,

they usually gave themselves away by changes in

behavior, such as increased lethargy, or by telling

their problems to their parents and nonmedical

staff who then reported to medical personnel.

Some patients intermittently refused to

cooper-ate, partly in response to feeling so sick and partly

as another attempt to achieve a sense of mastery

in the face of helplessness. This was a particular

problem in regard to eating. Although no patient

absolutely refused to take oral medications, their

administration took considerable effort from the

nurse, parents, and often the psychologist. One

child hid his pills in very imaginative ways,

including beneath the tape that held down his

intravenous needle.

No child suffered prolonged psychological

deterioration. There were no episodes of

psycho-sis or suicidal behavior. Though patients generally

enjoyed the feeling of being “spaced out” on

drugs, no one became addicted. Although all

patients underwent physical changes such as hair

loss, body image was not as severe a problem as

we expected. For example, several parents

brought in wigs but none of the children wore

them. Patients were encouraged to transform

passivity into activity by brushing out loose hair

and even saving it if they wished. We do not want

to imply that the children had no concerns about

body image at this stage; rather, the point is that

they were so concerned with pain and survival

that issues of modesty and appearance necessarily

took on a more minor role.

Bone Marrow Donors

Among our sibling donors, the degree of

psychopathology ranged from very mild to

severe, with one donor being a borderline

schizo-phrenic. Although we initially focused our

psychological support on the patients, we soon

learned that the donors too should have

psycho-logical evaluation prior to the transplant and that

a therapist should be available to them from the

beginning.

The donors felt a tremendous responsibility for

the outcome of the transplant and experienced

inappropriate feelings of guilt when

graft-versus-host reactions or other complications arose. One

donor thought her occasional drinking caused

problems for her sibling, while another thought

that she might have passed on infection and stated

that she too should have been isolated before the

transplant. Still another donor tried to help her

brother by secretly fasting.

(5)

Though donors denied continued guilt feelings

after counseling, it is not clear how many really

resolved this problem and how many attempted

to appease the physicians by telling them what

they wanted to hear. More than a year after one

patient’s death, his donor admitted that she still

felt very guilty.

Parents

The parents also experienced guilt and

misgiv-ings. These usually reached a maximum during

the pretransplant immunosuppression with lethal

doses of total body x-ray or chemotherapy. The

parents who witnessed their child’s total body

irradiation saw this process as an execution. One

parent, whose child died, had a recurring dream

of the boy sitting in the radiation therapy room

and pitifully asking for help.

Though a few parents coped with the stress of

the transplant by avoiding their children, most

spent a tremendous amount of time in the

isola-tion room with the patients. This often created

disruption of the family at home. Other children

were frequently sent off with friends or relatives

and certainly received much less parental

atten-tion. One mother whose child later underwent a

second transplantation indicated that she just

hoped it would end-whatever the outcome-so

that the family might be united again.

Parents also experienced increased anxiety

when their child was discharged from the

hospi-tal. Removing a transplant patient from the

atmosphere of isolation with 24-hour nursing care

directly to the home intensified parental

inse-curity and fear even though the transition was

permissible from the medical standpoint once the

graft was well functioning.

MANAGEMENT OF PSYCHOLOGICAL PROBLEMS

Patients

Since we believed that we could obtain the

greatest cooperation from the patients in the

climate of maximum honesty, we explained the

transplant procedure in great detail to the

patients, donors, and parents. No patient seemed

harmed by having such information. In fact, they

demonstrated a need for cognitive mastery by

asking questions frequently and by becoming less

anxious when their questions were answered.

Generally the children did not talk openly

about fear of death with their parents or medical

staff. They knew their parents had already

endured tremendous emotional and financial

strain and they appeared not to want to increase

that burden. The reasons for their not talking to

the medical staff are less clear. Generally there

was little opportunity since medical staff was

usually busy doing procedures. It is possible that

some staff conveyed their own reluctance to talk

openly about death. It was our feeling that all

patients should have at least one person with

whom they might safely talk about anything.

With older children, the therapist elicited

discussion of death anxiety by simple questions

such as “Why do you need a transplant?” or

“What do you know about leukemia?” With

younger children, adjunctive play interviews with

puppets offered opportunities to express fears

while at the same time maintaining defenses.

Thus, the 4-year-old patient repeatedly used

puppets, insisting that he was the physician and

that the therapist was a child with leukemia who

might die.

We attempted to answer the children’s

ques-tions about other patients honestly, especially

about those who died. The importance of this

approach was soon evident when we found some

children asking the same questions of several

people as if to confirm the answer. We found that

the patients were quite concerned about each

other and at times the sense of relationship and

responsibility seemed inappropriate. When one

patient died, a survivor wept, saying she knew

that he had sometimes disobeyed restrictions and

that she felt she should have made him behave.

