Public knowledge about and attitudes toward organ donation, and public barriers to donate in Jordan: A cross-sectional study

BACKGROUND

Organ donation is a critical issue that is receiving greater attention worldwide. In Jordan, the public's knowledge about and attitudes toward organ donation play a significant role in the availability of organs for transplantation.

AIM

To assess the public knowledge about and attitudes toward organ donation in Jordan.

METHODS

A cross-sectional design was used to collect data from 396 Jordanian citizens via an online self-reported questionnaire.

RESULTS

Overall, 396 participants were recruited. Of the entire sample, 93.9% of the participants had heard about and had sufficient knowledge about organ donation but they had limited knowledge about brain death. The most common source of information about organ donation was social media networks. Females were found to score significantly higher than males for attitude. Those who had thought about organ donation or registered their names to donate scored significantly higher in terms of attitudes to donation than their counterparts who had not. The most common reasons for limited organ donation practices in Jordan were a lack of awareness programs and insufficient knowledge in society.

CONCLUSION

Greater public understanding of organ donation appears to be associated with more positive attitudes toward organ donation. Most participants responded positively regarding their attitude toward organ donation as they believed that this action could give another person a chance to live. Moreover, most agreed that they would donate their organs after their death. Otherwise, the participants had limited general knowledge about brain death, and most had not registered their names to donate their organs. These findings indicate the need for public awareness campaigns and educational programs to encourage more people to become organ donors.

A ten-year retrospective analysis of decompressive craniectomy or craniotomy after severe brain injury and its implications for donation after brain death

Craniotomy or decompressive craniectomy are among the therapeutic options to prevent or treat secondary damage after severe brain injury. The choice of procedure depends, among other things, on the type and severity of the initial injury. It remains controversial whether both procedures influence the neurological outcome differently. Thus, estimating the risk of brain herniation and death and consequently potential organ donation remains difficult. All patients at the University Hospital Münster for whom an isolated craniotomy or decompressive craniectomy was performed as a treatment after severe brain injury between 2013 and 2022 were retrospectively included. Proportion of survivors and deceased were evaluated. Deceased were further analyzed regarding anticoagulants, comorbidities, type of brain injury, potential and utilized donation after brain death. 595 patients were identified, 296 patients survived, and 299 deceased. Proportion of decompressive craniectomy was higher than craniotomy in survivors (89% vs. 11%, p < 0.001). Brain death was diagnosed in 12 deceased and 10 donations were utilized. Utilized donations were comparable after both procedures (5% vs. 2%, p = 0.194). Preserved brain stem reflexes as a reason against donation did not differ between decompressive craniectomy or craniotomy (32% vs. 29%, p = 0.470). Patients with severe brain injury were more likely to survive after decompressive craniectomy than craniotomy. Among the deceased, potential and utilized donations did not differ between both procedures. This suggests that brain death can occur independent of the previous neurosurgical procedure and that organ donation should always be considered in end-of-life decisions for patients with a fatal prognosis.

The effect of the Iranian family approach-specific course (IrFASC) on obtaining consent from deceased organ donors' families

Background

A family approach and obtaining consent from the families of potential brain-dead donors is the most important step of organ procurement in countries where an opt-in policy applies to organ donation. Health care staff's communication skills and ability to have conversations about donation under circumstances of grief and emotion play a crucial role in families' decision-making process and, consequently, the consent rate.

Methods

A new training course, called the Iranian family approach-specific course (IrFASC), was designed with the aim of improving interviewers' skills and knowledge, sharing experiences, and increasing coordinators' confidence. The IrFASC was administered to three groups of coordinators. The family consent rate of participants in the same intervals (12 months for group 1, 6 months for group 2, and 3 months for group 3) was measured before and after the training course. The Wilcoxon signed-rank test was used to make comparisons.

Results

The family consent rate was significantly different for all participants before and after the training, increasing from 50.0% to 62.5% (P=0.037). Furthermore, sex (P=0.005), previous training (P=0.090), education (P=0.068), and duration of work as a coordinator (P=0.008) had significant effects on the difference in families' consent rates before and after IrFASC.

Conclusions

This study showed that the IrFASC training method could improve the success of coordinators in obtaining family consent.

Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM

There is a wide gap between patients who need transplants and the organs that are available in India. Extending the standard donation criterion is certainly important to address the scarcity of organs for transplantation. Intensivists play a major role in the success of deceased donor organ transplants. Recommendations for deceased donor organ evaluation are not discussed in most intensive care guidelines. The purpose of this position statement is to establish current evidence-based recommendations for multiprofessional critical care staff in the evaluation, assessment, and selection of potential organ donors. These recommendations will give "real-world" criteria that are acceptable in the Indian context. The aim of this set of recommendations is to both increase the number and enhance the quality of transplantable organs.

How to cite this article

Zirpe KG, Tiwari AM, Pandit RA, Govil D, Mishra RC, Samavedam S, et al. Recommendations for Evaluation and Selection of Deceased Organ Donor: Position Statement of ISCCM. Indian J Crit Care Med 2022;26(S2):S43-S50.

Cost-Effectiveness and Budget Impact Analysis of Implementing a 'Soft Opt-Out' System for Kidney Donation in Australia

INTRODUCTION

There is a severe shortage of donor organs globally. There is growing interest in understanding how a 'soft opt-out' organ donation system could help bridge the supply and demand gap for donor organs. This research aims to estimate the cost-effectiveness and budget impact of implementing a 'soft opt-out' organ donation system for kidney donation.

METHODS

A decision-analytic model was developed to estimate the incremental costs from a health system's perspective, quality-adjusted life-years (QALYs), and death averted of people who have kidney failure, comparing a 'soft opt-out' organ donation system to an 'opt-in' system. This study analysed three scenarios where the 'soft opt-out' system generated a 20%, 30%, and 40% increase in deceased organ donation rates over 20 years. A 5-year time horizon was adopted for the budget impact analysis.

RESULTS

A 20% increase in organ donation rates could have a cost saving of 650 million Australian dollars (A$) and a 10,400-QALY gain. A 20% increase would avert more than 1500 deaths, while a 40% increase would avert 3200 deaths over a time horizon of 20 years. Over the first 5 years, a 20% increase would have a net saving of A$53 million, increasing to A$106 million if the donation rate increases by 40%.

CONCLUSION

A 'soft opt-out' organ donation system would return a cost saving for the healthcare system, a net gain in QALYs, and prevention of a significant number of deaths. Advantageous budgetary impact is important, but understanding the aversion for a 'soft opt-out' system in Australia is also important and remains a priority for further research.

