“It’s not a job; it’s a lifestyle”: the experience of being a donation coordinator
Blumenthal, Patricia A
Lifesaving organ transplantations cannot be performed without the donation of organs from another human being. The donation coordinator in an organ procurement organization has the responsibility of coordinating this “gift of life”-a highly stressful, but inherently rewarding occupation. Although numerous studies have examined the medical and social implications of organ donation, little has been written about the experiences of donation coordinators. This qualitative study examines the experiences of donation coordinators at a large metropolitan organ procurement organization, to understand how they perform under stress, the ways that they cope with this stress, and the meaning that they attribute to their roles. Implications for organ procurement organizations are discussed to assist such organizations in recruiting donation coordinators and in developing supportive interventions for current employees. Suggestions to help donation coordinators maintain good mental health are also offered. (Progress in Transplantation. 2007;17:8-22)
Lives depend on the clinical competence and interpersonal skill that donation coordinators bring to the field of organ donation and transplantation. To carry out their jobs successfully, donation coordinators must use every strength and resource at their disposal. However, because organ donation is a human process, it is likely that circumstances will arise in which donation coordinators are unable to perform at their best. Certainly, personal characteristics, styles of coping, and personal histories play a dynamic role in how donation coordinators meet the demands of their jobs. Environmental and situational factors are also likely to play an important part.
We must be reminded-the transplant community as well as society at large-that donation coordinators are working behind the scenes to make the success of transplantation a reality, and they shoulder a heavy responsibility. Given how little we know about their experiences, the following study is a starting point in discerning some of the human variables at play in the organ donation process, with regard to those professionals who guide this process. What is the experience of being a donation coordinator? How do they make meaning of their roles in the “gift of life”? How do their job experiences affect the way they think, feel, and believe the world to be? Furthermore, how do donation coordinators balance the existential and mundane aspects of their work, and how do they integrate these aspects into their everyday lives? These questions are examined in this study to help us understand what donation coordinators bring to the donation process.
Motivation for Helping
Why do people seek careers in the helping professions? Is it a way of satisfying some unfulfilled need or is it a purely altruistic motivation? This fundamental question lies at the heart of understanding the work of donation coordinators. Although many of us wonder how and why one could perform this stressful work, rewards may exist in this profession that nourish and sustain the donation coordinators.
For centuries, great thinkers from Aristotle to Freud have maintained the view that humans are basically egoistic-that we care for others only to the extent that we can somehow benefit.1 This case for universal egoism appears to have some credibility, and it is easy to think of examples in which people do for others so that they may receive praise or rewards. An egoistic explanation for why people seek careers as donation coordinators (just as people may seek careers in other helping professions) may be to consider themselves as “good-doers” in the eyes of others or to receive praise and admiration from family and friends.
Of course, there is also the plausible explanation that donation coordinators perform the job for a very basic reason: to earn money. There are, however, less demanding ways to earn a living. Donation coordinators, most of whom have nursing degrees or allied health backgrounds, can certainly find jobs outside of organ donation with comparable pay. Other jobs would also be less likely to entail as much on-call work, which is both demanding and stressful.2
If, however, donation coordinators perform this specialized type of work in order to obtain praise and admiration from their own social circles, this can hardly be construed as a sustaining motivation. The foremost reason for this inability to bask in the praise of their heroic efforts is the relative anonymity of their work. Donation coordinators are not at liberty to disclose the details of their work even to close friends. They must abide by the same confidentiality rules as psychotherapists, clergy, and other professionals. Not only must they never reveal the names of the donors or recipients, they also cannot reveal that they were even called to respond to any particular case. This limitation can often become an issue when a death has been publicized, and people wonder if the victim has been an organ donor. The donation coordinator cannot divulge whether she or he was involved in the case. Such a “gag order” prevents donation coordinators from receiving any continual public rewards for their work.
Empathy and Altruism
Research in the past decade has posited another reason that people seek to help others, which is not predicated on social or monetary rewards. Instead, there appears to be a prosocial need to help others that is evoked by empathy. Empathy is an emotional response to seeing another person in need,3 and it is considered to be a fundamental attribute in the helping professions. The claim that empathic emotion for someone in need elicits altruistic motivation has been called the empathy-altruism hypothesis.4 This hypothesis has been tested against assumptions that people are always motivated by selfish reasons, and it appears to hold up under empirical scrutiny.5,6 Certainly, donation coordinators are continually in the position to empathize with the people they serve. The transplant waiting list is a constant reminder of those who live in pain and despair, and it can be an especially difficult reminder when the list contains children’s names. Although they are essentially invisible to the organ recipients, donation coordinators do know that they have been instrumental in saving lives. This pleasure is often what donation coordinators find most rewarding about their work.7
Compassion and Compassion Fatigue
Compassion is an emotion born of social connection. It is evoked by the witnessing of suffering in others.8 Not all human suffering stirs compassion, however, and it has been generally accepted that 3 requirements are necessary for compassion. First, people must believe that the suffering is serious; second, that the suffering is not self-inflicted; and finally, that people must be able to picture themselves in the same predicament.9 For donation coordinators, these requirements are usually met. The experience of donor families after losing a loved one, usually from a sudden and traumatic event, would certainly be considered a serious tragedy, unanticipated and beyond their control. Further, one may be able to imagine oneself in the same circumstances.
Compassion is a desirable emotion, and one that figures prominently in the helping professions. There is a cost to compassion, however, and it comes in the form of repeated exposure to painful emotions and tragic circumstances. Compassion fatigue, also identified in the literature as secondary traumatic stress and vicarious traumatization, is the result of listening to others’ traumatic material.10-12 Given the nature of the donation coordinators’ work-case after case of sudden death and grieving families-the conditions are in place for the occupational hazard of compassion fatigue. The circumstances of a donor’s death, the age of the donor, and the emotional reactions of the donor’s loved ones will most likely be factors in how it may be experienced.
Compassion fatigue is identified by criteria that are similar to the criteria for diagnosis of posttraumatic stress disorder listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. It includes recollections of traumatic events and efforts to avoid thoughts and feelings associated with them, diminished affect, irritability, and difficulty concentrating.10 These effects can be short-lived or prolonged. The nature of the donation coordinator’s work sets the stage for compassion fatigue; however, it does not necessarily guarantee it.
