Having a sibling as donor: Patients' experiences immediately before ...

European Journal of Oncology Nursing 18 (2014) 436e442

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European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon

Having a sibling as donor: Patients’ experiences immediately before allogeneic hematopoietic stem cell transplantation Annika Kisch a, b, *, Ingrid Bolmsjö b, Stig Lenhoff a, Mariette Bengtsson b a b

Department of Haematology, Skåne University Hospital, S-221 85 Lund, Sweden Faculty of Health and Society, Malmö University, S-205 06 Malmö, Sweden

a b s t r a c t Keywords: Allogeneic stem cell transplantation Patients’ experiences Qualitative content analysis Sibling donor

Background: Allogeneic hematopoietic stem cell transplantation (HSCT) offers a potential cure for a variety of diseases but is also associated with significant risks. With HSCT the donor is either a relative, most often a sibling, or an unrelated registry donor. Purpose: The aim was to explore patients’ experiences, immediately before transplantation, regarding having a sibling as donor. Method: Ten adult patients with sibling donors were interviewed before admission for HSCT. The interviews were digitally recorded, transcribed verbatim and subjected to qualitative content analysis. Results: The main theme Being in no man’s land is a metaphor for the patients’ complex situation with its mixture of emotions and thoughts prior to transplantation. The three subthemes Trust in the sibling donor, Concern about others and Loss of control cover the various experiences. The patient’s experiences are influenced by their personal situation and the quality of the relationship with the sibling donor. While patients feel secure in having a sibling donor, they are dependent for their survival on the cell donation and feel responsible for the donor’s safety during donation. These emotions intensify the patients’ sense of dependency and loss of control. Conclusions: In caring for HSCT patients the nurses should be aware of the complexity of the patients’ situation and keep in mind that having a sibling donor might imply extra pressure, including a sense of responsibility. Caring for both patients and sibling donors optimally is a challenge, which needs further improvement and exploration. Ó 2014 Elsevier Ltd. All rights reserved.

Introduction Allogeneic hematopoietic stem cell transplantation (HSCT) offers a potential cure for a variety of diseases, mainly hematological malignancies. However there is a significant risk of complications and side effects, including the risk of mortality (Copelan, 2006; Ljungman et al., 2010; Pidala et al., 2009). There are several eligibility criteria which have to be met before an HSCT can be performed, i.e. a diagnosis which indicates HSCT, reasonable control over the disease, approved medical examination showing no or low levels of risk factors and comorbidities and being young enough (Sorror et al., 2005). One essential prerequisite for an HSCT is a

* Corresponding author. Department of Haematology Skåne, University Hospital, S-221 85 Lund, Sweden. Tel.: þ46 46 176133, þ46 46 172318, þ46 708 211373; fax: þ46 46 176021. E-mail addresses: [email protected], [email protected] (A. Kisch), [email protected] (I. Bolmsjö), [email protected] (S. Lenhoff), mariette. [email protected] (M. Bengtsson). http://dx.doi.org/10.1016/j.ejon.2014.03.004 1462-3889/Ó 2014 Elsevier Ltd. All rights reserved.

suitable donor, i.e. finding a donor who is reasonably HLA-matched. Thus, the patient is in need of a donor to increase their chances of survival (Coolbrandt and Grypdonck, 2010). Usually the search for a donor starts among the patient’s siblings, where there is a 25 percent chance that each sibling will be HLA-matched. Around a third of all HSCTs are performed with stem cells from sibling donors, two thirds with cells from unrelated registry donors and, to a small extent, from relatives other than siblings. In HSCT the donor usually donates the stem cells on the same day or one to two days prior to the patient receiving them. The method of donation is either harvesting of bone marrow, where the donor is sedated, or peripheral stem cell apheresis, which lasts for many hours with the donor awake. Thus, when the stem cells are being harvested from the donor the patient has already undergone the conditioning treatment with chemotherapy, sometimes combined with irradiation. This treatment is strenuous and severely impairs the hematological system meaning that the patient is dependent on receiving new stem cells from the donor. Fig. 1 shows a schematic flowchart of the transplantation e donation procedure.

A. Kisch et al. / European Journal of Oncology Nursing 18 (2014) 436e442

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Fig. 1. Flowchart illustrating the transplantation e donation procedure. The time schedule is approximate and the flowchart is schematic, showing the timeframe when a peripheral blood stem cell harvest is performed.

