Brain death

The diagnosis of brain death should be based on a simple premise. If every possible confounder has been excluded and all possible treatments have been tried or considered, irreversible loss of brain function is clinically recognized as the absence of brainstem reflexes, verified apnea, loss of vascular tone, invariant heart rate, and, eventually, cardiac standstill. This condition cannot be reversed - not even partly - by medical or surgical intervention, and thus is final. Many countries in the world have introduced laws that acknowledge that a patient can be declared brain-dead by neurologic standards. The U.S. law differs substantially from all other brain death legislation in the world because the U.S. law does not spell out details of the neurologic examination. Evidence-based practice guidelines serve as a standard. In this chapter, I discuss the history of development of the criteria, the current clinical examination, and some of the ethical and legal issues that have emerged. Generally, the concept of brain death has been accepted by all major religions. But patients' families may have different ideas and are mostly influenced by cultural attitudes, traditional customs, and personal beliefs. Suggestions are offered to support these families.

Iranian nurses' experiences of brain dead donors care in intensive care units: A phenomenological study

BACKGROUND

Care of brain dead donors is complex, critical, and sensitive and has a direct and positive impact on the end result of organ and tissue transplantation process. This study describes the nurses' experiences of care of brain dead donors in intensive care units (ICU).

MATERIALS AND METHODS

This research was performed by phenomenological method that is a qualitative approach. Purposive sampling was used to gather the data. The researcher reached to data saturation by deep interviews conducted with eight participants from ICU nurses in Isfahan hospitals who cooperated in care of brain dead donors. Data analysis was performed according to Colaizzi analysis method.

RESULTS

Interviews were analyzed and the results of analysis led to "Excruciating tasks" as the main theme formed by psychological effects of facing the situation, heavy and stressful care, defect of scientific knowledge, conflict between feeling and duty, outcome of attitude change in behavior, emotional responses to perceived psychological afflictions, doubt to medical diagnosis, spiritual perceptions, and biological responses when faced with the situation.

CONCLUSION

Caring of brain dead organ donors is difficult and stressful for intensive care nurses and can be a threat for nurses' health and quality of nursing care. So, providing suitable physical, mental, and working conditions is necessary to make suitable background to maintain and increase nurses' health and quality of care and effective cooperation of this group of health professionals in organ procurement process.

The definition and criterion of death

The definition and criterion of death have been rendered ambiguous by developments in organ support technology, particularly the positive-pressure ventilator and vasopressor medications, that uncouple the unitary loss of vital functions in death and create cases in which the brain has been destroyed while circulation and ventilation can be supported. Developing a biophilosophic analysis of the meaning of death before physicians can declare it requires four sequential steps: (1) agreement on the paradigm conditions that frame the analysis and clarify the task; (2) identifying the definition of death, which makes explicit the meaning of death that is accepted in our consensual usage of the term but that has become obscured by technology; (3) identifying the criterion of death that shows that the definition has been fulfilled, and that can be incorporated into a death statute; and (4) devising bedside tests of death for physicians to perform to satisfy the criterion. Although there is a strong consensus on death determination medical standards in countries around the world that has been enshrined into laws, and accepted by most societies and religions, there remains an active dispute among scholars on the precise definition and criterion of death.

Declining liver utilization for transplantation in the United States and the impact of donation after cardiac death

Worsening donor liver quality resulting in decreased organ utilization may be contributing to the recent decline in liver transplants nationally. We sought to examine trends in donor liver utilization and the relationship between donor characteristics and nonuse. We used the United Network for Organ Sharing database to review all deceased adult organ donors in the United States from whom at least 1 solid organ was transplanted into a recipient. Trends in donor characteristics were examined. Multivariate logistic regression was used to evaluate the association between donor characteristics and liver nonuse between 2004 and 2010. Population attributable risk proportions were determined for donor factors associated with nonuse. We analyzed 107,259 organ donors. The number of unused livers decreased steadily from 1958 (66% of donors) in 1988 to 841 (15%) in 2004 but then gradually increased to 1345 (21%) in 2010. The donor age, the body mass index (BMI), and the prevalence of diabetes and donation after cardiac death (DCD) all increased over time, and all 4 factors were independently associated with liver nonuse. DCD had the highest adjusted odds ratio (OR) for nonuse, and the odds increased nearly 4-fold between 2004 [OR = 5.53, 95% confidence interval (CI) = 4.57-6.70] and 2010 (OR = 21.31, 95% CI = 18.30-24.81). The proportion of nonuse attributable to DCD increased from 9% in 2004 to 28% in 2010. In conclusion, the proportion of donor livers not used has increased since 2004. Older donor age, greater BMI, diabetes, and DCD are all independently associated with nonuse and are on the rise nationally. Current trends may lead to significant declines in liver transplant availability.

Project ACTS II: organ donation education for African American adults

OBJECTIVE

Project ACTS "About Choices in Transplantation and Sharing" is a culturally sensitive intervention designed to address organ donation concerns among African American adults. Our study sought to evaluate the efficacy of two versions of the Project ACTS intervention and to determine whether reviewing materials in a group setting would be more effective at increasing participants' interest in organ and tissue donation than allowing participants to review the materials at home with friends and family.

DESIGN

A pre-post simple factorial experimental design was used to assess differences between intervention package (Project ACTS I vs II) and mode of delivery (group vs take home).

METHODS

Participants completed a baseline and 1-year follow-up assessment of donation-related knowledge, attitudes, and interest.