She said, “He was like my brother.” Though she

wept, at the same time she thanked us for our

honesty. We concluded that the gain in trust

outweighed the burden of knowledge.

In dealing with the patients’ depression, the

staff initially tried to counteract it by reassuring

the patients with favorable laboratory data and

by being optimistic. Later it seemed more

effec-tive also to acknowledge the patients’ feelings and

to empathize with them about their physical and

emotional experiences. This kind of sharing gave

the patient a sense of being understood and

allowed him a face-saving device or excuse for

what he knew was “bad” behavior; this then

made it possible for him to acknowledge his

behavior and shift to more adaptive ways of

coping. Similarly, shared understanding was more

effective than “lectures” or other forms of

doer-cion when dealing with patients’ anger at staff.

Anxiety regarding procedures could be

de-creased by the use of mild tranquilizers and even

heavy sedation for painful procedures such as

bone marrow biopsy. Occasional refusal to

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630 PSYCHOLOGICAL ISSU ES I N TRANSPLANTATION

a staff attitude of firmness and understanding.

Based on psychological evaluations and on

mdi-vidual observations, we tried to draw on the

children’s emotional strengths and to guide them

toward more adaptive coping mechanisms.

Donors

Simple explanation did little to alleviate the

irrational guilt found in many donors. It seemed

more helpful to provide an atmosphere of

continued interest and acceptance. In this

supportive climate the donors sometimes found it

possible to develop an appropriate sense of pride

associated with their contribution. One donor,

whose brother did not survive transplantation,

commented almost a year later that she was sad

that the scars were fading from the marrow

donation sites. She had felt fulfillment to notice

the scars or to have others see them.

Parents

All parents received continuing psychological

support. Since they sometimes associated seeing a

psychologist with “being crazy,” regularly

sched-uled appointments were deliberately not

sug-gested after the initial interview in which the

psychologist took care to focus on the child.

As the stress of the transplant increased,

parents more frequently initiated contact. At such

times they talked not only about the patient but

also about personal problems. When discussing

long-standing family problems, the therapist

made no attempt to resolve underlying conflicts

but focused instead on managing the acute

aspects of the situation. Thus, if parents quarreled

over some detail such as not sharing information

about the patient, the psychologist focused only

on the issues and avoided obvious undercurrents

of communication problems between the

par-ents.

Parents also formed bonds with each other,

especially families whose children had died. The

grieving parents hoped that the meaning of their

child’s life might be enhanced if the physicians

learned something from their child that might

help another person. Some presented gifts to

other transplant patients. One father who worked

for an escort service requested and was given

permission to ride motorcycle escort at the

funeral of another transplant patient whom he

had never met. One family dreaded the first

Christmas after their son’s death the previous

spring but found comfort and meaning in sharing

that Christmas Day with the family of another

patient who had died only a few hours earlier on

Christmas Eve. Somehow this extended “kinship”

reduced the sense of isolation and loss. The staff

now encourage families to exchange ideas and

experiences.

DISCUSSION

Although there appear to be a few differences

in the psychological problems encountered in

bone marrow as compared with renal

transplanta-tion, the many similarities suggest that there may

be psychological problems common to all

trans-plant procedures. Prominent issues discussed in

the renal transplant literature which were also

observed in our group of bone marrow transplant

patients and their families are (1) fear of death

alternating with uncertainty about whether the

quality of life during and after transplantation

makes the procedure worthwhile’#{176}; (2) situational

anxiety and depression in the patients, leading to

temporary withdrawal and/or demanding

behav-ior with increased dependency’2; (3) patient guilt

related to being financial and emotional burdens

to their families; (4) the patients’ concerns for

each other”; (5) the importance of honest

communication with the staff5; (6) the value of

parents communicating with each other’2; (7)

jealousy manifested by sibling donors who feel

neglected by parents who focus much time and

attention on the patients8; and (8) lack of

perma-nent and severe psychological impairment in

patients or donors as a result of

transplanta-tion.6

From a psychological standpoint, the major

difference in renal and bone marrow

transplanta-tion has to do with the attitudes of the donors.

Compared with reports of kidney donors, marrow

donors appear to be more positive in their

atti-tudes about participating in the transplant

proce-dure. While our donors’ reactions consisted

mainly of anxiety appropriate for .any simple

surgical procedure, kidney donors were reported

as mourning their lost kidney9 and being

concerned about whether the patient would

appreciate the sacrifice and take proper care of

the donated organ.3

These differences may be related to the fact

that the kidney is conceptualized as a discrete

organ which, once removed, does not regenerate.

