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 bone marrow transplantation at the University of
problems experienced by seven children and their families Colorado Medical Center had suggested that
who underwent bone marrow transplantation at the Univer-
sity of Colorado Medical Center from 1973 to 1975. These
severe psychological stress was associated with
problems included (1) anxiety and depression relating to this procedure. Therefore, in 1973 a psychologist
isolation, fear of death, and painful procedures; (2) an joined the pediatric bone marrow transplant
overdependence associated with a feeling of helplessness; (3) team, not only for diagnostic purposes, but also
anger directed toward both the staff and the parents; (4) a
for day-to-day support of the patients and their
reduced tolerance for medical procedures; and (5) periodic
refusal to cooperate. Initially we had been concerned that
families. This report describes some of the
patients might become agitated, psychotic, or even suicidal. psychological issues that have arisen in the last
These did not occur. Severe anxiety over bodily changes was three years.
not a problem. We did not encounter prolonged refusal to
cooperate, refusal to remain in isolation, or drug addiction. PATIENTS AND METHODS
Important aspects in management included an honest,
straightforward, and direct discussion of all aspects of This study includes seven children who have
transplantation, including the potential complications and undergone bone marrow transplantation at our
the risks of death from the underlying disease or from center since 1973. The patients ranged in age
complications of transplantation. A firm but understanding from 4 to 15 years, while the sibling donors
approach to the patients appeared to be the most effective
ranged in age from 7 to 19 years. The Table lists
method to develop their continuing cooperation. The oppor-
tunity for patients to express verbally their fears of them in detail with the diagnoses, lengths of
procedures and of death was essential. The donors needed isolation and hospitalization, and outcomes. All of
help in working through their feelings of guilt if a transplant the patients suffered from primary diseases that
was not successful. The parents needed continuing psycho- were expected to cause death within one to six
logical support for the many personal, social, and psycholog-
months. The two leukemia patients (acute
ical difficulties which they had to face. Pediatrics 60:625-631,
1977, BONE MARROW TRANSPLANTATION, PSYCHOLOGICAL
lymphoblastic leukemia) who were in remission
PROBLEMS, ANXIETY, FEAR OF DEATH. 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. ‘

Received June 18; revision accepted for publication

Many renal transplant programs identify and/or
September 14, 1976.
treat psychological problems of the patient,
Supported by U.S. Public Health Service grant RR-69 from
donor, family, and staff by working with a mental the General Clinical Research Centers Program of the
health specialist who is either a consultant or an Division of Research Resources.
active participant on the transplant team.813 Dr. August is now with The Children’s Hospital of Philadel-
In contrast to the abundant literature on phia.
ADDRESS FOR REPRINTS: (G.G.G.) Department of Pedi-
psychological aspects of renal transplantation, atric Psychology, Container C 231, University of Colorado
similar issues in bone marrow transplantation Medical Center, 4200 East Ninth Avenue, Denver, CO
have not been described. Our early experience in 80220.

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PEDIATRICS Vol. 60 No. 4 Part 2 October 1977 625
 BONE MAiuow TRANSPLANTATION

Pa tients Sibling Before During & Posttransplant

Donors’ Tr anspiant After Transplant Survival
,-- J - Age/Sex ,- r- - Period
Age/Sex Diagnosis Duration Number Days in Days in (Days)
of of Isolation Hospital
Illness Relapses

13/M Congenital 15/F 13 yr No remission 40 70 55

hypoplastic anemia
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; 379
2,54 2,89
#{176}ALL= acute lymphoblastic leukemia.
t Underwent second transplantation after first transplant relapsed.