MAIN OUTCOME MEASURES

A summed score that represents participants' interest in being recognized as an organ donor on their driver's license, via donor card, and by talking to family.

RESULTS

From baseline to follow-up, participants increased their knowledge, attitudes, and interest in being recognized as an organ donor regardless of intervention package (Ps<.05). Regarding setting, participants who reviewed materials in a group setting demonstrated greater increase from baseline to follow-up in interest in organ donation (beta=.22, P<.01) and positive attitudes toward donation (beta=.22, P<.05) than those who were allowed to review materials at home with friends and family.

CONCLUSION

Project ACTS I and II are equally efficacious; reviewing the intervention in a group setting may be necessary for low vested interest/high ambivalence health behaviors such as organ donation.

Shifting towards an opt-out system in Greece: a general practice based pilot study

New legislation in Greece towards presumed consent for organ donation, effective as of June 2013, has come at a critical moment. This pilot study aims to explore awareness, specific concerns and intentions about the new organ donation framework among patients attending Greek general practices in a rural and urban setting. Only 2.6% of respondents had a donor card, a mere 9.6% was aware of new legislation, whereas only 3.8% considered that the public had been adequately informed. Higher income respondents were more likely to be aware that they would be considered organ donors upon death, unless declared differently. Urban practice respondents were less likely to have previously discussed with a significant other their intentions in regards to presumed consent. One quarter of all respondents (22.4%) intended to carry out their right to prohibit organ removal upon death. Survey results reveal that organ donation reform has yet to be disseminated by the Greek society, underscoring the urgency for targeted information campaigns.

Misguided presumptions: British Medical Association (BMA) and National Institute for Health and Clinical Excellence (NICE) guidance on organ retrieval and 'opt out' or 'presumed consent'

Three documents have been produced in an attempt to increase the number of organs available for transplant: a National Institute for Health and Clinical Excellence (NICE) clinical guideline, a British Medical Association (BMA) report and a Welsh Government white paper. All three are ethically flawed: NICE and the BMA recommend that whenever there is intention to withdraw life-sustaining treatment and death is expected, patients should instead be stabilised to assess for donation. This is contrary to patients' best interests, the principles of mental capacity legislation and current criteria for accessing intensive care units. Regarding consent, the BMA and Welsh Government recommend an 'opt-out' policy, but consent in law requires information and cannot be 'presumed' or 'deemed' on the basis of failure to express or register 'opting out'. The language of all three proposals is manipulative, and patient trust may be undermined because the doctor's attention must move from the interests of the patient to those of the unknown organ recipients.

BMA and NICE guidance on organ retrieval: neither misguided nor presumptuous

Organ donation from deceased donors should occur whenever appropriate: that is, when there is evidence, belief or understanding that donation was the stated wish of the potential donor or would be in accordance with their wishes, is lawful and in line with current guidelines and will not add further distress to the family. This is the underlying assumption of the British Medical Association (BMA) report, National Institute for Health and Clinical Excellence (NICE) Guideline and Welsh Government Assembly Report. For potential donors after circulatory death, it might be necessary to support the potential donor until the wishes of the person and their family are ascertained. Provided that such interventions are reasonable, explained and do not cause distress to the patient and their family, such measures are surely suitable and will also enable donation to occur when appropriate. Publication and adherence to guidelines that have clinical, legal and ethical validity will reassure the public. Organ donation not only improves the length and quality of life of recipients, but also saves resources for the NHS and provides benefit to the donor family.

Interim results of a national test of the rapid assessment of hospital procurement barriers in donation (RAPiD)

Organ donation remains a major public health challenge with over 114 000 people on the waitlist in the United States. Among other factors, extant research highlights the need to improve the identification and timely referral of potential donors by hospital healthcare providers (HCPs) to organ procurement organizations (OPOs). We implemented a national test of the Rapid Assessment of hospital Procurement barriers in Donation (RAPiD) to identify assets and barriers to the organ donation and patient referral processes; assess hospital-OPO relationships and offer tailored recommendations for improving these processes. Having partnered with seven OPOs, data were collected at 70 hospitals with high donor potential in the form of direct observations and interviews with 2358 HCPs. We found that donation attitudes and knowledge among HCPs were high, but use of standard referral criteria was lacking. Significant differences were found in the donation-related attitudes, knowledge and behaviors of physicians and emergency department staff as compared to other staff in intensive care units with high organ donor potential. Also, while OPO staff were generally viewed positively, they were often perceived as outsiders rather than members of healthcare teams. Recommendations for improving the referral and donation processes are discussed.

Preventable errors in organ transplantation: an emerging patient safety issue?

Several widely publicized errors in transplantation including a death due to ABO incompatibility, two HIV transmissions and two hepatitis C virus (HCV) transmissions have raised concerns about medical errors in organ transplantation. The root cause analysis of each of these events revealed preventable failures in the systems and processes of care as the underlying causes. In each event, no standardized system or redundant process was in place to mitigate the failures that led to the error. Additional system and process vulnerabilities such as poor clinician communication, erroneous data transcription and transmission were also identified. Organ transplantation, because it is highly complex, often stresses the systems and processes of care and, therefore, offers a unique opportunity to proactively identify vulnerabilities and potential failures. Initial steps have been taken to understand such issues through the OPTN/UNOS Operations and Safety Committee, the OPTN/UNOS Disease Transmission Advisory Committee (DTAC) and the current A2ALL ancillary Safety Study. However, to effectively improve patient safety in organ transplantation, the development of a process for reporting of preventable errors that affords protection and the support of empiric research is critical. Further, the transplant community needs to embrace the implementation of evidence-based system and process improvements that will mitigate existing safety vulnerabilities.

