Post-COVID-19 pandemic organ donation activities in Germany: a multicenter retrospective analysis

Introduction

The COVID-19 pandemic had a negative impact on the number of solid organ transplantations. After a global decline of 16% in 2020, their numbers subsequently returned to pre-pandemic levels. In contrast, numbers in Germany remained almost constant in 2020 and 2021 but fell by 6.9% in 2022. The reasons for this divergent development are unknown.

Methods

The number of deceased with a severe brain damage, potential and utilized donors after braindeath and the intensive care unit treatment capacity were retrospectively compared for the years 2022 and 2021 at five university hospitals in North Rhine-Westphalia, Germany. Reasons for a donation not utilized were reviewed. To enable a comparison of the results with the whole of Germany and the pre-pandemic period, numbers of potential and utilized donors were extracted from official organ donation activity reports of all harvesting hospitals in Germany for the years 2019-2022.

Results

The numbers of deceased with a severe brain damage (-10%), potential (-9%), and utilized donors after braindeath (-44%), and intensive care unit treatment capacities (-7.2%) were significantly lower in 2022 than 2021. A COVID-19 infection was a rarer (-79%), but donor instability (+44%) a more frequent reason against donation in 2022, whereas preserved brain stem reflexes remained the most frequent reason in both years (54%). Overall numbers of potential and utilized donations in Germany were lower in 2022 than in the pre-pandemic period, but this was mainly due to lower numbers in hospitals of lower care. The number of potential donors in all university hospitals were higher in 2022 but utilized donations still lower than in 2019.

Conclusion

The decrease in potential and utilized donations was a result of reduced intensive care unit treatment capacities and a lower conversion rate at the five university hospitals. A COVID-19 infection did not play a role in 2022. These results indicate that ICU treatment capacities must be restored to increase donations. The lower number of potential donors and the even lower conversion rate in 2022 throughout Germany show that restructuring the organ procurement process in Germany needs to be discussed to increase the number of donations.

Donor audits in deceased organ donation: a scoping review

PURPOSE

We sought to collate and summarize existing literature on donor audits (DA) and how they have been used to guide deceased organ donation and transplantation system performance and quality assurance.

SOURCE

We searched MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and Web of Science supplemented by Google to identify grey literature on 6 May 2022, to locate studies in English, French, and Spanish. The data were screened, extracted, and analyzed independently by two reviewers. We grouped the results into five categories: 1) motivation for DA, 2) DA methodology, 3) potential and actual donors, 4) missed donation opportunities, and 5) quality improvement.

PRINCIPAL FINDINGS

The search yielded 2,416 unique publications and 52 were included in this review. Most studies were from the UK (n = 13) and published between 2001 and 2006 (n = 15). The methodologies described for DA were diverse. Our findings showed that the primary motivation for conducting DA was to identify potential donors and the number of potential deceased organ donors is significantly higher than the number of actual donors. Among retrieved studies, the proportion of donation opportunities following neurologic determination of death was 95/222 (43%) compared with 25/181 (14%) for donation after cardiocirculatory death (DCD), suggesting that the missed donation rate is higher for DCD.

CONCLUSION

Donor audits help identify missed donation opportunities along the deceased donation pathway and can help support the evaluation of quality improvement initiatives.

How Large is the Potential of Brain Dead Donors and what Prevents Utilization? A Multicenter Retrospective Analysis at Seven University Hospitals in North Rhine-Westphalia

Organ donation after brain death is constantly lower in Germany compared to other countries. Instead, representative surveys show a positive attitude towards donation. Why this does not translate into more donations remains questionable. We retrospectively analyzed all potential brain dead donors treated in the university hospitals of Aachen, Bielefeld, Bonn, Essen, Düsseldorf, Cologne and Münster between June 2020 and July 2021. 300 potential brain dead donors were identified. Donation was utilized in 69 cases (23%). Refused consent (n = 190), and failed utilization despite consent (n = 41) were reasons for a donation not realized. Consent was significantly higher in potential donors with a known attitude towards donation (n = 94) compared to a decision by family members (n = 195) (49% vs. 33%, p = 0.012). The potential donor´s age, status of interviewer, and the timing of the interview with decision-makers had no influence on consent rates, and it was comparable between hospitals. Refused consent was the predominant reason for a donation not utilized. Consent rate was lower than in surveys, only a known attitude towards donation had a significant positive influence. This indicates that survey results do not translate well into everyday clinical practice and promoting a previously documented decision on organ donation is important.

