How to improve organ donation: results of the ISHLT/FACT poll

To donate, or not to donate, that is the question: Latino insights into brain donation

INTRODUCTION

Latinos are underrepresented in brain autopsy research on Alzheimer's disease and related dementias (ADRD). The study's purpose is to identify Latinos' attitudes about brain donation (BD) to inform methods by which researchers can increase autopsy consent.

METHODS

Forty Latinos (mean age: 59.4 years) completed a semi-structured interview and were presented with educational information about BD. Participants completed a questionnaire assessing their understanding of BD and willingness to donate their brain for research.

RESULTS

Among participants, there was near unanimous support for BD to study ADRD after hearing educational information. However, prior to the information presented, participants reported a lack of knowledge about BD and demonstrated a possibility that misunderstandings about BD may affect participation.

DISCUSSION

While nearly all study participants agree that donating is beneficial for research and for future generations, the lack of BD information must be addressed to help support positive attitudes and willingness for participation.

The impact of donor consent mechanism on organ procurement organization performance in the United States

BACKGROUND

Lack of donor organ availability represents a major limitation to the success of solid organ transplantation. The Scientific Registry of Transplant Recipients (SRTR) publishes performance reports of organ procurement organizations (OPO) in the United States, but does not stratify by the mechanism of donor consent, namely first-person authorization (organ donor registry) and next-of-kin authorization. This study aimed to report the trends in deceased organ donation in the United States and assess the regional differences in OPO performance after accounting for the different mechanisms of donor consent.

METHODS

The SRTR database was queried for all eligible deaths (2008-2019) which were then stratified based on the mechanism of donor authorization. Multivariable logistic regression was performed to assess the probability of organ donation across OPOs based on specific donor consent mechanisms. Eligible deaths were divided into 3 cohorts based on the probability to donate. Consent rates at the OPO level were calculated for each cohort.

RESULTS

Organ donor registration among adult eligible deaths in the U.S. increased over time (2008: 10% vs 2019: 39%, p < 0.001), coincident with a decline in next-of-kin authorization rates (2008: 70% vs 2019: 64%, p < 0.001). At the OPO level, the increased organ donor registration was associated with lower next-of-kin authorization rates. Among eligible deaths with medium- and low-probability of donation, recruitment was highly variable across OPO's, ranging from 36% to 75% in the medium-probability group (median 54%, IQR 50%-59%) and 8% and 73% in the low-probability group (median 30%, IQR 17%-38%).

CONCLUSION

Significant variability exists across OPOs in the consent of potentially persuadable donors after adjusting for population demographic differences and the mechanism of consent. Current metrics may not truly reflect OPO performance as they do not account for consent mechanism. There is further opportunity for improvement in deceased organ donation through targeted initiatives across OPOs, modeled after regions with the best performance.

Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation

Despite the effectiveness of solid organ transplantation, progress to close the gap between donor organs and demand remains slow. An organ shortage increases the waiting time for transplant and involves significant costs including patient morbidity and mortality. Against the background of a low deceased organ donation rate, this article discusses the option of introducing incentives and removing disincentives to deceased organ donation. Perspectives from ethics, general public opinion, and the health care profession are examined to ensure a comprehensive appraisal and illustrate different facets of opinion on this complex area. Special cultural and psychosocial considerations in Asia, including the family based consent model, are discussed.

Donor Troponin and Survival After Cardiac Transplantation: An Analysis of the United Network of Organ Sharing Registry

BACKGROUND

Despite a limited supply of organs, only 1 in 3 potential donor hearts is accepted for transplantation. Elevated donor troponin levels have generally been considered a contraindication to heart transplantation; however, the data supporting this practice are limited.

METHODS AND RESULTS

We identified 10 943 adult (≥18 years) heart transplant recipients in the United Network of Organ Sharing (UNOS) database with preserved donor left ventricular ejection fraction (≥50%) and where peak donor troponin I values were available. When analyzed as a continuous variable, there was no association between peak donor troponin levels and recipient mortality up to 1 year follow-up in unadjusted (hazards ratio, 0.999; 95% confidence interval, 0.997-1.002; P=0.856) and adjusted Cox models (hazards ratio, 1.000; 95% confidence interval, 0.997-1.002; P=0.950). Next, we divided the entire cohort into 3 groups based on donor troponin I values: <1 ng/mL (n=7812), 1 to 10 ng/mL (n=2770), and >10 ng/mL (n=361). Using unadjusted and adjusted Cox models and Kaplan-Meier analysis, there was no significant difference in recipient mortality at 30 days, 1 year, 3 years, or 5 years between the 3 groups. Similarly, cardiac allograft vasculopathy up to 5 years and primary graft failure up to 30 days of follow-up post transplant did not differ between the 3 donor troponin groups. The median length of hospital stay post transplant was also similar across groups.