Impact of compliance with the American College of Surgeons trauma center verification requirements on organ donation-related outcomes

BACKGROUND

In order to maximize organ donation opportunities, the American College of Surgeons (ACS) requires verified trauma centers to have a relationship with an organ procurement organization (OPO), a policy for notification of the OPO, a process to review organ donation rates, and a protocol for declaring neurologic death. We hypothesized that meeting the ACS requirements will be associated with improved donation outcomes.

STUDY DESIGN

Twenty-four ACS-verified Level I and Level II trauma centers were surveyed for the following registry data points from 2004 to 2008: admissions, ICU admissions, patients with a head Abbreviated Injury Score ≥ 5, deaths, and organ donors. Centers were also queried for the presence of the ACS requirements as well as other process measures and characteristics. The main outcomes measure was the number of organ donors per center normalized for patient volume and injury severity. The relationship between center characteristics and outcomes was determined.

RESULTS

Twenty-one centers (88%) completed the survey and referred 2,626 trauma patients to the OPO during the study period, 1,008 were eligible to donate, and 699 became organ donors. Compliance with the 4 ACS requirements was not associated with increased organ donation outcomes. However, having catastrophic brain injury guidelines (CBIGs) and the presence of a trauma surgeon on a donor council were associated with significantly more organ donors per 1,000 trauma admissions (6.3 vs 4.2 and 6.0 vs 4.2, respectively, p < 0.05).

CONCLUSIONS

Although the ACS trauma center organ donation-related requirements were not associated with improved organ donor outcomes, involvement of trauma surgeons on donor councils and CBIGs were and should be encouraged. Additionally, incorporation of quantitative organ donation measures into the verification process should be considered.

End-of-life care in Muslim brain-dead patients: a 10-year experience

BACKGROUND

In Muslim countries, end-of-life practices in Muslim brain-dead patients are unknown. We conducted this study to evaluate this issue.

RESULTS

We identified 42 brain-dead patients between 2001 and 2011. The expectant terminal extubation occurred only in 5. Largely due to family opposition, 2 patients remained "full code," and rests were "do not attempt resuscitation" with varying usage of "life-sustaining" therapies. Only 2 out of 24 eligible patients donated organs. There was minimal involvement of social worker, palliative team, or Muslim chaplain in the end-of-life discussions.

CONCLUSION

In Muslim patients, the concept of terminal withdrawal and organ donation after brain death is still not well accepted. Future multicenter studies, involving palliative teams, should focus on improving these issues.

Understanding and overcoming barriers to living kidney donation among racial and ethnic minorities in the United States

In the United States, racial-ethnic minorities experience disproportionately high rates of ESRD, but they are substantially less likely to receive living donor kidney transplants (LDKT) compared with their majority counterparts. Minorities may encounter barriers to LDKT at several steps along the path to receiving it, including consideration, pursuit, completion of LDKT, and the post-LDKT experience. These barriers operate at different levels related to potential recipients and donors, health care providers, health system structures, and communities. In this review, we present a conceptual framework describing various barriers that minorities face along the path to receiving LDKT. We also highlight promising recent and current initiatives to address these barriers, as well as gaps in initiatives, which may guide future interventions to reduce racial-ethnic disparities in LDKT.

Religio-ethical discussions on organ donation among Muslims in Europe: an example of transnational Islamic bioethics

This article analyzes the religio-ethical discussions of Muslim religious scholars, which took place in Europe specifically in the UK and the Netherlands, on organ donation. After introductory notes on fatwas (Islamic religious guidelines) relevant to biomedical ethics and the socio-political context in which discussions on organ donation took place, the article studies three specific fatwas issued in Europe whose analysis has escaped the attention of modern academic researchers. In 2000 the European Council for Fatwa and Research (ECFR) issued a fatwa on organ donation. Besides this "European" fatwa, two other fatwas were issued respectively in the UK by the Muslim Law (Shariah) Council in 1995 and in the Netherlands by the Moroccan religious scholar Mustafā Ben Hamza during a conference on "Islam and Organ Donation" held in March 2006. The three fatwas show that a great number of Muslim religious scholars permit organ donation and this holds true for donating organs to non-Muslims as well. Further, they demonstrate that transnationalism is one of the main characteristics of contemporary Islamic bioethics. In a bid to develop their own standpoints towards organ donation, Muslims living in the West rely heavily on fatwas imported from the Muslim world.

Religious attitudes towards living kidney donation among Dutch renal patients

Terminal kidney patients are faced with lower quality of life, restricted diets and higher morbidity and mortality rates while waiting for deceased donor kidney transplantation. Fortunately, living kidney donation has proven to be a better treatment alternative (e.g. in terms of waiting time and graft survival rates). We observed an inequality in the number of living kidney transplantations performed between the non-European and the European patients in our center. Such inequality has been also observed elsewhere in this field and it has been suggested that this inequality relates to, among other things, attitude differences towards donation based on religious beliefs. In this qualitative research we investigated whether religion might indeed (partly) be the explanation of the inequalities in living donor kidney transplants (LDKT) among non-European patients. Fifty patients participated in focus group discussions and in-depth interviews. The interviews were conducted following the focus group method and analyzed in line with Grounded Theory. The qualitative data analyses were performed in Atlas.ti. We found that religion is not perceived as an obstacle to living donation and that religion actually promotes helping and saving the life of a person. Issues such as integrity of the body were not seen as barriers to LDKT. We observed also that there are still uncertainties and a lack of awareness about the position of religion regarding living organ donation within communities, confusion due to varying interpretations of Holy Scriptures and misconceptions regarding the process of donation. Faith leaders play an important educational role and their opinion is influential. This study has identified modifiable factors which may contribute to the ethnic disparity in our living donation program. We argue that we need to strive for more clarity and awareness regarding the stance of religion on the issue of living donation in the local community. Faith leaders could be key figures in increasing awareness and alleviating uncertainty regarding living donation and transplantation.