Stress and Models of Coping
Although stress is always present in donation coordinators’ work, several important factors play a part in how individuals cope with stress. Research on these factors has typically been divided into 2 areas, environmental factors and individual differences. Environmental factors include social supports and the extent to which individuals participate in decision making.13,14 Individual differences include resilience, hardiness, and affective disposition.15,16
Studies have shown that people who have control over their work and who are able to participate actively in decision making consider their jobs less stressful.13 This ability has also been a predictor in positive health outcomes.17 Although decision making may be embedded in the work of donation coordinators, the perceived control and influence that donation coordinators actually experience on the job may vary.
Individual differences are also a factor in stress and coping. These differences have been identified in a variety of ways including affective disposition, locus of control, and coping styles. Affective disposition refers to enduring personality traits that are consistent across situations and time. Two of these traits, trait anxiety and trait anger, for example, correlate with an individual’s ability to handle stress.18 Individuals that are high in either trait may be predisposed to interpreting the environment as threatening or stressful.
Locus of control refers to an individual’s belief that she or he has control over personal outcomes. At either end of the spectrum, there are those who believe they have complete control and those that believe that fate or others have control in their lives. Persons who believe they have more control have lower stress reactions, and those who believe they have little control experience greater stress.19,20 The roles of environmental influences and individual differences no doubt play a part in the experiences of donation coordinators. The extent to which these variables are set in motion will provide a framework to understand the dimensions of their experience.
Recently, interest has shifted away from the study of stress and coping to an understanding of healthcare professionals’ reactions to death and trauma as grief reactions.21-23 Working with the deceased, donation coordinators are repeatedly faced with loss and grief as a routine part of their jobs. They read through medical charts that describe the circumstances of a person’s death in vivid detail. They view the body of the donor, and determine the extent of injuries, as part of donor management. They offer their condolences to the family and listen to stories of their loved ones. Many times the donors are young, and donation coordinators must facilitate the donation from the accidental death of a child or a young motorcycle victim or the young mother of small children. Each of these deaths is a bittersweet reminder of the unpredictability of life, a fact that is not lost on donation coordinators.
Research in the area of grief among healthcare professionals shows that grief is a normal reaction to a patient’s death, especially the deaths of children and young adults.24,25 Sometimes, however, professionals are discouraged from expressing this grief, whether implicitly or explicitly, and as a result, deny the natural expression of this emotion.23 Other times, professionals consciously avoid their own grief to protect themselves from being overwhelmed by multiple deaths or from having to face their own mortality.24
Disenfranchised grief and ambiguous loss have also been identified in the literature, which describes the effects of multiple losses and/or losses that are ignored, minimized, or unaccepted.26,27 This grief can occur because the relationship is not socially sanctioned or the loss is hidden from others. For example, the parents of a deceased child will openly grieve their loss, but the healthcare professionals involved in their child’s care may not be “allowed” to grieve. Colleagues, friends, and family of the professional may communicate the message that grieving would be inappropriate, given the professional nature of the relationship. One can imagine how donation coordinators may not feel justified in their own sorrow, given that they have had a circumscribed experience with the donor and the donor’s family. Therefore, the possibilities for disenfranchised grief in these professionals are as real as they are for other healthcare workers.
Making Meaning of Death
Making meaning of death is a central aspect of the grieving process.28 Victor Frankl, a leading figure in existential psychology, made that assertion decades ago and argued that the desire to make meaning was a fundamental, motivating force in people’s lives.29 Given this drive to find meaning in life, how do people cope with misfortune and trauma? After all, generally, people believe that negative events do not happen randomly and that people get what they deserve.30 Therefore, being involved with the sudden, unanticipated deaths of so many, donation coordinators (as do donor family members) must come to grips with events that challenge these assumptions.
Baumeister and Vans31 have delineated 4 main ways that guide how people make sense of their lives. First, there must be a sense of purpose in what they do. They must see a connection between what they are doing in the here-and-now and future events. Donation coordinators, fortunately, know that all of their efforts in facilitating the donation process will result in the saving of lives-that there is a direct and immediate connection between donation and transplantation.
Second, people must have the opportunity to act in accordance with their values, which reinforces a sense of goodness or positivity in their lives. They must believe that their values justify certain courses of actions. This way of making meaning can be particularly important for donation coordinators, who may feel conflicted about asking a donor family to donate after they have suffered such a loss. The value of saving another person’s life, as well as the value of giving a donor family the opportunity to give the gift of life, can justify their actions and resolve conflict about the request for donation.
Third, people must fulfill their need for efficacy; that is, the belief that they can make a difference in the world. People, of course, always seek to have control over their environments, and a lack of control can have an adverse effect on their psychological well-being. In this area, donation coordinators have a significant opportunity to fulfill this need, because their work makes an important difference in the world by saving lives.
Finally, the need for self-worth contributes to a person’s ability to make meaning. Most people seek reasons for believing they are good people, and they can do this either individually or collectively. For example, donation coordinators may see their work as a way of feeling good about themselves. Because their jobs are guarded from the outside world by confidentiality, they may be able to derive feelings of personal satisfaction through shared experiences with their colleagues.
Finding meaning in their careers, however, is not the only area in which donation coordinators find meaning. Having multiple sources of meaning in life-family, work, religion, hobbies-is essential to preventing a sense of meaninglessness.31 In fact, research has shown that putting too much emphasis on career to find meaning in life can result in career burnout.32,33 Researchers argue that work has taken the place of religion in American culture, which normally does not lend itself to existential significance. However, this is not the case with the work of donation coordinators, and it may be that their work fulfills or complements their religious or spiritual leanings.
Beyond Grief and Loss
Donation coordinators appear to have ample opportunity for making sense of the losses they encounter in their work, but there has not been any research to date that shows whether they are able to do so and to what extent. Further, for those donation coordinators who are able to make meaning of the suffering that they witness, what more do they gain from their experiences that enable them to grow personally and professionally?
Several recent studies30,34 have identified the ability to find benefit in loss, which pushes beyond meaning-making. This benefit-finding involves a true transformation of character in the face of tragedy. For example, there are people who have suffered great losses who describe their relationships with family members and friends as being stronger and richer, mostly because of their heightened appreciation of the shortness of life. These people are also more apt to engage in active problem-solving, seek social supports, and find constructive ways of expressing their emotions.34
Role of Optimism
To date, the most consistent predictor of being able to find benefit in suffering is dispositional optimism.35,36 It appears that those people who generally expect positive outcomes will look for the positive aspects of any experience. As Frankl noted years before, it is a person’s attitude toward adversity and hardship that seems to make the difference in how that person adapts and grows. And so, just as donation coordinators may have the opportunity to make meaning of their challenging work, some may also be dispositionally oriented toward finding personal benefits in the work.
