and its family assistance, a list of those is provided at the end of our presentation. We have a lot of slides, and I'm going to figure out exactly. We have a lot of slides to present, and we don't have enough time to go into the detail we want to. So during the next few slides, I'm going to talk about some of the background information from our earlier presentations. This slide shows the mission statement of CCDC. The mission statement for the CMS program was to provide a modular systems architecture for rapid deployment of new capabilities to the UH-60 fleet in the shortest timeframe possible. I'm going to manipulate this differently than I thought it would, so it's taken me a little bit more time. To perform that mission, CMS selected the face technical standard and face approach as its foundation for its architecture and management plan. In 2018, the CMS project served as the basis for a large-scale integration event at the PO Aviation Face Tim. 19 vendor products were shown in alternative versions of CMS. The alternatives included replacement key components of CMS as well as extending CMS capabilities. This demonstration started what we call the rapid integration framework, a set of architectural approaches, including the face technical standard that a family of systems can follow to better share software and hardware capabilities. Since that 2018 event, the number of systems in our CMS team has supported, has grown. CMS has flown with an active duty unit as part of a limited user evaluation, and CMS was permanently installed in the UA-60 Air Force HH-60U with additional capabilities to support its gimbal-mounted sensor. Today, the CMS family systems continues to grow across more laboratory systems for demonstration of technologies and is progressing toward deployment on more new aircraft systems. So today, our presentation is on how the common set of architectural approaches can facilitate the rapid integration of new technologies. The time it takes to get a new technology out to our airborne weapons systems is unacceptable when compared to our adversaries. The direction we're getting from DoD leadership is to find new ways to reduce this lag. The face approach was developed to enable the deployment of new capabilities across a variety of weapons systems by having the architectures of each weapon system open to accepting complex software from other platforms. Thus, the deployment of software to the first platform would burn down the schedule and cost of the alignment to other platforms. This technique can be attended to the technology demonstrations we use as technology evolves. This chart shows the TRL levels. As technology moves, it moves from refresh level one through nine. The CMS systems or the systems within the CMS family systems currently include a number of laboratory systems for early technology demonstration through the field of aircraft, and that list is growing as we can see. In the early stages, technology is primarily in the hands of the vendor. As technology demonstrators within the Army, our technology is demonstrated on technology demonstrators within the Army to show how the technology can be used to support the Army's mission. User interface working groups can help evolve the technology in preparation for use by flight crews, and the technology is also demonstrated in flight tests from bolt-on pallets to eventual integration into permanently mounted aircraft equipment. I'm starting to catch up on where I should be on my schedule. Sorry for talking so fast. If we apply a set of common architecture approaches across these systems, we can see the benefits shared software components can provide. We can also see the technology evolution rapidly moving toward a set of components that are ready to deploy. Simulations, for example, can be factored into the architectural approach and reused across early demonstrations. The adoption of architectural approaches common with the field of systems can allow field of software systems for use in early demonstrations. A wider application of these common approaches can lead to a reduction in costs and schedule for the deployment of these laboratory systems as well as provide a path for technology evolution that moves the technology closer to the final architecture, integrates the technology with production systems, and reduces the rework of software after the demonstration period. So, through our experience on CMS, there are several architectural approaches that we recommend. The first of those is the face technical standard. It's an obvious choice. It provides a foundation for a software MOSA that has been directed for use by PU Aviation on development for new and existing platforms. And it stands to reason that new technologies should embrace the face technical standard for deployment to Army aircraft. Some of the other architectural approaches to consider, including in the family systems, include configurable core capabilities that adopts to deployment of new capabilities without the need to recompile or requalify them. This is particularly of interest when a system supports mixed design assurance level capabilities. Core system components can be built to support higher criticality capabilities and simply to configure to support new lower criticality capabilities as they're added. This leads directly to the airworthiness considerations. The patterns for separation of the software capability throughout the family systems application of some of those approaches limits the impacts of airworthiness and future integration of capability software based upon those technologies. Normalizing a set of common services is also critical to a more unified approach throughout the family systems. What language should be the software be developed for? How will the configuration of the capabilities be used in the final aircraft systems? How should the software log events? What user interface capabilities will the software be used for display and control? All of these things could be applied to early technology demonstrators that match what we would find in the production aircraft. We should also be working toward a domain specific data model that's used across the family systems. This can allow the development of new technologies around the data modeled elements that are already existing on the aircraft that can greatly reduce the need for transforms and marshalling within the transport layer. Through this, we can identify a shared data model of changes that will need to be made in support of new technology. We're not asking for conformance early in the process. So those identified elements can be submitted to the shared data model PCB and given a time to get approved prior to the eventual fielding. As mentioned earlier, the factoring of simulations and simulation interfaces into the architecture for reuse across family systems constructed along architecture patterns are better able to adopt to a changing set of real and simulated equipment. This can extend their value to a wider set of systems within the family systems. The use of simulations also plays into training and software development kits. If the family systems has a simulation environment that was portable and available to technology suppliers, the suppliers can get a better understanding of the architecture and develop their software in the architecture prior to the arrival of the first demonstration. This SDK would be developed based upon a reference avionics system that meets the architecture in an aircraft agnostic manner. The architectural approach to user interfaces is a principal concern. Most new capabilities brought to the aircraft will have a new user interface. The user interfaces will likely be provided by a set of configurable core capabilities that deal with the rendering to a display or the inputs from switches such as touchscreens and keyboards. The model view controller pattern expresses the user interface in terms of a model, which is the new capability, a view that the user has of the model, and a controller through which the user can manipulate the model. Software developed for new aircraft systems should separate the user interface from the model in terms of the controller and view components. Having a set of well-defined standards for doing so seems an obvious key interface to include an architectural approach that's selected for the family of systems. Another thing to consider is the rendering of geospatial entities. Many new capabilities we bring to aircraft systems include the situational awareness of the air crew to be informing them of objects and entities around the aircraft. Having a common interface for sending geospatial entities can allow for configurable core components to render this situational awareness data. This can allow new capabilities to be added to the SA system without recompilation or requalification of the SA system itself. So if we look at the selection of the architectural approach using a trade study methodology, we've done a development of the trade study for a graphical standard. We can look at the criteria for evaluation of a graphical standard that fits within what we desire for an avionic system. The portability, the standardized interface, standardized control, limited recompilation, you can read these on your own. Mill Standard 1472G, which is the standard for display, is one of the critical things and, of course, separation of criticality. If we evaluate various alternatives against the list, we see that Eric661 provides the standard that we need for separation of safety concerns. This should come as no surprise as Eric661 was developed to specifically answer these concerns where the other alternatives were developed for other purposes. Some of the alternatives shown here have been proposed as alternatives to 661 and could be utilized as a face technical standard. The rating scale we've used here treats a one as an objective that's built into the relevant standard while a four represents an objective that is not obtainable using that standard alone. And as I said, from this, we can see Eric661 is the only thing that can really meet the