CONCLUSIONS

Elevated donor troponin I levels in the setting of preserved left ventricular ejection fraction were not associated with intermediate-term mortality, cardiac allograft vasculopathy, or primary graft failure rates in hearts accepted for transplantation. This finding could help expand the donor pool.

For and against Organ Donation and Transplantation: Intricate Facilitators and Barriers in Organ Donation Perceived by German Nurses and Doctors

Background. Significant facilitators and barriers to organ donation and transplantation remain in the general public and even in health professionals. Negative attitudes of HPs have been identified as the most significant barrier to actual ODT. The purpose of this paper was hence to investigate to what extent HPs (physicians and nurses) experience such facilitators and barriers in ODT and to what extent they are intercorrelated. We thus combined single causes to circumscribed factors of respective barriers and facilitators and analyzed them for differences regarding profession, gender, spiritual/religious self-categorization, and self-estimated knowledge of ODT and their mutual interaction. Methods. By the use of questionnaires we investigated intricate facilitators and barriers to organ donation experienced by HPs (n = 175; 73% nurses, 27% physicians) in around ten wards at the University Hospital of Munich. Results. Our study confirms a general high agreement with the importance of ODT. Nevertheless, we identified both facilitators and barriers in the following fields: (1) knowledge of ODT and willingness to donate own organs, (2) ethical delicacies in ODT, (3) stressors to handle ODT in the hospital, and (4) individual beliefs and self-estimated religion/spirituality. Conclusion. Attention to the intricacy of stressors and barriers in HPs continues to be a high priority focus for the availability of donor organs.

Is it Ethical to Prioritize Patients for Organ Allocation According to Their Values about Organ Donation?

Because the supply of deceased donor organs fails to meet demand, patients needing a transplant frequently have lengthy waits or die while waiting. In an effort to reduce waiting times, the concept of “preferred status” has emerged. In the United States, preferred status has taken the form of a community of individuals called LifeSharers. Using directed donation, this group aims to facilitate priority organ allocation to its members—people who have agreed to be organ donors. Such preferred status programs increase societal awareness about organ donation and transplantation, but they are not without ethical controversy, as some term them “clubs.” In the case of LifeSharers, the potential to increase the pool of deceased donor organs is a worthy goal that would benefit the community of patients awaiting transplantation, not just LifeSharers members.

Attitudes toward Death Criteria and Organ Donation among Healthcare Personnel and the General Public

Objective

To examine attitudes toward death criteria and their relation to attitudes and behaviors regarding organ donation.

Data Sources

This article reviews empirical studies on the attitudes of healthcare personnel and the general public regarding death criteria and organ donation.

Study Selection and Data Extraction

The review was restricted to studies that had as a primary focus attitudes toward 1 or more of the following 3 specific criteria for determining death: (1) brain death, the irreversible loss of all functions of the entire brain; (2) higher brain death, the loss of cerebral cortex function alone; and (3) the circulatory-respiratory criteria commonly used in donation after cardiac death.

Data Synthesis

Studies consistently show that the general public and some medical personnel are inadequately familiar with the legal and medical status of brain death; attitudes toward the dead donor rule are strong predictors of willingness to donate organs using controversial criteria; concerns about donation after cardiac death surround the withdrawal of life support more than the actual death criteria used; and concerns about death criteria correlate with less favorable attitudes toward organ donation.

Conclusions

Both general and ethical education may serve to guide policy and facilitate family member requests and informed consent dialogues. Furthermore, helping families to understand and accept not only medical and legal criteria for determining death, but also ethical criteria for withdrawing life support may help them be more comfortable with their decisions.

Does Presumed Consent Save Lives? Evidence from Europe

One policy tool that could affect organ donation rates is legislative defaults. In this study, we examine how presumed consent impacts cadaveric donations and kidney transplantations, using a panel dataset from the EU-27 countries plus Croatia in the period 2000-2010. We find that presumed consent countries have 28% to 32% higher cadaveric donation and 27% to 31% higher kidney transplant rates in comparison to informed consent countries, after accounting for potential confounding factors. After studying willingness to donate one's organs and registering preferences for organ donation, we find that presumed consent could increase cadaveric donation rates, because people fail to register their preferences and many have no preference for organ donation.

Consent to organ donation: a review

Successful transplant medicine hinges on consent to deceased organ donation. Yet rates of consent remain suboptimal. To increase the availability of transplantable organs, several policy strategies along with a rich body of evidence aimed at identifying best practices for obtaining consent have accumulated. This review describes past and current policies and practices, presents evidence illustrating the impact of these policies and practices on consent, and summarizes future directions and recommendations for the field. Key findings include evidence that although past policies such as required request have been unsuccessful, the recent policy, first-person authorization, shows promise. Additionally, practices such as decoupling and detailed discussions of brain death are unwarranted. On the other hand, the Organ Donation Breakthrough Collaboration was successful. We also underscore the impact of alternative procedures such as donation after cardiac death. Last, effective communication that is delivered by trained, caring requesters at the appropriate time, in a supportive environment, and allows sufficient time for families to make an informed decision, optimizes the request process. Organ procurement organizations' adoption of such request practices, implementation of evidence-based policies regarding donation after cardiac death, and further investigations of the medical basis for dual brain death examinations are recommended.