Organ Donation Decision in Families With Brain-Dead Patients: An Evolutionary Concept Analysis

BACKGROUND AND AIM

Organ donation decision is a complicated process for bereaved families; however, its attributes and associated factors are not clear. Accordingly, the purpose of this study was to analyze the concept of organ donation decision in families with brain-dead patients.

METHODS

Concept analysis was performed using Rodgers' evolutionary method. For this purpose, PubMed, OVID, Scopus, and ProQuest databases were searched in English from 1985 to 2019. In total, 54 articles were analyzed using the thematic analysis to identify the attributes, antecedents, and consequences of the concept. The validity of the data was provided by examining the analysis process by 2 independent researchers.

FINDINGS/CONCLUSIONS

Organ donation decision in these families is a complicated and conflicting process of vicarious decision-making that begins with an organ donation request: a difficult, painful, and critical experience that requires extensive interpersonal interactions and is ultimately influenced by various factors, leading to the acceptance or refusal. The antecedents include deceased-related factors, family-related factors, the quality of organ donation request, and the quality of health care professionals' interactions. The consequences include the positive outcomes (grief solace, gift of life, and promoting human values) and negative outcomes (ambiguity, doubt and regret, and psychological inconsistency). The results of this concept analysis led to a better understanding of the complexity of an organ donation decision in these families. In this way, in addition to knowledge development, it assists the health care staff to support families in making the organ donation decision.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Although case managers rarely participate in organ donation, they definitely need to understand the concepts related to organ donation decision while advocating for the patients or families. The results of this concept analysis can broaden the case managers' and other health care professionals' knowledge about families' organ donation decision and help them take more effective interventions for management of this process. Case managers and the health care team can use the information of this article for informing families about brain death, negotiating with families for organ donation, preparing information, and caring and facilitating the families in making the clear and unconflicted decision.

Education and training methods for healthcare professionals to lead conversations concerning deceased organ donation: An integrative review

OBJECTIVES

To determine which training methods positively influenced healthcare professionals' communication skills and families' deceased organ donation decision-making.

METHODS

An integrative review using systematic methods and narrative synthesis for data analysis. Electronic databases of PubMed, Cumulative Index to Nursing and Allied Health Literature (EBSCO), Embase (OVID) and ProQuest Dissertations & Theses Global, were searched between August 1997 and March 2020, retrieving 1019 papers. Included papers (n = 14) were appraised using the Medical Education Research Study Quality Instrument.

RESULTS

Training programmes offered theory, experiential learning, feedback and debriefing including self-reflection, the opportunity to role-play and interact with simulated participants within realistic case scenarios. Programmes reported observed and self-rated improvements in communication learning and confidence. The methodological quality score averaged 13, (72% of maximum); few studies used an experimental design, examined behavioural change or families' perspectives. Weak evidence suggested training could increase organ donation authorisation/consent rates.

CONCLUSIONS

Multiple training strategies are effective in improving interprofessional healthcare professionals' confidence and learning of specialised communication. Methodological limitations restricted the ability to present definitive recommendations and further research is warranted, inclusive of family decision-making experiences.

PRACTICE IMPLICATIONS

Learning of specialised communication skills is enhanced by using multiple training strategies, including role-play and debriefing.

[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.

Changes in consent rate, expressed deceased donation decision-making, and family interactions in Israel-a national retrospective cohort study

This study aimed to compare the consent rate for deceased organ donation in Israel over two time periods, namely 2004-2009 (2004/9) and 2016-July 2020 (2016/20). Donor and family data were collected from the Israel National Transplantation Center Registry and included donor characteristics, reasons for family consent and refusal, and a subjective assessment of donor coordinator-family interactions. The consent rate increased from 41.6% over the period 2004/9 to 61.8% for the period 2016/20 (P < 0.0001). A significant increase in the proportion of Jewish donors was noted (49.8% in 2004/9 vs. 67.5% in 2016/20, P < 0.0001), while no increase in the consent rate for the Muslim population was noted. Religious objections as a reason for refusal decreased significantly (37.6% vs. 27.3%; P = 0.02), while the proportion of families citing donating as the "right thing to do" increased significantly (7% vs. 26.6%; P < 0.0001). Finally, a significant increase in the proportion of very positive DC-family interactions (59% to 78.3%, P < 0.0001) was noted. In conclusion, the increased consent rate in 2016/20 was associated with changes in expressed decision-making and donor coordinator-donor family interactions. Additional interventions tailored to all different populations groups need to be developed and further investigated.

New procedures for the confirmation of brain death in Brazil: results from the Central Estadual de Transplantes de Santa Catarina

Objective

To analyze the impact of Resolution 2.173/2017 of the Federal Council of Medicine on results from the Central Estadual de Transplantes de Santa Catarina.

Methods

This was a cross-sectional observational study of medical records of all patients (1,605) with suspected brain death notified to the Central Estadual de Transplantes de Santa Catarina; for this study, procedures to confirm this diagnosis were initiated between July 2016 and December 2017 and between January 2018 and June 2019. The median duration of the protocol in each period was considered for the comparison between the intervals. The collected data were transformed into rates (per million population). The mean rates for the periods before and after the implementation of the protocol were analyzed by Student’s t-test, and qualitative variables were analyzed by Pearson’s chi-squared test.

Results

The mean duration of brain death confirmation procedures decreased more than 1 hour in the second period compared to the first period, with statistical significance (p = 0.001). The rates of harvested livers and transplanted pancreas, the number of notifications by hospital size and the rate of cardiac arrest in the macro-region of the Itajaí Valley were significantly different between the two periods.

Conclusion

In the period after the new resolution on brain death, there was a reduction in the duration for diagnosis. However, other indicators did not change significantly, providing evidence for the multidimensional nature of the organ transplantation process in Santa Catarina and the need for further studies to better understand and optimize the process.

A study on the performance of the Donation Improvement Program in Korea

Background

Methods

Results

Conclusions

A qualitative exploratory case series of patient and family experiences with ECPR for out-of-hospital cardiac arrest

Objective

There is currently no existing data examining the opinions of patients and families after treatment with extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). We sought to interview family members and patients to learn from their experiences and satisfaction with treatment.

Methods

We contacted family members and survivors for all cases treated with ECPR for refractory OHCA at St. Paul’s Hospital between January 2014 and July 2018. We performed semi-structured interviews with participants, specifically within the topics of: information sharing (including impressions of an ECPR informational pamphlet), prognostication, organ donation, and perceived value of ECPR. Due to low participant enrolment, we described all interviews in a narrative approach.