Thus, the donor is aware not only of the

tempo-rary discomfort and disruption caused by

hospi-talization but also of the permanent sacrifice that

increases his own risk of permanent disability or

death, should the remaining kidney cease to

function. By contrast, our bone marrow donors

equate bone marrow with blood, saying they have

(7)

plenty of both and can easily give some away, confident that it will soon regenerate.

The lesser concern of the bone marrow donor

for himself may partially explain another

differ-ence, namely, the direction of guilt between

recipient and donor. In kidney transplants, the

recipient has been described as feeling initially

guilty about jeopardizing the life of the donor,

while the donor focuses on anticipating personal

gain such as military discharge or praise from the

family.4 In our bone marrow transplants, it was

the donors who usually experienced significant

guilt while the recipients either showed no guilt

or expressed only mild concern that the donors

had to be briefly hospitalized. Putting it another

way, our donors did not seem to experience the

degree of personal sacrifice that might allow a

sense of absolution and freedom from further

responsibility.

Though actuarial statistics on persons with

nephrectomy indicate very little increase in

mortality risk,’6 the kidney donor’s feeling of

great sacrifice is nonetheless real and apparently

serves a useful purpose. The irrational guilt of the

bone marrow donor, on the other hand, is

poten-tially harmful and deserves particular attention,

especially since a single sibling is often the only

possible histocompatible donor. He therefore

probably feels an added pressure to participate in

the transplant procedure and is less likely to be

rejected on psychological grounds than potential

donors in other transplant procedures where

cadavers or unrelated living persons may be

reasonably sought as donors.

REFERENCES

1. Hall JH, Swenson DD: Psychological and social aspects of human tissue transplantation: An annotated bibliography, in Hall JH, Swenson DD (eds): National Clearinghouse for Mental Health Informa-tion. Chevy Chase, Md, US Dept of Health, Educa-tion, and Welfare, 1968.

2. Bernstein DM: After transplantation-the child’s emo-tional reactions. Am J Psychiatry 127: 1 189, 1971.

3. Feliner CH, Marshall JR: Twelve kidney donors. JAMA 206:2703, 1968.

4. Short MJ, Harris NL: Psychiatric observations of renal homotransplantation. South Med J 62: 1479, 1969. 5. Sonnenberg SM, Kaplan NL: Treatment of depression

following surgical removal of a rejected renal

homotransplant. Psychosomatics 10: 181, 1969. 6. Fine RN, Edelbrock HH, Brennan LP, et al: Cadaveric

renal transplantation in children. Lancet 1:1087, 1971.

7. Korsch BM, Fine RN, Grushkin CM, Negrete VF: Experiences with children and their families during extended hemodialysis and kidney transplantation. Pediatr Clin North Am 18:625, 1971.

8. Kemph JP, Bermann EA, Coppolillo HP: Kidney trans-plant and shifts in family dynamics. Am J

Psychiatry 125:39, 1969.

9. Kemph JP: Observations of the effects of kidney

trans-plant on donors and recipients. Dis Nerv Syst

31:323, 1970.

10. Crombez J, Lefebvre P: The behavioural responses of renal transplant patients as seen through their fantasy life. Can Psychiatr Assoc J 17:SS-19, 1972. , 11. Beard BH: Fear of death and fear of life: The dilemma in

chronic renal failure, hemodialysis and kidney transplantation. Arch Gen Psychiatry 21:373, 1969.

12. Wilson WP, Stickel DL, Hayes CP Jr, et al: Psychiatric considerations of renal transplantation. Arch Intern Med 122:502, 1968.

13. Gelfman M, Wilson EJ: Emotional reactions in a renal unit. Compr Psychiatry 13:283, 1972.

14. Levine AS, Siegel SE, Schreiber AD, et al: Protected environments and prophylactic antibiotics: A prospective controlled study of their utility in therapy of acute leukemia. N Engi J Med 288:477, 1973.

15. Thomas ED, Storb R, Clift BA, et al: Bone marrow transplantation. N EngI J Med 292:832, 1975. 16. Merrill JP: Clinical experience is tempered by genuine

human concern. JAMA 189:626, 1964.

ACKNOWLEDGMENT

The authors thank Kathy Hoyer for expert secretarial assistance. We acknowledge the dedicated service and the devotion to the children and families described in this report provided by Drs. E. King, R. Montgomery, T. Bell, S. Rusnak, L. Odom, M. Blumberg, J. Pollack, Paul Kelker, the nursing

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1977;60;625

Pediatrics

G. Gail Gardner, Charles S. August and John Githens