The incidence of potential missed organ donors in intensive care units and emergency rooms: a retrospective cohort

PURPOSE

There is a shortage of organ donors in Canada. The number of potential organ donors that are not referred to organ procurement organizations in Canada is unknown.

METHODS

We conducted a retrospective cohort study of all deaths in ICUs and emergency rooms not referred to the Human Organ Procurement and Exchange Program in four hospitals between 1 January 2008 and 31 December 2010. The primary outcome was the number of normal and expanded criteria heart-beating donors and circulatory death (DCD) donors.

RESULTS

Of 2,931 deaths, 64 patients were identified as having a high probability for progression to heart-beating donation (Glasgow Coma Score of 3 and three or more absent brainstem reflexes) and 130 patients were assessed for possible DCD donation. The number of potential abdominal and lung heart-beating donors ranged from 3.2 to 7.5 and 0.5 to 2.7 per million population. The number of potential DCD abdominal and lung donors ranged from 3.9 to 6.5 and 2.7 to 4.3 per million population. Potential heart-beating abdominal (p = 0.04) and lung (p = 0.06) donors increased after legislation mandating donation discussion. Non-pupillary brainstem reflexes were documented in fewer than 60 % of records. Life-sustaining treatment was withdrawn in 19 of 46 (41.3 %) cardiac arrest patients not requiring high doses of vasoactive drugs within 24 h.

CONCLUSION

The number of heart-beating or DCD organ donors represented by missed referrals may represent up to 7.5 donors per million population. Improved documentation of brainstem reflexes and encouraging referral of patients suffering cardiac arrest to ICU specialists may improve donor numbers.

Attitudes and acceptance of First Person Authorization: a national comparison of donor and nondonor families

BACKGROUND

First Person Authorization (i.e., donor designation) legislation makes indicating one's intent to be a posthumous organ donor legally binding, much like a living will or advance directive. Such legislation is the most recent in a long history of organ donation policies in the United States and has received little attention in the literature.

METHODS

This retrospective cohort study recruited nine US organ procurement organizations (OPOs) and their staff who make requests for organ donation as well as family decision makers approached by OPO staff about organ donation. Telephone interviews (N = 1,087) with family decision makers assessed the attitudes, perceptions, and behaviors regarding the request for organ donation of families of designated donors as compared with those of patients who did not formally designate themselves as donors.

RESULTS

Almost two thirds (65.7%) of the families of registered donors were aware of the decedent's decision to register as a posthumous donor. Family decision makers who authorized donation and those of designated donors exhibited greater knowledge of organ donation and more positive attitudes than decision makers who refused to donate. Families of designated donors had more favorable perceptions of the request for organ donation and were more satisfied with both the time spent discussing donation and the request process; fewer donor designation families were surprised at the request for donation.

CONCLUSION

The enactment of First Person Authorization legislation increases the likelihood of familial authorization and satisfaction with the final donation outcome. As compared with other families approached about the option of organ donation, families of designated donors report having a more positive experience with the organ donation request process overall and greater comfort and satisfaction with the donation decision.

LEVEL OF EVIDENCE

Epidemiologic study, level II.

Priority in Organ Allocation to Previously Registered Donors: Public Perceptions of the Fairness and Effectiveness of Priority Systems

A priority system is one in which previously registered donors receive a preference in the allocation of organs for transplant ahead of those who have not registered. Supporters justify these systems on the basis that they are fair and will encourage donor registration. This article reviews existing studies of public reactions to priority systems, as well as studies of the extent to which the moral principle of reciprocity affects decision making in organ donation. The role of reciprocity in the public discourse surrounding the enactment of priority systems in Singapore and Israel is described. One factor that seems to have been relevant in these countries is the existence of a religious minority that is perceived as willing to take an organ but not to donate one. Although this perception may have fueled a resentment of perceived “free-riders,” concerns were raised about the social divisiveness of priority systems. In sum, people appear to be sensitive to the principle of reciprocity in the context of organ donation, but this sensitivity does not always translate into support for priority systems. Further research into whether public messaging about organ donation could be modified to encourage registration by appeal to the golden rule would be worthwhile.

Attitudes toward strategies to increase organ donation: views of the general public and health professionals

BACKGROUND AND OBJECTIVE

The acceptability of financial incentives for organ donation is contentious. This study sought to determine (1) the acceptability of expense reimbursement or financial incentives by the general public, health professionals involved with organ donation and transplantation, and those with or affected by kidney disease and (2) for the public, whether financial incentives would alter their willingness to consider donation.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Web-based survey administered to members of the Canadian public, health professionals, and people with or affected by kidney disease asking questions regarding acceptability of strategies to increase living and deceased kidney donation and willingness to donate a kidney under various financial incentives.

