Nurses' responses to organ procurement from nonheartbeating cadaver donors

Experiential learning not enough for organ procurement surgery: implications for perioperative nursing education

CONTEXT

Perioperative nurses play a vital role in assisting in surgical procedures for multiorgan procurement, receiving little education apart from on-the-job experiential learning when they are asked to participate in these procedures.

OBJECTIVES

Within an Australian context and as part of a larger study, this article describes issues that hindered perioperative nurses' participatory experiences as a result of lacking education, previous exposure, and preparation for assisting in surgical procedures for organ procurement.

DESIGN

The grounded theory method was used to develop a substantive theory of perioperative nurses' experiences of participating in surgical procedures for multiorgan procurement.

PARTICIPANTS

Thirty-five perioperative nurses who had experience in surgical procedures for organ procurement from regional, rural, and metropolitan hospitals of 2 Australian states, New South Wales and Western Australia, participated in the research.

RESULTS

Levels of knowledge and experience emerged from the data as an influencing condition and was reported to affect the perioperative nurses' participatory experiences when assisting in procurement surgical procedures. Six components of levels of knowledge and experience were identified and are described.

CONCLUSION

The findings from this study provide a unique contribution to the existing literature by providing an in-depth understanding of the educational needs of perioperative nurses in order to assist successfully in multiorgan procurement procedures. These findings could guide further research with implications for clinical initiatives or education programs specifically targeting the perioperative nursing profession both locally and internationally.

Non-therapeutic intensive care for organ donation

Background and Purpose:

Providing non-therapeutic intensive care for some patients in hopeless condition after cerebrovascular stroke in order to protect their organs for possible post-mortem organ donation after brain death is an effective but ethically tricky strategy to increase organ grafting. Finding out the feelings and opinion of the involved healthcare professionals and assessing the training needs before implementing such a strategy is critical to avoid backlash even in a presumed consent system.

Participants and methods:

A single-centre opinion survey of healthcare professionals was conducted in 2013 in the potentially involved wards of a French University Hospital: the Neurosurgical, Surgical and Medical Intensive Care Units, the Stroke Unit and the Emergency Department. A questionnaire with multiple-choice questions and one open-ended question was made available in the different wards between February and May 2013.

Ethical considerations:

The project was approved by the board of the Lorraine University Diploma in Medical Ethics.

Results:

Of a total of 340 healthcare professionals, 51% filled the form. Only 21.8% received a specific education on brain death, and only 18% on potential donor’s family approach and support. Most healthcare professionals (93%) think that non-therapeutic intensive care is the continuity of patient’s care. But more than 75% of respondents think that the advance patient’s consent and the consent of the family must be obtained despite the presumed consent rule regarding post-mortem organ donation in France.

Conclusion:

The acceptance by healthcare professionals of non-therapeutic intensive care for brain death organ donation seems fairly good, despite a suboptimal education regarding brain death, non-therapeutic intensive care and families’ support. But they ask to require previously expressed patient’s consent and family’s approval. So, it seems that non-therapeutic intensive care should only remain an ethically sound mean of empowerment of organ donors and their families to make post-mortem donation happen as a full respect of individual autonomy.

Pediatric critical care nurses' perceptions, knowledge, and attitudes regarding organ donation after cardiac death

OBJECTIVE

Donation after cardiac death (DCD) is being implemented nationwide in the United States to increase the number of organ donors. Pediatric critical care nurses (PCRNs) are key facilitators in the organ donation process. This study assesses their perception, level of knowledge, and understanding of DCD and the effect of an educational intervention.

DESIGN

Anonymous questionnaire administered before and after an educational intervention.

SETTING

Children's hospital with 39 pediatric and cardiac/transplant intensive care unit beds.

SUBJECTS

PCRNs in these intensive care units.

INTERVENTIONS

DCD education.