Participants in this study included 16 donation coordinators currently employed by an organ procurement organization (OPO) and 5 former donation coordinators from this same organization. The OPO covers a large metropolitan area. The participants were between 27 and 55 years old and had been employed between 2 years and 19 years. Their mean length of employment in the field of organ donation was 6.7 years. Of the 21 participants, 18 were women and 3 were men.
Although the position of the donation coordinator varies somewhat from OPO to OPO, most donation coordinators share certain responsibilities that include speaking with families and donor management. Many perform other duties as well, such as organ placement and consent. The donation coordinators in this study had all performed these services. Of the total participants, 16 have nursing degrees and 5 have allied health or general science degrees.
After approval was received from the institutional review board, a presentation was made to all donation coordinators at this OPO during their monthly staff meeting. The presentation briefly stated the researcher’s interests, explained the purpose of the study, and invited listeners to participate in the study. The donation coordinators were assured that their participation would be confidential and voluntary. A letter of consent was made available to them at the time of the meeting. A follow-up e-mail outlining the purpose of the study was sent to all interested donation coordinators. No further requests for participation were made.
A semistructured interview was conducted with each participant, allowing for both open-ended questions and some closed questions. These interviews were held at a location of convenience to the donation coordinators, mostly at their offices, and were audiotaped. Three of the donation coordinators (2 former and 1 current) were not interviewed in person because of their physical distance from the study site; they instead chose to type out their responses to the interview questions.
The questions in the interview process were guided by certain content areas: reasons for working in the field, positive experiences, negative experiences, ways of coping, how they assigned meaning with regard to involvement and outcome of cases, personal experiences related to death, and self-development. All interviews began with questions relating to how the participant entered the field of donation. Follow-up questions were posed in direct reference to the material being offered, usually to clarify or request elaboration.
An independent transcriber then transcribed the audiotapes. A code name was assigned to each participant during the transcription and analysis. The researcher protected the confidentiality of the participants by eliminating identifying information. After the interviews were transcribed, all of the recordings were erased, as indicated on the consent form.
A grounded theory approach was used, allowing the research situation to emerge.37 The 4 levels of analysis that constitute the process of grounded theory were used. The first level consisted of the systematic presentation of the data gathered from the interviews. The second level lead to the generation of categories that organized the data. This entailed a coding process, in which the content of the transcripts were assessed and given codes identifying certain themes or categories. At the third level, initial themes were then analyzed for overlapping content and identification of broader categories. This process resulted in the identification of core categories. Finally, at the fourth level of analysis, the core categories were integrated into a theoretical scheme, which led to the formulation of a model regarding the experience of donation coordinators.
Several core categories that emerged from the transcripts resonated profoundly with the constructs culled from the literature review. Specifically, empathy and compassion figured prominently in the transcripts of donation coordinators as well as factors in successful coping strategies. In addition, themes of meaning-making and benefit-finding emerged significantly. The unique and moving aspects of the donation coordinators’ work are framed by these concepts and lend themselves to greater insight into the complexities of their experiences.
The paths that led donation coordinators to finding careers at the OPO were diverse. For some, it was a new and interesting job that provided excitement; for others, it was a midlife career change that promised an invigorating challenge. Nearly all donation coordinators in this study cited the need for autonomy, variety, and challenge as being the critical factors in taking the position, as well as the chance to save lives. Choosing to become a donation coordinator was, in fact, often their decision after a negative experience in a previous job-an experience that left the individual feeling powerless, frustrated, and/or devalued. For instance, one donation coordinator recalls learning of a junior colleague receiving a promotion over her; another remembers having a major philosophical disagreement with a boss just before discovering a job opening at the OPO. It is little wonder that the job of a donation coordinator, with all its power and excitement, would sound appealing. Other donation coordinators describe the job as a “calling” and “the chance to make a dramatic difference in people’s lives.” It appears that their decisions to work in the field are not driven by dichotomous motives-egoistic or altruistic-but rather, a combination of both.
The attraction of autonomy and excitement often seems to come at the expense of feeling isolated, and donation coordinators are well aware of this downside. As one donation coordinator put it, “I feel like the chief cook and bottle-washer” and another, “I think this job requires a bit of a cowboy loner kind of attitude.” Another donation coordinator summed up the sentiments of many in this way:
The thing about our job is that you really work by yourself. And it can be very lonely. Even though you’re working and there’s staff around you, there’s no one who really knows what you’re feeling except one of your colleagues.
This sense of being different from others permeates the experience of being a donation coordinator in many ways. It is sometimes perceived as a negative attribute of being a donation coordinator, in relation to not having others understand the nature of the work. As one donation coordinator commented, “[Other people] think they know what I do, but they have no idea what I do.” Another donation coordinator remarked, “Sometimes I don’t have the energy to explain [what I do], so I just don’t. I just say, ‘You wouldn’t believe me anyway if I told you.'”
Being different from others, however, has its advantages. One donation coordinator shared the sentiments of others: “Knowing that we’re doing something that is so special, we’re doing something that not too many people on the planet could do. It’s a very special select group. I won’t say that it’s elite, but it’s very unique.” Although most donation coordinators acknowledged the uniqueness of their jobs, they were reluctant to credit their own talents, skills, or abilities. Instead, they attributed the exceptionality of their work to their colleagues, and most of all, to the donor families that they serve. One donation coordinator said, “We’re not special. The people [we work for] are special.”
The Power of Relationship
If isolation and loneliness are perils of being a donation coordinator, then connection with others is the antidote. Nowhere is that connection more deeply felt than with the donor families. Donation coordinators respect and revere donor families and often find themselves in awe of the families’ capacities. One donation coordinator summed up the attitudes of all:
I’ve met the most amazing people, the most amazing families. It has really been a great privilege to meet people with the strength that organ donor families have. Strength and faith and love, because you have to have a certain amount of love in order to be able to give this type of gift. Really, just an amazing privilege and that is what makes the whole job and all the negatives that go along with the job worth it.