safety, separation of criticality, and the integration of a single unified display across multiple capabilities. Some performance concerns around Eric661 when it comes to the generation of complex imagery. Eric661 was developed primarily for the display of gauges and simple, clean user interfaces. When it comes to displaying video, fabricated external views, or rendering PDF pages, the standard provides an external source widget. This widget allows applications to bypass the restrictions of the traditional widgets and render to the graphics card directly. Note that this does bypass some of the user interface advantages of traditional Eric661 widgets and should be used sparingly. The face technical standard 3.0 has formalized the manner that a widget can be used to provide the same level of criticality protections that this external source widget can be used and still allow multiple software units to render to OpenGL. Overlaying the model view controller on the face technical standard with Eric661 and OpenGL might look like this image here. So trying to get to my conclusion so I can get the questions. So the family of systems, reference avionics system utilized in the technology demonstrators can provide the greatest level of reuse within these systems. Using face technical standard Eric661 and a common domain specific data model can get those technologies to the field faster. And using informed engineering decisions should be able to make each program or should allow each program to assess if that program fits within this kind of a family of systems following those strategies. And of course, programs seeking to take advantage of CMS lessons learned may be better served to adopt the decisions presented here. My last slide is the list of presentations that Steve Price and I have done in the past. And Steve can say now, high now, since we have a little bit of time left, if he unmuted himself. We don't see him on there, Chris. Oh, okay. He knew I was gonna be presenting because we didn't have time to really trade off like we had planned. Okay. But this is our Q&A section, so... I do not see any questions in the Q&A. Does any... Joanne, do you? I do not. Okay. Okay, Chris, I don't think we have any questions at all. Thank you very much. Our next paper will... Oh, wait a minute, one just came in. How do geo-entities... This is what it says. How do geo-entities handled by CVS? So in ERIK661, there is a... In the earlier supplements, there is a map horizontal component, which has a way of sending geospatial entities, basically a symbol and a location or a label and a location. You can draw triangles. You can draw a grid of information like you could draw weather on top of a map by sending what's called a map item list to the map horizontal, which individual user applications within ERIK661 can then just render to geospatial without necessarily knowing where the view is on the map. Supplement 8, which came out this year, has brought in three-dimensional mapping, which we can use for out-the-cockpit views. You can overlay that on top of a sensor, a geosensor, or you can use it to render synthetic vision and pan around using 3D. Does that answer your question? I believe it does. Since it came into Q&A, we can't really see. If there are any follow-on questions, please put them in the Q&A and we will get them to Chris. Thank you, Chris. Very much. Appreciate your... Oh, here comes another one. Does FACE account for infrastructure management of the physical network hardware? No, the physical network hardware is something that can be handled by the transport layer. So FACE is basically abstracted that away. Within a family of systems, if we're focusing on a software-centric aspect of the family systems, we should be able to write to a generic transport and we've used multiple transports using the CMS code. So the transport and the physical layer can be agnostic. And the person wrote perfect. Thank you.


I'm delighted to welcome you to today's meeting of these seminar series on ethical issues and organ transplantation. Our speaker today is Dr. Eliza Gordon from Northwestern University, where Eliza is a research associate professor in the Institute for Healthcare Studies and the Department of Surgery. Eliza earned her MD, I'm sorry, her PhD in medical anthropology at Case Western, did a year with us as an ethics fellow at the McLean Center, and then completed a master's degree at UIC in public health, where she specialized in community health. Eliza has published over 50 peer-reviewed publications, and her research interests include the Ethics of Organ Transplantation and Donation, Healthcare Access and Outcome Disparities, Research Ethics, and Chronic Illness Management. Currently Eliza serves on the Ethics Committee of UNOS, on the board of the American Society for Bioethics and Humanities, and as the director of CTECH. CTECH stands for the Chicago Transplant Ethics Consortium, a group that does research and writing on current topics in organ transplantation. It's a very active group, and they meet, I guess, weekly by telephone and computer. So I'm delighted that Eliza will be talking to us today about ethical challenges in informed consent for living donors. Welcome. Thank you, Mark. I really appreciate the invitation to come and speak to you and your colleagues here. It's a real honor to be a part of this transplant lecture series. So I've been doing some research in informed consent for living donation for the past several years, and this is kind of a nice synthesis of some of these ethical issues. So can you all hear me okay? Great. All right. So what I want to do is start off with providing the basic, you know, groundwork of the definition of informed consent and move into how informed consent pertains to transplantation and specifically living donation. I feel like I need a stepping stool because I want to see everyone over the screen. I also will go into some of the epidemiological context about living donation because that helps set the scene or give you a little bit of important background to understand what's going on in the minds of living donors. Then I'll move into some of the ethical issues in living donation and really zero in more on the ethical issues in informed consent. If there's time, I'll present some of the findings of one of my research studies and also then conclude with some future directions and interventions that may help to improve informed consent. So just to start off with, a basic definition of informed consent that can be described as an informed consent is an autonomous authorization by individuals of a medical intervention or of involvement in research that occurs if and only if a patient or subject with substantial understanding and in substantial absence of control by others intentionally authorizes a professional to do something. So there are several required elements of informed consent and informed consent is a process. It entails clinician and transplant candidate or patient or researcher communication and it's designed to assess in this case transplant candidates or living donor potential donors competency to make decisions. The disclosure of information regarding the risks, benefits, alternatives, the procedure and assurance of donor comprehension of disclosed information and informed consent involves and a voluntary decision and agreement to undergo the suggested procedure. So obtaining informed consent upholds the principle of self-determination and supports autonomous treatment decisions consistent with the candidates or potential donors life goals values and beliefs. So informed consent applies to any treatment procedure in the context of clinical research or treatment or research and informed consent for surgery is an ethical obligation a legal requirement and part of the patient's rights condition of Medicare participation for hospitals so Medicare has its own very specific requirements when it comes to informed consent in the transplant context. So in the context of transplantation these conditions of Medicare participation specify that each patient undergoes an extensive process of informed consent. It begins at referral and then ends with the written consent for surgery. And so CMS centers for Medicare and Medicaid services and the OPTN specify very particular information that should be disclosed to potential living donors and you can even go to the UNOS website and look at the revised policy that was revised just last month or two months ago. So with regard to living donors there are some specific required elements that need to be disclosed. The advisory committee on organ transplantation ACOT of the United States Department of Health and Human Services has established standards for informed consent for living donors and in particular they state that living donors must be informed about the risks benefits and alternatives to the donor and to the recipient. So in a way there are there's more than just the donor's life at stake there's also the recipient's life at stake and so it really requires balancing an extra set of perspectives when considering informed consent. The living kidney donor follow-up consensus conference stressed the need to inform living donors about the risks specific to themselves and I'll get into the rationale for why that's important in just a couple minutes but just keep that in mind so when I discuss some of my own research you'll remember that. And then respect for autonomy means that living donors have the right to determine how much risk they are willing to accept and that living donors as well as recipients have the right to refuse the donation so just because a potential donor wants to donate doesn't necessarily mean that the recipient will accept it. Okay and as I mentioned the OPTN has just revised their policy and updated their content that has to be disclosed. So in addition to the reason I just mentioned about why it's important to undergo informed consent there are a couple other things to keep in mind. One is that informed consent is important for ensuring patient safety especially in high risk clinical situations you want to make