MEASUREMENTS AND MAIN RESULTS

Response to the initial questionnaire was 93 of 123 (76%): 63% of PCRNs supported organ donation, 69% felt it gives meaning and worth to death, and 76% felt that it contributes positively to the donating family's grieving process. Ninety-five percent agreed that DCD patients have a right to pain medications, and 92% supported such medications even if they hasten death. However, 11% feared that the DCD donor feels pain and suffering. Fourteen percent felt that a 5-min observation period after asystole is insufficient to pronounce death, and 8% feared legal repercussions. PCRNs scored lower on questions assessing their knowledge (p < .01), their comfort answering family questions (p < .05), and their comfort in calling the organ procurement agency about DCD donors compared with similar questions about brain-dead donors. One month after 104 PCRNs attended the educational intervention, 64 (62%) completed a follow-up survey. Correct identification of the DCD process improved from 20% to 79%. Confidence with knowledge, comfort answering family questions, and comfort in calling the organ procurement agency about DCD donors improved by 41%, 25%, and 18%, respectively.

CONCLUSIONS

PCRNs are generally supportive of organ donation but have a self-perceived and objectively identified knowledge deficit regarding DCD, resulting in their being unprepared to identify potential DCD donors or handle family questions. A simple educational intervention can improve PCRNs' knowledge of the DCD process and their confidence and comfort with this process. As DCD policies are implemented, specific interventions should target these key members of the intensive care unit team.

National evaluation of healthcare provider attitudes toward organ donation after cardiac death

OBJECTIVE

Organ donation after cardiac death will save lives by increasing the number of transplantable organs. But many healthcare providers are reluctant to participate when the withdrawal of intensive care leads to organ donation. Prior surveys indicate ethical concerns as a barrier to the practice of organ donation after cardiac death, but the specific issues that characterize these concerns are unknown. We thus aimed to identify what barriers healthcare providers perceive.

DESIGN

We conducted a qualitative analysis of focus group transcripts to identify issues of broad importance.

SETTING

Healthcare setting.

PARTICIPANTS

Participants included 141 healthcare providers representing critical care and perioperative nurses, transplant surgeons, medical examiners, organ procurement personnel, neurosurgeons, and neurologists.

INTERVENTIONS

Collection and analysis of information regarding healthcare providers' attitudes and beliefs.

MEASUREMENTS AND MAIN RESULTS

All focus groups agreed that increased organ availability is a benefit but questioned the quality of organs recovered. Study participants identified a lack of standards for patient prognostication and cardiopulmonary death and a failure to prevent a conflict between patient and donor interests as obstacles to acceptance of organ donation after cardiac death. They questioned the practices and motives of colleagues who participate in organ donation after cardiac death, apprehensive that real or perceived impropriety would affect public perception.

CONCLUSIONS

Healthcare providers are uncomfortable at the clinical juncture where end-of-life care and organ donation interface. Our findings are consistent with theories that care providers are hesitant to perform medical tasks that they consider to be outside the focus of their practice, especially when there is potential conflict of interest. This conflict appears to impose moral distress on healthcare providers and limits acceptance of organ donation after cardiac death. Future research is warranted to examine the effect of standardized procedures on reducing moral distress. The hypothesis generated by this qualitative study is that use of neutral third parties to broach the subject of organ donation may improve acceptance of organ donation after cardiac death.

Intensive Care Unit Extubation Does Not Preclude Extrarenal Organ Recovery from Donors after Cardiac Death

BACKGROUND

We have sought to increase the utilization of both renal and extrarenal organs from donors after cardiac death (DCD), including DCD donors with ICU extubation.

METHODS

Extubation occurred in the intensive care unit (ICU; n=15) and operating room (OR; n=5). The charts of donors were reviewed for demographics, cause of death, time of asystole and cold perfusion. Recipient's charts were reviewed for graft function, length of hospitalization, serum creatinine (Cr) at discharge and last follow-up. Peak transaminases, amylase, and lipase for liver and pancreas recipients were also reviewed. Data are presented as means+/-SEM.

