[Family approach--retrospective analysis of 6,617 donation requests]

Effekte des Organspendeskandals 2012 auf die Gewebespende am Institut für Rechtsmedizin München

Hintergrund

Der Organspendeskandal (OSS) 2012 führte zu einem dramatischen Einbruch der Spendebereitschaft. Im Zeitraum nach dem OSS verantwortete die Rechtsmedizin München 2013–2015 mit 51 muskuloskeletalen, 145 Cornea- und 38 Herzklappenentnahmen zahlreiche Gewebespenden im süddeutschen Raum.

Fragestellung

Die Ziele dieser Studie waren die Bestimmung des Einflusses des OSS auf die Gewebespende sowie die Auswirkung des ärztlichen Aufklärungsgespräches auf das Entscheidungsverhalten der Angehörigen.

Material und Methoden

Die Protokolle der Aufklärungsgespräche mit den Angehörigen im Zeitraum von Juli 2012 bis Dezember 2015 wurden auf Diskussionen, Erwähnungen sowie Entscheidungsverhalten im Zusammenhang mit dem OSS evaluiert. Zudem erfolgte im Jahresabstand nach der Spende eine retrospektive Evaluation des Aufklärungsgespräches durch die Angehörigen anhand eines Fragenkatalogs mit 9 Items.

Ergebnisse

Bei 388 potenziellen Spendern lag die Zustimmung bei 54,9 %. In 40 Fällen war der OSS Diskussionspunkt und resultierte in 15 Fällen in Ablehnung. Davon wurde in 6 Fällen ein Spendeausweis zuvor vom Verstorbenen aufgrund des OSS vernichtet, wobei in 4 Fällen nach Diskussion mit den Angehörigen eine Zustimmung erreicht wurde. Insgesamt bewerteten 142 Angehörige das Aufklärungsgespräch als positiv und die Spende als sinnstiftend. Die Entscheidungen waren zu 100 % stabil.

Diskussion

Die guten Resultate der Evaluation sowie der dieses Spendeprojekt nur gering beeinflussende OSS beruhen vor allem auf der mit Empathie und Erfahrung durchgeführten Aufklärung. Zum Vertrauensaufbau der Bevölkerung benötigt es ärztlicherseits ein aktives Informationsangebot und lückenlose Transparenz.

[Considerations for quality assurance of discussions with relatives in direct association with organ donation]

BACKGROUND

Discussions with relatives are relevant and crucial aspects of the organ donation process and contribute to a consolidated and sustainable decision by the families of the deceased. Despite the great importance of family care, there is no systematic analysis of the quality of this communication, in contrast to the diagnosis of irreversible loss of brain function, organ retrieval and organ transplantation. For this reason, organ donation experts were interviewed about recurring characteristics of communication with relatives of the deceased. The aim of this qualitative study was to define criteria for the assessment of the structure and quality of the communication process with relatives for internal quality management in Germany.

METHODS

Based on a systematic literature review and with the help of the 5‑stage S²PS² (system for creating a questionnaire) procedure according to Kruse, interview guidelines were initially developed. As a second step, in guideline-based interviews 10 experienced organ donation experts were questioned about structural, procedural and ethical aspects of their discussions with relatives. Following the interviews, a software-based qualitative content analysis was carried out with a combined inductive-deductive category system. Finally, the first quality assurance measures for the interviews with relatives were developed in a multistep process, closely following the methodological principles V1.1 of the Institute for Quality Assurance and Transparency in Health Care (IQTIG). The individual research steps were accompanied by an expert group consisting of physicians, nurses, theologians and ethicists utilizing an anonymous Delphi procedure.

RESULTS

In the qualitative content analysis, 5 main categories with 30 subcategories on quality relevant aspects could be identified (including, standardization and technique of conversation, interview framework and context factors, professional expertise of the interviewers, wishes of the organ donation experts). On this basis, 6 criteria for the structural quality and 7 criteria for the process quality of the discussions with relatives were formulated and summarized in a respective quality bundle. These criteria address, among other things, interprofessional communication, structured training concepts, regular further training of all team members, use of standardized communication and counselling strategies as well as documented preliminary meetings and debriefings, including supervising elements. They emphasize interdisciplinary professionalism and process management in a protected environment as well as quality assured communication and documentation. Recommendations were made for expanding the existing documentation for the organ donation process and for documenting the preliminary meetings and debriefings.

CONCLUSION

Recurring communication and process characteristics as well as requirements for the members of the treatment team who conduct the conversation can be identified for the interviews with relatives, which show potential for improvement to various degrees. This justifies the structured derivation of a quality bundle for the structural and process quality family care related to organ donation, which should enable a low-threshold entry into an institution internal systematic quality assessment of communication with relatives in Germany. Due to the different legal, medical and social specifics in an international context, the study results cannot be directly transferred to other countries.