Survey of Canadian critical care physicians' knowledge and attitudes towards legislative aspects of the deceased organ donation system

PURPOSE

We surveyed Canadian critical care physicians who may care for patients who are potential organ donors to understand their attitudes and knowledge of legislation governing the deceased organ donation system.

METHODS

We used a web-based, self-administered survey that included questions related to opt-out consent and mandatory referral legislation. Potential participants were identified through membership lists of professional societies and manual searches. We designed our survey using standardized methods and administered it in February and March 2018.

RESULTS

Fifty percent (263/529) of potential participants completed the questionnaire. A majority (61%; 144/235) supported a change towards an opt-out consent model, and 77% (181/235) stated they believe it would increase donation rates. Asked if opt-out consent would change their practices, 71% (166/235) stated an opt-out model would not change how or if they approach families to discuss donation. Fifty-six percent (139/249) supported mandatory referral laws, while only 42% (93/219) of those working in provinces with mandatory referral correctly stated that such laws exist in their province. Respondents gave variable responses on who should be accountable when patients are not referred, and 16% (40/249) believed no one should be held accountable.

CONCLUSIONS

While a majority of critical care physicians supported opt-out consent and mandatory referral, many were neutral or against it. Many were unaware of existing laws and had variable opinions on how to ensure accountability. Efforts to increase understanding of how legislative models influence practice are required for any law to achieve its desired effect.

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.

Qualitative Analysis of Factors That Hinder Intensive Care Unit Nurses in Western China From Encouraging Patients to Donate Organs

BACKGROUND

Organ transplantation is an important method to save the lives of patients suffering from organ failure. However, the low rate of organ donation is a common problem worldwide. Many potential organ donors in the intensive care unit (ICU) are not properly identified, which is one reason for the low donation rate. ICU nurses play a key role in organ donation but may be uncertain regarding some issues. In this study, an analysis of the reasons why ICU nurses in western China are reluctant to encourage patients and their families to donate organs is performed, providing a reference for promoting ICU nurse participation in organ donation work.

METHODS

From August to November of 2017, using a purposive sampling method, we conducted semi-structured, in-depth interviews using a phenomenological research method with 18 ICU nurses who were working in 4 large hospitals with organ transplant accreditation in Chongqing City, China, and analyzed the data with phenomenology.

RESULTS

Reasons for the reluctance of ICU nurses in encouraging patients to donate organs were categorized into the following 4 themes: limitation of the nurses' professional role, influence of the family's negative emotions, lack of training regarding organ donation in medical institutions, and impact of a conservative social attitude.

CONCLUSION

Chinese medical and health institutions need to attach importance to the duties and roles of ICU nurses in organ donation work, the creation of a good death culture, the implementation of training for organ donation specialist nurses, and the strengthening of advocacy efforts for organ donation so that ICU nurses' reluctance in engaging in organ donation coordination in China can be mitigated and the nurses can better participate in promoting organ donation to potential donors.

The effectiveness of an interactive organ donation education intervention for Dutch lower-educated students: a cluster randomized controlled trial

BACKGROUND

Organ donation registration rates remain low, especially among people with lower educational levels. An interactive educational intervention was developed to prepare lower-educated students in the Netherlands for making a well-informed decision about organ donation. This article reports on the effects of this intervention on the intention to register (i.e., the primary outcome in the study at hand) and beliefs regarding organ donation.

