Considering adult living donor liver transplantation: A qualitative study of patients and their potential donors

Exploration Into Donor-Recipient Relationship After Living-Donor Liver Transplantation Using Gift-Exchange Theory

AIM

This qualitative study aimed to explore the donor-recipient relationships following living-donor liver transplantation.

METHOD

A 1-time cross-sectional qualitative interview was conducted with liver transplant recipients (n = 17) and living liver donors (n = 11) post-transplant. The interviews were transcribed verbatim and analyzed manually by using thematic content analysis.

RESULTS

The mean age of the recipients and the donors was 54.41 ± 8.0 (range 39-71) and 36.6 ± 7.69 (range 28-57) years, respectively. Following the interviews, 2 overarching themes emerged: (1) Became care providers, and (2) differentiation in relationships after transplantation. A total of 3 sub-themes were explained under "differentiation in relationships after transplantation;" feeling guilty, becoming closer and more intense owing to a feeling of indebtedness, and putting some distance owing to a feeling of indebtedness.

CONCLUSION

The study focused on the reciprocation stage according to gift-exchange theory. During reciprocation, although recipients expressed positive feelings such as gratitude, closer relationships, and special bonds; they also reported negative feelings like guilt and indebtedness resulting in a purposeful distancing from their donors. Most donors understood what the recipients felt, but they wanted their relationship to return to normal. Married female donors had worse experiences, such as divorce or a weakened marital relationship after donation.

Beliefs of Living Donors About Recipients' End-Stage Liver Failure and Surgery for Organ Donation

BACKGROUND

The concept of beliefs could provide a basis for how donors may perceive recipients' end-stage liver failure (ESLF) and surgery for organ donation. However, there is no such quantitative study. Therefore, the objective of this study was to explore beliefs of living donors about recipients' ESLF and surgery for organ donation.

METHODS

The sample comprised 16 living donors who donated a part of their liver to a patient who had ESLF. The data were analyzed by following established procedures for inductive qualitative analysis.

RESULTS

Analysis showed that donors' beliefs can be viewed in a number of groups. Beliefs about recipients' ESLF included diverse explanations for ESLF (blaming oneself and physicians) and physical symptoms (developmental slowing down). Beliefs about being a donor included reasons for being a donor (performing a good deed, being healed), barriers to being a donor (other people being ignorant and selfish), ways to manage these barriers (following one's gut feeling), and factors facilitating being a donor (the feeling that one does not have many people to leave behind). Beliefs about surgery for organ donation included physical effects (pain, feeling stiff). Beliefs about organ donation included views that general organ donation should be encouraged and that people's awareness should be raised.

CONCLUSIONS

Existing psychological perspectives could help to interpret some beliefs. Nevertheless, other beliefs, not previously reported, could be considered as targets for individual consultations/psycho-educational programs for fostering emotional well-being.

Liver Transplantation: Recipients' Evaluation of Life From the Perspective of Living Donors

AIM

Liver transplantation affects not only recipients and living donors' lives, but also the nature and quality of their relationship. Moreover, the ways in which recipients of liver transplant experience life and views of living donors on how recipients experience life may differ. These differences may account for relational changes. It is also important to understand how recipients and their living donors' views differ if the aim is to devise psychoeducational programs for recipients and living donors. Therefore, the present study examined the recipients' experience of life after a diagnosis of end-stage liver failure (ESLF) and transplantation surgery from donors' perspective.

METHODS

The sample consisted of 16 living donors who donated a part of their liver to a patient with ESLF. Thematic analysis was undertaken in parallel with interviews during which an interview guide was followed.

FINDINGS

Donors felt that recipients evaluated life after the diagnosis of ESLF and transplantation surgery in terms of limitations, mixed relationships, emotional changes, and improvement in life.

CONCLUSION

Experience of social limitations, negative emotions, and the feeling that one is supported by others could be interpreted in terms of existing psychological theory. Some ways of adjusting that have not been reported before within the context of ESLF extended the literature. These included others being frightened of being infected by ESLF and being insensitive, experience of positive emotions, and ways of improving. Overall, compared with findings of previous qualitative work among recipients, our findings suggest that donors' evaluation of recipients' lives converge with that of recipients.

Live liver donors' information needs: A qualitative study of practical implications for informed consent

BACKGROUND

As live donor liver transplantation is increasingly used to expand the donor pool, concerns remain regarding how best to obtain live liver donors' informed consent. This study assessed donors' information preferences and their perceptions of informed consent.

METHODS

Cognitive interviews were conducted with donors by telephone about how knowledge items in a new survey instrument were material to informed consent, between November 2011 and April 2012. Thematic analysis was used to analyze qualitative data until reaching saturation.

RESULTS

Twenty-nine liver donors participated (85% participation). Donors commonly reported being unable to understand or retain much information disclosed during education. Donors preferred information about major donation risks, eg, death and minor risks that would likely affect their daily lives, eg, wound infection. Donors expressed less interest in information about their rights, confidentiality, or the medical procedure itself. Donors' preferences varied regarding statistical information. Many perceived the disclosure of risk information to be excessive, and rationalized risks they believed to be uncommon or not serious. Donors were disappointed by the brevity of the postdonation hospital stay.

CONCLUSION

Our findings suggest that the complexity and volume of disclosed information during evaluation were difficult for donors to adequately comprehend. Donors' lack of appreciation for the seriousness of complications may undermine their ability to provide informed consent. Future research should develop effective methods of information delivery to enhance informed consent.