All of the donation coordinators in this study identified the donor families as the people for whom their efforts are geared. This may be a surprising find, given the fact that the donation coordinators’ mission is to recover organs for transplant candidates-to save the lives of those patients awaiting these precious organs. However, virtually all the donation coordinators in this study acknowledged little interest in the recipients. As one donation coordinator commented, “The recipients at times are almost abstract because on the donor side of things, you don’t see the recipients.” Indeed, the wishes of the donor family provide the motivation for the work. Many donation coordinators shared the sentiments of this colleague:
It is enormously gratifying and sometimes I find that in the middle of the night when life sucks . . . it’s that family-it’s the tears, the hug that you shared with that family-that do keep you going. It’s really more the family, looking into those teary eyes, that’s your impetus to keep on trucking, than it is that you’re going to save somebody’s life.
This apparent lack of connection with recipients is perhaps not so surprising, given how the job of a donation coordinator is performed. Their immediate relationship is with the donor family, whose consent to donate is a critical piece of the donation coordinators’ work, and a necessary piece for transplantation to happen. The recipients are faceless names and blood types that appear on a list. Donation coordinators have not met any of the patients waiting on the transplant lists. Occasionally, they have the opportunity to meet them after they have received a transplant, usually during speaking engagements or public forums. Donation coordinators have received these meetings positively, although they are mentioned as afterthoughts. Clearly, the relationship with the donor family takes precedence. Some donation coordinators, in fact, continue to have correspondence and ongoing relationships with certain families.
The connection with the donor family is so important that without it donation coordinators often find that they are less invested in the process. Sometimes there are cases when a donation coordinator may not meet the family, either because a family counselor has been involved with the family, or because the donation coordinator is relieving another donation coordinator midway or at the end of the donation. One donation coordinator echoed the sentiments of many by saying:
It gives a lot more meaning when you’ve met the donor family and you’ve looked into their eyes and they trust you. You try as hard as you can, and I think that helps a lot. I’ve been on cases where I’ve never met the family and I think that’s kind of difficult. I mean, I believe in our mission wholeheartedly, but it depersonalizes it a little bit, and it’s nice to have that human part of it.
What is the nature of this relationship between donation coordinators and donor families? A predominant aspect of the relationship involves donation coordinators being charged with watching over the deceased, and making a promise to the donor family that they will ensure that the deceased is treated respectfully throughout the process-much like that of a guardian angel. Donation coordinators seem to embrace this role voluntarily, but donor families often remind them of it explicitly. It comes in the requests to place a teddy bear under the arm of a toddler, the promise to keep a body discreetly covered, or the message to tell their loved one, “when they turn off the machines, please tell her thank you from us, and if this wasn’t right, we were trying to do the best and that we loved her.”
The level of trust that a donor family has for the donation coordinator is often profound. All of the donation coordinators in this study, in fact, spoke of the awesome responsibility of making sure that the family’s wishes were carried out. This responsibility was personalized to the extent that the success or failure of the transplant outcome had a significant impact on the donation coordinators’ views of themselves. In instances where the outcome was positive-usually a multiorgan transplantation-donation coordinators were satisfied that they helped bring meaning to an otherwise meaningless death. They felt they had brought some measure of comfort to help ease the family’s grief. One donation coordinator described such an experience:
. . . we say it to each other all the time, “That was the most amazing family. That family was unbelievable!” And then the next time you meet another unbelievable family, and you say, “Oh my God, these people blow me away! They’re so incredible!” And the families thank me. The first time someone said that to me . . . [it made me] feel so small at first, but then you realize why they’re thanking you and what you have done for them. And that I wasn’t responsible for the death. I wasn’t responsible for what happened, but I was able to bring them something . . . that’s very rewarding.
Not all cases have positive outcomes, however, and donation coordinators consistently identified this as being the most stressful and upsetting aspect of the job. A negative outcome was one in which the organs could not be placed with a recipient, the organs were deemed medically unsuitable after recovery and discarded, or the organs were transplanted but the recipient ultimately died. It is the responsibility of the donation coordinator to deliver this news to the donor family, and it is always met with dread. This seems to be where a donor family’s trust becomes a burden. Despite preparing a donor family for the possibility of a negative outcome, donation coordinators still feel that they have let the family down when it happens. As one donation coordinator put it, “I just felt like, ‘my God, I’ve given them nothing. I gave them nothing,’ and I’ve never felt so bad about anything.”
Responses by donation coordinators after delivering bad news seemed to range from profound disappointment to intense self-criticism. Several donation coordinators admitted to ruminating about cases after they were completed. One donation coordinator commented:
If things didn’t go well for whatever reason, if there was anything in a case that went awry, I usually have a hard time falling asleep, and I’ll just lay in bed thinking about it over and over, because a lot of times there is nothing you can do about it. So, I’ll think what could have been done differently, that kind of thing, and it usually keeps me awake.
This self-criticism also appears to fuel a drive toward perfectionism, as well as the nagging feeling that they have not done enough. Two donation coordinators in this study admitted to being perfectionists and demanding the absolute highest level of performance. Several others often felt that they were not doing enough for donor families, even after successful outcomes. This donation coordinator perceived larger issues for which he felt responsible, but not equipped to handle: “You see people and you know they have bigger or additional issues than their dying loved one, and you feel at times that we’re not doing enough for them, more should be done, has to be done and isn’t.”
The Importance of Empathy
Given the intense and intimate circumstances under which donation coordinators interact with grieving families, the donation coordinators’ job is very much like a bereavement counselor. A remarkable finding in this study, in fact, was the exemplary counseling skills that the donation coordinators have developed and use in their work. Although they are not trained as therapists (only one of the donation coordinators in this study had a bachelor’s degree in psychology), they consistently demonstrate the fundamental skills that are taught to all therapists in training. Those attributes of a successful therapist-client relationship-empathy, compassion, positive regardare also present in the relationship between the donation coordinator and the donor family. Several donation coordinators remarked that it was essential to have these qualities to be successful in the job. This former donation coordinator summed up:
As I look back on the people whom I’ve admired and what their qualities were, I think they truly cared about the donor families. They had a caring nature where they could ease everyone’s worries and calm people down, and I think those are the best [donation coordinators].
Not all donation coordinators found that they were equipped with these skills when they first entered the profession. For those with nursing backgrounds, the skills were identified as natural traits or skills that were developed as critical care nurses; however, for those from other backgrounds, the skills were learned while on the job, usually by observing colleagues. One donation coordinator remembered initial contacts with donor families:
Answering technical questions [for the donor family], you try to do it in a compassionate way. The one thing I did know was to not go in with all this technical mumbo-jumbo or be too enthusiastic. You learned to follow the lead of your colleague and be soft-spoken, quiet. If you’re going to demonstrate patience, now was the time to do so.