The role of the relatives in opt-in systems of postmortal organ procurement

In almost all opt-in systems of postmortal organ procurement, if the deceased has not made a decision about donation, his relatives will be asked to make it. Can this decision power be justified? I consider three possible justifications. (1) We could presume the deceased to have delegated this power to his relatives. (2) It could be argued that, if the deceased has not made a decision, a proxy decision has to be made in his best interests. (3) The relatives could have a standing of their own because they are singled out from the parties whose interests are being affected by the decision by the special relation they had to the deceased. None of these arguments turns out to be convincing.

Prior family communication and consent to organ donation: using intensive care physicians' perception to model decision processes

Generally, the Swiss hold favourable attitudes to organ donation, but only few carry a donor card. If no card is found on a potential donor, families have to be approached about donation. The aim of this paper is to model the role that some family communication factors play in the family decision to consent or not to organ donation by a brain dead relative. Information was gathered in face-to-face interviews, using a questionnaire and recording open answers and comments. Eight heads of intensive care units (ICU) of Swiss hospitals and one representative from Swisstransplant were interviewed. Questions asked respondents to estimate the prevalence and effect of communication factors in families facing a decision to consent to donation. Answers were averaged for modelling purposes. Modelling also relies on a previous representative population survey for cross-validation. The family of the deceased person is almost always approached about donation. Physicians perceive that prior thinking and favourable predisposition to donation are correlated and that the relatives’ predisposition is the most important factor for the consent to donation, up to the point that a negative predisposition may override an acknowledged wish of the deceased to donate. Donor cards may trigger family communication and ease the physicians’ approach to family about donation. Campaigns should encourage donate-willing people to talk to their families about it, make people think about organ donation and try to change unfavourable predispositions.

Incentives for organ donation: proposed standards for an internationally acceptable system

Incentives for organ donation, currently prohibited in most countries, may increase donation and save lives. Discussion of incentives has focused on two areas: (1) whether or not there are ethical principles that justify the current prohibition and (2) whether incentives would do more good than harm. We herein address the second concern and propose for discussion standards and guidelines for an acceptable system of incentives for donation. We believe that if systems based on these guidelines were developed, harms would be no greater than those to today's conventional donors. Ultimately, until there are trials of incentives, the question of benefits and harms cannot be satisfactorily answered.

Distrust in the healthcare system and organ donation intentions among African Americans

The purpose of this study is to further understanding of the association between distrust in the healthcare system and written and verbal expressions of donation intentions among African Americans. We hypothesize that distrust in the healthcare system will be significantly, positively associated with both verbal and written donation intentions. Five hundred and eighty five participants completed a 98-item survey that included scales on distrust in the healthcare system and donation intentions. Bivariate analyses (t-tests, ANOVA, chi-square tests and odds ratios) were used to explore the extent to which donation intentions and distrust in the healthcare system varied by demographic characteristics and the association between the distrust in the healthcare system scale and verbal and written donation intentions. Separate logistic regressions were performed with each of the dependent variables to see if significant associations remained while controlling for confounders. Findings based on the multiple regression indicate that when controlling the participant's education level, distrust in the healthcare system was not significantly related to written donation intentions (OR = 1.04; P = .12). When controlling for education level, health insurance status, Community Health Advocates group and marital status, distrust in the healthcare system was significantly associated with verbal donation intentions (OR = 1.08; P < 0.05). Our results suggest that distrust in the healthcare system varies in the way that it is associated with donation intentions. Future organ donation studies should be conducted to determine the pathways through which distrust in the healthcare system impacts different types of organ donation intentions.

Donation after cardiocirculatory death: a call for a moratorium pending full public disclosure and fully informed consent

Many believe that the ethical problems of donation after cardiocirculatory death (DCD) have been "worked out" and that it is unclear why DCD should be resisted. In this paper we will argue that DCD donors may not yet be dead, and therefore that organ donation during DCD may violate the dead donor rule. We first present a description of the process of DCD and the standard ethical rationale for the practice. We then present our concerns with DCD, including the following: irreversibility of absent circulation has not occurred and the many attempts to claim it has have all failed; conflicts of interest at all steps in the DCD process, including the decision to withdraw life support before DCD, are simply unavoidable; potentially harmful premortem interventions to preserve organ utility are not justifiable, even with the help of the principle of double effect; claims that DCD conforms with the intent of the law and current accepted medical standards are misleading and inaccurate; and consensus statements by respected medical groups do not change these arguments due to their low quality including being plagued by conflict of interest. Moreover, some arguments in favor of DCD, while likely true, are "straw-man arguments," such as the great benefit of organ donation. The truth is that honesty and trustworthiness require that we face these problems instead of avoiding them. We believe that DCD is not ethically allowable because it abandons the dead donor rule, has unavoidable conflicts of interests, and implements premortem interventions which can hasten death. These important points have not been, but need to be fully disclosed to the public and incorporated into fully informed consent. These are tall orders, and require open public debate. Until this debate occurs, we call for a moratorium on the practice of DCD.