RESULTS

Responses were collected from 2004 members of the Canadian public October 11-18, 2011; responses from health professionals (n=339) and people with or affected by kidney disease (n=268) were collected during a 4-week period commencing October 11, 2011. Acceptability of one or more financial incentives to increase deceased and living donation was noted in >70% and 40% of all groups, respectively. Support for monetary payment for living donors was 45%, 14%, and 27% for the public, health professionals, and people with or affected by kidney disease, respectively. Overall, reimbursement of funeral expenses for deceased donors and a tax break for living donors were the most acceptable.

CONCLUSION

The general public views regulated financial incentives for living and deceased donation to be acceptable. Future research needs to examine the impact of financial incentives on rates of deceased and living donors.

Level of awareness of personnel in hospital services related to the donation process: A Spanish and Latin American multicenter study

BACKGROUND

Services related to the donation and transplantation process are fundamental for developing solid organ transplantation and procuring organs from deceased donors. This study was conducted to analyze the attitude toward deceased organ donation among hospital personnel working in donation- and transplantation-related services in hospitals in Spain and Latin America.

METHODS

Nine hospital centers within the "International Donor Collaborative Project" were selected (Spain, Mexico, Cuba, and Costa Rica). A random employee sample was taken and stratified according to the type of service and job category in transplant-related hospital services.

RESULTS

Of the 925 employees surveyed, 78% were in favor of donation. By job category, attitude was more favorable among physicians (89%; p < 0.001). By type of service, attitude was more positive among personnel in transplant patient follow-up units (87%; p = 0.018). By country, the Cubans were most in favor (91%), followed by the Mexicans (81%), the Costa Ricans (77%), and the Spanish (70%; p < 0.001). Other factors were age (p < 0.001), sex (p = 0.005), considering the possibility of needing a transplant (p = 0.002), understanding the concept of brain death (p < 0.001), being in favor of living donation (p < 0.001), having discussed the subject of donation and transplantation within the family and the partner (p < 0.001), carrying out pro-social activities (p = 0.002), and concern about mutilation after donation (p = 0.002).

CONCLUSIONS

Transplant-related personnel had a favorable attitude toward deceased donation, although it was not as positive as we would expect, especially among non-physicians. This attitude needs to be improved because of the negative effect that can result in organ donation. There were pronounced differences between countries, and the discordance between attitude and actual deceased donation rates in each country is notable.

The riskiest job in medicine: transplant surgeons and organ procurement travel

Transplant surgeons are exposed to workplace risk due to the urgent nature of travel related to organ procurement. A retrospective cohort study was completed using data from the Scientific Registry of Transplant Recipients and the National Transportation Safety Board. A web-based survey was administered to members of the American Society of Transplant Surgeons. The survey response rate was 38% (281/747). Involvement in > or =1 procurement-related travel accident was reported by 15% of respondents; surgeons reported 61 accidents and 11 fatalities. Air travel was used in 26% of procurements and was involved in 56% of accidents. The risk of fatality while traveling on an organ procurement flight was estimated to be 1000 times higher than scheduled commercial flight. Involvement in a 'near miss accident' was reported by 80.8%. Only 16% of respondents reported feeling 'very safe' while traveling. Procurement of organs by the geographically closest transplant center would have reduced the need for air travel (>100 nautical miles) for lung, heart, liver and pancreas procurement by 35%, 43%, 31% and 49%, respectively (p < 0.0001). These reductions were observed in each Organ Procurement and Transplantation Network region. Though these data have important limitations, they suggest that organ procurement travel is associated with significant risk. Improvements in organ procurement travel are needed.

Stimulus for organ donation: a survey of the American Society of Transplant Surgeons membership

Federal legislation has been proposed to modify the National Organ Transplant Act in a way that would permit government-regulated strategies, including financial incentives, to be implemented and evaluated. The Council and Ethics Committee of the American Society of Transplant Surgeons conducted a brief web-based survey of its members' (n = 449, 41.6% response rate) views on acceptable or unacceptable strategies to increase organ donation. The majority of the membership supports reimbursement for funeral expenses, an income tax credit on the final return of a deceased donor and an income tax credit for registering as an organ donor as strategies for increasing deceased donation. Payment for lost wages, guaranteed health insurance and an income tax credit are strategies most strongly supported by the membership to increase living donation. For both deceased and living donation, the membership is mostly opposed to cash payments to donors, their estates or to next-of-kin. There is strong support for a government-regulated trial to evaluate the potential benefits and harms of financial incentives for both deceased and living donation. Overall, there is strong support within the ASTS membership for changes to NOTA that would permit the implementation and careful evaluation of indirect, government-regulated strategies to increase organ donation.

Relationship of Exposure to Organ Donation Information to Attitudes, Beliefs, and Donation Decisions of Next of Kin

Context

Public education campaigns about organ donation are common, but their association to actual attitudes, beliefs, and decisions about organ donation among family members of donation-eligible individuals is unknown.