Our procedure for bone marrow transplanta- tration of the x-ray or the cyclophosphamide
tion involved an initial evaluation during which therapy. All patients and families to whom trans-
time informed consent was obtained from the plantation was proposed elected to have the
parents and whenever possible from the patient procedure, and two additional patients from our
and donors themselves. A series of conferences services were transplanted at other centers
was held in which one of the senior staff because our facilities were in use.
attempted to explain the rationale for under- Several parents said they felt they could not
taking marrow transplantation, the elements of refuse another chance, however small, to have
transplantation biology, and the potential bene- their child survive when they knew certain death
fits and risks of the procedure. The conferences was the alternative. Yet other parents, for whose
were illustrated with color slides showing the child there was no possible donor, said they were
course of patient 4. glad not to have to make the decision of whether
Written consent was obtained from the or not to put their child through the ordeal of
parents. The consent form described every transplantation. Thus, for the transplant group,
possible complication and all side effects in detail. the hope of survival was a most powerful force,
The chances of remission or possible cure were the parents asking only that suffering not be
estimated with a figure of 10% for leukemia and prolonged if the situation later became hope-
50% for aplastic anemia. The complications and less.
risks as well as the possible benefits were The children were then placed in total protec-
discussed in detail with all patients 10 years of age tive isolation with sterilization of everything that
or older (as well as with the parents) and the entered their room (including food) and adminis-
child’s verbal consent was required. The second tration of topical and oral antibiotics to suppress
transplant in patient 7 was based solely on the 10- the growth of all microbial flora.’4 The period of
year-old child’s request (with parental consent). A isolation generally lasted five to six weeks. Three
modified and less-detailed discussion was carried patients had elective central venous hyperalimen-
out with the 4- and 7-year-old patients, and the tation. Cyclophosphamide at near lethal doses
responsibility for consent was necessarily more (200 mg/kg) was given to patients with aplastic
dependent upon the decision of the parents. The anemia. Total body irradiation at lethal doses
staff attempted to present the facts objectively (1,000 rads) and cyclophosphamide (120 mg/kg)
and did not attempt to encourage patients or combined at times with other chemotherapeutic
families to participate. If a child had been reluc- agents were given to children with leukemia.’5
tant to undergo transplantation or had been During and after this therapy the patients experi-
considered to be psychologically unsuitable, the enced periods of profound pancytopenia. Trans-
staff would have refused the procedure at our fusions of RBCs and platelets were required
center. The patients had every opportunity to regularly, and the danger of bacterial or fungal
withdraw from the protocol up until the adminis- infections was great. In addition, the patients

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626 PSYCHOLOGICAL ISSUES IN TRANSPLANTATION
temporarily developed severe mucositis of their during transplantation in these patients were
mouth and gastrointestinal tract, developed diar- anxiety, depression, overdependence and regres-
rhea, lost all their hair, and experienced cycles of sion, anger with reduced tolerance for pro-
reddening and desquamation of their skin. Some cedures, and periodic refusal to cooperate.
children lost substantial amounts of weight. All patients had high levels of anxiety due
The donors underwent general anesthesia while primarily to fear of death and fear of procedures.
the marrow was removed by needle aspiration Fear of death was communicated in different
from both iliac crests. The marrow was then ways including humorous signs with captions such
filtered to create a single cell suspension and as “I’d sure hate it if I weren’t around,” or “This
administered to the recipients intravenously or place is condemned.” The children expressed
intraperitoneally. more concern when complications arose. Before
Psychological evaluation of and support for the transplant, one child frequently discussed her
patients began prior to transplantation and fear of death. Another child intellectualized his
included observation and interview of all patients fears until he developed fever and respiratory
and formal testing for some. The goals were to problems at which time he was able to express his
establish (1) the level of intelligence, (2) the fear of death and asked for all possible efforts to
degrees and kinds of emotional problems, and (3) save him. Like many gravely ill children, he
the characteristic coping mechanisms. By this requested that he not be left alone. Three hours
means we sought to anticipate emotional difficul- later he suffered a cardiac arrest from which he
ties and initiate psychological support strategies. did not recover. A third child expressed his fears
We also tried to determine how these children nonverbally by reaching for his religious medal
perceived their illnesses and what their attitudes whenever he was told of a setback. After multiple
were about the transplantation procedure. Five complications, he wept and discussed his fears of
patients took tests selected from the following: blindness and death with the psychologist.
the appropriate Wechsler intelligence scale, Anxiety regarding procedures and strict isola-
Rorschach test, thematic apperception test, tion was a universal reaction. It reduced the
Minnesota multiphasic personality inventory, tolerance for further procedures and for remain-
figure drawings, and sentence completions. ing in isolation. Although patients sometimes
wished the transplant had not been done and
RESULTS
wanted to die, hope usually predominated.
Patients
All patients except the 4-year-old child experi-
Though the interviews (verbal and play) clearly enced short periods of significant depression.
yielded the most clear and reliable information, They were invariably precipitated and aggra-
the tests-especially the IQ test, thematic apper- vated by the development of complications, by
ception test, and sentence completions-provided the knowledge that a procedure such as a bone
clarification and validation of hypotheses based marrow biopsy or an arterial puncture was to be
on interviews that were semistructured and performed, or by the very real threat of death.
designed to cover all major psychological issues as The children’s depression was generally charac-
mentioned above. At their initial psychological terized by an attempt to withdraw from the
assessment, all patients were found to be intelli- nurses and physicians or by uncharacteristic qui-
gent and none had severe emotional problems. All etude and inactivity. In more severe periods of
understood that they had life-threatening diseases depression, children refused to talk or hid under
and that they might die in spite of or because of the sheets.
their transplantation. Thus, one boy commented, Paradoxically, the patients were sometimes
“When I grow up I want to be an astronaut . . if. depressed when the staff felt optimistic. The
I do grow up.” Even the youngest patient, 4 years different reactions seemed due to the fact that the
old, described his leukemia as “a bad sickness and staff were responding to clinical and laboratory
you could die from it.” He added that death data, such as vital signs, platelet or leukocyte
meant “you just lie there and never wake up.” counts, while the patients were responding to
The results of the initial psychological evaluation their pain from procedures, nausea, lassitude, or a
revealed the patients’ primary emotional prob- lack of appetite.
lems to be (1) anxiety related to illness and death, Surviving patients were depressed even after
(2) feeling of being burdens to their families, (3) discharge, sometimes for several months. This was
low seff-esteem, and (4) feeling of helplessness and related to anxiety over continuing procedures and
vulnerability. to restrictions on activity. One patient’s diary
The major emotional problems encountered highlights the sense of isolation. “I’m getting sick