End of life issues in pediatric patients

Dealing with end-of-life issues in pediatric patients is difficult due to their young age, the complexities of situations leading to illness, and the multiple decision makers that exist in addition to parents and guardians. Pediatric patients do not have living wills addressing specific instructions for how long to continue life support systems such as a ventilator or a G-tube (gastrostomy tube for feeding). The dying pediatric patient also has typically not consented to organ donation either. The burden of decision making lies with the parents, guardians, and health-care providers of the dying child. This paper deals with these complexities and reflects the author's own experiences over nearly four decades of dealing with pediatric patients in her practice.

Development and Psychometric Evaluation of the Instrument: Attitudes Towards Organ Donor Advocacy Scale (ATODAS)

The consequences of advocacy in nursing are critical when caring for a potential organ donor. No specific instrument has been available to measure attitudes toward organ donor advocacy. The aim of this study was to develop and psychometrically evaluate an instrument for measuring intensive and critical care (ICU) nurses' attitudes toward organ donor advocacy. The study was conducted in two stages: instrument development and instrument evaluation and refinement. A questionnaire was developed (Attitude Toward Organ Donor Advocacy Scale (ATODAS)), which was sent to half of all nurses working in ICUs (general-, neuro-, thoracic- or paediatric-) in Sweden (n=1180). The final response rate was 42.5% (n=502). In order to explore validity and reliability, the expected scale dimensionality of the questionnaire was examined both by explorative principal component analysis (with oblique, varimax rotation) and by confirmatory multi-trait analysis. The confirmatory factor analysis indicated that the ATODAS could best be explained by five factors; Attitudes toward championing organ donation at a structural hospital level; Attitudes toward championing organ donation at a political and research level; Attitudes toward actively and personally safeguarding the will and wishes of the potential organ donor, Attitudes toward safeguarding the potential donor's will and wishes by a professional approach and Attitudes toward safeguarding the will and wishes of the relatives. This initial testing indicated that the ATODAS has good psychometric properties and can be used in future research to explore if interventions may influence attitudes and behaviors related to organ donor advocacy.

Blood component therapy in trauma guided with the utilization of the perfusionist and thromboelastography

25-35% of all seriously injured multiple trauma patients are coagulopathic upon arrival to the emergency department, and therefore early diagnosis and intervention on this subset of patients is important. In addition to standard plasma based tests of coagulation, the thromboelastogram (TEG) has resurfaced as an ideal test in the trauma population to help guide the clinician in the administration of blood components in a goal directed fashion. We describe how thromboelastographic analysis is used to assist in the management of trauma patients with coagulopathies presenting to the emergency department, in surgery, and in the postoperative period. Indications for the utilization of the TEG and platelet mapping as point of care testing that can guide blood component therapy in a goal directed fashion in the trauma population are presented with emphasis on the more common reasons such as massive transfusion protocol, the management of traumatic brain injury with bleeding, the diagnosis and management of trauma in patients on platelet antagonists, the utilization of recombinant FVIIa, and the management of coagulopathy in terminal trauma patients in preparation for organ donation. The TEG allows for judicious and protocol assisted utilization of blood components in a setting that has recently gained acceptance. In our program, the inclusion of the perfusionist with expertise in performing and interpreting TEG analysis allows the multidisciplinary trauma team to more effectively manage blood products and resuscitation in this population.

In the best interests of the deceased: a possible justification for organ removal without consent?

Opt-out systems of postmortem organ procurement are often supposed to be justifiable by presumed consent, but this justification turns out to depend on a mistaken mental state conception of consent. A promising alternative justification appeals to the analogical situation that occurs when an emergency decision has to be made about medical treatment for a patient who is unable to give or withhold his consent. In such cases, the decision should be made in the best interests of the patient. The analogous suggestion to be considered, then, is, if the potential donor has not registered either his willingness or his refusal to donate, the probabilities that he would or would not have preferred the removal of his organs need to be weighed. And in some actual cases the probability of the first alternative may be greater. This article considers whether the analogy to which this argument appeals is cogent, and concludes that there are important differences between the emergency and the organ removal cases, both as regards the nature of the interests involved and the nature of the right not to be treated without one's consent. Rather, if opt-out systems are to be justified, the needs of patients with organ failure and/or the possibility of tacit consent should be considered.

Partial siamese twin as potential organ donor

During evaluation of a partial Siamese twin for removal of nonviable parasitic part in an 8-year-old male child, a fully functional kidney was found. The functional status of the extra kidney was found to be within acceptable limits for the purpose of transplant, which was subsequently done in a 24-year-old patient with end-stage renal disease. The recipient is healthy 19 months after the surgery. The possibility of using organs from a partial Siamese twin makes this a unique case report.

Islamic sunni mainstream opinions on compensation to unrelated live organ donors

This article focuses on contemporary Islamic attitudes towards the question of compensation to a non-relative live organ donor. This article presents the history of the debate on organ transplantation in Islam since the 1950s and the key ethical questions. It continues by presenting the opinions of the mainstream ulema such as Tantawi and Qaradawi. The article ends with a conclusion that there must be no compensation made to a non-related live organ donor, not even a symbolic gift of honor (ikramiyya).