Results

Within the study period, there were 23 OHCAs treated with ECPR; two survivors and three family members agreed to participate. Participants were satisfied with the treatment provided, including information sharing and prognostication. There were mixed opinions about the best method of information-sharing (verbal vs written), as well as the timing of organ donation conversations. All participants believed ECPR for OHCA to be of high value.

Conclusion

Patient’s conveyed satisfaction with ECPR treatment, with mixed views on the best information sharing strategy. Further study is needed to define the optimal methods and timing for discussions of organ donation, especially for treatments of with a relatively low likelihood success.

Opt-Out Consent at Different Levels of Attitude to Organ Donation: A Household Survey in Qatar

Purpose

Demand for an organ transplant is surpassing the number of organ donors and hence increasing waiting lists worldwide, compelling many countries to adopt an opt-out consent system for organ donation. Opt-out is used in several European countries and has increased organ registration rate. No study on this subject has been published from the gulf region to associate sociodemographic characteristics, knowledge, attitude, beliefs, and intention domains regarding an opt-out consent for organ donation.

Materials and Methods

A household survey was conducted between October and November 2016 using a validated questionnaire. Integer codes were assigned for qualitative data to interpret results at par with quantitative data for each domain to allow data for advanced statistical analysis.

Results

Of 1044 surveyed participants, 724 (69.34%) those aged 37.7±10.4 agreed to adopting an opt-out consent system of which 231 (29.4%) were Qatari citizens and 353 (48.8%) were males. Mean levels of indices such as attitude, behavioral beliefs, and intention domains to organ donation were found higher in opt out participants. After adjusting statistical significant variables, multivariate analysis showed that attitude index was associated to opt out system (OR: 16.7, 95% C.I.:10.6-26.3, p=0.001) whereas; knowledge index (OR: 0.25, 95% C.I.: 0.07-0.83, p=0.03), behavioral beliefs (OR: 0.55, 95% C.I.: 0.35-0.86, p=0.009) and intention indices (OR: 0.42, 95% C.I.: 0.20-0.87, p=0.02) were associated with opt-in system for organ donation in Qatar. Regression model was able to discriminate (AUC: 84%, 95% C.I.:81% to 87%) for opt-out consent. Future probabilities for opt-out consent were 0.80, 0.88, 0.92,0.95,0.96,0.97,0.99 and 0.993 for 0.20, 0.30, 0.40, 0.50, 0.60, 0.70, 0.80 and 0.90 attitude levels after using 200 re-samples to make traditional multivariate regression model to realistic model for the population.

Conclusion

The majority of the survey participants showed a good attitude but less knowledge, behavioral beliefs, and intention towards adopting an opt-out system for organ donation in Qatar.

When Life Ceases-Relatives' Experiences When a Family Member Is Confirmed Brain Dead and Becomes a Potential Organ Donor-A Literature Review

Introduction

Most healthcare professionals rarely experience situations of a request for organ donation being made to the patient's family and need to have knowledge and understanding of the relatives' experiences.

Objective

To describe relatives' experiences when a family member is confirmed brain dead and becomes a potential organ donor.

Methods

A literature review and a thematic data analysis were undertaken, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting process. A total of 18 papers, 15 qualitative and 3 quantitative, published from 2010 to 2019, were included. The electronic search was carried out in January 2019.

Results

The overarching theme When life ceases emerged as a description of relatives' experiences during the donation process, including five subthemes: cognitive dissonance and becoming overwhelmed with emotions, interacting with healthcare professionals, being in a complex decision-making process, the need for proximity and privacy, and feeling hope for the future. The relatives had different needs during the donation process. They were often in shock when the declaration of brain death was presented, and the donation request was made, which affected their ability to assimilate and understand information. They had difficulty understanding the concept of brain death. The healthcare professionals caring for the patient had an impact on how the relatives felt after the donation process. Furthermore, relatives needed follow-up to process their loss.

Conclusion

Caring science with an explicit relative perspective during the donor process is limited. The grief process is individual for every relative, as the donation process affects relatives' processing of their loss. We assert that intensive care unit nurses should be included when essential information is given, as they often work closest to the patient and her or his family. Furthermore, the relatives need to be followed up afterwards, in order to have questions answered and to process the grief, together with healthcare professionals who have insight into the hospital stay and the donation process.

Expedited organ donation in Victoria, Australia: donor characteristics and donation outcomes

Background: Deceased organ donation work-up typically takes 24 hours or more. Clinicians may thus discount the possibility of donation when the potential donor is physiologically unstable or family requirements do not allow this length of time. This may lead to loss of transplantable organs. In 2015, we introduced an expedited work-up guideline with the aim of facilitating donation in these circumstances and maximising donation potential. Objective: To determine the number of expedited work-up (consent to retrieval procedure of 6 hours or less) donors from 2015 to 2018, compare their clinical and demographic characteristics with standard donors, and assess the outcome of transplanted organs and organ recipients. Design: We performed a retrospective audit of the electronic database for all Victorian donors from 2015 to 2018. We obtained transplant outcome data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). Results: Overall, 38 expedited pathway donors donated 78 organs for transplantation (70 kidneys, four lungs, three livers, one pancreas). Of these, 55 retrieved kidneys were successfully transplanted. The lungs, livers and pancreas retrieved were all transplanted. For the kidney recipients, early graft dysfunction requiring dialysis was more common than with organs from the standard pathway (71% v 38%; P < 0.0001); however, short and medium term graft and patient survival were similar. Three recipients from the expedited pool experienced graft failure and two subsequently died. Of the two lung recipients, one died at day 622 of chronic rejection. Conclusions: Expedited pathway donation is feasible with acceptable donation outcomes. Clinicians should consider donation even when physiological instability or family requirements preclude standard organ donation work-up times.