The eligibility criteria for related and unrelated donors usually differ. Donors who would not be eligible as volunteer, unrelated donors, can be accepted as related donors, for instance donors who are elderly or who have various comorbidities. Since relatives with comorbidities are sometimes accepted as donors, it is a challenge to take optimal care of both them and the patients. When a patient receives a stem cells transplant from a sibling donor who, for instance, may be mentally weak or elderly, there is little knowledge about the psychological impact, if any, on the patient or the donor, or on their relationship. Work is ongoing trying to define criteria intended to help to define the eligibility of related donors in general (Halter et al., 2013). Searching for a stem cell donor might be a time-consuming issue, which might prove fatal for the patient. Testing siblings for stem cell donation usually takes less time than searching for an unrelated donor. Most studies show that HSCT has a better outcome when the donor is a sibling than when the donor is unrelated (Ringdén et al., 2009; Weisdorf et al., 2009). However, in recent years studies have shown that results of HSCT using young, well-matched unrelated donors are comparable with HSCT using sibling donors (Ho et al., 2011; Mielcarek et al., 2007; Schetelig et al., 2008). Our own experiences (Kisch et al., 2008, 2013) and other studies (Christopher, 2000; van Walraven et al., 2010; Wiener et al., 2008) show that donating stem cells to a sibling or another relative and receiving stem cells from a sibling or another relative might be a complex issue. To our knowledge, the patients’ experiences immediately before a transplantation with stem cells from a sibling donor have not been explored. It is far from clear what thoughts and emotions patients have regarding having a sibling as donor. Thus, the aim of this study was to explore patients’ experiences, immediately before the transplantation, regarding having a sibling as donor.

Method Design A qualitative inductive approach with interviews was chosen for this study. A semi-structured interview guide was developed based on clinical experiences, relevant research and principles on developing an interview guide (Kvale and Brinkman, 2009). Participants Patients for whom HSCT was planned with a sibling donor, at a University Hospital in Sweden between March 2011 and December 2012 were asked to participate in the study. The inclusion criteria were: age at least 18 years with a sibling donor also aged at least 18 years and good competence in the Swedish language. Ten consecutive patients who met the inclusion criteria were asked to participate in the study and all ten agreed to do so. All donors of the patients participated in a corresponding interview study, the results of which will be presented in a separate report. Data collection Data were collected using face-to-face interviews before admission to hospital for the transplantation. For eight participants the interviews took place on the day of admission, for one participant one day prior to admission and for one participant eleven days prior to admission. The interviews were conducted at places chosen by the participants. All the interviews were conducted in a secluded room in the hospital by the first author (AK) who has significant professional experience with this patient group, but was

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not involved in the care of the participants in this study. The interviews were digitally recorded and lasted between 24 and 121 min (median 54 min). As stated above the interviews were semi-structured and used open-ended questions (Patton, 2002). All interviews started with an open question: Can you tell me about your feelings and thoughts when you got to know that you needed a stem cell donor for transplantation? And with the follow-up question: What did you feel and think when you were told that a sibling of yours could become your donor? The interviews continued with further questions in order to lead the informants to expand their answers and to clarify their thoughts about having a sibling donor. Data analysis The interviews were transcribed verbatim. The transcribed text was subjected to content analysis, inspired by the description of Graneheim and Lundman (2004). Content analysis was used not only to understand the manifest data but also to interpret the latent content. The first author (AK) simultaneously listened to and read all the interviews to check the accuracy of the transcript, become familiar with the text and gain a sense of the whole. Thereafter, each individual interview was divided into meaning units (sentences or paragraphs) and labeled with a code, according to the purpose of the study. All interview codes were compared and subcategories were identified based on differences and similarities. The subcategories were finally grouped into seven categories. The ultimate step in the analysis of the interviews was to interpret the underlying meaning of all codes and categories, which resulted in the formulation of one main theme and three subthemes. The first author (AK) conducted the analysis but, in order to increase trustworthiness, discussions between the first, the second (IB) and the fourth (MB) authors were held regularly throughout the entire analysis (Lincoln and Guba, 1985; Polit and Beck, 2012). The second (IB) and the fourth (MB) authors have significant experience in carrying out qualitative research, and interpreting interviews. Identified codes, subcategories, categories and overall themes from all ten interviews were discussed among the three authors. Alternative ways of interpreting, categorizing and organizing data were carefully discussed. The discussions resulted in final agreement regarding the results of the analysis. Ethical considerations This study was approved by the Regional Ethical Review Board for Southern Sweden (Dnr 541/2007). Written and oral information about the study was provided by the first author during the informants’ visit to the hospital 2e3 weeks prior to admission for transplantation. In accordance with the Declaration of Helsinki, the participants were informed that participation was voluntary and that they could withdraw at any time without there being any negative consequences. They were assured that their confidentiality would be respected throughout the research process. The first author telephoned the participants some days after the visit to ask for verbal informed consent and a time and place for the interview was set. Written informed consent was obtained from the participants just prior to the interview. Results Participant characteristics The participants in the study were four men and six women. The median age of the patients at the time of the interview was 61,5 years (range 19e68 years). The diagnoses were: Acute myeloid