sure that donors in particular know what they're getting themselves into. As well there's been some really interesting research showing that being prepared for your surgical procedure in surgery more broadly and having realistic expectations are associated with better post-surgical patient health outcomes. So for example people have better functional health outcomes, perceived health, quality of life, greater engagement in their post-operative care, all those things. So being informed means or being prepared means it really relies on being informed so the two kind of go hand in hand. Okay so now I'd like to provide a little bit of epidemiological background about living donation. So living donation has been performed essentially to remedy the organ shortage. There's only so many deceased donations and living donations offer a nice supplement to address the shortage. So living kidney donation has been going on since 1954. Adult to adult living donor liver transplantation has been going on across throughout the world since 1989 but in the United States since 1998. There are over 95,000 patients waiting for a kidney transplant and in 2012, 16,000 received one and with regard to liver over 15,000 patients are waiting for a liver and only 6,000 received one. So there's a much different I guess magnitude of the need and difference between who is waiting and who's receiving one. And then about a third of all kidney transplants come from living donors and then about 4% of all liver transplants are from adult living donors. Just to continue a bit, so living donation rates have really declined over the last several years and you can see that the peak was in 2004 for kidneys. It was up to 6,600 but it's dropped more recently to 5,600 and the same goes for livers. It's dropped from 2001 to 2012. It's just been this ongoing trend and there have been a number of speculations as to why this has been going on but no firm definitive answer. There have been a couple ideas. The decline has been attributed to the less availability of living donors given that family members tend to donate but the recipients tend to be a little bit older. Economic factors having to get out, having to not be at work and then taking the paid leave or taking leave and not getting paid. That's been another key issue that people have suggested. Some programs may not encourage living donation, particularly some programs may not have living liver donor programs, very few in the country have those. And then a number of well-publicized living donor deaths, there are more than four but this is the four I was thinking of, have raised a lot of concerns about the safety of the donor procedure. So I'd like to turn to some of the ethical issues in living donation and the three key ones are the issues of non-maleficence, the categorical imperative and informed consent. So let's turn to issues of non-maleficence for a store of do no harm. A key issue of concern particularly for surgeons cutting into a potential donor is that it presents a lot of serious harms. You're cutting into someone who is otherwise a healthy living person and they don't need any kind of, they will not gain any kind of medical benefit through the process of undergoing surgery. So this really counters the whole imperative to do no harm. We can see here in this chart that there's magnitudes of difference between living donor, living liver donors and living kidney donors in terms of the complications and outcomes. So for kidney you see 0.03 percent chance of mortality whereas for liver it's 0.4 percent. And then with regard to the major complications for kidney three to six percent whereas clavian grade two refers to the moderate complications, grade three is like really severe. So 48 percent get moderate kinds of complications. And then with regard to mild complications 22 percent of kidney donors experience those whereas 42. So living liver donors have I would say magnitudes greater risk that they're undertaking. And what's interesting is that while a lot of the complications do get resolved say within months to a year there are some that emerge after a year. So Dr. Michael Abacassus who's the chair of our transplant program at Northwestern he and other members of the adult to adult live liver donor transplant consortium or A2 all they in a series of nine transplant centers doing adult to adult living donor transplant consolidate their data and found that a lot of living liver donors experienced complications after one year you know after one year after two years after three years four years five years six years post donation so that remains a problem. Another concern is the issue of the categorical imperative basically using people as a means to an end. I mean essentially living donors are undergoing the surgery to help another person they're not doing it for themselves so that is a concern. I posted up here actually you know what I want to do is pull this out. I'm going to show you the special issue of narrative in Korean bioethics. Okay. Daniel you know what I'm talking about. So there's this journal that Jim Dubois at St. Louis University. He is the editor of and we have a special issue on living donation and informed consent in this issue. So what is included in here is I have a brief intro but the bulk of that special issue pertinent I can pass this around if anyone's interested to take a look. But the bulk of the stories are the stories of actual living donors and what they went through and some were good and some were bad and some were in the middle or you know kind of a mix. So some of those contributors who are living donors said you know I am more than a live organ donor or I am not just a kidney source. In a way it's like these affirmative statements are kind of like well trying to really address this I'm asserting I'm not a means to an end in a way it's kind of like reaffirming that they are. And then there's this whole website living donors are people too you know all of this just suggests that people are the living donors are grappling with this issue. Okay and now I want to go into issues of informed consent for living donors. And I put voluntariness first as opposed to at the end which you know typically kind of comes later on when people give a voluntary consent because I think voluntariness or undue pressure sets the tone for living donors and what they are going through. So let me give you some more details to that. Okay so the living donors sense of undue pressure is framed largely by the available treatment options for the potential recipient. Okay so with kidneys you know kidney transplant candidates they have dialysis okay it's not the best transplantation is better and of course you know when their AV access is all used up then they really have no other choice but transplantation. But really dialysis is an alternative so there's less pressure on the potential donor to donate to a kidney transplant candidate whereas with liver transplant candidates there's no alternative but death okay so you know putting yourself in the shoes of the potential living liver donor what are you going to do I mean either see your loved one die or you know consider the idea of donating. So we're really working within the high stakes arena of life and death particularly for the liver donor candidates okay. So what kinds of pressures do people do potential donors feel okay there's been quite a number of studies that have documented undue pressure among potential donors kidney and liver donors whether it's internal feelings family pressures cultural expectations people feeling guilt financial pressures that they have to do it because the recipient is the bread winner and they got to support them their senses of obligation or duty some people will say I have no choice but to save the life of a loved one especially the case in pediatric patient. There's also a gender disparity issue that's been documented around the world where females donate more than do males do so females donating to their husbands is quite common and so you know how does that contribute to the sense of obligation and pressure. So there's been some great work by Miriam Valapur in Minnesota who found that 40 percent of living kidney donors reported some pressure to donate okay and what's interesting is that they found that significantly more pressure was found was felt among those donating to related recipients as opposed to unrelated so that those family ties that bind really do bind I guess and I had conducted a systematic review of living liver donors and found that undue pressure rates of undue pressure varied internationally with lowest rates in the United States moderate rates in Europe and the highest rates in Asian countries and I wanted to give you a quote here again from the narrative inquiry special issue by one of the donors and she said the psychologist explained to me that I could decline to donate and they would tell my brother that a medical issue came up during testing which disqualified me as a donor that plan may work for people who never have to see each other again but families are forever connected even with the feelings of entitlement the flawed relationships and disappointments permission to back out needed to come from my brother and my parents not from a psychologist that would never see me again I thought that that was really quite telling what's really going on in people's experiences okay now with regard to informed information disclosure this issue brings up a whole host of additional issues so potential living donors must obtain the necessary information to understand the procedure and its outcomes in order to effectively decide if donating coincides with their values and beliefs okay however as again from this special issue one person noted all I needed to know all I really needed to know I learned after my donation years later still learning so I'll describe for you in a little bit more detail now what some of these issues are so one is a lack of information to disclose there's relatively little known about the long term outcomes and transplant recipients particularly or recipients