The impact of organ donation specialists on consent rate in challenging organ donation conversations

Background: Consent rates for organ donation conversations (ODCs) vary. We hypothesised that a simple grading system could identify challenging ODCs. We further hypothesised that challenging ODCs would have higher consent rates when conducted by ODC specialists. Objectives: We aimed to study the utility of a grading system for ODCs and test the hypothesis that any training effect would be associated with improved consent rates in ODCs graded as most challenging. Methods: We stratified 2017 Australian DonateLife Audit aggregate consent and donation discussion data into four ODC grades based on Australian Organ Donor Register (AODR) status and person first raising the topic of organ donation. Grade I: "yes" present on AODR and family-raised organ donation; Grade II: "yes" present on AODR, and clinician-raised organ donation; Grade III: no registration on AODR but family-raised organ donation; and Grade IV: no registration on AODR, and clinician-raised organ donation. Results: Grade I ODCs were uncommon 7.7% (109/1420), with a consent rate of 95.4% (104/109). Grade IV ODCs were frequent (60.4%, 857/1420), with a consent rate of 41.4% (355/857). However, in Grade IV ODCs, organ donation specialist consent rate was 53.5% (189/353), significantly greater than for other trained staff at 33.1% (88/266) (P < 0.005; odds ratio [OR], 2.33; 95% CI, 1.68-3.24) or untrained requestors at 32.8% (78/238; P < 0.005; OR, 2.36; 95% CI. 1.68-3.33). Conclusion: The likelihood of consent can be predicted using readily available variables. This allows prospective identification of Grade IV ODCs, which carry low but potentially modifiable likelihood of consent. Involving donation specialists was associated with more consents for organ donation when applied retrospectively to Australian audit data.

Seeking consent for organ donation: Process evaluation of implementing a new Specialist Requester nursing role

AIM

To explain the differences in organ donation consent outcomes of a new nursing role (Specialist Requesters) derived from the United States (US) compared with the existing nursing role (Specialist Nurses in Organ Donation).

DESIGN

Thirty-month observational qualitative process evaluation: Implementation theory-informed analysis.

METHODS

Qualitative content analysis of free text describing challenges, processes and practice from 996 bespoke routinely collected potential organ donor 'approach forms' from two regions: one where there was no difference, and one with an observed difference in consent outcomes.

RESULTS

Region A consent rate: Specialist Requester 75.8%, Specialist Nurse in Organ Donation71.8%. Region B consent rate: Specialist Requester 71.4%, Specialist Nurse in Organ Donation 82%. Region A Specialist Requesters turned the family position from no or uncertain to support organ donation in 73% of cases, compared with 27.4% in Region B. Two Specialist Requesters in Region A were highly effective. Region B experienced problems with intervention fidelity and implementation.

CONCLUSIONS

The benefits of the Specialist Requester role remain unclear. Positive differences in consent rates achieved by Specialist Requesters in the originator region reduced over time and have yet to be successfully replicated in other regions.

IMPACT

The impact of Specialist Requesters on consent outcomes varied across regions and it was not known why. Specialist Requesters in Region A were better at getting family member(s) to support organ donation. In Region B, Specialist Nurse in Organ Donation consent rates were higher and problems with intervention fidelity were identified (recruitment, staffing, less experience). Policy makers need to understand it is not just a matter of waiting for the Specialist Requester intervention to work. Ongoing training and recruiting the right people with the right skills need to be addressed and consistently reviewed.

Register to donate while you wait: Assessing public opinions of the acceptability of utilizing the emergency department waiting room for organ and tissue donor registration

OBJECTIVE

Our objectives were to identify barriers to the organ donation registration process in Ontario; and to determine the acceptability of using the emergency department (ED) waiting room to provide knowledge and offer opportunities for organ and tissue donor registration.

METHODS

We conducted a paper based in-person survey over nine days in March and April 2017. The survey instrument was created in English using existing literature and expert opinion, pilot tested and then translated into French. Data was collected from patients and visitors in an urban academic Canadian tertiary care ED waiting room. All adults in the waiting room were approached to participate during study periods. We excluded patients who were too ill and required immediate treatment.

RESULTS

The number of attempted surveys was 324; 67 individuals (20.7%) declined participation. A total of 257 surveys were distributed and five were returned blank. This gave us a response rate of 77.8% with 252 completed surveys. The median age group was 51-60 years old with 55.9% female. Forty-six percent reported their religion as Christian and 34.1% did not declare a religious affiliation. 44.1% were already registered donors. Most participants agreed or were neutral that the ED waiting room was an acceptable place to provide information on donation, and for registration as an organ and tissue donor (83.3% and 82.1%, respectively).

CONCLUSIONS

Individuals waiting in the ED are generally supportive of using the waiting room for distributing information regarding organ and tissue donation, and to allow donor registration.

Gender and educational attainment influence willingness to donate organs among older Nigerians: a questionnaire survey

Introduction

disparity between the demand for and the supply of organs for transplantation remains a major public health issue of global concern. This study evaluated the knowledge and determinants of willingness to donate organs among outpatient clinic attendees in a Nigerian teaching hospital.

Methods

a 43-item semi-structured interviewer-administered questionnaire was designed to assess awareness and willingness of individuals attending Neurology, Psychiatry and Geriatrics Outpatient clinics to donate bodily organs for transplantation. Association between participants' characteristics and willingness towards organ donation was investigated using logistic regression models.

Results

a total of 412 participants were interviewed and mean age was 46.3 (16.1) years. There were 229 (55.6%) females and 92.5% had at least 6 years of formal education. Overall, 330 (80.1%) were aware of donation of at least one organ for transplantation purposes but only 139 (33.7%) were willing to donate organ. In analyses, adjusting for sex, marital status, family setting and educational status, male gender AOR [2.066(1.331-3.2016)] secondary education [AOR 5.57 (1.205-25.729) p= 0.028] and post-secondary education [AOR-6.98 (1.537-31.702) p= 0.012 were independently associated with willingness towards organ donation.

Conclusion

the survey revealed high level of awareness but poor willingness towards organ donation among older Nigerians attending outpatient clinics of a premier tertiary hospital. Male gender and educational attainment were significantly associated with willingness to donate. Educational programs that particularly target women and less educated older Nigerians are needed to promote organ donation in Nigeria.

Physician Experiences with Communicating Organ Donation with the Relatives: A Dutch Nationwide Evaluation on Factors that Influence Consent Rates

Background

The aim of this nationwide observational study is to identify modifiable factors in communication about organ donation that influence family consent rates.

Methods

Thirty-two intensivists specialized in organ donation systematically evaluated all consecutive organ donation requests with physicians in the Netherlands between January 2013 and June 2016, using a standardized questionnaire.

Results

Out of 2528 consecutive donation requests, 2095 (83%) were evaluated with physicians. The questionnaires of patients registered with consent or objection in the national donor registry were excluded from analysis. Only those questionnaires, in which the family had to make a decision about donation, were analyzed (n = 1322). Independent predictors of consent included: requesting organ donation during the conversation about futility of treatment (OR 1.8; p = 0.004), understanding of the term ‘brain death’ by the family (OR 2.4; p = 0.002), and consulting a donation expert prior to the donation request (OR 3.4; p < 0.001).