leukemia (3), Non-Hodgkin lymphoma (2), Myeloproliferative disease (2), Acute lymphoblastic leukemia (1), Chronic myeloid leukemia (1) and Severe aplastic anemia (1). The median age of the sibling donors was 54 years (range 26e66 years). Five were men and five were women. The gender constellation was: male donor to male patient (3), male donor to female patient (2), female donor to male patient (1), female donor to female patient (4). For nine of the donors the collection of stem cells was performed by peripheral blood harvest and for one donor by bone marrow aspirate. Being in no man’s land All the participants’ narratives are pervaded by descriptions of being in a complex situation with a mixture of emotions and thoughts. When the patient is about to be admitted to hospital for the HSCT, it becomes obvious to them that the donor’s part is of considerable significance in increasing their chances of survival. While the patients experience a sense of security and trust in the sibling donor they also feel a sense of uncertainty about the future and a sense of dependency on others. One main theme Being in no man’s land emerged from the analysis and was supported by the three subthemes Trust in the sibling donor, Concern about others and Loss of control. During the analysis of the interviews it became evident that the personal situation of the participants has an impact on the experience of having a sibling as donor. This is reflected in the results. Experiences from the past, personal experiences and experiences in relation to the sibling donor, and the life situation of the patient at the time of the transplantation all have an influence. Past or on-going crises concerning money matters, separations and diseases of next-of-kin also influence the patients. Another factor that impacts on their experiences is the quality of their relationship with the sibling donor, i.e. if the relation is intimate, if it is strained or if there is no contact at all. As revealed in the interviews, siblings are not a homogeneous group, they are just individuals who happen to have the same parents. The interviews also show that the situation of the sibling donor, such as crises, diseases and mental condition, influence the patients’ experiences of having a sibling as donor. Under each of the three subthemes two or three categories were identified, giving a total of seven (Fig. 2). The categories are woven into the text below, printed in italics, with the subthemes used as headings. Quotations are included to express the participants’ experiences associated with each category in their own words. Trust in the sibling donor The narratives reveal a sense of calm with confidence in the sibling donor with no worries about withdrawal of the donation. While the participants count on the siblings there is at the same time a humility and gratitude felt towards the sibling for standing by the patient in this complex situation for being willing to help whatever the cost. The interviews demonstrate a sense of relief felt at two points in time: when the participant learned that the sibling was a matched donor and again later when the sibling had been approved as a donor after the health check. The sense of relief also includes the feeling that the donor is involved in the process and is happy to make the donation. “It was a relief when I got the news, I was a little calmer and felt that things were getting started. When I got the news I rang M (the donor) and he was so happy, he thought it was great that he was the one who had been chosen. I am sure, that’s how you would feel; I mean he is giving me the chance to get well.” (P4)


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Fig. 2. Illustration of the complexity of the patients’ situation immediately before HSCT with a sibling donor e being in no man’s land.