Interaction with potential donors' families: The professionals' community of concern-a phenomenological study

The aim of this paper was to explore the health professionals' experiences and gain a deeper understanding of interaction with families of critically ill or traumatized patients with severe brain injuries. The methodological approach was qualitative and phenomenological. Data were collected through participant observation and in-depth interviews with nurses, physicians, and chaplains working in two ICUs in a Norwegian university hospital. A thematic analysis was used for analyzing data. Two main themes emerged from analysis: Patient oriented even when present and Family oriented even when absent. Each main theme is divided into two sub-themes. The themes appeared as phases in an interaction process. In the two first phases the interaction may be characterized as Alternating between being absent and present and Following up and withholding information and in the two last phases as Turning point and changing focus and Partly present when waiting for death. The findings are in the discussion illuminated by the phenomenological concept of concern. Concern is visible as care, and the distinction in care between “leaps in” and “leaps ahead” and “ready-to-hand” and “unready-to-hand” are topics in the discussion. Because of the complexity of caring for both patient and family, the situation demands efforts to relieve nurses in particular, during the most demanding phases of the process.

Informed consent in research to improve the number and quality of deceased donor organs

Improving the management of potential organ donors in the intensive care unit could meet an important public health goal by increasing the number and quality of transplantable organs. However, randomized clinical trials are needed to quantify the extent to which specific interventions might enhance organ recovery and outcomes among transplant recipients. Among several barriers to conducting such studies are the absence of guidelines for obtaining informed consent for such studies and the fact that deceased organ donors are not covered by extant federal regulations governing oversight of research with human subjects. This article explores the underexamined ethical issues that arise in the context of donor management studies and provides ethical guidelines and suggested regulatory oversight mechanisms to enable such studies to be conducted ethically. We conclude that both the respect that is traditionally accorded to the prior wishes of the dead and the possibility of postmortem harm support a role for surrogate consent of donors in such randomized controlled trials. Furthermore, although recipients will often be considered human subjects under federal regulations, several ethical arguments support waiving requirements for recipient consent in donor management randomized controlled trials. Finally, we suggest that new regulatory mechanisms, perhaps linked to existing regional and national organ donation and transplantation infrastructures, must be established to protect patients in donor management studies while limiting unnecessary barriers to the conduct of this important research.

Bodies, organs and saving lives: the alternatives

In a paper in the last issue of Clinical Medicine, some of the background to attitudes to newly dead bodies, the current context of an urgent need for organs for transplant and the objections to calling a proposal to address this 'presumed consent' were outlined. Here further concerns are explored.

Current challenges of organ donation programs in syria

BACKGROUND

Renal transplantation is the optimal treatment for the majority of patients with end-stage renal disease.

OBJECTIVE

To examine the donor characteristics of kidney transplants in Syria and the impact of national Syrian legislation on the evolution of kidney transplantation activities in the private and public sectors.

METHODS

Available data on all kidney transplants performed in Syria over the last 2 decades was retrospectively analyzed to assess the characteristics of kidney donors and recipients with a focus upon transplants since 2003.

RESULTS

The kidney transplant rate has increased from 7 kidney transplants per million populations in 2002 to more than 17 in 2007. In the meantime, a substantial decline in the rate of kidney transplantation performed on Syrian nationals abroad was observed from 65% of all kidney transplantations in 1998 to less than 2% in 2007. Despite the prohibition to buy a kidney in Syria, vendors had found ways to sell their kidneys through disreputable brokers. Potential related donors were not inclined to donate kidneys to their relatives as long as kidneys could be bought from a non-related donor. By 2008, the percent of related donors in private sector represented only 8% of all donors, as compared to 50% in public hospitals. Consequently, in January 2008, the government of Syria issued a pronouncement restricting kidney transplantation to the public sector with a new national regulatory oversight of transplantation practices. Since this 2008 Administrative Order was promulgated, the kidney transplant rate in public hospitals has substantially increased by 55% with the establishment of new public transplant centers in the 3 largest cities in Syria.

CONCLUSION

The recommendations of the Istanbul Declaration and the Revised Guiding Principles of the World Health Organization have yet to be implemented in Syria but the expansion of kidney transplants in the public sector is an important initial step for initiating a deceased organ donation program as an essential component of a comprehensive approach to the problem of the organ shortage.

Randomized trial using hair stylists as lay health advisors to increase donation in African Americans

OBJECTIVE

To test the efficacy of using hair stylists as lay health advisors to increase organ donation among African American clients.

DESIGN

This study was a randomized, controlled intervention trial where we randomized 52 salons (2,789 clients) to receive a 4 session, stylist-delivered health education program (comparison) or a four session brief motivational intervention that encouraged organ donation (intervention). Intervention stylists received a four-hour training in organ donation education and counseling. Organ donation was measured by self-report questionnaire at 4-month posttest as well as by verified enrollment in the Michigan Organ Donor Registry.

SETTING

Hair salons in Michigan urban areas.

PARTICIPANTS

Blacks (n = 2,449), non-Blacks (n = 261) in Michigan.

MAIN OUTCOME MEASURES

Self-reported donation status, registration in Michigan Organ Donor Registry.

RESULTS

At posttest, rates of self-reported positive donation status were 19.8% in the intervention group and 16.0% in the comparison group. In multivariate analyses, intervention participants were 1.7 times (95% Cl = 0.98-2.8) more likely than comparison participants to report positive donation status at posttest. Based on verified organ registry data, enrollment rates were 4.8% and 2%, respectively for the intervention and comparison groups. In multivariate analyses, intervention group members were 4.4 (95% CI = 1.3-15.3) more likely to submit an enrollment card than comparison participants.