Conclusions

Our study showed that decoupling the organ donation conversation from the conversation about futility of treatment was associated with lower family consent rates. Comprehension of the concept of brain death by the family and consultation with a transplant coordinator before the organ donation request by the physician could positively influence consent rates.

Electronic supplementary material

The online version of this article (10.1007/s12028-019-00678-8) contains supplementary material, which is available to authorized users.

The Role of the Family in Deceased Organ Procurement: A Guide for Clinicians and Policymakers

Families play an essential role in deceased organ procurement. As the person cannot directly communicate his or her wishes regarding donation, the family is often the only source of information regarding consent or refusal. We provide a systematic description and analysis of the different roles the family can play, and actions the family can take, in the organ procurement process across different jurisdictions and consent systems. First, families can inform or update healthcare professionals about a person's donation wishes. Second, families can authorize organ procurement in the absence of deceased's preferences and the default is not to remove organs, and oppose donation where there is no evidence of preference but the default is to presume consent; in both cases, the decision could be based on their own wishes or what they think the deceased would have wanted. Finally, families can overrule the known wishes of the deceased, which can mean preventing donation, or permitting donation when the deceased refused it. We propose a schema of 4 levels on which to map these possible family roles: no role, witness, surrogate, and full decisional authority. We conclude by mapping different jurisdictions onto this schema to provide a more comprehensive understanding of the consent system for organ donation and some important nuances about the role of families. This classificatory model aims to account for the majority of the world's consent systems. It provides conceptual and methodological guidance that can be useful to researchers, professionals, and policymakers involved in organ procurement.

United Arab Emirates' Future Perspective: Converting Potential Organ Donors Into Actual Organ Donors in an Academic Setting

OBJECTIVES

The wide gap between organ demand and supply has been exponentially increasing worldwide, resulting in longer wait lists for patients. In response, a few countries have started deceased-donor programs. Thus, establishing national self-sufficiency and optimizing the deceased donation process are crucial steps. Recently, a deceased-donor program was initiated in the United Arab Emirates, and a process is being implemented to enhance the donation rate and to decrease the number of missed organ donors. This study aimed to estimate the number of potential brain-dead donors and eligible donors who are medically suitable and have been declared dead based on neurologic criteria. Additionally, the study aimed to highlight latent obstacles that could add valuable strategic input for establishing a successful organ donation process for new programs.

MATERIALS AND METHODS

For this retrospective study, we reviewed all patients who died at various intensive care units at Shaikh Khalifa Medical City (Abu Dhabi, UAE) from January 2018 to December 2018. Patients were classified as potential donors when meeting the neurologic criteria of brain dead and as eligible donors if no medical contraindication was shown. Barriers to donation were analyzed systematically.

RESULTS

In 2018, 411 inpatient deaths were recorded. Of the 39 patients identified as potentially brain dead, 25 were confirmed as brain dead, with 20 of these confirmed as eligible donors. However, none were converted to actual donors. The lack of proper identification and referral of potential organ donors constituted significant obstacles to the organ donation process.

CONCLUSIONS

This study described the potential organ donation program of our hospital and suggested a systemic approachthattargets the system,organ/donor factors, and consent process to improve the donor conversion rate. New programs might benefit highly from in-house organ donation coordinators, the education and proactive collaboration of hospital staff, and organizational support and management.

Incentivizing organ donation through a nonmonetary posthumous award

Since 2013, The Order of St John Award for Organ Donation has been offered to the families of deceased solid organ donors in the United Kingdom to honor the donors and inspire others to donate. We evaluate the effects of this award using a difference-in-differences approach that builds on the fact that solid organ donors are eligible for the award, whereas cornea-only donors are not. We find that the introduction of the award led to an increase in the number of deceased solid organ donors.

Appointing nurses trained in organ donation to improve family consent rates

Background

One of the most important bottlenecks in the organ donation process worldwide is the high family refusal rate.

Aims and objectives

The main aim of this study was to examine whether family guidance by trained donation practitioners increased the family consent rate for organ donation.

Design

This was a prospective intervention study.

Methods

Intensive and coronary care unit nurses were trained in communication about donation (ie, trained donation practitioners) in two hospitals. The trained donation practitioners were appointed to guide the families of patients with a poor medical prognosis. When the patient became a potential donor, the trained donation practitioner was there to guide the family in making a well‐considered decision about donation. We compared the family consent rate for donation with and without the guidance of a trained donation practitioner.

Results

The consent rate for donation with guidance by a trained donation practitioner was 58.8% (20/34), while the consent rate without guidance by a trained donation practitioner was 41.4% (41/99, P = 0.110) in those patients where the family had to decide on organ donation.

Conclusions

Our data suggest that family guidance by a trained donation practitioner could benefit consent rates for organ donation.

Relevance to clinical practice

Trained nurses play an important role in supporting the families of patients who became potential donors to guide them through the decision‐making process after organ donation request.

Simulation-Based Communication Skills Training for Experienced Clinicians to Improve Family Conversations About Organ and Tissue Donation

INTRODUCTION

The approach, communication skills, and confidence of clinicians responsible for raising deceased organ donation may influence families' donation decisions. The aim of this study was to increase the preparedness and confidence of intensive care clinicians allocated to work in a "designated requester" role.

DESIGN

We conducted a posttest evaluation of an innovative simulation-based training program. Simulation-based training enabled clinicians to rehearse the "balanced approach" to family donation conversations (FDCs) in the designated requester role. Professional actors played family members in simulated clinical settings using authentic scenarios, with video-assisted reflective debriefing. Participants completed an evaluation after the workshop. Simple descriptive statistical analysis and content analysis were performed.

RESULTS

Between January 2013 and July 2015, 25 workshops were undertaken with 86 participants; 82 (95.3%) returned evaluations. Respondents were registered practicing clinicians; over half (44/82; 53.7%) were intensivists. Most attended a single workshop. Evaluations were overwhelmingly positive with the majority rating workshops as outstanding (64/80; 80%). Scenario fidelity, competence of the actors, opportunity to practice and receive feedback on performance, and feedback from actors, both in and out of character, were particularly valued. Most (76/78; 97.4%) reported feeling more confident about their designated requester role.

DISCUSSION

Simulation-based communication training for the designated requester role in FDCs increased the knowledge and confidence of clinicians to raise the topic of donation.

DONORS (Donation Network to Optimise Organ Recovery Study): Study protocol to evaluate the implementation of an evidence-based checklist for brain-dead potential organ donor management in intensive care units, a cluster randomised trial

INTRODUCTION

There is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest.