Many donation coordinators believed that compassion is the most important element in doing this work. One donation coordinator even remarked, “once you lose compassion, it’s time to move on.” Another observed:
You have to have a very firm belief in yourself because the whole process stems from your heart and your ability, and there’s a huge amount of people that are trained in abilities, and a limited few people that are trained from their hearts.
In addition to the having the skills necessary for a therapeutic alliance, donation coordinators also appear to have a natural ability to set boundaries that are in both tdthe donor family’s and the donation coordinator’s best interests. Many donation coordinators cited their firm belief that they would never share their spiritual or religious views with a donor family, nor would they disclose personal information about themselves, unless there was a compelling reason to do so. An example that was most often given was in the circumstance of a parent questioning whether the donation coordinator had children of his or her own. In these cases, the donation coordinator felt that the parent wanted to know if he or she could truly understand the love one has for one’s own children, and by extension, could imagine how devastating it would be to lose one’s child.
Other examples of the donation coordinators’ natural counseling skills included the ability to acknowledge the fact that they were there for the family, and that they needed to leave their own personal issues outside of the room. One donation coordinator shared this attitude:
I have to go into every family as though this is the first family that I’ve ever met. This is the first family I’ve ever spoken to. What’s happening to this family is not about me. It has nothing to do with me . . . I’m there for this family to do whatever I can to help them through their situation, but it cannot be about me. I cannot bring in baggage from home. I cannot bring in baggage from work. I cannot bring in baggage from a previous case. I can’t go in and say, “Oh my God, I am so tired. I just drove 3 hours to get here.” It is not about me at all.
All of the donation coordinators in this study identified their interpersonal skill as their most important asset in performing the work. These skills were particularly useful in assisting donor families, but also extended to working with difficult or novice hospital staff. All of the donation coordinators spoke of the challenges in working with nurses and physicians who presented obstacles in the process. This was a key area in which they used sophisticated negotiation and persuasion techniques to engage hospital staff in the donation process. A former donation coordinator remembered how she managed difficult situations:
I made the nurse feel very important, that I wasn’t going to try to take over her territory which is what they don’t like you doing, telling them what to do. So, I would go in and say, I really need you. You have the skills to manage this patient because you know best, so I would hope that you could come to me if [the patient’s] potassium is getting low. You come to tell me what you think we should do and I’ll write the order to do it. So, they were perfectly happy firing orders at you, so I think going in and saying this is kind of what I need to be done. I used to say my skill was getting people to do what I wanted them to do and letting them think it was their idea.
Being with grieving families and experiencing compassion, what were the consequences of having repeated exposure to this grief, as well as the pressure to ensure a positive outcome? Many of the donation coordinators reported various symptoms of compassion fatigue, as defined in the literature” from time to time. For some, intrusive thoughts about donor families or donors surfaced occasionally. As one donation coordinator put it: “I’ve had to put images in my head that will never go away.” All of the donation coordinators in this study could recall emotionally charged situations with donor families that they said they would remember forever.
Disturbances in sleep were sometimes noted, but these disturbances were attributed to long periods of sleep deprivation while on the job. Once they were done with a case, most donation coordinators were able to sleep well. None of the donation coordinators noted any particular periods of irritability or depression related to their work. Although no formal assessment was done, it does not appear that donation coordinators met criteria for a “diagnosis” of compassion fatigue.
Absence of compassion fatigue did not preclude donation coordinators from experiencing various stressors, however. Besides being sleep deprived and at the mercy of their beepers, the most pervading source of stress was their relationship with the administration at the OPO. The problems were not noted with particular administrators, but instead with the structure and demands of running a business. One donation coordinator commented:
I think we’ve reduced things to money . . . every day you’re expected to drive one mile less to save them the extra nickel and dime, and they forget. It’s real easy that you don’t have HIV blood on you on any day, it’s real easy when you’re not carrying around someone’s organ, it’s real easy when you’re not watching a dead body at 3 o’clock in the morning, it’s real easy when you’re not carrying an infant back to the morgue wrapped in plastic that’s this big, it’s real easy when you’re not looking into the eyes of a grieving family, it’s real easy when you don’t have to deal with that cardiologist at 4 in the morning screaming at you at the top of his lungs . . .
The realities of running a business-needing to increase revenue and reduce costs-present a fundamental tension within the field of organ donation. The administration at the OPO is faced with stretching every resource to maximize the availability of transplantable organs. This pressure is especially felt by the donation coordinators, who must mediate between the need to obtain consent and recover multiple organs and the need to perform their work in a sensitive, ethical manner. Many donation coordinators in this study emphasized the fact that donation was not the best choice for every family, and that if the family was treated respectfully, given all the information to make a decision, and decided against donation, then it was still considered a positive outcome in their eyes. Although management may agree with them on principle, it is not a “good” outcome for the mission of an OPO. Most donation coordinators understand this natural tension. As one of them admitted:
I think sometimes they focus too much on the buck, having to have so many donors and forgetting that these are people and the donor families, they are our business too. Maybe that’s our job, to bring them down and remind them. But when you come right down to it, they are accountable for how they run a business, to the Board, even though we feel that it’s more they should be focusing on the human issues. It’s still a business.
The tension between administration and donation coordinators is also manifested in the ongoing demands for completed paperwork and documentation. Standards for these paperwork requirements have proliferated in the past few years, in response to tighter controls by accrediting agencies. Although accurate and timely documentation may be essential to those who must answer to these agencies, they are not priorities to donation coordinators who must juggle and prioritize many competing facets of their jobs. This mismatch of priorities leaves some donation coordinators “always feeling behind.” As another person said, “some of what is expected of us is truly a waste of time.” Since time is not something that most donation coordinators feel they have, to perform clerical job duties can be viewed as an extra stressor.
Given the job demands of donation coordinators, how do they cope with the ongoing stress? Two important factors emerged in this area. The first factor was the importance of emotion, which included the ability to titrate the release of emotions, control over when these emotions were expressed, and ability to experience a balance between positive and negative emotions. The second factor was the role of colleagues as a continuing source of support.
Almost all of the donation coordinators in this study used the term passion to describe their work-a descriptive word imbued with emotion. Emotions seemed to figure prominently in how donation coordinators experience their work. As one former donation coordinator recalled:
I remembered my husband saying, “your highs are really high in this job, but your lows are extremely low.” And you are on this emotional roller coaster when things were going well . . . that was great, but in order to get to that high, you had to go through some extreme lows-the big swing in emotion.