An international comparison of deceased and living organ donation/transplant rates in opt-in and opt-out systems: a panel study

BACKGROUND

Policy decisions about opt-in and opt-out consent for organ donation are based on limited evidence. To fill this gap we investigated the difference between deceased and living organ donation rates in opt-in and opt-out consent systems across a 13 year period. We controlled for extensive covariates and estimated the causal effect of consent with instrumental variables analysis.

METHOD

This panel study used secondary data analysis to compare organ donor and transplant rates in 48 countries that had either opt-in or opt-out consent. Organ donation data were obtained over a 13-year period between 2000 and 2012. The main outcome measures were the number of donors, number of transplants per organ and total number (deceased plus living) of kidneys and livers transplanted. The role of consent on donor and transplant rates was assessed using multilevel modeling and the causal effect estimated with instrumental variables analysis.

RESULTS

Deceased donor rates (per-million population) were higher in opt-out (M = 14.24) than opt-in consent countries (M = 9.98; Β = -4.27, 95% confidence interval (CI) = -8.08, -0.45, P = .029). However, the number of living donors was higher in opt-in (M = 9.36) than opt-out countries (M = 5.49; B = 3.86, 95% CI = 1.16, 6.56, P = .006). Importantly, the total number of kidneys transplanted (deceased plus living) was higher in opt-out (M = 28.32) than opt-in countries (M = 22.43; B = -5.89, 95% CI = -11.60, -0.17, P = .044). Similarly, the total number of livers transplanted was higher in opt-out (M = 11.26) than opt-in countries (M = 7.53; B = -3.73, 95% CI = -7.47, 0.01, P = .051). Instrumental variables analysis suggested that the effect of opt-in versus opt-out consent on the difference between deceased and living donor rates is causal.

CONCLUSIONS

While the number of deceased donors is higher than the number of living donors, opt-out consent leads to a relative increase in the total number of livers and kidneys transplanted.

Reclaiming their lives: the decision-making process in living liver donation--an interpretative phenomenological case study analysis of one couple

OBJECTIVES

Adult-to-adult living liver donation (LLD) is a controversial procedure due to the risk to the healthy donor. The decision to proceed with LLD is an important, yet under-researched area. This study aims to explore the decision-making process of the donor and recipient independently, and within the donor-recipient dyad.

DESIGN

A longitudinal, qualitative analysis of the LLD decision from the perspective of a LLD donor-recipient dyad.

METHODS

In-depth interviews were conducted with the donor and recipient separately on three occasions: pre LLD, six weeks post and six months post LLD. Transcripts were subject to interpretative phenomenological analysis.

RESULTS

During the pre-LLD interviews, a series of intra- and interpersonal negotiations were reported as both the donor and recipient grappled to make a decision about LLD. Following the decision, the focus then centred on the consequences of the decision and making sense of unanticipated outcomes. By six months post LLD, both were able to reflect on adapting to the changes their decision had ultimately caused.

CONCLUSIONS

This case study offers a unique insight into the risk assessment and decision-making demands of LLD and the results can help support future LLD candidates.

The ethics of living donation for liver transplant: beyond donor autonomy

This paper will present and discuss our conclusions about the ethics of living donation for liver transplant (LDLT) after 8 year of collaboration between our clinical ethics consultation service and liver transplant teams, in the course of which we met with all donor-candidates. We will focus on the results of a follow-up study that was conducted in order to evaluate the long-term consequences for potential donors and to interview them on the ethical aspects of the screening process. This study was conducted from April 2007 to November 2009 and consisted of interviews with donor-candidates, regardless of whether they underwent harvest surgery, at least 1 year after the recipient's transplant. We explored their views about their own and the recipients' physical and psychological condition, changes in family and career dynamics, their experience as potential or real donors, and their views about LDLT process in general. Results shed new light on the ethical grounds of LDLT and allow us to envisage new ways of improving the ethical soundness of current procedures and practices. In particular, we argue that the purpose of an ethics committee should be to provide follow-up support for the donors rather than merely to check the freedom of donors' consent. We also suggest that the recipient's consent deserves more attention than it currently receives.

Informed consent and decision-making about adult-to-adult living donor liver transplantation: a systematic review of empirical research

Adult-to-adult living donor liver transplantation (LDLT) is a complex procedure that poses serious health risks to and provides no direct health benefit for the donor. Because of this uneven risk-benefit ratio, ensuring donor autonomy through informed consent is critical. To assess the current knowledge pertaining to informed consent for LDLT, we conducted a systematic review of the empirical literature on donors' decision-making process, comprehension about risks and outcomes, and information needs for LDLT. Of the 1423 identified articles, 24 met final review criteria, representing the perspective of approximately 2789 potential and actual donors. As donors' decisions to donate often occur before evaluation, they often make uninformed decisions. The review found that 88% to 95% of donors reported understanding information clinicians disclosed about risks and benefits. However, donors reported unmet information needs, knowledge gaps regarding risks, and unanticipated complications. Few donors reported feeling pressure to donate. Most studies were limited by cultural differences, small sample sizes, inconsistent measures, and poor methodological approaches. This systematic review suggests that informed consent for LDLT is sub-optimal as donors do not adequately appreciate disclosed information during the informed consent process, despite United Network for Organ Sharing/CMS regulations requiring formal psychological evaluation of donor candidates. Interventions are needed to improve donor-clinician communication during the LDLT informed consent process such as through the use of comprehension assessment tools and e-health educational tools that leverage adult learning theory to effectively convey LDLT outcome data.