The narratives show a strong sense of security in having a sibling as donor. Many of the participants feel more secure than if the donor had been unrelated, i.e. they feel better knowing where the cells come from, what kind of life the donor has lived and have a sense that the donor will not withdraw the offer. This sense of security encompasses the feeling of receiving support from the donor and his/her family and, according to the participants’ descriptions, of the transplantation and donation being a joint project for the two siblings. The interviews also demonstrate that the relationship with the sibling improved after they decided to become the donor. “It just feels calm, knowing you have the hundred percent best donor possible feels just fine. I have never been worried.” (P8) There are expressions of sense of gratitude to the donor. The donation is perceived as a gift from the sibling. The narratives show an awareness that the donation is not painless or free from risks. At the same time there are perceptions that the donor is acting with enthusiasm in order to help the patient to survive. The interviews show that the participants feel that sibling donors should be recognized, by the families and healthcare professionals, for their efforts and they should be supported in their situation, since they are important, valuable and save lives. ”It’s a great gift. I use the word gift all the time, and he is so very happy that he can help out and then I ’m happy.” (P2)

Concern about others Concerns about responsibility and caring about others are clearly expressed in the thoughts presented in the narratives. These emotions concern the donor particularly. Even feelings about what

the transplantation and donation entail for other relatives are revealed, including a sense of being a burden to others and a feeling of responsibility. The sense of responsibility for the donor is presented by an emphasized disinclination to expose the sibling to risks and unpleasantness and a wish to spare them from as much inconvenience as possible. Responsibility is shown in connection with concern about the sibling during donation. The interviews reveal feelings of obligation, of knowing what the sibling donor is going to go through, and of concern from knowing about the risks associated with the donation. The patients expressed feelings of having a duty to support the sibling. Feelings that they had been selfish and not engaged in the situation of the sibling donor until shortly before the donation were also stressed. The sense of responsibility for the donor increases when the participant is aware of the donor’s anxiety about the donation. Concern about the sibling donor also includes positive feelings that the sibling develops from doing a good deed and benefitting by donating stem cells. Then I can feel that she will be in much pain and I feel sorry for her about that. She has never been under anesthetic and she has said ‘what if I don’t wake up’ then I try to reassure her. When I try to reassure her I get worried for her sake because she is so worried about it.” (P9) A sense of responsibility for relatives is highlighted by thoughts and feelings expressed regarding the influence of the donation and transplantation on various relatives. Siblings who do not match as donors appear to feel left out of the shared communion between the donor and the recipient, and even left out of the family as a whole. Such experiences highlight the participants’ unease about causing siblings to feel they are left out. However, some participants experienced that the transplantation-donation brought all siblings in the family closer together. Some siblings even seemed to be relieved at not having to donate.

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“I believe that, in a way, he (brother, not the donor) would have wanted to be the donor because he feels he has lost out in the relationship, I notice that he can feel a little excluded. I haven’t thought about it in this way before, but it would probably have meant something to him in fact.” (P1) There is a feeling among the participants that they have the duty to support the family of the sibling donor. The participants had not talked much about these feelings to the relatives, but they had observed them and been thinking about it. The family of the donor had expressed, verbally and in their behavior, that they were worried about the donor and the donation procedure. “I have just changed focus over to his wife and children, that they are putting up their husband and father if something happens. And I feel I have to talk more to my sister-in-law, because I think she is making a contribution, but it will have to be spontaneous because she doesn’t know my thoughts. (P2) The patient’s family worry about the transplantation-donation procedure, focusing on the patient, and the participants seem to feel it is their responsibility to reassure them. The concern about their own family and how their lives will be affected during and after the transplantation is much in focus and together with all other emotions, takes a lot of energy from the participants. ”The only thing that worries me is how my wife will cope at home, because she is not well, yes, that’s the biggest problem. I have to help her with everything because she can’t manage anything, she’ll soon be just like a vegetable. So she thinks things are really difficult now, she will be very much alone” (P8)

their lives. Some interviews reveal that the participants feel obliged to be extra kind to the donor until the donation, to ensure that the sibling completes the donation process. The changed relationship with the donor was seen as a positive change by some participants but as creating a forced and binding relationship by others. “When she wants to meet it’s not in my thoughts to say that I don’t have the energy. I have to give her priority otherwise I don’t really know how she will take it and if there could be consequences... It’s a matter of keeping up her energy because she obviously thinks that this is very important, and it is, it’s a matter of life and death!” (P5) The feeling of being a burden on the sibling donor, and even on other relatives, strengthens the patients’ sense of being dependent on the sibling donor. Such feelings are perceived to complicate the already difficult situation for the patient with the various symptoms and worries about survival. Along with these feelings come feelings of powerlessness, they cannot do much to influence the future; they have to rely on others and on the treatment. “You feel a bit of a burden, since a registry donor, as I understand, is someone who voluntarily, with no relation to anyone chooses to be tissue typed. With siblings it’s a bit like asking a favor. From that point of view, it would in a way have felt better with a registry donor . but then you know there is a certain difference to the prognosis. But you do feel a bit of a burden and that feeling of being a burden you wouldn’t have had towards a registry donor.” (P3)