and donors excuse me particularly in the case of liver donors okay and then another issue is that there's always this issue of how much information do disclose we don't want to overburden people with too much information and cause overloads that they stop paying attention and zone out and you know some ethicists have commented about you can never really be fully informed but you can be relevantly informed to be able to appreciate what some of the data mean and opinions do vary within the transplant field about the amount and specificity of information that is needed by potential living donors as well as recipients another key problem is that there's a lot of variation across transplant centers and the types of information disclosed during living kidney donation informed consent processes so a couple studies demonstrate this an international study of a 221 transplant professionals found that US transplant centers were more likely to disclose potential travel expenses and loss of work income than non transplant non US transplant centers a study of consent processes for living kidney donors in 132 US programs found that 58 excuse me 57% of the programs presumed candidates consent to undergo evaluation as opposed to you know asking them and other transplant programs varied in the extent to which the informed consent elements were disclosed only 42% of those programs disclosed all of the elements of informed consent you know risks benefits alternatives all those things another international study found that 30% of 203 transplant professionals had discussed the long-term risks of premature cardiovascular disease or death with living kidney donor candidates in one of the studies I did I assessed consent forms across transplant centers and found that with regard to the readability they were written at a college reading level so they're at health literacy issues so information is inconsistently disclosed and within providers perhaps across providers across centers and a concern is that a lack of any kind of standardization of the consent process may result in under informing patients another key concern is that patients report being inadequately informed and having unmet information needs so a number of studies for both living liver donors and living kidney donors have documented you know precisely this that they're neither well informed or prepared they desired more information to prepare for the donation they had an unmet information needs they didn't feel that the information was really well explained they didn't understand the procedures for testing and surgical procedures furthermore with regard to a lack of understanding some had limited knowledge about the risks they found that living liver donors perceived unrealistically low risks they had a difficult time appreciating the risks in a way all of these sentences kind of blend together and you know capture a kind of a sense of this issue about people not really quite getting the risks okay and then here's an issue about expectations so donors experience greater morbidity than they expected more painful surgery and recovery than they expected they thought their explanations didn't match their experiences and and what was interesting there's only this one study that looked at associations among those who reported feeling less informed and found that those who are less informed were more likely to report that the donation was harmful to their health and that they were inadequately prepared for poor recipient outcomes so now I'd like to kind of switch gears a little bit and turn to you know the the relationship between disclosure and comprehension and the two kind of go hand in hand here so a key question is how much understanding is sufficient for valid consent and as I alluded to earlier the goal is not so much full understanding but substantial understanding you can't really give everyone every single detail but you can try to cover the key grounds that would be material to their decision-making so one of the questions that comes up is how should clinicians ensure patients understanding you know you certainly don't want to ask people did you understand that and you know people will nod their heads certainly the teach back to goal is an option but generally no formal assessment of comprehension is used by transplant centers that at least that I've documented and seen documented in the literature and this is a problem particularly given that CMS conditions for hospital participation specify that there needs to be an assessment conducted okay how's our time do we have like 15 great okay good all right so what I'd like to do is give you an example of some of the findings from my research that I've done on living liver donors okay so what I did was investigated prospecting living liver donors comprehension information needs and decision-making we so I conducted semi-structured interviews used like her scales and so all of the living liver donors who consecutively came into our transplant center and were evaluated participated were invited to participate in the study after they completed their final phase of evaluation so this is just two days before the actual surgery that might affect the findings so after they completed their final phase and informed consent and this was between 2009 and 2011 at Northwestern okay so I had interviewed 30 living liver donors and just to put this into perspective 30 is a large sample believe it or not but at Northwestern we do about you know 17 living adult-to-adult live liver donor transplants a year and Northwestern is one of you know nine leading transplant centers in the A2L consortium so that's among the high and in in the country so 30 is a nice size sample to help you understand this so okay so one of the things I wanted to point out was that there's a big fissure between being perceived as informed and perceiving that they understood the information so 90% rated on a Likert scale that they were informed about donation a great deal so like a five on the Likert scale that's the very end by contrast 66% reported that they understood the information about donation a great deal so there's something going on here there I would hope that they would match up on the high end and one of the things I was really interested in looking at is is their level of interest in learning about the risk information you know how much did they want it how much did they appreciate it or understand it and there seems to be some tensions about this some they wanted it but not quite or they had a difficult time understanding and so what I think is feeding into this tension is in part different expectations by providers and patients and the lack of long-term outcomes particularly for the liver donor context as and this tension is also compounded by a broader social context so I think that providers really expect to disclose what all these risks are whether or not the patient fully understands or appreciates it but you know here are the risks you got to know it but I'm not so sure that the donors totally get it and necessarily want it okay and the rest of my presentation will explain that and unpack it a little bit more in detail so you'll see what I mean and by social context a really interesting theme that came up in in the donor stories in the narrative inquiry special issue as one donor said the medical industry promotes only the happily ever after stories so a couple of the contributors to that special issue commented that there's kind of like the social pressure to not talk in any negative way about living donation because you don't want to threaten the you know the country's efforts to reduce the organ shortage you want to there's always this pressure to promote it and be the hero and speak positively but in fact some people have you know some bad outcomes and they experience pressure to not discuss it okay so a major finding was that while donors seem to acknowledge the information about the magnitude of donor risks they didn't seem to fully appreciate the potential impact of the risks on their lives so at Northwestern the liver surgeons and the independent donor advocate they routinely and directly reviewed the potential complications of donation and explicitly told donor candidates that they could die from donation I mean they they really pounded that into people's heads and in fact in the interviews with the donors they said that they liked that go figure but it really helped them recognize the serious the seriousness the severity of what they're about to go through and so when I had asked donors to identify the risks of donation to the donor living donors acknowledged that a list of risks was presented to them in their educational materials they remember having received it and they you know they were they were able to recall death by a leak and infection as the leading risks but there was no consensus on these identified risks and fewer than 60% of donors mentioned any given risk so you see here you know 60% of the 30 mentioned death and Diane a point Redo who is the medical director of the living donor program at Mount Sinai she had similarly found that only 70% of donors identified death from a list of risks so while so these findings are a little bit difficult to interpret so they may reflect reflect a lack of recall okay and that that's fair or it may recall it may reflect information overload that's fine or it could reflect that the risks were simply not of high significance for donors that they didn't care to remember it could be any of these things and so I found some further evidence of this last point you know that the risks may not necessarily be of importance and so specifically when I asked them how would you rate donation in terms of its risk to yourself 83% said that donation is not at all to somewhat so that's like on a Likert scale from one to five one two and three three being somewhat 83% the majority said it wasn't really risky to themselves liver donation go figure and then 50% verbally through their comments and statements downplayed the risks of living donation to themselves so they what I mean by that is that they