Objective

To examine the sources of organ donation information identified by donor and nondonor families who participated in a large-scale study to examine factors that influence organ donation decisions.

Design

Semistructured telephone survey conducted after a passive recruitment strategy.

Setting and Participants

Participants were 285 next of kin of donor-eligible individuals (147 donors, 138 nondonors) from one organ procurement organization.

Results

Most (85.6%) of next of kin were exposed to at least 1 source of donation information that was important to them, although the types of donation information they were exposed to varied widely. White and educated adults were more likely to have been exposed to more donation information than had minorities and persons with less education. Favorable attitudes and beliefs about organ donation, donor designation, and sharing donation intentions with others were all associated with more exposure to different types of donation information. Donation consent was more likely when next of kin had been exposed to more donation information in the months preceding the family member's death.

Conclusions

When examined in the context of other recent research, these findings argue for continued development and implementation of public education campaigns for organ donation, with an emphasis on repeated exposure over time.

Communication as a Predictor of Willingness to Donate One's Organs: An Addition to the Theory of Reasoned Action

Fishbein and Ajzen's theory of reasoned action has been used by many researchers, particularly in regard to health communication, to predict behavioral intentions and behavior. According to that theory, one's intention is the best predictor that one will engage in a behavior, and attitudes and social norms predict behavioral intentions. Other researchers have added different variables to the postulates of attitudes and social norms that Fishbein and Ajzen maintain are the best predictors of behavioral intention. Here we draw on data from a 2006 telephone survey (N=420) gauging the awareness of an organ donation campaign in Northeast Ohio to examine the impact of communication on people's intentions. The current study supports the hypothesis that those who communicate with others are more likely to express a greater willingness to become an organ donor, but it expands the range of communication contexts. With demographics and attitudes toward organ donation controlled for, this study shows that communication with others about organ donation increases the willingness of individuals to have favorable attitudes about being an organ donor.

Donation after uncontrolled cardiac death (uDCD): a review of the debate from a European perspective

Presumed consent alone will not solve the organ shortage, but it will create an ethical and legal context that supports organ donation, respects individuals who object to organ donation, relieves families from the burden of decision making, and can save lives.

Review of Pathologic Findings in Remnant Hearts Following Valve Donation

The failure of medical examiners/coroners (ME/C) to allow heart valve donation is a major problem encountered by tissue agencies. Even though many ME/C favor tissue donation they remain responsible for determination of cause and manner of death. In 2001, the Jesse E. Edwards Registry of Cardiovascular Disease was approached by one of the nation's largest tissue procurement agencies (The American Red Cross--ARC) for the purpose of performing cardiovascular pathologic examinations following valve donation. The affiliation existed from October 2001 to January 2005. This study was undertaken to review all 593 postvalve recovery heart remnants received during that time period to tabulate the abnormalities identified and to determine whether donation interfered with the determination of cause of death. For each case, a preliminary cause of death was provided by the ARC. The decedent's body height and weight were also provided. Using the preliminary cause of death, the 593 cases were divided into natural and nonnatural manner of death groups. This division of the cases resulted in 106 cases placed in the natural manner of death group and 487 cases in the nonnatural manner of death group. For each case, all cardiac findings including significant conditions, additional findings, incidental findings, and congenital abnormalities were tabulated. Within the natural manner of death group, 15 cases had a noncardiac cause of death and 91 cases had a cause of death suspected to be cardiac related. In the 91 cases, a total of 132 significant cardiac findings were identified and there were six structurally normal hearts including two infants. In the nonnatural manner of death group, 214 significant cardiac findings were identified and 222 cases had a structurally normal heart. In both natural and nonnatural groups, the most common cardiac abnormality was atherosclerotic coronary artery disease. Other frequently encountered conditions were also identified including 11 cases with acute angle of origin of a coronary artery (five cases natural group; six cases nonnatural group). An important feature of this review was the recognition of potentially inheritable conditions that were diagnosed in both natural and nonnatural manner of death groups. There were three cases of hypertrophic cardiomyopathy (one natural; two nonnatural), three cases of arrhythmogenic right ventricular cardiomyopathy (one natural; two nonnatural), and one case of mitral valve prolapse (natural). In reviewing these cases, we did not feel that valve donation severely impaired cardiac pathologic examination. The benefits of cardiovascular pathologic examination by a cardiac pathologist include the identification of significant and incidental findings and recognition of potentially inheritable conditions.