Discussion Loss of control Uncertainty about the future due to the life-threatening diseases pervades the narratives and together with the feeling of being dependent on others, especially the donor, makes the patient feel that they have lost control. The sense of uncertainty is central in thoughts and emotions emphasized in the interviews. All the participants had lifethreatening diseases and were worried about whether they were going to survive. Waiting for some weeks to be told if the sibling was a matched donor was difficult and worrying. Some participants felt uncertainty immediately before transplantation about whether the donor would go through with the donation process due to medical circumstances and the mental condition of the donor. There is a sense of uncertainty about how the transplantation will proceed coupled with a desire to survive and continue to live. Even if the patient were to survive there remains an uncertainty about what the future will hold, i.e. what side-effects there will be and how will these affect them and their lives. “I thought, if no one is suitable I’ll have to wait for a very long time. Then, of course you feel sad, and then what happens to the illness, perhaps it will progress or something, I don’t know that, but still it felt a bit scary.” (P9) The sense of dependency on the sibling donor is strong since the patient is in need of a donor to increase their chance of survival. The feeling of being dependent on the sibling donor is highlighted in various ways. A sense of indebtedness towards the sibling and an obligation to compensate the sibling afterward emerged from the narratives. Some participants’ perceptions show that they believe that the feeling of dependency and debt will remain for the rest of

The results from this study clearly show the complex situation of patients with sibling donors, experiencing a variety of emotions and thoughts immediately before transplantation. The main theme Being in no man’s land is a metaphor of the patients’ situation of being in a kind of vacuum before HSCT. The different experiences of trust, concern about others and loss of control do not come in a particular order. They sometimes appear one at a time and sometimes several at the same time depending on the circumstances, as is illustrated in Fig. 2. Having a sibling as donor was, not surprisingly, regarded as positive by many patients and comprises one of the subthemes, Trust in the sibling donor. A sense of security was clearly shown and the patients compared it to the situation of having an unrelated donor. The donation was seen as a gift from the donor and welcomed with expressions of gratitude. However, to donate stem cells is not a risk-free procedure (Halter et al., 2009; Wiersum-Osselton et al., 2013), and the patients’ awareness of this is demonstrated by their worries about the donor’s safety. Our study clearly shows that this leads to feelings of concern for the donor since it is the patient who is putting the sibling in the situation of becoming a donor and all the accompanying unpleasantness. These emotions complicate the situation, putting extra pressure on the patient who is already in a difficult situation struggling with a life-threatening disease, strenuous treatments and uncertainty about the future. While the patients are worried about the donor’s safety they are also grateful for the donor’s contribution since they need them to make the effort. As far as we know, there is little knowledge about HSCT patients’ experiences of having a sibling as donor. However, in studies of recipients of kidneys from living related donors, who are in a comparable situation to recipients of sibling stem cell donors, there are several descriptions of gratitude, guilt, willingness to repay the donor, responsibility, being indebted to and worried about the donor (Gill