Emotions experienced as positive seemed to come most frequently in the perspective that the donation coordinators were performing a valuable service to others, notably the donor families. By carrying out the wishes of the donor family, and especially in securing a positive outcome, donation coordinators often experienced the satisfaction of a job well done.
Sadness and grief were also emotions that donation coordinators encountered routinely, as one would imagine. Most of the donation coordinators discussed the emotional aspects of working with grieving families-some of them were more inclined to cry openly with the family when it seemed appropriate. Others reported that they very much felt the weight of their sadness and expressed this to the donor family in their words and body language, but never actually cried. One donation coordinator reported:
In this job, you have time to cry. You can cry with the family, you can cry on the way home, you can take a break and cry. I’m not afraid of my emotions anymore. I’m not afraid of showing them. I know that tears on your face can say a lot to a family.
Another coordinator also used the expression of emotion as a barometer of job satisfaction:
I get emotional a lot when I talk to families. I’ve never actually broken down and cried, but I get teary-eyed a lot when I feel real connected to the family. Sometimes I feel bad if I leave and I haven’t gotten teary-eyed because I haven’t had that connection to that family . . . yeah, I get very emotional. That’s one of the things that make the job really hard because you put so much . . . into it, but it’s also one of the things that makes the job most rewarding.
But not all donation coordinators felt they had the time to process their feelings. One individual admitted:
It’s very emotional and you’ve put a lot of work into it, and you’re just exhausted and it all just comes out. Other times . . . I’m driving around and I’ll just start crying for no reason, and I’ll be looking around and think, why am I crying? And I think sometimes it’s because I don’t have that outlet.
None of the donation coordinators in this study seemed to experience disenfranchised grief, as previously suggested in the literature. They all felt that it was appropriate and acceptable to express their feelings of sadness and loss, whether it was done with the donor family, with their own family, or with their colleagues. In fact, to donation coordinators, the expression of emotion is not just acceptable, it is preferred.
The ability to control when and how much emotion they would express during a donation event was very important to donation coordinators. They were very much aware of the tension between expressing their emotion and not letting it interfere with their ability to perform their jobs. To manage the stress effectively in their work, they would often express their sadness, but then were able to remove themselves from the emotion to conduct themselves professionally.
The second most important factor in the coping strategies of donation coordinators was the ability to use colleagues as a source of support. One donation coordinator noted:
There’s a common thread that goes through all of us, which I felt when I interviewed. That everybody, starting out at the front desk all the way through, all the way down the corridor, there is something common to all of us. There’s something that we all have. That’s got to be why we work here.
Indeed, that common thread seems to be passion for this type of work. Even those who may not always see eye to eye with colleagues admitted that when there are clashes among staff, “everybody’s heart is in the right place.”
Part of this trust and reliance on colleagues for support may stem from the uniqueness of the job, as previously discussed, as well as the oath of confidentiality that they must take. Another aspect may be the perception of the job as a “lifestyle.” Several of the donation coordinators referred to the adage that “this is not just a job-it’s a lifestyle,” drawing attention to the fact that the boundaries between work and personal life are often blurred. Essentially, colleagues become like extended family. One donation coordinator even stated that they finish each other’s sentences. Many of the donation coordinators in this study spoke very highly of their colleagues. As one individual put it, I just see this specialness in every one of them, and I see the dedication and commitment, and I see the frustration, but they’re some of the best people I’ve ever met in my life.
Because of this issue of boundaries, some donation coordinators have had difficulties in their personal relationships. Carrying a pager and being on-call frequently would pose hardships on those whose family members disliked the intrusion. Those staff who could incorporate their children and partners into their work in some way seemed to handle this stress better than others. Educating children about the nature of the job helped, so that they understood the importance of the work. One donation coordinator commented that her children were so attuned to her work that they were quite fluent in the vernacular of the field. Others had partners who understood the importance of the work and showed their support in little ways. One former donation coordinator said, “my husband was very supportive. He would wait up for me, run my bath when he knew I was on my way home. Things like that, he always made me feel like, what an incredible thing you’re doing.”
Although the role of emotions and the use of supports were the most salient coping mechanisms for donation coordinators, other factors played a part as well. As noted in the literature on job stress,” participation in decision making is a critical aspect in the perception of stress. For donation coordinators, the autonomy and power of managing a donor case helps to offset the stress. As one donation coordinator exclaimed: “If you can manage a brain-dead donor, a grieving family, and unsure staff, and do all this over a 24-hour period with little or no food or sleep-it’s quite empowering.”
Dispositional optimism also played a role for some of the donation coordinators, who explicitly identified themselves as optimistic people. As one donation coordinator put it, “I am a more optimistic person. I tend to work through the things early on, and then put it behind me.” Another commented that she doesn’t like when others see the glass as “half empty.” Even for those who did not explicitly cite this dispositional trait, almost all of the donation coordinators conveyed an overriding sense of optimism in the way that they discussed their work.
In a profession that often speaks of gifts to others-the gift of life-there are also the gifts of working in this field. All of the donation coordinators in this study were able to discuss the meaningfulness of their work. For many, this meaning was interwoven in their faith, spirituality, or religion. Interestingly, half the participants in this study felt that it was fate that brought them to work at the OPO. For some, it was picking up the newspaper and finding the advertisement after a difficult day at work. One donation coordinator remembers, “Someone was trying to tell me something-this was what I needed to do.” For others it was a persistent co-worker or friend who kept telling them that it was the perfect job. The sense of being directed toward this profession permeated many of the donation coordinators’ experiences and seemed to be interwoven with the way they make meaning of their roles.
As Baumeister and Vahs31 have discussed in their work on meaning-making, several key elements of experience must be present in order for individuals to find meaning. These elements emerged compellingly during the interviews. First, there was an overarching sense of higher purpose in their jobs, which often made the demands and stressors manageable. As one donation coordinator recalls, “A really high sense of purpose [drew me to the field], a high sort of calling. This was an opportunity to make a dramatic impact on the lives of people who are desperately ill . . . beyond hope.” Others also experienced their role as having a dramatic impact on lives. As another donation coordinator put it, “it is more meaningful than going to work for Fidelity.”