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ARTICLES 627
 from being home all the time and not having any they knew might immediately initiate studies
hair . I want to be able to walk into stores with
. . involving further pain and suffering. Fortunately,
all the rest of the people why can’t
. . . I have a they usually gave themselves away by changes in
normal life like everybody in the family? God behavior, such as increased lethargy, or by telling
help me sometimes . . I wish I had never
. had it their problems to their parents and nonmedical
done God,
. why
. . do things happen to me? staff who then reported to medical personnel.
Why?” Some patients intermittently refused to cooper-
Patients’ feelings of helplessness and vulnera- ate, partly in response to feeling so sick and partly
bility prior to transplantation became heightened as another attempt to achieve a sense of mastery
during the transplant itself, with total isolation in the face of helplessness. This was a particular
and 24-hour special-duty nursing care, creating problem in regard to eating. Although no patient
an environment of marked dependence upon absolutely refused to take oral medications, their
others. All persons entering the room wore caps, administration took considerable effort from the
masks, gowns, gloves, and boots. The sterile food, nurse, parents, and often the psychologist. One
frequent bathing, and culturing added to the child hid his pills in very imaginative ways,
seemingly endless series of indignities. At times, including beneath the tape that held down his
regression alternated with pseudomaturity. The intravenous needle.
children all understood the need for strict No child suffered prolonged psychological
routines and hypervigilance, which also served as deterioration. There were no episodes of psycho-
defenses against feelings of vulnerability. One sis or suicidal behavior. Though patients generally
child said his family treated him “like an enjoyed the feeling of being “spaced out” on
egg . very carefully;
. . they’re afraid I’m going to drugs, no one became addicted. Although all
break if I touch anything.” Patients lost their patients underwent physical changes such as hair
desire and willingness to eat and drink even after loss, body image was not as severe a problem as
the gastrointestinal tract had healed, probably in we expected. For example, several parents
part because of their dependence on the intrave- brought in wigs but none of the children wore
nous hyperalimentation that was carried out for them. Patients were encouraged to transform
approximately three weeks, and, in part, as an passivity into activity by brushing out loose hair
expression of control, albeit passive and negative. and even saving it if they wished. We do not want
All patients became increasingly dependent upon to imply that the children had no concerns about
their parents and behaved in ways characteristic body image at this stage; rather, the point is that
of children considerably younger than their they were so concerned with pain and survival
chronological ages. that issues of modesty and appearance necessarily
Having to submit passively to so many routines took on a more minor role.
and procedures, the patients struggled to gain
Bone Marrow Donors
some sense of being the masters of their lives. One
boy became angry and belligerent at the nurses, Among our sibling donors, the degree of
maintaining this behavior for several weeks. psychopathology ranged from very mild to
Another patient frequently blamed his parents for severe, with one donor being a borderline schizo-
his suffering. Thus, the children’s ways of coping phrenic. Although we initially focused our
with stress were sometimes troublesome. Parents psychological support on the patients, we soon
tended to take these and other rebellious behav- learned that the donors too should have psycho-
iors in stride, having been told in advance that the logical evaluation prior to the transplant and that
children might act this way. a therapist should be available to them from the
All patients accepted the frequent procedures beginning.
surprisingly well, but as the weeks passed, their The donors felt a tremendous responsibility for
tolerance clearly decreased. Patients who at first the outcome of the transplant and experienced
had required only local anesthesia for bone inappropriate feelings of guilt when graft-versus-
marrow aspirates later insisted on heavy sedation. host reactions or other complications arose. One
Although no patient truly refused necessary treat- donor thought her occasional drinking caused
ment or study, delaying tactics were frequent. problems for her sibling, while another thought
Patients at all age levels manifested their that she might have passed on infection and stated
reduced tolerance for procedures by developing that she too should have been isolated before the
pseudostoical attitudes. That is, they denied transplant. Still another donor tried to help her
symptoms, especially to the medical staff whom brother by secretly fasting.