Opportunities not taken: Successes and shortcomings in the Institute of Medicine's report on organ donation

The Institute of Medicine's recent report, Organ Donation: Opportunities for Action, studies the current problems facing organ donation in the USA, making suggestions for quality improvement and analyzing various proposals of incentivized donation and presumed consent (PC). Although the report deals with the donation of several solid organs, this mini review examines the findings from the perspective of kidney transplantation. The committee's recommendations to move from circulatory to neurologic criteria for cadaveric donation and to increase opportunities for donor decision making are prudent. We agree with the committee's arguments against providing incentives for donation because of the inherent distributional inequalities and imperfect information; the intrinsic difficulties in establishing market equilibrium for such heterogeneous and perishable goods; the implied commoditization of the human body; and the inadequate data regarding the long-term risks of living donation. However, we question the committee's firm opposition to PC, especially given recent data from 22 European countries showing a 25-30% increase in organ supply attributable to a PC policy. If this simple change in the default position on donation has the potential to increase organ supply, decrease the need for living donation, reduce the burden on grieving families, maintain familial authority over the deceased, and respect patient autonomy, at least a pilot program of PC seems warranted.

Traumatic memories of relatives regarding brain death, request for organ donation and interactions with professionals in the ICU

Little is known about the memories of relatives after they have been confronted with the brain death of a loved one and the request for organ donation. We conducted this study, guided by Grounded Theory, to explore relatives' experiences, their interactions with health care providers and what influenced their memories. We interviewed 40 relatives (31 consenting to and 9 refusing organ donation) of 33 brain-dead individuals. Relatives described their experiences as a difficult process composed of several stages spanning from the initial encounter to the final decision about donation. Long-term memories of bereaved relatives were influenced by the characteristics of their decision-making style (clear vs. ambivalent) and the perceived quality of the interaction with professionals on the intensive care unit. Organ-focused behavior of professionals and an ambivalent decision-making style of relatives appear to be risk factors for traumatic memories.

What Is the Attitude of Hospital Transplant-related Personnel Toward Donation?

The attitude of health-care workers, especially in transplant-related services, is fundamental in the process of organ procurement. In this study we examine the attitude of workers in transplant-related services toward cadaveric organ donation and transplantation (ODT) in a third-level hospital in Spain. A random sample was stratified according to type of service and job category (n = 309) among personnel in transplant-related services (organ procurement units, transplant units and follow-up units). Attitude toward cadaveric organ donation was evaluated using a validated psychosocial questionnaire. Seventy percent (n = 215) of respondents were found to be in favor of donation, as opposed to 30% against or undecided (n = 94). Regarding job category, attitude was most favorable among physicians (86%, n = 99; p = 0.000). With respect to type of service, attitude tended to be more negative in organ procurement units and more positive in the follow-up units of transplanted patients (41% vs 81%, p = 0.013). Upon analysis of the psychosocial variables, significant results were found with respect to the following factors: (1) age (39 vs 42 years, p = 0.007); (2) having discussed ODT with family members or with a partner (p = 0.007); (3) understanding of the concept of brain death (p = 0.001); (4) attitude toward carrying out an autopsy (p = 0.001); and (5) concern about the possibility of mutilation after organ extraction. Attitude toward cadaveric donation was lower than expected among personnel in transplant-related services, especially among ancillary personnel and workers in organ procurement units.

The impact of presumed consent legislation on cadaveric organ donation: a cross-country study

In the U.S., Great Britain and in many other countries, the gap between the demand and the supply of human organs for transplantation is on the rise, despite the efforts of governments and health agencies to promote donor registration. In some countries of continental Europe, however, cadaveric organ procurement is based on the principle of presumed consent. Under presumed consent legislation, a deceased individual is classified as a potential donor in absence of explicit opposition to donation before death. This article analyzes the impact of presumed consent laws on donation rates. For this purpose, we construct a dataset on organ donation rates and potential factors affecting organ donation for 22 countries over a 10-year period. We find that while differences in other determinants of organ donation explain much of the variation in donation rates, after controlling for those determinants presumed consent legislation has a positive and sizeable effect on organ donation rates. We use the panel structure of our dataset to test and reject the hypothesis that unmeasured determinants of organ donation rates confound our empirical results.

Attitudes toward financial incentives, donor authorization, and presumed consent among next-of-kin who consented vs. refused organ donation

BACKGROUND

Financial incentives, donor authorization, and presumed consent are strategies designed to increase organ donation rates. Surveys designed to assess attitudes toward these initiatives have been conducted with the general public, transplant patients, and transplant professionals.

METHODS

To assess attitudes toward financial incentives, donor authorization, and presumed consent and to identify multivariate predictors of such attitudes, we conducted telephone interviews with 561 family members who had recently been asked for consent to donate the organs of a deceased family member (348 donors, 213 nondonors).

RESULTS

Financial incentives would have made a difference in the donation decision for 54% of nondonors (vs. 46% of donors, P=0.02), and a higher percentage of nondonors would themselves become donors if financial incentives were available (P=0.03). Donors had significantly more favorable attitudes toward donor authorization (P<0.0001) and presumed consent (P<0.0001) policies. Overall, 54% of participants thought that family permission for donation was unnecessary when the deceased documented their donation intention, and 24% favored a presumed consent law with an opting out provision.