Another salient feature of the donation coordinators’ experience was the opportunity to act in accordance with their values. All of the participants in this study spoke of the importance of doing what was right for the donor family and of the discord that they felt when they were asked to perform tasks that they felt were in direct contradiction to those values. Sometimes this was experienced within the consent process. One donation coordinator echoed the sentiments of many:
That’s one piece I struggle with . . . I would never ever try to convince somebody to do something that they didn’t believe in. I just can’t do that. I feel too much of my own integrity that I could not do that. And if I were expected to do that, then I would struggle with the job.
Others experienced this tension when they were expected to offer less than optimal organs for transplantation, knowing that it would only slow down the process for the donor family and staff. For some, this act represented the most stressful aspects of their work. One donation coordinator reported, “[the most difficult part of the job is] when a particular donor is not ‘ideal’-the hospital staff knows it, I know it, the AMD [assistant medical director] and case director know it-yet I am still told to go forward.” The donation coordinators in this study conveyed a definite and clear sense of their ethical standards. They seemed acutely attuned to acts that may violate their sense of a moral code of conduct; specifically, a code that prioritized the donor family’s needs and the hospital staff’s needs over all others. Therefore, in their eyes, any actions that were construed as possibly causing undue harm to others were experienced as repugnant.
One third of the participants in this study had had a personal experience with organ donation or transplantation before taking a position with the OPO. For these people, the work that they do takes on personal meaning. These donation coordinators, through a heightened sense of empathy, seem to be able to use these experiences to better deliver their services to others. They are able to use the memories of their experiences to drive their energies during a donor case, which for example, may give them the courage to call a cardiologist at two in the morning to interpret an echocardiogram despite protests.
Even beyond the ability to derive meaning from their work, the donation coordinators in this study were able to find numerous ways in which they derive benefit from their work. The most prominent aspect of this benefit-finding was in their acute appreciation for life. Because of their continual experiences with tragedies and grieving families, they were able to readily identify the poignancy in everyday events. This person shared a typical response from most of the donation coordinators:
I think that working at this job in general gives me a perspective on life that I would not have if I were doing something else . . . We are faced everyday with the fact that your life can change in an instant without any warning whatsoever, and it definitely gives you an appreciation for what you have, and sometimes you feel bad and you complain and you know you do all the things that everybody else does, but then, particularly when you come off a case, you really appreciate what you have, and it really does make your problems seem so small.
All of the participants in this study voiced this same perspective. Just as Victor Frankl noted decades ago, in the face of tragedy, they have been able to use their job experiences for personal growth. As another donation coordinator eloquently noted, “we search for joy and take joy where we can find it. If it’s just going outside to see the moon and stars and realizing how beautiful it is, then that’s where we need to take it.”
The gains that the donation coordinators have experienced also come from lessons about humanity that they have learned from donor families. Many spoke of the tremendous awe they had for donor families, but many also went beyond this appreciation to acknowledging an increase in faith in people. One donation coordinator remembers donor parents who told her that they were just honored to have been able to have their son for the short time they had him. This selflessness made a lasting impression. Another donation coordinator recalls a father putting his son in his care:
He said to me, I gave my son to you. You do what you would do as his [parent], because he’s yours. It was really overwhelming to me that this man, who clearly loved his son, would . . . give his son, body and soul, to a total stranger.
These kinds of experiences clearly left their marks. One donation coordinator reported that she felt blessed for having them and that the cases that she distinctly remembers are the ones where she learned something. Others also shared cases that gave them a new perspective or greater faith in humanity.
Being a donation coordinator is both exhilarating and exhausting. The autonomy and power that come with the position are very appealing, and yet they can also be isolating. To fulfill a desire for personal connection, donation coordinators are drawn to the donor family. It is through this relationship that they take on the role of therapist and guardian angel, counseling the family and promising to watch over their loved one. Most of the time, donation coordinators are able to derive much satisfaction in bringing good news to donor families. However, their role has its inherent pressures, as they find themselves at times with a negative outcome and must deliver bad news to a donor family. This job task violates the implicit (but sometimes explicit) expectation that good outcomes should always be the result of such an altruistic action. After all, guardian angels are protectors of all that is good.
The stressors that the participants identified were not only the more obvious (sleep deprivation, long oncall hours), but also stemmed from their own high standards for performance and responsibility to donor families. These stressors were most often handled through the expression of emotion-whether it was crying with donor families or on their way home from cases. Those who had access to these feelings seemed to be more satisfied with their work. Strong bonds with colleagues also contributed to donation coordinators’ emotional well-being.
Compassion fatigue and disenfranchised grief did not appear to be problems for this group of donation coordinators, despite the propensity for such job hazards. Protective factors seemed to be a supportive work environment for the expression of feelings (whether formally or informally) and the donation coordinators’ ability to derive meaning from their work. They were able to readily identify the rewards of their hard workboth in terms of the lives that they helped to save, and especially, the donor families to whom they brought comfort. Even beyond this recognition, donation coordinators in this study engaged in benefit-finding, in which they were able to reap benefits for their personal and professional growth. The most salient benefit was their acute appreciation for life-the ability to find joy in everyday things that most take for granted. As one donation coordinator seemed to sum up:
It’s not just a job; it’s a way of life. And it truly is because you have to be nuts to do it. On the other hand, once you’ve done it, it’s like you wouldn’t want to do anything else.
Generalizability of Study
In determining the kinds of experiences that are the hallmark of donation coordinators, it is important to ask whether this study is representative of the pool of donation coordinators in the country and in what ways the donation coordinators studied here might differ from the larger pool. Sampling in this study involved the interviewing of 21 current and former donation coordinators from 1 metropolitan OPO. Although many donation coordinators across the country share very similar job descriptions, donation coordinators in other service areas should determine the extent to which the experiences reported here accurately reflect their experiences. Those who spend more or less time with families, and those who serve both as donation coordinator and transplant coordinator, may identify with some of the material or not at all.
Implications for Management
Results of this research study have direct implications for both the administration at the management level of an OPO and for the donation coordinators themselves. Paramount to these findings is the systemic and social context in which the field of organ donation finds itself. With the administration of an OPO propelled by its mission to maximize the availability of organs for transplantation, so too are the donation coordinators propelled by their own agendas, that is, to find meaning in their work through a moral set of guidelines that are sometimes at odds with the administration to which they answer. A natural tension between these parties has created a successful balance insofar as the organization has been able to maintain valuable employees to carry out the work, and insofar as the donation coordinators have been able to find more gains than losses in their work. Overall, the balance seems to work.
