First prospective study on brain stem death and attitudes toward organ donation in India

The influence of socioeconomic factors on deceased organ donation in Iran

Background

There is a large gap between the number of patients on organ waiting lists and the number of available organs for donation. This study investigated the socioeconomic factors in Iran that influenced decisions for organ donation among the families of brain-dead donors.

Methods

This retrospective cross-sectional study was performed among the families of 333 organ donors in Iran. Two trained researchers interviewed family members about the donor’s age, sex, cause of brain death, education level, marital status, number of children, history of addiction, the financial status of the donor’s family, and reasons for which they considered refusing organ donation.

Results

The mean age of the donors was 37.23±16.59 years. During 2017–2019, significant differences were found according to income (P<0.001), marital status (P<0.001), sex (P=0.04), and occupation (P=0.04). More than half of the organ donors were of low socioeconomic status, and nearly half were the sole income earners of large families. Trauma was the most common cause of death (44.6%). The most common reasons for which the families considered refusing organ donation were unfamiliarity with the concept of brain death, denial, and the expectation of a miracle.

Conclusions

The donor’s socioeconomic status and availability of social services, such as insurance coverage, psychological services, and mourning therapy courses, play an important role in organ donation. Adequate support for the deceased’s family after organ donation is imperative.

Correlation of Organ Donors' Age With Duration Between Admission and First Brain Death Examination: A Five-Year Study in South Korea

BACKGROUND

Deceased organ donation can be performed only with the consent of the donor or their family members. The aim of this study was to determine whether donor age is related to families' decision-making regarding consent for organ donation.

METHODS

We obtained the data of 2451 organ donors with brain death (men 1645, women 806; mean age, 46.5 ± 16.2 years) registered with the Korean Network for Organ Sharing for the period between December 2012 and December 2017. The duration between the admission of the patient and the first brain death assessment was determined.

RESULTS

The mean duration from admission to the first brain death examination was significantly longer in the 0 to 30 age group (16.23 ± 6.01 days) compared with the 31 to 83 age group (6.7 ± 1.07 days) (P < .001). There was a strong negative correlation (r = 0.795, P = .010) between age and the mean duration from admission to the first brain death examination.

CONCLUSION

Because the family members of younger potential organ donors needed more time to provide consent, the first brain death examination and, therefore, the donation process was delayed in cases of young donors.

Hypothalamic function in patients diagnosed as brain dead and its practical consequences

Some patients who have been diagnosed as "dead by neurologic criteria" continue to exhibit certain brain functions, most commonly, neuroendocrine functions. In this chapter, we review the pathophysiology of brain death that can lead either to neuroendocrine failure or to preserved neuroendocrine functioning. We review the evidence on continued hypothalamic functioning in patients who have been declared "brain dead," examine potential mechanisms that would explain these findings, and discuss how these findings create additional confounds for brain death testing. We conclude by reviewing the evidence for the management of hypothalamic-pituitary failure in the setting of brain death and organ transplantation.

The obstacles to organ donation following brain death in Iran: a qualitative study

Background

Organ donation following brain death has become an important way of supplying organs for transplantation in many countries. This practice is less common in Iran for different reasons. Therefore, this study aims to explore the obstacles to organ donation following brain death in Iran.

Methods

This qualitative research was conducted following the conventional content analysis method. The study population consisted of individuals with a history of brain death among their blood relatives who refused to donate the organs. Snowball sampling was employed to select the participants. In-depth semi-structured interviews were conducted for data gathering. Theoretical saturation was achieved through 20 interviews. Data analysis was done following the steps proposed by Graneheim and Lundman. Lincoln and Guba’s criteria were used to ensure data rigor and transferability of the study.

Results

Data analyses revealed 185 codes, 23 categories, and seven themes including, poor knowledge about brain death and organ transplantation from a dead body, cultural beliefs, religious beliefs, deficiencies of requesting process, fear and concerns, inability to make a decision, and social learning.

Conclusion

There were several factors in families’ reluctance to donate organs of a brain-dead patient. Through improving knowledge and changing cultural beliefs in society, it is possible to take large steps towards promoting organ donation from brain-dead patients.

Elements of a successful hospital-based deceased donation programme in India: Zero to eighty-five in two years

Background

Legislation has made organ donation after brain death (DBD) possible in India since 1994. However, no organs are donated in most parts of the country; the national organ donation rate is estimated at between 0.08 and 0.34 donors per million population-one of the lowest in the world.