dismissed the complications as par for the course something to deal with and get through okay and so you know importantly although transplant clinicians really want to inform the donors about the risks so that they know what they're getting themselves into and and can make an informed decision the donors reported that they didn't really utilize this risk information for decision making calculations so to me that was very surprising here are a couple of examples of how donors minimize the risks to themselves they place responsibility for managing the risk within the clinicians or trust in the hospital they believe that the risks are a normal and acceptable part of surgery and daily life they also believe the the likelihood of experiencing complications is low and that the relative impact of the complications on their health is minimal and manageable in comparison to the bigger picture of saving their loved ones life okay and the unlikely chances of death occurring remember what I told you about the voluntariness that that kind of provides the big picture of what these donors are going through here's some illustrative quotations to support this point of how living liver donors were minimizing the risks to themselves as one person said I think the chance for risk is so minimal that they're not important to me that's really striking another said I don't think risk is the right word it seems normal because like I said this is the biggest surgery you can have done so I imagine there's going to be some complications but it's reassuring knowing that none of them are life-threatening you know little thing here and there that's got to be normal in a type of surgery this big another said I have the list all the statistics and the minor minor ones I guess I think if the possibility of death was much much higher than what it is that would be the only thing right now that possibility is so minuscule that it's not even on the radar but that would be the only thing all other complications you can deal with so as these comments show downplaying the risks appears to have also served as a strategy motivating living donors to proceed with the donation process maybe it's rationalizing so that is donors were reassured by their own assessment that the risks were low so if we were to set aside the ethical excuse me like the legal requirements the hospital requirements for informed consent for protection for disclosure I think that these findings raise a question of what is the purpose of disclosing risk information and particularly if the risk information was downplayed and played a little role in decision-making by many donors so so here's just briefly the theoretical framework for informed consent informed decisions are really informed consent is really designed to help people make informed treatment choices right to make a decision to act here a couple quotes by fading and informed informed consent are acts of autonomous authorizing and in the case of refusals of declining so it's an action a decision okay um but in this case it wasn't so much used for decision-making as some of the respondents indicated rather it was used for preparation for donation not for decision-making and most donors had decided to donate before receiving much education from the transplant center to begin with and that that's a finding often found in in the literature so the information needs for decision-making were distinct from the information needs relating to feeling prepared for donation and a third of donors emphasized that information was vital for feeling prepared for donating and feeling secure in the decision that had already been made here's a couple more quotes about this the importance that they're placing on feeling prepared so I asked was there any other information that you really relied upon to help you with your decision-making and the respondents said not for the decision-making but most of the information I get was to prepare rather than to decide I mean this is people are just telling you directly there wasn't anything that they could have told me to change my mind if they had given me more information it wasn't that it would have changed my mind but it would have helped me feel prepared for the procedure and more aware of what to expect so just to wrap this up here I know we're running out of some time um providing risk information is generally touted as enabling patients researcher research participants and living donors to express their self determination for autonomous decision-making but although it's grounded in law this perspective really minimally explains the actual thought process is used by living liver donors rather an ethical analysis of the construct of informed consent should focus on identifying information that is material to their living liver donors preparedness rather than decision-making per se okay so disclosing the risk statistics may be insufficient for adequately preparing living donors to appreciate the impact of a complication on a donor's life so um so although they generally felt informed they insufficiently understood the donation process and downplayed the risks and decision-making so this raises questions about comprehension it illuminates the value of informed consent for preparation rather than decision-making um more comprehensible disclosure of information is needed in order to optimize the informed consent process and it's essential of course that prospective donors are adequately informed and that their information needs are addressed to ensure that they're well prepared um couple quick points here so how do we do this how can we ensure that patients are optimally informed and comprehend one suggestion and um uh some of my colleagues I don't know if um is Yolanda here and James out there so I'm really pleased so Yolanda and um James Chon um we collaborated on this paper it just got accepted it's impressed on shared decision-making and we propose how shared decision-making can help with informed consent process um and enhance um people's understanding um a couple other suggestions there's been a move in in transplantation I think jumping onto the bandwagon overall of utilizing you know the internet as a an inter a great intervention um to utilize interactive computer-based programs and so the the folks listed here a lot of these are surgeons not me but Schenker and Leclerc so within the world of surgery they're recognizing the value of using computer programs to facilitate the informed consent process others um Melul here from France they articulated an urgent need to produce website compliant with international standards for the quality of donor information so um there are a couple other interventions that are being done using the internet I've got an intervention I'm in the middle of doing so it's a promising one and it's promising because I think it serves to um standardize as well as personalize the information disclosure process and by doing so it can provide a delivery that is consistent across all all individuals it can prevent under informing or overwhelming people providing information at a level of detail that is preferred or desired um and enhances patient self-determination by ensuring that people are optimally informed and these kinds of web-based programs can also minimize the potential for fragmentation and education amongst various transplant clinicians or clinicians in general within a given center there's a little bit of a precedent for this in the in the VA system for informed consent and I thank you all for listening it was uh it was really interesting it's the first time seeing this phenomenon of a difference between the risk that's communicated and the risk that's under stood or expressed by uh patients in a clinical setting but you may be aware that there is a literature about this in the research informed consent setting um in which a distinction is made between frequency type probabilities which is a sort of fact about the world um and belief type probabilities which are beliefs people can have and recognizing that there's no necessary connect logical connection between the two so it's logically and chromatically okay for somebody to say I know that 20 percent of people you know are going to have x complication um but I'm sure I'm going I'm 100 sure I'm not going to be one of them now there are two reactions to that one has been that that's okay and people can have this kind of hope Christine Grady for instance has sort of talked about that then there's another school and Lynn you know Lynn Janssen's on this calling it unrealistic optimism which is a cognitive bias that people have so the people who smoke or unrealistically optimistic about their ability to avoid cancer etc and I wondered whether you looked at the transcripts or thought about um the responses in terms of that kind of a an interpretation is this unrealistic optimism is it hope the other possibility is just cognitive dissonance I've already decided to do this therefore um I you know none of these risks can pertain to me and I wondered if you had some sort of sort of psychological interpretation of it that way yeah really good point thank you um you know I thought a little bit about this you know what's going on you know hey wake up you know smell the roses this is a very serious situation so um you know I've tried to think about it from their standpoint you know it's a life and death situation and I think on the one hand you know there um I'm interviewing them two days before their donation so while you know they have all the way up to the point of getting you know anesthesia to back out I think they probably are quite resolved to proceed by that point some people do back out you know at the last minute but not many so in a way I think there is this you know I'm gung-ho I I need to just do it um you know there may be risks but I just have to save my my loved one's life and I think that when I had asked them so why are you donating I mean that was the vast majority of the reason is that you know I have to um I love my mom I love my dad or whoever and I have to save them um you know it may be that