and Lowes, 2008; Sanner, 2003; Sajjad et al., 2007), similar to the findings revealed in our study. Before HSCT the patients may experience some sort of control of the situation at one moment and be overshadowed the next by a sense of no control at all and being powerless. The sense of loss of control has been described earlier as part of the experience of patients going through HSCT, related to control over life in general and over one’s health status (Coolbrandt and Grypdonck, 2010; Cooper and Powell, 1998; Haberman, 1995; Larson et al., 1993; Steeves, 1992). However, our study is the first, as far as we know, to throw light on the situation of HSCT patients’ loss of control related to having a sibling as donor. The fact that the patients have to rely on the sibling donor’s input to increase their chances of survival intensifies their sense of dependency and having lost control. To become dependent for survival on a sibling willing to become the donor might be a distressing situation, mainly psychologically and socially, and might even influence recovery. It became evident from the results that the personal situation of the patient, including the quality of the relationship with the donor, influences the experiences. Relations differ and might be complex depending on their history, and sometimes siblings do not have any contact at all, for years. If the relationship between the siblings is good the patient feels secure in having the sibling as donor, but if it is poor the patient might not feel certain that the sibling will go through with the donation procedure. The result that patients experience a changed relationship with the sibling donor should be seen in relation to sibling donors’ experiences of a changed relationship with the patient after the donation, which has been shown in earlier research (Christopher, 2000; Wiener et al., 2008; Williams et al., 2003). We may assume that if the patient experiences a strengthened relationship, the sibling donor has the same kind of experience, and the reverse if the relationship is felt to be weakened. In some cases, however, the patient and the sibling donor might have opposite experiences. In studies of recipients of kidneys from living related donors psychosocial issues and an understanding of the relational history of donors and recipients have been highlighted in the provision of supportive care (Gill and Lowes, 2008; Sanner, 2003; Sajjad et al., 2007). These findings should be extended to the research and care of recipients of stem cells from sibling donors. Patients who are about to undergo HSCT with stem cells from an unrelated donor probably have experiences similar to those shown in this study. Having a sibling as donor might strengthen the sense of security and trust but might also complicate the situation. All HSCT patients face uncertainty about the future, irrespective of donor, but feeling responsible for the donor and unsure about whether medical or mental conditions will prevent the donation process going ahead probably do not exist to the same extent for patients with unrelated donors since the donor is unknown.

Implications for clinical practice and research Experiences of HSCT patients and their family members have been described in previous studies (Andrykowski, 1994; Syrlaja et al., 2004). However, to our knowledge this is the first study with the aim to explore patients’ experiences by interviews regarding having a sibling as donor. In the care of HSCT patients the nurses should be aware of the complexity of their situation and the diverse emotions and thoughts. The nurses should keep in mind that having a sibling as donor might exert extra pressure on the patients, including a sense of responsibility. One way to enable individualized care and support is for nurses, prior to the transplantation, to dare to ask the patients about their personal situation, the quality of the relationship with the sibling donor and what

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feelings the patient has towards them, as has been pointed out in an earlier study (Kisch et al., 2012). The care of recipients from sibling donors and sibling donors themselves needs to be further improved and explored. To gain knowledge about whether the experiences revealed in this study remain static or change over time we are conducting an ongoing interview study with the patients up to one year after HSCT. It is challenging to take optimal care of both patients and sibling donors, irrespective of the quality of the relationship. We are also conducting an ongoing interview study with sibling donors in order to explore their experiences and perceptions of being a stem cell donor for a sibling, to enable improvement in the care of sibling donors.

Strengths and limitations The results of this study have been evaluated in terms of trustworthiness (Lincoln and Guba, 1985; Polit and Beck, 2012). Credibility was strengthened by the differences in the participants’ age, gender and kind of relationship with the sibling donor. Credibility was further increased by making the interpretation of the data visible to the reader by the incorporation into the text of quotations from the participants’ narratives. The quotations are translated from Swedish, but to reduce the threat to credibility they have been translated and back-translated. The first author made efforts to increase dependability by attempting, during the interviews, to achieve a mutual understanding of the meaning of the questions and responses and inviting the participants to deepen their narratives. The first author’s pre-understanding from the care of HSCT patients could have influenced the interpretation of the interviews, but the open dialogue with the other authors, who have no experience from this context but are experienced in qualitative research, helped to minimize potential misinterpretation and enhanced the confirmability and trustworthiness of the study. Concerning transferability, the results of this study may be applicable to HSCT patients with a sibling donor in other settings.

Conclusion To conclude, this study clearly shows that, immediately before HSCT, patients with a sibling as donor are in a complex situation and experiencing a mix of emotions: relief, security, gratitude, uncertainty, dependency and responsibility for the sibling donor and for other relatives. The personal situation of the patient and the quality of the relationship with the donor impact on the experiences. Knowledge that the patients experience these emotions can help nurses to better understand the patients and provide individualized supportive care in a professional manner. We want to stress that the care of each patient should take into consideration his or her personal situation and needs, including the relationship with the sibling donor. The results of this study can certainly contribute to the quality of care and support for HSCT patients with a sibling donor.

Conflict of interest The authors declare they have no conflicts of interest.

Acknowledgment We would like to thank the patients who agreed to participate in this study.

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