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628 PSYCHOLOGICAL ISSUES IN TRANSPLANTATION
 Though donors denied continued guilt feelings that burden. The reasons for their not talking to
after counseling, it is not clear how many really the medical staff are less clear. Generally there
resolved this problem and how many attempted was little opportunity since medical staff was
to appease the physicians by telling them what usually busy doing procedures. It is possible that
they wanted to hear. More than a year after one some staff conveyed their own reluctance to talk
patient’s death, his donor admitted that she still openly about death. It was our feeling that all
felt very guilty. patients should have at least one person with
whom they might safely talk about anything.
Parents With older children, the therapist elicited
The parents also experienced guilt and misgiv- discussion of death anxiety by simple questions
ings. These usually reached a maximum during such as “Why do you need a transplant?” or
the pretransplant immunosuppression with lethal “What do you know about leukemia?” With
doses of total body x-ray or chemotherapy. The younger children, adjunctive play interviews with
parents who witnessed their child’s total body puppets offered opportunities to express fears
irradiation saw this process as an execution. One while at the same time maintaining defenses.
parent, whose child died, had a recurring dream Thus, the 4-year-old patient repeatedly used
of the boy sitting in the radiation therapy room puppets, insisting that he was the physician and
and pitifully asking for help. that the therapist was a child with leukemia who
Though a few parents coped with the stress of might die.
the transplant by avoiding their children, most We attempted to answer the children’s ques-
spent a tremendous amount of time in the isola- tions about other patients honestly, especially
tion room with the patients. This often created about those who died. The importance of this
disruption of the family at home. Other children approach was soon evident when we found some
were frequently sent off with friends or relatives children asking the same questions of several
and certainly received much less parental atten- people as if to confirm the answer. We found that
tion. One mother whose child later underwent a the patients were quite concerned about each
second transplantation indicated that she just other and at times the sense of relationship and
hoped it would end-whatever the outcome-so responsibility seemed inappropriate. When one
that the family might be united again. patient died, a survivor wept, saying she knew
Parents also experienced increased anxiety that he had sometimes disobeyed restrictions and
when their child was discharged from the hospi- that she felt she should have made him behave.
tal. Removing a transplant patient from the She said, “He was like my brother.” Though she
atmosphere of isolation with 24-hour nursing care wept, at the same time she thanked us for our
directly to the home intensified parental inse- honesty. We concluded that the gain in trust
curity and fear even though the transition was outweighed the burden of knowledge.
permissible from the medical standpoint once the In dealing with the patients’ depression, the
graft was well functioning. staff initially tried to counteract it by reassuring
the patients with favorable laboratory data and
MANAGEMENT OF PSYCHOLOGICAL
by being optimistic. Later it seemed more effec-
PROBLEMS
tive also to acknowledge the patients’ feelings and
Patients
to empathize with them about their physical and
Since we believed that we could obtain the emotional experiences. This kind of sharing gave
greatest cooperation from the patients in the the patient a sense of being understood and
climate of maximum honesty, we explained the allowed him a face-saving device or excuse for
transplant procedure in great detail to the what he knew was “bad” behavior; this then
patients, donors, and parents. No patient seemed made it possible for him to acknowledge his
harmed by having such information. In fact, they behavior and shift to more adaptive ways of
demonstrated a need for cognitive mastery by coping. Similarly, shared understanding was more
asking questions frequently and by becoming less effective than “lectures” or other forms of doer-
anxious when their questions were answered. cion when dealing with patients’ anger at staff.
Generally the children did not talk openly Anxiety regarding procedures could be de-
about fear of death with their parents or medical creased by the use of mild tranquilizers and even
staff. They knew their parents had already heavy sedation for painful procedures such as
endured tremendous emotional and financial bone marrow biopsy. Occasional refusal to
strain and they appeared not to want to increase cooperate was short-lived as a rule when met with