there is some cognitive dissonance I I am concerned because you know I work with surgeons and they're telling me they have to understand the risks but I'm not seeing that everyone necessarily does so I'm struggling it it's this so thank you very much very interesting presentation have you ever disqualified someone because you felt they truly had no concept of understanding especially if it's not to a loved one if they're just there to donate because they feel that they're calling um I am not a transplant clinician so I'm I'm not in that um in that position to to make that call but you can make the recommendation after your evaluation of them I'm not involved I was doing research oh okay so my other question is you talked about that four it's been well publicized that four living donors have died during uh the surgery for living donors for livers is that comparable to what goes on in kidneys in the same amount of time the four included kidney and liver but I think oh it included kidney and liver okay I think there might be more than that like five I have to it's really hard to get those news stories actually and some publications will list them but not all but I know for sure there are four I just wondered if that was a reason for people stepping away from living kidney donation you hear a lot about what happens if it's a liver but I just wanted that influence kidney donation at all um I don't have any direct data however you know the transplant center probably shuts down its program after that happens and you know that might have some reverberation you know it it it transforms from my understanding of talking with the surgeons when these things happen and they happen relatively recently that um there's kind of a um a sense of like let's um kind of a cold feet feeling cold feet let's let's quiet down our program let's be extra cautious and um you know not take marginal candidates who are potential donors let's kind of scale back our our efforts and and then build up again hi lisa tiolanda it's nice to meet you in person not over phone so thank you very much that was an excellent talk um just so I can't help but say but we do have to report this nationally to UNOS if there is a donor and you have to report it within 24 hours um otherwise UNOS the government will shut us down so it there is some safety net from the government but my question actually is um yeah have you queried or looked at what we as surgeons think we said and if there's any veracity to what we think we said versus what we really did say really thanks very much you made an important distinction between recall and recognition so I really do wonder what that table would have looked like had you provided the recipient or the donors a list of complications as opposed to ask them to recall it out of memory the the numbers that you gave for the recall is not that far out of line from other studies about research studies where patients in my arena cardiac are asked to recall what the risks are to prepare present participate in research study now that you've completed this study what are your further plans you have recommendations for how to handle a consent differently do you plan to do more studies what are you expecting yeah good always the tough question um so you know um I have this paper almost done as far as written up and in it I've proposed some of the ideas I've suggested here but better comprehensibility of the information provided another thing that I've been thinking about about is not just presenting the risks but talking about the risks in terms of the impact on their lives and I don't think that that's necessarily done so how does it affect me how does it affect my life what will what will my life be like um and and I think that that would help facilitate people's appreciation I mean that's really what it's not just understand I have a 10% chance of blah blah blah but how does that if I were to get blah blah blah how would that affect me and I think that would really help make the message sink in better Eliza I think one conclusion from your data might be that informed consent is working much better than you think it is or that you give it credit for I mean I'm struck by these numbers that you showed of the decline in adult living liver donors from 412 in a decade to 194 and so one one follow-up to the study that you did of 30 patients who were within two days of donating might be to interview 30 patients who had declined to donate and to find out what their recollection was of the risk factors that were given and and how they reached their decision as you pointed out correctly there are so many factors that that patients might invoke to account for their refusing to go forward with the procedure it might not be as clean a study as I envision that it should be but but it would be interesting to know just the difference and recall yeah between those who didn't do it compared to those who did do it okay thank you all right thank you uh so and I don't think we we are unique in the following way but given all the rules and regulations given um the intensity of the focus on ethics most programs that I know of that have at least existed for a while expend a lot of energy in making sure in a very layered way that donors are in fact informed and as a social worker and part of the living donor advocate team that is definitely one of the things that I focus on very intensively in a very lengthy interview that I have with donors it's a question that we ask at the point at which each of us sees the potential donor and the discussion um it's not just about who says what and who heard what but in fact the point you're making is very much the issue that is how does a donor talk about these concerns these issues and interpret those in the light of their own life so that means everything family work well-being psychological issues hopes fears future everything so I just wanted to say that to the best of my knowledge um on the part of myself and my colleagues this is happening so I think your um your presentation was really interesting but I did just want to make the point that I know of many instances certainly where it is more the rule than the exception and to let you know many people are involved in it not just the surgeon and you know the the nephrologist but all of us who play a role it's one of the reasons that the work up is in fact as intensive as it is so thank you sure yes thank you yep definitely it's a team effort as as required by uh cms that's a good thank you


Hey now, take a step outside and seize the day now, set aside your worris- Hi guys, welcome back to my channel. So today I wanted to clean up the house because my parents were stopping through on their way home to Pennsylvania. We live in North Carolina and they were in Florida for three weeks and so on their way home they were just stopping in and the house was just a bit of a mess from the day. I have a two, three and four year old and they were taking naps while I did this. I just wanted to quick buzz through and get everything kind of picked up and cleaned up before my parents arrived. A lot of the time I have the girls pick up their own toys. They've been doing really really well with this but like I said I was kind of in a hurry and I just wanted to get it all done and picked up before my parents got there. I've been getting a lot of comments and questions about this rug and I will be sure to link it below. It's on major sale right now so I highly recommend checking it out especially for the large size that it is. I've been getting a lot of comments recently of why I don't use my cordless vacuum cleaner on the hard floor and a lot of the reason is just because my daughters eat at that little table over there all the time and they get lots of food all over the floor and so I don't really want it in my vacuum cleaner so I go ahead and use the broom. Next I went into our bedroom to make the bed and this is a work in progress. I'm actually about ready to paint this room and I'm going to decorate it and whatnot. We just moved here a month ago and so it's just kind of in limbo. It's not decorated at all and I'm so excited to kind of put my vision on this room because it's so pretty. It's got a high ceiling and really pretty windows that sit to the side of the bed and I have lots of great ideas for it. I just did a once-over on the bathroom that my parents would be using. I recently painted this room and also hung the shower curtain up that's why it hasn't been steamed or anything. It still has all of the creases in it and I love using the method anti-back. I get it from Grove. If you guys are unfamiliar with Grove or have never ordered from them if you check out the link in the description box it will give you a lot of free items in your first order and I love this anti-back that's what's in the purple spray that I'm using on everything. We were planning to eat dinner out on the back porch so I went out and picked up just different things. We were doing beads this day, making bracelets and stuff like that and so it just all needed to be picked up so that we could actually eat at the table.  I do this pretty much every night but I figured with my parents being around I would not get to it or remember it this night so I went ahead and just put it in so that the next morning I could put it in the dryer. And method laundry detergent is my go-to. I get this from Grove as well. I've been using that blue one. I can't remember what it's called. I think there's a blue and a green but the blue one and it smells so good. After I did that I went up to our bonus room and vacuumed it. This is something I do like once a month. I did it one other time when right after we moved in and then I went ahead and did it this day since it had been about a month. We plan to make this into like another living room area. We just haven't gotten the furniture and everything for it. I hope this gave you guys a ton of motivation for whatever you're trying to accomplish today. If you're new to my channel don't forget to hit that subscribe button, give this video a like and I will see you in my next video.