Methods

A 350-bedded private hospital in Kochi started its DBD programme in September 2013 with a structured approach based on counselling of family members of critically ill individuals. A counsellor trained to diagnose family dynamics, and recognize different stages of the grieving process, chose the right time, and the correct family member to whom the donation request could be made. Regular debriefing sessions of the core team consisting of a transplant surgeon, a transplant coordinator, an ICU counsellor and a unit administrator resulted in setting up systems that supported families of patients with catastrophic brain injury, and created an environment conducive to obtaining consent.

Results

A total of 85 organ donations took place in the first 24 months (September 2013 to September 2015) of instituting the programme.

Conclusion

It is possible with hospital-based teamwork and a structured approach to consistently elicit organ donation.

Establishing a deceased donor program in north Indian region: lessons learnt

INTRODUCTION

Living-related donors are the source of almost all organ transplants in India. However, these donations fall far short of current needs, and there remains a huge disparity between demand and supply of organs. In the last five yr, a consistent increase in deceased donor transplant activity has been observed in some southern Indian states. This report describes our experience of establishing a new deceased donor program in the state of Uttar Pradesh in north India.

METHODS

We describe our experience on counseling families of all brain-dead patients admitted to our center from October 2013 to September 2014 and data on retrieving and transplanting organs.

RESULTS

A total of 99 brain-dead patients were identified, of which 67 were medically eligible as donors. Fourteen patients developed cardiac arrest before the counseling could begin. Only eight families agreed for multi-organ donation.

CONCLUSION

Lack of consensus among the family members, mistrust of the medical system, fear of mutilation of the body, and delay in the funeral were identified as the main reasons behind negative consent. Conversely, mass media campaign, proper ICU care of brain-dead patients, rapport with the family and streamlining all medico legal processes were associated with positive consent.

A narrative review of the empirical evidence on public attitudes on brain death and vital organ transplantation: the need for better data to inform policy

Vital organ transplantation is premised on 'the dead donor rule': donors must be declared dead according to medical and legal criteria prior to donation. However, it is controversial whether individuals diagnosed as 'brain dead' are really dead in accordance with the established biological conception of death-the irreversible cessation of the functioning of the organism as a whole. A basic understanding of brain death is also relevant for giving valid, informed consent to serve as an organ donor. There is therefore a need for reliable empirical data on public understanding of brain death and vital organ transplantation. We conducted a review of the empirical literature that identified 43 articles with approximately 18,603 study participants. These data demonstrate that participants generally do not understand three key issues: (1) uncontested biological facts about brain death, (2) the legal status of brain death and (3) that organs are procured from brain dead patients while their hearts are still beating and before their removal from ventilators. These data suggest that, despite scholarly claims of widespread public support for organ donation from brain dead patients, the existing data on public attitudes regarding brain death and organ transplantation reflect substantial public confusion. Our review raises questions about the validity of consent for vital organ transplantation and suggests that existing data are of little assistance in developing policy proposals for organ transplantation from brain dead patients. New approaches to rigorous empirical research with educational components and evaluations of understanding are urgently needed.

Attitude and awareness towards organ donation in western India

BACKGROUND

To determine the knowledge, attitudes and practices regarding organ donation in western India.

METHODS

Convenience sampling was used to generate a sample of 250; 200 interviews were successfully completed and used for analysis. Data collection was carried out via face to face interviews based on a pre-tested questionnaire in selected public areas of Ahmedabad, Gujarat state of India. Data entry was made in excel software in codes and analysis was done by SPSS software.

RESULTS

About 86% of participants were aware of the term organ donation but knowledge about its various aspects was low. About 48% aware people heard about organ donation through medical fraternity, whereas only about 21% became aware through mass media. About 59% of aware people believed there is a potential danger of donated organs being misused, abused or misappropriated. About 47% of aware people said they would consider donating organs, while only 16% said they would definitely donate irrespective of circumstances. Around 97.67% participants said they would prefer to donate to nonsmokers. About 74.41% participants were unaware about any legislation regarding organ donation. About 77% participants showed their will to donate to mentally sound persons, and 42.04% participants showed their will to donate even physically challenged people. Around 78 participants felt that they would donate organs to persons irrespective of their religion. About 81% of aware people were of the opinion that consent for organ donation after death should be given by family members. None of the interviewed participants had a donor card.

CONCLUSION

Better knowledge and awareness will help in promoting organ donation. Effective campaign needs to be driven to educate people with relevant information with the involvement of media, doctors and religious scholars.

Attitudes of medical students and staff toward organ donation in cases of brain death: a survey at Shiraz University of Medical Sciences

CONTEXT

Organ transplant is one of the most important management strategies for end-of-life patients. The demand for organs in patients awaiting transplant is increasing, and many of these patients die before a donor is found.

OBJECTIVE

To determine the attitudes of medical students and staff at clinical institutions affiliated with a large medical university in the Eastern Mediterranean region toward organ donation in cases of brain death.

