OPTN Living Kidney Donor Psychosocial Evaluation Checklist

[Clark]

Living Kidney Donor
Psychosocial Evaluation Checklist

Evaluation must be performed by one of the following:   
   Psychiatrist
   Psychologist
   Clinical social worker

Psychosocial assessment documentation must include:   
   Psychosocial (including mental health) issues that might complicate recovery
   Potential risks for poor psychosocial outcome
   High risk behaviors as defined by US Public Health Services (PHS) that have potential to increase risk of disease transmission
   History of smoking, alcohol and drug use/abuse and dependence
   Recommendation for additional evaluation and/or intervention prior to final donation decision
   Potential donor understanding of donor’s:
   Short term medical risks
   Long term medical risks
   Short term psychosocial risks
   Long term psychosocial risks
   Whether decision to donate is free of inducement, coercion or other undue pressure
   Motivation for donation
   Relationship with intended recipient
   Potential donor’s ability to make an informed decision
   Ability to cope with major surgery and related stress
   Donor plan for donation and recovery
   Social, emotional and financial support available to the donor
   Donor’s occupation
   Donor’s employment status
   Donor’s health insurance status
   Donor’s living arrangements
   Donor’s social support
   Donor’s understanding of the potential financial implications of donation

This checklist contains required elements found in OPTN Policy 14.0 that pertain to psychosocial evaluations for the living donor patient. Use of this checklist is not required, nor does its use guarantee an assessment of compliance upon site survey. The checklist can be used as a tool for members in the development of their site-specific templates, tools, and internal policies and procedures.  Use of this checklist does not replace the need to thoroughly document completion of all elements required by OPTN policy.

01/23/14