Measures influencing post-mortem organ donation rates in Germany, the Netherlands, Spain and the UK : A systematic review

BACKGROUND

German post-mortem organ donation rates have been declining since 2010. Several transplantation scandals led to a negative portrayal of organ donation in the media. Spain, the UK and the Netherlands achieved a rise in organ donation rates while retaining organ donation legislation.

METHODS

A systematic review of publications focusing on (1) organ donation legislation, (2) data on post-mortem organ donation rates and (3) measures to increase post-mortem organ donation rates in Europe was conducted in November 2017 in PubMed, PsycINFO and Web of Science. Quality parameters of the World Bank and the World Health Organization (WHO) were studied to analyze national health services, frequent causes of death and life expectancy.

RESULTS

Quality parameters of national health services were similar in all countries. The Netherlands and Germany have an opt in system. An increase of 37.4% in post-mortem organ donation rates from 2008 to 2015 in the UK was accomplished through the establishment of a donation task force, adopting parts of the Spanish model, while maintaining an opt in system. Spain has the highest organ donation rate worldwide (39.7 per million persons in 2015). The implementation of transplantation coordinators and the change in legislation in Germany in 2012 has so far shown no effect. Public awareness of organ donation in the Netherlands increased following various information campaigns.

CONCLUSION

Donation after cardiac death (DCD), expanded donor criteria, increasing public awareness and introduction of an organ donor register should be discussed as measures to increase organ donation rates in Germany.

An Integrated Psychosocial Model of Relatives' Decision About Deceased Organ Donation (IMROD): Joining Pieces of the Puzzle

Organ transplantation remains currently limited because the demand for organs far exceeds the supply. Though organ procurement is a complex process involving social, organizational, and clinical factors, one of the most relevant limitations of organ availability is family refusal to donate organs of a deceased relative. In the past decades, a remarkable corpus of evidence about the factors conditioning relatives' consent has been generated. However, research in the field has been carried out mainly by means of merely empirical approaches, and only partial attempts have been made to integrate the existing empirical evidence within conceptual and theoretically based frameworks. Accordingly, this work articulates the proposal of an Integrated Psychosocial Model of Relatives' Organ Donation (IMROD) which offers a systematic view of the factors and psychosocial processes involved in family decision and their interrelations. Relatives' experience is conceptualized as a decision process about the possibility of vicariously performing an altruistic behavior that takes place under one of the most stressful experiences of one's lifetime and in the context of interaction with different healthcare professionals. Drawing on this, in the proposed model, the influence of the implied factors and their interrelations/interactions are structured and interpreted according to their theoretically based relation with processes like rational/heuristic decision-making, uncertainty, stress, bereavement, emotional reactions, sense of reciprocity, sense of freedom to decide, and attitudes/intentions toward one's own and the deceased's organ donation. Our model also develops a processual perspective and suggests different decisional scenarios that may be reached as a result of the combinations of the considered factors. Each of these scenarios may imply different balances between factors that enhance or hinder donation, such as different levels of uncertainty and potential decisional conflict. Throughout our work, current controversial or inconsistent results are discussed and interpreted on the basis of the relationships that are posited in the proposed model. Finally, we suggest that the structure of the relationships and interactions contained in our model can be used by future research to guide the formulation of hypotheses and the interpretation of results. In this sense, specific guidelines and research questions are also proposed.

Organ donation in Switzerland--an analysis of factors associated with consent rate

Background and Aim

Switzerland has a low post mortem organ donation rate. Here we examine variables that are associated with the consent of the deceased’s next of kin (NOK) for organ donation, which is a prerequisite for donation in Switzerland.

Methods and Analysis

During one year, we registered information from NOK of all deceased patients in Swiss intensive care units, who were approached for consent to organ donation. We collected data on patient demographics, characteristics of NOK, factors related to the request process and to the clinical setting. We analyzed the association of collected predictors with consent rate using univariable logistic regression models; predictors with p-values <0.2 were selected for a multivariable logistic regression.

Results

Of 266 NOK approached for consent, consent was given in 137 (51.5%) cases. In multivariable analysis, we found associations of consent rates with Swiss nationality (OR 3.09, 95% CI: 1.46–6.54) and German language area (OR 0.31, 95% CI: 0.14–0.73). Consent rates tended to be higher if a parent was present during the request (OR 1.76, 95% CI: 0.93–3.33) and if the request was done before brain death was formally declared (OR 1.87, 95% CI: 0.90–3.87).

Conclusion

Establishing an atmosphere of trust between the medical staff putting forward a request and the NOK, allowing sufficient time for the NOK to consider donation, and respecting personal values and cultural differences, could be of importance for increasing donation rates. Additional measures are needed to address the pronounced differences in consent rates between language regions.