METHODS AND ANALYSIS

The study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor.

ETHICS AND DISSEMINATION

The institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT03179020; Pre-results.

Interventions aimed at healthcare professionals to increase the number of organ donors: a systematic review

Background

The last decade, there have been many initiatives worldwide to increase the number of organ donors. However, it is not clear which initiatives are most effective. The aim of this study is to provide an overview of interventions aimed at healthcare professionals in order to increase the number of organ donors.

Methods

We systematically searched PubMed, EMBASE, CINAHL, PsycINFO, and the Cochrane Library for English language studies published until April 24, 2019. We included studies describing interventions in hospitals aimed at healthcare professionals who are involved in the identification, referral, and care of a family of potential organ donors. After the title abstract and full-text selection, two reviewers independently assessed each study’s quality and extracted data.

Results

From the 18,854 records initially extracted from five databases, we included 22 studies in our review. Of these 22 studies, 14 showed statistically significant effects on identification rate, family consent rate, and/or donation rate. Interventions that positively influenced one or more of these outcomes were training of emergency personnel in organ donation, an electronic support system to identify and/or refer potential donors, a collaborative care pathway, donation request by a trained professional, and additional family support in the ICU by a trained nurse. The methodological quality of the studies was relatively low, mainly because of the study designs.

Conclusions

Although there is paucity of data, collaborative care pathways, training of healthcare professionals and additional support for relatives of potential donors seem to be promising interventions to increase the number of organ donors.

Trial registration

PROSPERO, CRD42018068185

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2509-3) contains supplementary material, which is available to authorized users.

Accounting for organ donation decision-making: Analyzing interview discourse of the donors' relatives and intensive care unit physicians in Greece

The study casts light on the organ donation decision-making process by exploring the experiences of families and physicians involved. Specifically, semi-structured interviews were conducted with 11 family members of 11 different donors and with 13 intensive care unit physicians. Data collection and analysis draws on the principles of Grounded Theory Methodology. Analysis indicated that in the accounts of both groups, organ donation is represented as a multi-faceted process that includes various social and ideological dilemmas. Overlap and mutual influence was found connecting the experiences of family members and those of physicians, highlighting the need for further education and training for physicians and aftercare for families.

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.

Management of donation after brain death (DBD) in the ICU: the potential donor is identified, what's next?

The success of any donation process requires that potential brain-dead donors (PBDD) are detected and referred early to professionals responsible for their evaluation and conversion to actual donors. The intensivist plays a crucial role in organ donation. However, identification and referral of PBDDs may be suboptimal in the critical care environment. Factors influencing lower rates of detection and referral include the lack of specific training and the need to provide concomitant urgent care to other critically ill patients. Excellent communication between the ICU staff and the procurement organization is necessary to ensure the optimization of both the number and quality of organs transplanted. The organ donation process has been improved over the last two decades with the involvement and commitment of many healthcare professionals. Clinical protocols have been developed and implemented to better organize the multidisciplinary approach to organ donation. In this manuscript, we aim to highlight the main steps of organ donation, taking into account the following: early identification and evaluation of the PBDD with the use of checklists; donor management, including clinical maintenance of the PBDD with high-quality intensive care to prevent graft failure in recipients and strategies for optimizing donated organs by simplified care standards, clinical guidelines and alert tools; the key role of the intensivist in the donation process with the interaction between ICU professionals and transplant coordinators, nurse protocol managers, and communication skills training; and a final remark on the importance of the development of research with further insight into brain death pathophysiology and reversible organ damage.

Contemporary issues in law and ethics: Exploring the family veto for organ donation

This article explores current issues surrounding the impact of family veto for organ donation in the UK. A critical, reflective analysis of the theoretical, legal and ethical aspects aims to evaluate how the deceased’s explicit wish to donate may be revoked. Under current UK legislation and upon death, money and property are protected; however, the body is not. When investigating personal wishes, interests and decisions must be weighed against the moral legitimacy of the family veto.

Organ and Tissue Donations for Transplants in the Macroregional North of Paraná, Brazil

BACKGROUND

Few studies have analyzed the results of the organ and tissue donation process for transplants.

OBJECTIVES

To analyze donations of organs and tissues for transplants in the Macroregional North of Paraná.

MATERIAL AND METHODS

Cross-sectional and retrospective study, using data from 7383 death certificates of eligible donors notified in 2015 by 16 hospitals accredited to the Organ Procurement Organization. The data were analyzed using the prevalence ratio (PR) and the Wald test.

RESULTS

Among the 934 eligible donors, the prevalence of effective donations was 23.4% (219) Among the 582 organs and tissues donated, corneas were predominant. Organs became available for donation from younger individuals (PR = 0.992), due to brain death (PR = 2.482), notified by the type III Intra-Hospital Organ and Tissue Donation Commissions for Transplants (PR = 2.016), which took place in intensive care units (PR = 1.471). The relatives interviewed were the partners and/or children (PR = 0.469), and the interviews were held by the nurse (PR = 1.324).

CONCLUSION

Effective donations were able to take place through proper organizational structure and trained human resources, highlighting the role of the nurse in the optimization of the organ and tissue donation process for transplants.

Barriers to Registration in the National Donor Registry in Nations Using the Opt-In System: A Review of the Literature

BACKGROUND

To increase the number of postmortem organ and tissue donors, donor registries (DRs) have been introduced. The aim of this review was to understand why people in nations with an Opt-in system, who are for or against donation after death, do not register in the DR. Knowing these barriers will help in developing policies to increase the registration rate in the DR.

METHODS

For this review, 2 authors independently assessed the eligibility of the identified studies from 2000 to 2015 in the Pubmed- Medline database. Included were observational and interventional studies concerned with reported barriers to residents joining the national DR in Denmark, The Netherlands, and the United Kingdom.

RESULTS

We included 15 relevant articles for the review. The main barriers to signing the DR in nations using the Opt-in system were: religion; medical mistrust, anxiety, and affective emotions; lack of information; concern about insufficient time to mourn, and that the funeral may be delayed and the deceased not look presentable; physical integrity; ignorance about how to register in the DR; own benefit; and social status.

CONCLUSIONS

The outcome suggests that the main barriers to enrolling in the DR are based on people's doubts about their own ability to perform the registration and cope with the consequences, knowledge, outcome expectations, and concerns about what others will think of them for agreeing to donation. However, not all barriers are easily modifiable, owing to their association with affect or emotions.