Hi everybody. We did it. Jaspy's 12 box training camp football mixer full. Thanks everybody for getting in for making this happen There's all the teams or there's all the boxes here and at the end of the break we're going to randomize Everybody's names and someone's going to win a Justin Herbert full-size helmet right over here Which is pretty awesome. So Big thanks everyone here for making this happen congrats again to the winners right there and All 32 football teams are in let's roll it. Let's randomize it for the hard way two and a two one two three and four After four ties we got Jackson down to Ryan two and a two for the hard way for the NFL teams one two three and four After four times we've got the Houston Texans down to the Chicago Bears Page glitching out. Sorry. You can see all the teams right there. Give me a second. Let me just refresh this page Google sheets are acting a little weird right now weird All right Jackson With the Texans and of the Colts Simon with the Jaguars, Asa with the Eagles, Ryan with the Chiefs, Jackson with the Ravens Jason with the Jets, Brian with the Niners, Simon with the Saints, Ryan with the Washington football team Jason with New England, Matthew with the Vikings, Ryan with the Denver Broncos, Joe with the Titans, Brian with the Panthers David with the Dolphins, Daniel with the Chargers, Anthony with the Rams, Sean with the Cowboys, David with the Lions, Sassan with the Buccaneers, Anthony with the spot that you won, Buffalo Bills, Randy with the spot that you won You got my Raiders. Sean O with the Giants, Daniel with the Packers, David with the Steelers, Daniel with the Seahawks Anthony with the Falcons, Arthur with the Bengals, Daniel with the Browns, Sean with the Cardinals, Ryan with the Chicago Bears Let's alphabetize everything by column B by team And we're gonna pause the video when we come back We're gonna see if there's any trades and then we'll have the break. Stick around. BRB All right, welcome back. No deals were done here in this 12 box training camp football mixer on Tuesday the 20th Thanks everybody for making this happen. Thanks for filling up the filler breaks. Thanks for buying spots straight up I appreciate it. And there's all 12 boxes right here. 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Excellent. We're gonna start off with 2018 Valiant Football, which does have a checklist on grouprakechecklist.com That's what we'll be going by Thanks for the fill everybody. Yeah, we were able to knock this football mixer out Giving away a Justin Herbert helmet at the end of this. Everyone has a shot at that. All right. Take it to the house Justin Jackson 7 out of 35 Justin Jackson is a charger and that'll go to Daniel Lyman Take it to the house We've got here comes the boom Bradley Chubb 12 out of 35. I know where he goes. He goes Denver Denver Broncos. That's gonna go to Ryan Ryan Hines with that here comes the boom and we've got Baker Mayfield nice Cleveland this is for you Daniel Lyman with the Cleveland Browns and that is 15 out of 35 On their Baker Mayfield great season for him last year. Hopefully he keeps keeps it up this year We got a redemption and it's gonna be Bradley Chubb signed this one, but you couldn't sign the other one, huh? Another one for Denver So that'll be for Ryan Hines There you go 2018 Valiant Let's dig into some optic. We've we've seen a lot of these for our filler breaks So let's do let's get this one out of the way I've seen this before we don't need to wait on this one. All right Dodgers down to their last Three outs down by one run To the Giants. Is this gonna be extras or a walk off?  All right. Good luck Um, do all car chip? Yes all car chip in this break as in this mixer as well. Nice We got our first hit is a relic Devin Duvernay rookie phenom for the purple birds Jackson With the Ravens last spot mojo strikes again Nice rated rookie pink Michael Pittman jr Rated rookie hollow Michael Pittman jr And cam acres. All right, what about some elite? We've got a half case picker team of this 2021 elite in the store folks. Something we can definitely work on Um and break tomorrow I think we're halfway there on that Go Chris Taylor work that walk Nice lead-off walk. She's kind of terrible Easy there play some patches Easy. All right. Let's see what we got here. Good luck. Oh hit already. We got Dalvin cook Moxie relic That's going to be Matthew hedges and the minnesota vikings We'll do a randomizer for this right here And that'll represent that card will represent all the other cards too that are similar to that 75 givante williams There's Tyler Heineke to three ninety nine Rashad Bateman to Nine ninety nine We got Panay Sewell I think this is a short print With a razzle dazzle short print David with the lions julian edelman to three ninety nine and a redemption And he guesses on the redemption for bragging rights His elite deck josh jaco that looks different me the refractor hollow Mr. Marr jefferson to nine ninety nine Wow two walks in a row I'll take it Will smith walk it off Joey bosa to ninety nine And we've got what do we have here fletcher cox autograph back to the future autograph asa With the eagles with the fly eagles fly not numbered trailance Oh It's gone Wow will smith walk off three run homer I he heard me. I told him to walk it off clutch We've got another trailance for the niners to three ninety nine. It's going to go to brian frank So two sixty eight out of three ninety nine What a hit 12th home run of the season for will smith third career walk off His full throttle alvin kamara to three forty nine See that hit Oh That's a halfway up the pavilion What a hit. All right No guests is on the redemption. It's des Fitzpatrick pen pals autograph Des Fitzpatrick is a tennessee titan It's going to go to joe christian. You know, that's where the spot that joe won In the uh filler. All right plates and patches kept falling over eager to be busted open. Let's see what's inside here What year 2018 plates and patches Should be the one per box plate jamal williams For the packers daniel nelson All aboard the big hit express I did see john lester's 419 foot home run yesterday. It was pretty amazing. There's odell beckham jr It's out of 50 not nearly as awesome as this home run though We'll walk off Three run jack Cleveland, this is for you Baker mayfield nick chubb 10 out of 85 dual relic daniel lineman with the browns And we've got 24 out of 30 leaps and bounds Insert autograph kareem hunt. That's some good photography there 24 out of 30 That'll be for ryan hines and kansas city And jaylon ramsey to 99 for the jags simon. All right. What about some uh some 2021 lumen It's kind of jumping around different years here There's chase young to 35. Oh points We'll randomize that to one person in the break Winner take all the points if we find any more of those kind of a bummer that takes the place of a Of a hit here. There's quitty pay Year one on card autograph He's a pretty pay. I think is a nine No a colt All right colt's that's gonna be For jackson from the spot that he won Tyson cambell 42 out of 50 Elijah mitchell to 299 and we've got a justin herbert relic Luminance relic going to daniel and the chargers tarence marshal jr to 99 and We've got levi Oh rosarrique 270 out of 349 That's a detroit lion for david And all these numbered cards, of course, will be top loaded before they're sorted and shipped out Yeah, chris taylor. He did all right. How about some xr football? Look at that land them. Yeah, that