CONCLUSIONS

Of the three initiatives, donor authorization is likely supported by more donor and nondonor families than either financial incentives or presumed consent. Public education efforts should aim to better inform the public regarding existing and proposed donor authorization legislation and its benefits for registered organ donors and their families.

Coronary artery bypass grafting in patients with low ejection fraction

BACKGROUND

Patients with low ejection fraction (EF) are at a higher risk for postoperative complications and mortality. Our objective was to assess the effect of low EF on clinical outcomes after coronary artery bypass grafting (CABG).

METHODS AND RESULTS

We analyzed 55,515 patients from New York State database who underwent CABG between 1997 and 1999. Patients were stratified into 1 of the 4 EF groups: Group I (EF< or =20%), Group II (EF 21% to 30%), Group III (EF 31% to 40%), and Group IV (EF>40%). History of previous myocardial infarction, renal failure, and congestive heart failure were higher in patients with low EF (all P<0.001). Group I experienced a higher incidence of postoperative respiratory failure (10.1% versus 2.9%), renal failure (2.5% versus 0.6%), and sepsis (2.5% versus 0.6%) compared with Group IV. In-hospital mortality was significantly higher in Group I (6.5% versus 1.4%; P<0.001). Multivariate analysis showed hepatic failure [odds ratio (OR), 11.2], renal failure (OR, 4.1), previous myocardial infarction (OR, 3.4), reoperation (OR, 3.4), emergent procedures (OR, 3.2), female gender (OR, 1.7), congestive heart failure (OR, 1.6), and age (OR, 1.04) as independent predictors of in-hospital mortality in the low EF group. The discharges to home rate were significantly lower in Group I versus Group IV (73.1% and 87.7%, respectively; P<0.001).

CONCLUSIONS

Patients with low EF are sicker at baseline and have >4 times higher mortality than patients with high EF. However, outcomes are improving over time and are superior to historical data. Therefore, CABG remains a viable option in selected patients with low EF.

Should status II patients be removed from the pediatric heart transplant waiting list? A multi-institutional study

BACKGROUND

The survival benefit of cardiac transplantation (CTx) among Status 2 (stable outpatient) adult recipients has been questioned, but few studies have addressed this issue in pediatric patients. This study examined the following hypothesis: "Status 2 pediatric recipients have a survival benefit with CTx."

METHODS

Between 1993 and 2003, 2,375 patients were listed for CTx at 24 institutions; 614 (26%) of these patients were Status 2. By multivariate competing outcomes hazard function analysis, death after listing and post-transplant survival were analyzed.

RESULTS

A single-phase hazard function described the risk of death after listing, with 20% actual mortality within 2 months after Status 1 listing. The "natural history" of Status 2-listed patients was estimated by the risk of death, whereas waiting and risk of deterioration to Status 1 at CTx (weighted by the probability of death at 3 months after Status 1 listing). At 4 months after CTx, survival with CTx exceeded the predicted "natural Hx" survival in all diagnostic categories out to 4 years of follow-up.

CONCLUSIONS

Pediatric patients currently listed as Status 2 have a survival benefit with transplant out to at least 4 years. A pediatric allocation system restricted to Status 1 patients could only be justified if the vast majority of such patients could be transplanted within 1 to 2 months.

Waiting for a thoracic transplant in Eurotransplant*

The prospects of patients on the thoracic waiting list are governed by the chance of receiving an organ in time and by the outcome of the transplantation. The former probability is determined by a triad of disease severity, resource size and allocation rules. The aim of this study was to provide an objective description of the distributional effects of the thoracic allocation system in Eurotransplant. It appears that the interpretation of waiting-list outflow indicators is not straightforward and that it is difficult to assess the fairness of an organ allocation system in the framework of changing donor-organ availability. The timing of listing for heart transplantation can substantially be improved; whether this is also true for lung transplantation cannot be determined from the available data. Allocation schemes cannot solve the problem of organ shortage; a shift of attention toward collaboration with procurement professionals is needed.

The life-years saved by a deceased organ donor

Understanding the additional life-years given to patients by deceased organ donors is necessary as substantial investments are being proposed to increase organ donation. Data were drawn from the Scientific Registry of Transplant Recipients. All patients placed on the wait-list as eligible to receive or receiving a deceased donor solid organ transplant between 1995 and 2002 were studied. The benefit of transplant was determined by the difference in the expected survival experiences of transplant recipients and candidates expecting transplant soon. An average organ donor provides 30.8 additional life-years distributed over an average 2.9 different solid organ transplant recipients, whereas utilization of all solid organs from a single donor provides 55.8 additional life-years spread over six organ transplant recipients. The relative contribution of the different organs to the overall life-year benefit is higher for liver, heart and kidney, and lowest for lung and pancreas. The life-year losses from unprocured and unused organs are comparable to suicide, congenital anomalies, homicide or perinatal conditions and half that of HIV. Approximately 250,000 additional life-years could be saved annually if consent for potential deceased donors could be increased to 100%. Therefore, increasing organ donation should be considered among our most important public health concerns.