Keeping this balance is a great challenge, however. Some of the changes that this OPO has instituted have caused disequilibria among staff and have taxed their personal resources. Larger numbers of donation coordinators and bigger teams have resulted in a loss in the familylike atmosphere in which donation coordinators seem to thrive. Also, with the addition of family counselors, many donation coordinators are spending far less time with donor families. This experience is essential to carrying out their work: not only does it give them a sense of meaning and personal satisfaction, it also gives them the energy and physical stamina to withstand the long hours and stressful interactions with hospital staff and/or transplant surgeons.
With relationships as one of the keys to a donation coordinator’s mental health, it is essential that administration assist staff with ways of fostering their relationships with donor families, recipients, and one another. Beyond just contact with donor families at the time of a donation event, donation coordinators would benefit from interaction with them well after such an event. One former donation coordinator in this study offered this very suggestion: By getting to know donor families outside of the donation event, the individual explains, “it prevents [donation coordinators] from having a memory of people who are frozen in time-a memory of people who are in overwhelming grief and deciding to donate.” Structured, professional events such as the donor family ceremonies are one way for this connection, but other ways such as through a speaker’s bureau or inviting donor families to speak with staff are others.
Interaction with recipients may also benefit staff. Opportunities to hear recipients speak about their transplants and what it has meant to them may add another dimension to the work of donation coordinators. These kinds of opportunities may add to their feelings of personal fulfillment. It would not be advisable, however, for donation coordinators to interact with people awaiting transplants, because that may cause undue pressure and grief for them, should these transplant candidates not survive.
Fostering positive interactions among donation coordinators is also critical to maintaining the health of both the staff and the organization. Ironically, many of the participants in this study felt that the size of the teams and the recent increase in donation coordinators has led to a feeling of isolation at the OPO. Most of the donation coordinators, however, could appreciate management’s efforts to reduce the amount of on-call time by increasing the staff size. Perhaps more opportunities for team-building would offset this feeling of getting “too big.” The importance of team-building should not be minimized, especially when new staff is added. Several of the participants in this study remembered having a difficult beginning with the organization, mostly because they felt like an outsider-little effort was made for them to be included. As one donation coordinator put it:
I don’t think they realized what it was like for [a new donation coordinator] to come and spend the week there and really not know that much about what was going on. I don’t think they even had any sense that I was uncomfortable.
Establishing welcoming rituals or traditions when new donation coordinators are hired may assist them in connecting with others immediately. As many donation coordinators reported, a more friendly beginning would have made a big difference in tapping into those external sources of support that have been instrumental in retaining valuable employees.
Another important implication for management is the organization’s recognition of the donation coordinators as being effective counselors. Donation coordinators seem to possess the critical skills needed in order to establish a therapeutic alliance with donor families-whether they learned these skills from their backgrounds in nursing, prior life experiences, or on the job, it was a notable finding in this study that their counseling skills are equivalent to those of persons who have had extensive clinical training and coursework in counseling. These skills are valued by the donation coordinators themselves and should be valued by management as well. Recognition for working with difficult families and difficult situations should be given routinely. Additionally, the skills they bring to the consent process should be recognized as being part of their jobs and cannot easily be parsed out to other staff with less experience or skill.
As with the demands of any high-stress job, a time and place must be made available for donation coordinators to process their thoughts and emotions on a regular basis. Because they deal with so many unusual and tragic circumstances, which may become layered upon one another over time, the ability to have a regular meeting (formally or informally) to debrief with peers is essential. Senior peers seem best equipped to facilitate these meetings, since most of the donation coordinators appear to have modeled themselves after these successful individuals. These senior peers would continue to serve as role models and assist others in finding ways to balance the hardships and rewards of work.
Implications for Donation Coordinators
Self-care is perhaps the most important ingredient in maintaining good mental health and being a successful donation coordinator-and it is perhaps the most difficult thing for them to do. Selflessness pervades the profession in such a way that caring for oneself has very low priority. The job itself begs an altruistic nature and care-taking mentality; however, donation coordinators must be encouraged to access whatever resources are available to nourish them. This would include reaching out to other donation coordinators and processing their reactions to donation events. There is a very distinct commonality in the experiences of donation coordinators, and this commonality can be an anchor during stormy times.
Given that all the donation coordinators in this study describe their work as a lifestyle, it is apparent that the boundaries between work and personal life are blurred. The blurring is due, in part, to being on-call for long periods and the length of time required to complete a donation event. There is no such thing as a 9 to 5 workday for a donation coordinator. The job becomes a “lifestyle” in the same way that physicians and other professionals maintain their identity across many spheres of their life.
Key to the emotional well-being of donation coordinators may be the ability to juggle 2 important processes: establishing clear boundaries, while at the same time, integrating those elements of their personal lives that remain on the periphery of their work experiences. Some of the donation coordinators were able to do this successfully. These individuals were able to establish boundaries through the development of outside hobbies (unrelated to donation), by developing friendships with people with no connection to donation, and by using vacation time to travel.
Those donation coordinators who had families, especially children, had the extra stressors of managing family time with work. The donation coordinators who seemed to juggle these demands well were the ones who made efforts to include their families in their work. Inclusion meant explaining the nature of their work to their partners and children, answering questions related to their work, and bringing them to outside events that were sponsored by the OPO or transplant community. By inclusion, these donation coordinators found that their families were less inclined to see work as an invasion of their personal lives.
This study was a beginning in understanding the complex and multilayered experiences of donation coordinators. Clearly, the talents and skills that they bring to the field of organ donation are invaluable and are deserving of attention. Further studies may be beneficial in exploring the perceptions of donor families in relation to their experiences with donation coordinators. Do they experience the donation coordinators as empathie and attuned to their emotional state? What attributes did donor families find helpful in easing them through the process? This information may provide OPOs and their staff with useful information for how best to conduct family discussions with potential donor families.
Let us not forget the important work of donation coordinators, without whom transplantation could not occur. The circumstances under which they work to bring the gift of life to others is humbling, especially to those of us who do not work under such intense pressure. Certainly, should any one of us find ourselves in the position of deciding to donate a loved one’s organs, it would be a privilege to be in the care of these selfless individuals.
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Patricia A. Blumenthal, PsyD
Family Service, Inc, Lawrence, Mass
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Phone (800) 809-2273 (ext 532) or (949) 362-2050 (ext 532)
Fax (949) 362-2049
Copyright North American Transplant Coordinators Organization Mar 2007
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