[Communication with relatives]

BACKGROUND

Communication with relatives is a central part of the decision-making process. In the absence of the patient's direct consent to a potential organ donation, the next of kin must provide information about a potential wish to donate and give permission in the context of an extended consent solution. At the same time, family members must also cope with the death of a loved one.

OBJECTIVE

To determine how relatives can be optimally supported during the decision-making process.

MATERIALS AND METHODS

Narrative review.

RESULTS

In the context of potential or confirmed irreversible brain death, communication with family members or legal representatives serves to deliver bad news as well as to determine whether the patient had a wish to donate his/her organs and to clarify the resultant steps. Communication strategies such as the SPIKES or VALUE models provide emotional and cognitive support for relatives and strengthen clinicians' communication skills. Clinicians' behavior towards patients, deceased, and next of kin may influence relatives' decision-making; respectful and competent behavior seems to contribute towards relatives granting permission for organ donation.

CONCLUSION

Clinicians must be trained and skilled in communication strategies which are used in critical situations to provide emotional support to relatives during the organ donation decision-making process. Relatives are more likely to achieve a satisfying and sustainable decision if a strong relationship exists between clinicians and relatives based on information giving, openness, trust, and empathy.

How the mode of organ donation affects family behaviour at the time of organ donation

Introduction

End of life and organ donation discussions come at a time of acute emotional unrest for grieving relatives. Their attitudes and eventual decisions regarding consent to organ donation are shaped by multiple factors during these stressful periods. At our tertiary centre intensive care unit, we anecdotally observed that the mode of organ donation affects family behaviour as to whether families stay until transfer to theatre for organ recovery, or leave after consenting for donation. We sought to ascertain if this observation was true and then to hypothesise reasons for why this may be the case.

Methods

Records of patients consented for deceased organ donation between 1 January 2015 and 31 December 2017 at the Nottingham University Hospitals NHS Trust were reviewed and analysed.

Results

After exclusion criteria were applied, 91 patient cases were included in the final analysis (donation after brainstem death (DBD), 36; donation after circulatory death (DCD), 55). Thirty-six per cent of DBD families stayed until the point of organ recovery compared to 80% of DCD families (p < 0.00001).

Discussion

We hypothesise that this family behaviour may be indicative of an acceptance in DBD of the patient's death, and therefore that the patient has moved beyond further harm. For this reason, the family may feel able to leave after consent for donation. A greater understanding of how family behaviours differ depending on the mode of organ donation may aid how these families are best cared for in the intensive care unit.

Family Interview to Enable Donation of Organs for Transplantation: Evidence-based Practice

BACKGROUND

In this study we propose a theoretical and practical basis for the best practices for interviewing relatives of brain-dead eligible organ donors.

METHODS

This investigation was a reflective study of the methodologic factors of the family interview that affect their decision regarding the donation of a deceased patient's organs for transplantation. The articles that formed the empirical basis of the trial were obtained from PubMed, which is a free-access tool of the MEDLINE database of the United States National Library of Medicine. Published articles that allowed us to reflect on evidence-based family interview practice were selected.

RESULTS

Thirty-six scientific articles were used to guide our assessment the family interview, providing evidence for its adequate execution in view of the following prerequisites: When should the family interview be performed? Where should it be done? How many and which people should participate in the interview? Who should perform it? How should it be done?

CONCLUSION

Scientific studies offer evidence to donation and transplantation specialists that can help them in their daily work regarding their interactions with relatives in the process of decisionmaking and family consent.

Impact of a National Controlled Donation After Circulatory Death (DCD) Program on Organ Donation in the United Kingdom: A 10-Year Study

Organ transplantation is the most successful treatment for some forms of organ failure, yet a lack of organs means many die on the waiting list. In the United Kingdom, the Organ Donation Taskforce was set up to identify barriers to organ donation and in 2008 released its first report (Organ Donation Taskforce Report; ODTR). This study assesses the success since the ODTR and examines the impact of the United Kingdom's controlled donation after circulatory death (DCD) program and the controversies surrounding it. There were 12 864 intended donation after brain death (DBD) or DCD donors from April 2004 to March 2014. When the 5 years preceding the ODTR was compared to the 5 years following, intended DCD donors increased 292% (1187 to 4652), and intended DBD donors increased 11% (3327 to 3698). Organs retrieved per intended DBD donor remained static (3.30 to 3.26), whereas there was a decrease in DCD (1.54 to 0.99) due to a large rise in donors who did not proceed to donation (325 to 2464). The majority of DCD donors who proceeded did so within 30 min from time of withdrawal. Our study suggests further work on converting eligible referrals to organ donation and exploring methods of converting DCD to DBD donors.

Determination of Imminent Brain Death Using the Full Outline of Unresponsiveness Score and the Glasgow Coma Scale: A Prospective, Multicenter, Pilot Feasibility Study

PURPOSE

To evaluate the accuracy of the imminent brain death (IBD) diagnosis in predicting brain death (BD) by daily assessment of the Full Outline of Unresponsiveness (FOUR) score and the Glasgow Coma Scale (GCS) with the assessment of brain stem reflexes.

MATERIALS AND METHODS

Prospective multicenter pilot study carried out in 5 adult Italian intensive care units (ICUs). Imminent brain death was established when the FOUR score was 0 (IBD-FOUR) or the GCS score was 3 and at least 3 among pupillary light, corneal, pharyngeal, carinal, oculovestibular, and trigeminal reflexes were absent (IBD-GCS).

RESULTS

A total of 219 neurologic evaluations were performed in 40 patients with deep coma at ICU admission (median GCS 3). Twenty-six had a diagnosis of IBD-FOUR, 27 of IBD-GCS, 14 were declared BD, and 9 were organ donors. The mean interval between IBD diagnosis and BD was 1.7 days (standard deviation [SD] 2.0 days) using IBD-FOUR and 2.0 days (SD 1.96 days) using IBD-GCS. Both FOUR and GCS had 100% sensitivity and low specificity (FOUR: 53.8%; GCS: 50.0%) in predicting BD.

CONCLUSIONS

Daily IBD evaluation in the ICU is feasible using FOUR and GCS with the assessment of brain stem reflexes. Both scales had 100% sensitivity in predicting IBD, but FOUR may be preferable since it incorporates the pupillary, corneal, and cough reflexes and spontaneous breathing that are easily assessed in the ICU.

Incidence and etiology of mortality in polytrauma patients in a Dutch level I trauma center

BACKGROUND

Earlier studies assessing mortality in polytrauma patients have focused on improving trauma care and reducing complications during hospital stay. The same studies have shown that the complication rate in these patients is high, often resulting in death. The aim of this study was to assess the incidence and causes of mortality in polytrauma patients in our institute. Secondarily, we assessed the donation and autopsy rates and outcome in these patients.