RESULTS

From December 2002 until December 2004, 20 DCD donors were utilized yielding 34 kidney transplants (33 recipients), five liver (1 liver-kidney), and two pancreas (SPK) transplants. Mean follow-up overall is 260 days. ICU extubation occurred in 26/33 (78.8%) kidneys, 3/5(60%) livers and 1/2 (50%) pancreata performed. Time from extubation to asystole was 15.9+/-1.9 min and overall warm ischemia time was 12.5+/-1.0 min. Serum Cr at discharge and at last follow-up for renal grafts are 4.3+/-0.5 and 1.9+/-0.3 mg/dl, respectively. Peak AST and ALT levels after OLTx were 3620+/-951 and 1955+/-266 i.u., respectively. Peak and discharge total bilirubin were 8.1+/-0.9 and 2.5+/-0.5 mg/dl. Length of hospitalization was 9.6+/-1.0 and 15.8+/-2.3 days for kidney and liver recipients, respectively. Both pancreas recipients were insulin free after transplant.

CONCLUSIONS

ICU extubation should not eliminate extrarenal organs from consideration and may be preferable to OR extubation by improving family support and eliminating OR staff concerns about their role in end-of-life care.

Caring for organ donors: the intensive care unit nurses' view

The nursing care for patients who are pronounced brain-dead but kept alive to serve as organ donors demands technical-scientific skills and the ability to handle situations that are often in conflict with the traditional concepts of nursing care. Based on the phenomenological approach in this article, essential themes of the lived experience of caring for these patients, including the technical and specific nursing care, the relationship with organ donors and their families, and the nurses' perception of themselves in this professional situation are described. The results point to the contradictions and ambiguities of this type of nursing, especially in regards to the affective and philosophical aspects.

Cadaveric donotransplantation: nurses' attitudes, knowledge and behaviour

Human organ transplantation is an important treatment for certain medical conditions, and for irreversible organ failure. There is a shortfall in the number of organs required for transplantation. The close and continuous proximity of nurses to potential donors and their families make them critical links in the organ donation process. Therefore, success in organ procurement may depend on nurses' awareness and integration of knowledge about donotransplantation (the process of organ/tissue donation and transplantation). Postal questionnaires were distributed throughout the United Kingdom (UK) to 2465 registered nurses, to assess their personal attitudes, knowledge and behaviour regarding cadaveric donotransplantation. One thousand, three hundred and thirty-three questionnaires were returned, a response rate of 54%. Overall, nurses held positive attitudes to donotransplantation, with 78% agreeing with organ donation and only 10% clearly being opposed. However, nurses were found to share ambivalent attitudes of altruism and fear which appear to surround decisions about donation. Factor analysis was used to further explore nurses' attitude structure. Six factors were confirmed providing a non-significant likelihood ratio fit (P = 0.468) and a well reproduced correlation matrix. The factors related to: (1) the value and contribution made by donotransplantation; (2) the unique idea of having another's tissue in one's own body; (3) the importance of organ donation; (4) the individual's moral, and nurses' professional rejection of the responsibility for organ/tissue donation; (5) the post-mortem mutilation of the body; and, (6) the potential distress donation may cause a bereaved family. Comparisons were made between certain of nurses' specialist groups and significant differences were found. Comparisons of factor scores between certain specialist groups or other strata were assessed by analysis of variance. Nurses working in renal units were significantly more in favour of donotransplantation than any other group of nurses.

Non-heart-beating cadaver procurement and the work of ethics committees

Recent ethics literature suggests that issues involved in non-heart-beating (NHB) organ procurement are both highly charged and rather urgent. Some fear that NHB is a public relations disaster waiting to happen or that it will create a backlash against organ donation. The purpose of the study described below was to assess ethics committees' current level of involvement in and readiness for addressing the difficult issues that NHB organ retrieval raises—either proactively through policy development or concurrently through ethics consultation.