Defaults and donation decisions

The well-documented shortage of donated organs suggests that greater effort should be made to increase the number of individuals who decide to become potential donors. We examine the role of one factor: the no-action default for agreement. We first argue that such decisions are constructed in response to the question, and therefore influenced by the form of the question. We then describe research that shows that presumed consent increases agreement to be a donor, and compare countries with opt-in (explicit consent) and opt-out (presumed consent) defaults. Our analysis shows that opt-in countries have much higher rates of apparent agreement with donation, and a statistically significant higher rate of donations, even with appropriate statistical controls. We close by discussing the costs and benefits associated with both defaults as well as mandated choice.

Factors that identify survival after liver retransplantation for allograft failure caused by recurrent hepatitis C infection

Hepatitis C virus (HCV) is becoming the most common indication for liver retransplantation (ReLTx). This study was a retrospective review of the medical records of liver transplant patients at our institution to determine factors that would identify the best candidates for ReLTx resulting from allograft failure because of HCV recurrence. The patients were divided into 2 groups on the basis of indication for initial liver transplant. Group 1 included ReLTx patients whose initial indication for LTx was HCV. Group 2 included patients who received ReLTx who did not have a history of HCV. We defined chronic allograft dysfunction (AD) as patients with persistent jaundice (> 30 days) beginning 6 months after primary liver transplant in the absence of other reasons. HCV was the primary indication for initial orthotopic liver transplantation (OLT) in 491/1114 patients (44%) from July 1996 to February 2004. The number of patients with AD undergoing ReLTx in Groups 1 and 2 was 22 and 12, respectively. The overall patient and allograft survival at 1 year was 50% and 75% in Groups 1 and 2, respectively (P = .04). The rates of primary nonfunction and technical problems after ReLTx were not different between the groups. However, the incidence of recurrent AD was higher in Group 1 at 32% versus 17% in Group 2 (P = .04). Important factors that predicted a successful ReLTx included physical condition at the time of ReLTx (P = .002) and Child-Turcotte-Pugh score (P = .008). In conclusion, HCV is associated with an increased incidence of chronic graft destruction with a negative effect on long-term results after ReLTx. The optimum candidate for ReLTx is a patient who can maintain normal physical activity. As the allograft shortage continues, the optimal use of cadaveric livers continues to be of primary importance. The use of deceased donor livers in patients with allograft failure caused by HCV remains a highly controversial issue.

Clinical review: moral assumptions and the process of organ donation in the intensive care unit

The objective of the present article is to review moral assumptions underlying organ donation in the intensive care unit. Data sources used include personal experience, and a Medline search and a non-Medline search of relevant English-language literature. The study selection included articles concerning organ donation. All data were extracted and analysed by the author. In terms of data synthesis, a rational, utilitarian moral perspective dominates, and has captured and circumscribed, the language and discourse of organ donation. Examples include "the problem is organ shortage", "moral or social duty or responsibility to donate", "moral responsibility to advocate for donation", "requesting organs" or "asking for organs", "trained requesters", "pro-donation support persons", "persuasion" and defining "maximising donor numbers" as the objective while impugning the moral validity of nonrational family objections to organ donation. Organ donation has recently been described by intensivists in a morally neutral way as an "option" that they should "offer", as "part of good end-of-life care", to families of appropriate patients. In conclusion, the review shows that a rational utilitarian framework does not adequately encompass interpersonal interactions during organ donation. A morally neutral position frees intensivists to ensure that clinical and interpersonal processes in organ donation are performed to exemplary standards, and should more robustly reflect societal acceptability of organ donation (although it may or may not "produce more donors").

Survival of patients removed from the heart transplant waiting list

OBJECTIVE

End-stage heart failure has been associated with high mortality in the absence of transplantation. We evaluated the outcome of patients receiving optimal medical therapy who were removed from the cardiac transplant waiting list to determine survival and predictors of mortality.

METHODS

We performed a retrospective review of 27 patients removed from the cardiac transplant waiting list from 1999 to 2001 at our institution.

RESULTS

Mean age was 53 +/- 11 years; 16 of the patients were male. Status was IB in 3 cases and II in 24. Median time on the list was 32 months, and median follow-up was 2.9 years. Patients were removed from the transplant list because of either clinical improvement (group A, n = 18) or deterioration (group B, n = 9). In group A, 13 patients had improved functional status and 10 were in New York Heart Association class 1 or 2; 16 had improved echocardiographic left ventricular function. Survivals at 3 years were 100% in group A and 44% in group B (P <.01).

CONCLUSION

Patients with end-stage heart failure who have clinical response to medical therapy have excellent 3-year survival. These data suggest the necessity of close evaluation of patients waiting for transplantation, with a low threshold for inactivation if persistent clinical improvement is observed.