landed like five six rows up the pavilion That's the pit on the bottom Hey j hamler to 199 And staphon diggs to 199 Yeah, we've got a zack moss buffalo Five out of 25 nice looking triple relic For anthony and the bills Who won the bills? In that uh in that filler break A nice little bit of color right down there, too And then we got a clave on chasen autograph 63 out of 199 jaguars It's gonna be for simon with the jags And that's uh, where's the number there? It's 63 out of 199 All right. Odell beckham jr. We got a denzel mims to 249 For the jets jason we got out of 49 big ben And we got a daunte colpepper for the vikings to 49 Matt hedges with the vikings david with the stealers jason with the jets And behind austin echler is a kj hamler rookie jersey and onograph from my rivals the broncos That is looks like 12 out of 75 Ryan hanks with denver All right, let's start rolling through some of these little boxes here. And this is mosaic It looks like team all addition with the gold and red wave parallels The gardener minchew born sap and some gold here ty hilton gold 4 out of 17 nice low number there ricky williams silver patrick queen And chase claypool nfl debut insert. All right. What about here? We got red and yellow Red and yellow red and yellow There's the other gross matos There's a gelani to vie red and yellow exclusive to the set james morgan jerry judy And behind kenny g is a hunter henry Autograph nice still chargers addition here that goes to daniel lineman Who uh won the spot and got randomized the bolts? All right, let's see what we have in here This we're also looking for asia inclusive red stars Parallels There are the red stars right there. There's adaria smith Dwayne haskins drew breeze. It's gonna be weird not seeing drew breeze Playing every week and jimmy garoppolo and t higgins Are your red stars jimmy g going to the niners brian frank And the t higgins rated rookie For arthur and the bangles All right, some mini helmets and they're going to close out with 2019 panini one football Let's set that back here And again just a reminder on the um on the no checklist rule So breaks like these mini helmets or jerseys And some collegiate breaks won't have a an official checklist by on group break checklist calm Which is what we use And stuff like this traditionally does not have checklist either it'll just be like They'll just be like a sell sheet. It's like hey, here's what you could get So sometimes they could be in their college gear. So if that's the case if they're Active they'll go to the team that they're currently on And if they're retired, they'll go to the team they played for the longest according to pro football reference dot com Let's see what we have here. This is a pro helmet Well, let me just see what the name is going to be on this Play a little round of who am I and I'll give you some clues And let's see if you can figure out who the player is I am an active wide receiver and return specialist in the nfl Drafted in 2019 in the second round out of georgia 5 10 187 a super bowl champ a pro bowler a pfwa all rookie teamer 67 receptions in my career for 1098 receiving yards 48 rushing yards 1231 return yards and 12 touchdowns 12 total touchdowns And my 40 time 4 3 3 40 Fast Who am I? No, no guesses It's the speedy meekle harman jr So you got his red ink autograph right here Kind of hard to see through the plastic doesn't really do it justice looks pretty great. There's the uh Superbowl champ Inscription right there as well. There's his autograph The helmet is pretty cool. There's the sticker there And there's the jsa card in there meekle harman You missed most of it. Yeah Sasson we're we're down to uh the the last two boxes We got the now this time that was a gold rush This time this is tri star mini helmet same rules apply In terms of uh college stuff You ended up getting randomized So son you got ended up getting randomized the buccaneers All right, who am I? The former number five overall pick i'm a retired Uh defensive back an eight time pro bowler A nine time all-pro a defensive player of the year award winner a jim Thorpe award winner a two time super bowl champion On the nfl 100th anniversary all-time team College football hall of famer and a pro football hall of famer in 2011. Who am I? Yes, this is the mixer with the herbert helmet that we're giving away at the end of the break Any guesses no nobody seems to want to guess here Number five overall pick in 1989 By the atlanta falcons But this is a different team It's for the cowboys. It's neon dion sanders There's his autograph. There's the becket sticker and the becket card and the becket sticker right there dion sanders dallas cowboys That is gonna be shon aldinger with the boys Nice dion sanders right there cowboys edition Is he is he coaching college now? I want to say All right, the final thing is 2019 Panini one football I'll see what we got here. I don't think there's anything that's covering it. Okay, there you go Good luck everybody last card of the 12 box training camp football mixer is gonna be David montgomery three color patch an autograph 142 out of 199 Rookie patch auto for da bears ryan heintz with the bears There you go everybody. Thank you very much. We're gonna do a couple quick randomizers here The points we're gonna give as a consolation prize to the person who doesn't win the helmet So the second spot down name on top. We'll get the helmet. So let's go back to Let's get some new dice here. So for that elite card, we're gonna go position one Two three four I think there's actually only one of these cards. So that's position one two three and four The points Let's get a new list here. We'll be the uh, we'll be the consolation prize. Let's grab everyone's names from shon down to ryan And everybody in between name on top gets the herbert helmet Which I have right here. There's the becket card Here's the herbert helmet Nice full-size helmet. All right. Good luck everybody one dice roll for both lists Three and a four lucky seven times for both one two three four five six And seventh and final time It'll go to spot two So it'll be that position right there. It'll go to the justin jefferson spot So that'll be for minnesota matt hedges Now name on top. We'll get the helmet second name. We'll get the consolation prize the 250 points Good luck everybody after seven times three and a four Good luck one two three four five six And seventh and final time Now first off. Thanks everybody. I appreciate everybody giving this a shot Thanks for joining the break Whether it's whether it's spots you got straight up or whether it's filler spots that you got into Oh very close to sun 250 points consolation prize going your way name on top is very happy though That's going to be jackson with the spot that you won in that blaster break Your name's on top. You win the justin herbert helmet Full-sized chargers helmet his autograph right on there Pretty good-looking stuff. There should be a becket sticker right back there The becket card right over here. We got the chargers Badge right on the front you can kind of see the uh the sort of sparkle and speckle In the helmet Maybe it's harder to see Without getting some direct light on there, but that's pretty awesome There you go, man Thanks for getting in and trying all those fillers you got in you got randomized and it worked out I'm joe for jaspy's case breaks.com. Thanks for watching. Thanks for breaking with us And we'll see you next time for the next break. Bye. Bye