PATIENTS AND METHODS

All polytrauma patients (injury severity score≥16) transported to and treated in our institute during a period of 6 years were retrospectively analyzed. We included all patients who died during hospital stay. Prehospital and in-hospital data were collected on patients' condition, diagnostics, and treatment. The chance of survival was calculated according to the TRISS methodology. Patients were categorized according to the complications during treatment and causes of death. Logistic regression analysis was used to design a prediction model for mortality in major trauma. A statistical analysis was carried out.

RESULTS

Of the 1073 polytrauma patients who were treated in our institute during the study period, 205 (19.1%) died during hospital stay. The median age of the deceased patients was 58.8 years and 125 patients were men. Their mean injury severity score was 30.4. The most common mechanism of injury involved fall from height, followed by bicycle accidents. Almost 50% of the patients underwent an emergency intervention. Almost 92% of the total population died because of the effects of the accident (primary trauma). Of these, 24% died during primary assessment in the emergency department. Most patients died because of the effects of severe head injury (63.4%), followed by exsanguination (17.6%). The most common type of complications causing death during treatment was respiratory failure (6.3%), followed by multiple organ failure (1.5%). Autopsy was performed in 10.4%. Organ donation procedure was performed in 14.5%. Permission for donation was not provided in almost 20% of the population.

CONCLUSION

The mortality rate in polytrauma patients in our institute is considerable and comparable with the international literature. Most patients die because of the effects of the accident (primary trauma). Autopsy and organ donation rates are low in our institution and leave room for substantial improvements in the future.

In-hospital logistics: what are the key aspects for succeeding in each of the steps of the process of controlled donation after circulatory death?

Donation after circulatory death (DCD) donors are becoming an increasingly important population of organ donors in Europe and worldwide. We report the state of the art regarding controlled DCD donation describing the organizational and technical aspects of establishing a controlled DCD programme and provide recommendations regarding the introduction and development of this type of programme.

Effect of Interviews Done by Intensive Care Physicians on Organ Donation

In this study, we examined the correspondence between intensive care unit physicians and the relatives of potential brain-dead donors regarding the decision to donate or the reasons for refusing organ donation. A total of 12 consecutive cases of potential brain-dead patients treated in intensive care units of Marmara University Pendik Education and Research Hospital in 2013 were evaluated. For each of the cases, the Potential Donor Questionnaire, and Family Notification, Brain Death Criteria Fulfilment and Organ Donation Conversation Questionnaires were used to collect the required data. Statistically, descriptive analyses were performed. We concluded that honestly, regularly, and sufficiently informed relatives of the potential brain-dead donor more readily donate organs, with a positive contribution from the intensive care physician.

Ethical Challenges and the Donation Physician Specialist: A Scoping Review

Deceased donation medicine involves unique ethical challenges. Physicians who are focused on deceased donation medicine as part of their practice can expect to encounter these challenges. The goal of this review is to identify and describe these challenges, highlight existing guidelines and policy regarding the management of these challenges and to describe how the donation physician role might promote ethical practice in deceased donation medicine. Themes of discussion include: communication with families, interprofessional conflict, donation physician personal characteristics, donation clinical processes, health resource allocation, research and education, and remuneration. The information presented in this review can be used to inform development of recommendations and guidelines for the management of ethical challenges encountered by donation physicians.

COMmunication with Families regarding ORgan and Tissue donation after death in intensive care (COMFORT): protocol for an intervention study

Background

Discussing deceased organ donation can be difficult not only for families but for health professionals who initiate and manage the conversations. It is well recognised that the methods of communication and communication skills of health professionals are key influences on decisions made by families regarding organ donation.

Methods

This multicentre study is being performed in nine intensive care units with follow-up conducted by the Organ and Tissue Donation Service in New South Wales (NSW) Australia. The control condition is pre-intervention usual practice for at least six months before each site implements the intervention. The COMFORT intervention consists of six elements: family conversations regarding offers for organ donation to be led by a “designated requester”; family offers for donation are deferred to the designated requester; the offer of donation is separated from the end-of-life discussion that death is inevitable; it takes place within a structured family donation conversation using a “balanced” approach. Designated requesters may be intensivists, critical care nurses or social workers prepared by attending the three-day national “Family Donation Conversation” workshops, and the half-day NSW Simulation Program. The design is pre-post intervention to compare rates of family consent for organ donation six months before and under the intervention. Each ICU crosses from using the control to intervention condition after the site initiation visit. The primary endpoint is the consent rate for deceased organ donation calculated from 140 eligible next of kin families. Secondary endpoints are health professionals’ adherence rates to core elements of the intervention; identification of predictors of family donation decision; and the proportion of families who regret their final donation decision at 90 days.

Discussion

The pragmatic design of this study may identify ‘what works’ in usual clinical settings when requesting organ donation in critical care areas, both in terms of changes in practice healthcare professionals are willing and able to adopt, and the effect this may have on desired outcomes. The findings of this study will be indicative of the potential benefits of the intervention and be relevant and transferrable to clinical settings in other states and countries.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000815763 (24 July 2013). ClinicalTrials.gov: NCT01922310 (14 August 2013) (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1964-7) contains supplementary material, which is available to authorized users.

Premortem interventions in dying children to optimise organ donation: an ethical analysis

A range of interventions in dying patients can improve both the possibility of successful organ donation and the likely long-term success of transplantation. The ethical and legal issues surrounding such interventions, which most frequently occur in the context of donation after circulatory determination of death, are complex, controversial and many remain unresolved. This is true with adults, but even more so with children, where the issue of organ donation and premortem interventions to facilitate it, are highly sensitive. Essentially, such interventions are being undertaken in dying children who cannot medically benefit from them, though arguments have been advanced that becoming a donor might be in a child's extended best interest. However, certain interventions carry a potential risk, although small, of direct harm and of course overall objections to child donation after circulatory determination of death per se are still expressed in the literature. But, unlike the case in critically ill adults, those giving permission for such interventions are normally able to fully participate in decision-making, and indeed to consent, to both donation and premortem interventions. We review the issue of the use of premortem interventions in dying children to facilitate organ donation, including decision-making and ethical justification. Individual interventions are then considered, including an ethical analyse of their use. Finally, we recommend an approach using a combination of welfare checklist strategy, coupled with the establishment of an agreed zone of parental discretion about individual interventions which might be used in dying children to increase the possibility of successful organ donation.