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ARTICLES 629
a staff attitude of firmness and understanding. Christmas Eve. Somehow this extended “kinship”
Based on psychological evaluations and on mdi- reduced the sense of isolation and loss. The staff
vidual observations, we tried to draw on the now encourage families to exchange ideas and
children’s emotional strengths and to guide them experiences.
toward more adaptive coping mechanisms.
DISCUSSION
Donors
Although there appear to be a few differences
Simple explanation did little to alleviate the in the psychological problems encountered in
irrational guilt found in many donors. It seemed bone marrow as compared with renal transplanta-
more helpful to provide an atmosphere of tion, the many similarities suggest that there may
continued interest and acceptance. In this be psychological problems common to all trans-
supportive climate the donors sometimes found it plant procedures. Prominent issues discussed in
possible to develop an appropriate sense of pride the renal transplant literature which were also
associated with their contribution. One donor, observed in our group of bone marrow transplant
whose brother did not survive transplantation, patients and their families are (1) fear of death
commented almost a year later that she was sad alternating with uncertainty about whether the
that the scars were fading from the marrow quality of life during and after transplantation
donation sites. She had felt fulfillment to notice makes the procedure worthwhile’#{176}; (2) situational
the scars or to have others see them. anxiety and depression in the patients, leading to
temporary withdrawal and/or demanding behav-
Parents ior with increased dependency’2; (3) patient guilt
All parents received continuing psychological related to being financial and emotional burdens
support. Since they sometimes associated seeing a to their families; (4) the patients’ concerns for
psychologist with “being crazy,” regularly sched- each other”; (5) the importance of honest
uled appointments were deliberately not sug- communication with the staff5; (6) the value of
gested after the initial interview in which the parents communicating with each other’2; (7)
psychologist took care to focus on the child. jealousy manifested by sibling donors who feel
As the stress of the transplant increased, neglected by parents who focus much time and
parents more frequently initiated contact. At such attention on the patients8; and (8) lack of perma-
times they talked not only about the patient but nent and severe psychological impairment in
also about personal problems. When discussing patients or donors as a result of transplanta-
long-standing family problems, the therapist tion.6
made no attempt to resolve underlying conflicts From a psychological standpoint, the major
but focused instead on managing the acute difference in renal and bone marrow transplanta-
aspects of the situation. Thus, if parents quarreled tion has to do with the attitudes of the donors.
over some detail such as not sharing information Compared with reports of kidney donors, marrow
about the patient, the psychologist focused only donors appear to be more positive in their atti-
on the issues and avoided obvious undercurrents tudes about participating in the transplant proce-
of communication problems between the par- dure. While our donors’ reactions consisted
ents. mainly of anxiety appropriate for .any simple
Parents also formed bonds with each other, surgical procedure, kidney donors were reported
especially families whose children had died. The as mourning their lost kidney9 and being
grieving parents hoped that the meaning of their concerned about whether the patient would
child’s life might be enhanced if the physicians appreciate the sacrifice and take proper care of
learned something from their child that might the donated organ.3
help another person. Some presented gifts to These differences may be related to the fact
other transplant patients. One father who worked that the kidney is conceptualized as a discrete
for an escort service requested and was given organ which, once removed, does not regenerate.
permission to ride motorcycle escort at the Thus, the donor is aware not only of the tempo-
funeral of another transplant patient whom he rary discomfort and disruption caused by hospi-
had never met. One family dreaded the first talization but also of the permanent sacrifice that
Christmas after their son’s death the previous increases his own risk of permanent disability or
spring but found comfort and meaning in sharing death, should the remaining kidney cease to
that Christmas Day with the family of another function. By contrast, our bone marrow donors
patient who had died only a few hours earlier on equate bone marrow with blood, saying they have