PARTICIPANTS

A total of 500 medical students, physicians, and nurses recruited at hospitals and medical centers affiliated with Shiraz University of Medical Sciences in Shiraz, Iran.Design and Setting-Information about participants' demographic characteristics, knowledge of organ donation, and willingness to donate their own organs after death was collected by using self-administered questionnaires.

RESULTS

Most participants (78%) had favorable attitudes toward donating their own organs after brain death. However, only about 25% of them carried an organ donation card. In addition to public media, the main sources of information about organ donation after brain death were their professors and textbooks. An association in charge of improving public awareness and facilitating the process of registration and issuance of donation cards appears to be necessary.

Knowledge of the Brain Death Concept by Personnel in Spanish and Latin-American Healthcare Centers

Background

The knowledge and acceptance of the concept of brain death (BD) among health care personnel is fundamental.

Objective

To analyze the level of understanding of the BD concept among personnel in Spanish and Latin American healthcare centers and to determine the factors affecting this attitude.

Material and methods

Data from 12 hospitals and 32 primary care centers in 4 countries within the International Collaborative Donor Project were selected (Spain, Mexico, Cuba and Costa Rica (n = 4378)).

Results

62% of the personnel (n = 2714) understood BD and believed that this was the death of an individual. Of the rest, 30% (n = 1 333) did not understand it and the remaining 8% (n = 331) believed it did not mean the death of a patient. 83% (n = 931) of physicians understood BD, compared to 75% (n = 895) of nurses, 55% (n = 299) of healthcare assistants, 53% (n = 108) of non-healthcare university-educated personnel and 36% (n = 481) of those without a university education (p<0.001). 68% (n = 1084) of Mexicans understood BD compared to 66% (n = 134) of Cubans, 58% (n = 1411) of Spaniards, and 52% (n = 85) (p<0.001) of Costa Ricans. There were significant relationships between knowledge of the concept and the following: type of healthcare center (p<0.001), clinical service (p<0.001), having spoken about organ donation within the family (p<0.001) and one's partner's attitude to the subject (p<0.001). A direct relationship has been found between understanding the concept and attitude toward deceased donation (p<0.001).

Conclusions

The understanding of BD by personnel from healthcare centers was not as good as expected. There were marked differences depending on job category.

Hypothalamic-Pituitary Function in Brain Death: A Review

The Uniform Determination of Death Act (UDDA) states that an individual is dead when "all functions of the entire brain" have ceased irreversibly. However, it has been questioned whether some functions of the hypothalamus, particularly osmoregulation, can continue after the clinical diagnosis of brain death (BD). In order to learn whether parts of the hypothalamus can continue to function after the diagnosis of BD, we performed 2 separate systematic searches of the MEDLINE database, corresponding to the functions of the posterior and anterior pituitary. No meta-analysis is possible due to nonuniformity in the clinical literature. However, some modest generalizations can reasonably be drawn from a narrative review and from anatomic considerations that explain why these findings should be expected. We found evidence suggesting the preservation of hypothalamic function, including secretion of hypophysiotropic hormones, responsiveness to anterior pituitary stimulation, and osmoregulation, in a substantial proportion of patients declared dead by neurological criteria. We discuss several possible explanations for these findings. We conclude by suggesting that additional clinical research with strict inclusion criteria is necessary and further that a more nuanced and forthright public dialogue is needed, particularly since standard diagnostic practices and the UDDA may not be entirely in accord.

Liver transplantation in Indian Armed Forces-initial experience

BACKGROUND

This study retrospectively analyses the initial experience of liver transplantation (LT) in the Indian Armed Forces.

METHODS

Fifty-three patients underwent LT at Army Hospital (R&R) Delhi Cantt. between March 2007 and March 2011. Of these 35 patients underwent deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT) was carried out in 18 patients. The surgical techniques, complications and mortality were analysed.

RESULTS

A high consent rate of 35.9% for organ donation was achieved by the Armed Forces Organ Retrieval and Transplantation Authority (AORTA). Biliary complications occurred in five patients (9.4%). However, most of them could be managed by endoscopic interventions. Hepatic artery thrombosis (HAT) occurred in five patients (9.4%). Of these, two DDLT grafts were revascularised following HAT, by creating extra-anatomic arterial conduits with excellent outcome. The overall mortality was 18.8% (n = 10). There was no significant difference in the overall complications or mortality in patients undergoing DDLT or LDLT.

CONCLUSION

The overall survival and morbidity in this study is comparable to those from other centres. Urgent revascularisation of grafts following HAT should be attempted as it can salvage grafts with satisfactory outcome. There is a reduction in the incidence of biliary complications with refinements in surgical techniques.