CONCLUSION

Clients of hair stylists trained to provide brief motivational intervention for organ donation were approximately twice as likely to enroll in the donor registry as comparison clients. Use of lay health advisors appears to be a promising approach to increase donation among African Americans.

The instability of organ donation decisions by next-of-kin and factors that predict it

We examined the instability of organ donation decisions made by next-of-kin and factors that predict whether nondonors wish they had consented to donation. Next-of-kin of donor-eligible individuals from one organ procurement organization participated in a semistructured telephone interview. Participants were asked if they would make the same decision if they had to make it again today. Of the 147 next-of-kin donors, 138 (94%) would make the same decision again, 6 (4%) would not consent to donation and 3 (2%) were unsure. Of the 138 next-of-kin nondonors, 89 (64%) would make the same decision again, 37 (27%) would consent to donation and 12 (9%) were unsure. Regret among nondonors was more likely when the next-of-kin had more favorable transplant attitudes (OR = 1.76, CI = 1.15, 2.69), had the first donation discussion with a non-OPO professional (OR = 0.21, CI = 0.13, 0.65), were not told of their loved one's death before this discussion (OR = 0.23, CI = 0.10, 0.50), did not feel they were given enough time to make the decision (OR = 0.25, CI = 0.11, 0.55), had not discussed donation with family members (OR = 0.30, CI = 0.13, 0.72) and had not heard a public service announcement about organ donation (OR = 0.29, CI = 0.13, 0.67). Organ procurement organizations (OPOs) should consider targeting these variables in educational campaigns and donation request approaches.

Pediatric organ donation: what factors most influence parents' donation decisions?

OBJECTIVE

To identify factors that influence parents' decisions when asked to donate a deceased child's organs.

DESIGN

Cross-sectional design with data collection via structured telephone interviews.

SETTING

One organ procurement organization in the Southeastern United States.

PARTICIPANTS

Seventy-four parents (49 donors, 25 nondonors) of donor-eligible deceased children who were previously approached by coordinators from one organ procurement organization in the southeastern United States.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Multivariate analyses showed that organ donation was more likely when the parent was a registered organ donor (odds ratio [OR] = 1.4, confidence interval [CI] = 1.1, 2.7), the parent had favorable organ donation beliefs (OR = 5.5, CI = 2.7, 12.3), the parent was exposed to organ donation information before the child's death (OR = 2.6, CI = 1.7, 10.3), a member of the child's healthcare team first mentioned organ donation (OR = 1.4, CI = 1.2, 3.7), the requestor was perceived as sensitive to the family's needs (OR = 0.4, CI = 0.2, 0.7), the family had sufficient time to discuss donation (OR = 5.2, CI = 1.4, 11.6), and family members were in agreement about donation (OR = 2.8, CI = 1.3, 5.2).

CONCLUSIONS

This study identifies several modifiable variables that influence the donation decision-making process for parents. Strategies to facilitate targeted organ donation education and higher consent rates are discussed.

Liver transplantation alcohol related liver disease: (deliberately) stirring a hornet's nest!

Outcomes after liver transplantation for alcohol related liver disease compare very favourably with those documented for other causes of cirrhosis. Despite this, 5% or less of patients with advanced alcohol related liver disease are considered for transplantation. The reasons for this are complex but include professional reluctance to refer these patients for formal assessment as well as a limited and dwindling number of organs available for transplantation. Demonstrating abstinence from alcohol consumption remains central to the assessment of candidates for transplantation. Return to alcohol consumption after transplantation can follow a pattern of abuse with consequences for health and survival but may also be controlled and of little clinical significance. A better understanding of the issues influencing these outcomes should decrease the tension that currently exists between patient expectations, professional opinion, and the attitude of the general public who gift organs for donation.

Racial disparities in preferences and perceptions regarding organ donation

OBJECTIVES

To identify reasons for lower organ donation rates by African Americans, we examined knowledge and attitudes about brain death, donation, and transplantation and trust in the health care system.

METHODS

Data were collected from 1,283 subjects in Ohio using a random digit dial telephone survey. Items were developed based on focus group results. Willingness-to-donate indicators included a signed donor card and willingness to donate one's own and a loved one's organs.

RESULTS

Compared with whites, African-Americans had lower rates of signing a donor card (39.1% vs 64.9%, P < .001), and willingness to donate their own organs (72.6% vs 88.3%, P < .001) or a loved one's organs (53.0% vs 66.2%, P < .001). African Americans had lower scores on the Trust in the Health Care System scale (mean scores +/- SD, 9.43 +/- 3.05 vs 9.93 +/- 2.88, P < .01) and were more likely to agree that "if doctors know I am an organ donor, they won't try to save my life" (38.6% vs 25.9%, P < .001), the rich or famous are more likely to get a transplant (81.9% vs 75.7%, P < .05), and less likely to agree that doctors can be trusted to pronounce death (68.2% vs 82.9, P < .001). African Americans were also more likely to agree that families should receive money for donating organs (45.6% vs 28.0%, P < .001) and funeral expenses (63.1% vs 46.6%, P < .001).

CONCLUSIONS

African Americans reported greater mistrust in the equity of the donation system and were more favorable about providing tangible benefits to donor families than white respondents.