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630 PSYCHOLOGICAL ISSU ES I N TRANSPLANTATION
plenty of both and can easily give some away, 3. Feliner CH, Marshall JR: Twelve kidney donors. JAMA
confident that it will soon regenerate. 206:2703, 1968.
4. Short MJ, Harris NL: Psychiatric observations of renal
The lesser concern of the bone marrow donor
homotransplantation. South Med J 62: 1479, 1969.
for himself may partially explain another differ- 5. Sonnenberg SM, Kaplan NL: Treatment of depression
ence, namely, the direction of guilt between following surgical removal of a rejected renal
recipient and donor. In kidney transplants, the homotransplant. Psychosomatics 10: 181, 1969.
recipient has been described as feeling initially 6. Fine RN, Edelbrock HH, Brennan LP, et al: Cadaveric
renal transplantation in children. Lancet 1:1087,
guilty about jeopardizing the life of the donor,
1971.
while the donor focuses on anticipating personal 7. Korsch BM, Fine RN, Grushkin CM, Negrete VF:
gain such as military discharge or praise from the Experiences with children and their families during
family.4 In our bone marrow transplants, it was extended hemodialysis and kidney transplantation.
the donors who usually experienced significant Pediatr Clin North Am 18:625, 1971.
8. Kemph JP, Bermann EA, Coppolillo HP: Kidney trans-
guilt while the recipients either showed no guilt
plant and shifts in family dynamics. Am J
or expressed only mild concern that the donors Psychiatry 125:39, 1969.
had to be briefly hospitalized. Putting it another 9. Kemph JP: Observations of the effects of kidney trans-
way, our donors did not seem to experience the plant on donors and recipients. Dis Nerv Syst
degree of personal sacrifice that might allow a 31:323, 1970.
10. Crombez J, Lefebvre P: The behavioural responses of
sense of absolution and freedom from further
renal transplant patients as seen through their
responsibility. fantasy life. Can Psychiatr Assoc J 17:SS-19, 1972.
Though actuarial statistics on persons with , 11. Beard BH: Fear of death and fear of life: The dilemma in
nephrectomy indicate very little increase in chronic renal failure, hemodialysis and kidney
mortality risk,’6 the kidney donor’s feeling of transplantation. Arch Gen Psychiatry 21:373,
1969.
great sacrifice is nonetheless real and apparently
12. Wilson WP, Stickel DL, Hayes CP Jr, et al: Psychiatric
serves a useful purpose. The irrational guilt of the considerations of renal transplantation. Arch Intern
bone marrow donor, on the other hand, is poten- Med 122:502, 1968.
tially harmful and deserves particular attention, 13. Gelfman M, Wilson EJ: Emotional reactions in a renal
especially since a single sibling is often the only unit. Compr Psychiatry 13:283, 1972.
14. Levine AS, Siegel SE, Schreiber AD, et al: Protected
possible histocompatible donor. He therefore
environments and prophylactic antibiotics: A
probably feels an added pressure to participate in prospective controlled study of their utility in
the transplant procedure and is less likely to be therapy of acute leukemia. N Engi J Med 288:477,
rejected on psychological grounds than potential 1973.
donors in other transplant procedures where 15. Thomas ED, Storb R, Clift BA, et al: Bone marrow
transplantation. N EngI J Med 292:832, 1975.
cadavers or unrelated living persons may be
16. Merrill JP: Clinical experience is tempered by genuine
reasonably sought as donors. human concern. JAMA 189:626, 1964.

REFERENCES ACKNOWLEDGMENT
1. Hall JH, Swenson DD: Psychological and social aspects The authors thank Kathy Hoyer for expert secretarial
of human tissue transplantation: An annotated assistance. We acknowledge the dedicated service and the
bibliography, in Hall JH, Swenson DD (eds): devotion to the children and families described in this report
National Clearinghouse for Mental Health Informa- provided by Drs. E. King, R. Montgomery, T. Bell, S. Rusnak,
tion. Chevy Chase, Md, US Dept of Health, Educa- L. Odom, M. Blumberg, J. Pollack, Paul Kelker, the nursing
tion, and Welfare, 1968. staff of the Pediatric Clinical Research Center, and the
2. Bernstein DM: After transplantation-the child’s emo- special marrow transplant nurses of the University of
tional reactions. Am J Psychiatry 127: 1 189, 1971. Colorado Medical Center.

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ARTICLES 631
 Psychological Issues in Bone Marrow Transplantation
G. Gail Gardner, Charles S. August and John Githens
Pediatrics 1977;60;625

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 Psychological Issues in Bone Marrow Transplantation
G. Gail Gardner, Charles S. August and John Githens
Pediatrics 1977;60;625

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