Transplantation of the Heart

FOR MOST PATIENTS and families, the psychological stresses and adjustments associated with cardiac transplantation originate not during the process of transplantation itself but with the discovery of lifethreatening illness. Their responses and coping mechanisms frequently reflect the stages described by Kubler-Rossl: denial of the severity of illness and a search for better physicians or treatment, anger at fate for being randomly victimized by heart disease or for membership in a family with a history of early cardiac death, bargaining behavior such as impeccable dietary compliance or exercise in the hope of reducing cardiac disability, and depression when nothing stops the progression of the disease. When the onset of illness is gradual, changes in patterns of family interaction and role assignment often occur. An ill child may require a disproportionate share of parental attention and resources. Siblings experience jealousy and guilt while simultaneously having more difficulty in school and in relationships with peers. Parents' feelings of helplessness because they are unable to make the child well may lead to occasional, painful skirmishes over whose "side of the family" contributed the genes that led to the illness. If the patient is an adult, the range and magnitude of his or her contributions to the family are diminished. Loss of strength and cardiac capacity reduce parental ability to keep up with the activities of children. Family income may shrink, either through loss of the patient' s salary or through the de facto loss of previously discretionary income that is now used to pay medical bills. Marital problems develop, particularly in recent marriages, if one partner perceives that he or she is now responsible for "taking care of" the other for an extended time. In reviewing notes from more than ten years of interviews with potential recipients and their families, I have found that almost all spouses in mar-