"Because you're worth it?" The taking and selling of transplantable organs

In the UK, the legal processes underpinning the procurement system for cadaveric organs for transplantation and research after death are under review. The review originated after media reports of hospitals, such as Alder Hey and Bristol, retaining organs after death without the full, informed consent of relatives. The organ procurement systems for research and transplantation are separate and distinct, but given that legal change will be applicable to both, some have argued now is the time to introduce alternative organ transplant procurement systems such as presumed consent or incentive based schemes (despite inconclusive British and American research on the status of public attitudes). Findings are reported in this paper from qualitative and quantitative research undertaken in Scotland in order to ascertain the public acceptability of different procurement systems. Nineteen in depth interviews carried out with donor families about their experiences of donating the organs of the deceased covered their views of organ retention, presumed consent, and financial incentives. This led onto a representative interview survey of 1009 members of the Scottish public. The originality of the triangulated qualitative and quantitative study offers exploration of alternative organ procurement systems from different "sides of the fence". The findings suggest that the legal changes taking place are appropriate in clarifying the role of the family but can go further in strengthening the choice of the individual to donate.

The UK Human Tissue Act and consent: surrendering a fundamental principle to transplantation needs?

Legislation that authorises controversial organ procurement strategies but ignores respect for autonomy is flawed in principle and predictably unworkable in practice

Organ donation decision: comparison of donor and nondonor families

Family members continue to play a prominent role in donation decisions at time of death. This study examined the relative influence of donor and next-of-kin factors, requestor characteristics, communication processes and satisfaction with the health care team on the donation decision. Data were gathered via structured telephone interview with 285 next-of-kin of donor-eligible deceased individuals who had been approached by coordinators from one organ procurement organization (OPO) in the southeastern USA from July 2001 to February 2004. Univariate and multivariate analyses showed that several variables were associated with the donation decision. Subsequent logistic regression analyses revealed that donation was more likely when the deceased was younger, white (OR = 3.20, CI = 1.3, 5.7) and had made his/her donation intentions known (OR = 4.35, CI = 2.6, 7.3), and when the next-of-kin had more favorable organ donation beliefs (OR = 8.72, CI = 5.2, 14.7), was approached about donation by an OPO coordinator (OR = 3.74, CI = 2.2, 6.4), viewed the requestor as sensitive to their needs (OR = 2.70, CI = 1.6, 4.5) and perceived the timing of the request as optimal (OR = 6.63, CI = 3.6, 12.1) (total regression model, chi square = 133.2, p < 0.001, 92.7% of cases correctly predicted). Findings highlight the need for continued public education efforts to maximize positive beliefs about organ donation, to share and document donation decisions and to improve communication processes among the OPO personnel, hospital staff and prospective donor families.

Using a standardized donor ratio to assess the performance of organ procurement organizations

OBJECTIVE

To develop a Standardized Donor Ratio (SDR) as an outcome measure for evaluating the effectiveness of organ procurement organizations (OPOs).

DATA SOURCES/STUDY SETTING

All deaths by cause in the United States during 1993-1994 as reported in the Vital Mortality Statistics, Multiple Cause of Death files. The OPO-specific data were provided by the United Network for Organ Sharing (UNOS).

STUDY DESIGN

Each OPO's expected number of donors was calculated by applying national donation rates to deaths with potential for donation in 24 age, sex, and race cells. The SDR was calculated by dividing the observed number of donors by the expected number. The chi2 tests of the hypothesis that the OPO's performance differed from the national norm of 1.0 were performed. The SDR was compared to the existing performance standard based on the unadjusted number of donors per million live population in the OPO's service area. An ordinary least squares (OLS) regression assessed predictors of the SDR.

PRINCIPAL FINDINGS

The SDRs ranged from 0.41 to 1.99. Twenty-nine of 64 OPOs had SDRs significantly different than 1.0. The SDRs were positively associated with the percent of white living population and the number of organ types transplanted per transplant center served by the OPO.

CONCLUSIONS

The SDRs can be used by Centers for Medicare and Medicaid Services (CMS), UNOS, and OPOs to target quality improvement initiatives, present more accurate comparisons of OPO performance, and develop public policy on the evaluation of the effectiveness of organ procurement efforts.

An organ donor memorial

This article describes how a memorial to transplant donors was created in a district general hospital. The subjects discussed include: how to start, the official ceremony, the value of such a venture to those concerned, finance and time involved, a description of the memorial itself, the ongoing promotion of the scheme, and the pressing need for organ donors.

Does the presence of a measurable blood alcohol level in a potential organ donor affect the outcome of liver transplantation?

The widespread application of hepatic transplantation has created a tremendous demand for donor organs. An assessment of donor parameters is thought to be important in selecting good donors; however, the criteria utilized have not been standardized. This study was performed to determine the effect of a measurable donor blood alcohol level on graft survival. Fifty-two patients who underwent orthotopic liver transplantation at the University of Pittsburgh were included in the study. Twenty-five patients received liver grafts from donors having a blood alcohol level between 0.04 and 0.4 g/l with a mean of 0.17 g/l. Twenty-seven patients received a liver graft from a donor who had no measurable blood alcohol. There were no differences between these two groups of donors regarding the time of initial hospitalization until the time of donation. Graft failure within the first 30 days was 24% for those receiving an organ from an alcohol-positive donor as compared with 22.2% in those receiving an organ from an alcohol negative donor. The recipient mortality rate was 16% and 11%, respectively. No relationships between the donor blood alcohol level and organ performance, frequency of primary graft nonfunction, or number of episodes of acute cellular rejection were evident. Based upon these data, the presence of a measurable blood alcohol level in a donor should not mitigate against organ donation.