MATERIALS AND METHODS

The effectiveness was investigated in a post-test-only cluster randomized controlled trial, in which the intervention was offered to the experimental group and after measurement also to the control group. Randomization to the experimental and control groups took place at a class level. Teachers of schools for Intermediate Vocational Education who taught a course on Citizenship delivered three intervention elements (i.e., video fragments and discussion, quizzes with tailored feedback and exercise filling out a registration form) to their students during two 50-min lessons.

RESULTS

A total of 1170 students participated in the trial and filled out a questionnaire (45 experimental and 43 control classes). Compared to the control group, students in the experimental group had higher odds of having positive registration intentions (OR = 1.81; 95%CI [1.10-2.96]), their perceived knowledge was higher (B = 0.62; 95%CI [0.23-1.01]) and they had higher intentions to talk to family members (B = 0.68; 95%CI [0.28-1.08]) and friends (B = 0.36; 95%CI [0.07-0.66]) about organ donation. There were no effects on the choice students intended to register (OR = 1.08; 95%CI [0.67-1.73]).

CONCLUSIONS

Providing education in a classroom setting is an effective tool in increasing registration intentions. Despite uncertainties about the effects on actual registration behavior, a larger-scale dissemination of this intervention is recommended. Providing clear information and opening the discussion about organ donation is an important and promising first step towards higher registration rates.

TRIAL REGISTRATION

The Dutch Trial Register, ID: NTR6771. Registered on 24 October 2017. https://www.trialregister.nl/trial/6557.

Criteria to Identify a Potential Deceased Organ Donor: A Systematic Review

OBJECTIVES

To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral.

DATA SOURCES

Medline and Embase databases from January 2006 to September 2017.

STUDY SELECTION

All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations.

DATA EXTRACTION

Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers.

DATA SYNTHESIS

One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported.

CONCLUSIONS

Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation.

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.

Evolution of Deceased Organ Donation Activity Versus Efficiency Over a 15-year Period: An International Comparison

BACKGROUND

The donation rate (DR) per million population is not ideal for an efficiency comparison of national deceased organ donation programs. The DR does not account for variabilities in the potential for deceased donation which mainly depends on fatalities from causes leading to brain death. In this study, the donation activity was put into relation to the mortality from selected causes. Based on that metric, this study assesses the efficiency of different donation programs.

METHODS

This is a retrospective analysis of 2001 to 2015 deceased organ donation and mortality registry data. Included are 27 Council of Europe countries, as well as the United States. A donor conversion index (DCI) was calculated for assessing donation program efficiency over time and in international comparisons.

RESULTS

According to the DCI and of the countries included in the study, Spain, France, and the United States had the most efficient donation programs in 2015. Even though mortality from the selected causes decreased in most countries during the study period, differences in international comparisons persist. This indicates that the potential for deceased organ donation and its conversion into actual donation is far from being similar internationally.

CONCLUSIONS

Compared with the DR, the DCI takes into account the potential for deceased organ donation, and therefore is a more accurate metric of performance. National donation programs could optimize performance by identifying the areas where most potential is lost, and by implementing measures to tackle these issues.

Failed Organ Donations After Transfer to an Organ Procurement Unit

OBJECTIVES

In Iran, each medical university can have one organ procurement unit for its own hospital. If the family consents, all patients with brain death must be transferred to the organ procurement unit. When brain death is officially confirmed and the family gives the second consent, the organs are then retrieved in the operating room.

MATERIALS AND METHODS

To minimize the number of "failed donations" (and to reduce their related costs), we studied 685 patients with brain death who were transferred to the Masih Daneshvari Organ Procurement Unit (Tehran, Iran) from 2016 to 2018 in terms of their outcomes. Of these, 623 led to (at least one) organ donation, whereas the remaining 62 had different causes for unsuccessful organ retrieval and donation.

RESULTS

Two causes (not officially confirmed and family withdrawal) were responsible for 4 failed donations (0.5%). We focused on the remaining 58 cases, which had principally medical grounds for unsuccessful organ retrieval and donation. These were further subcategorized into 3 groups: expired, unacceptable laboratory results, and exclusion in the operating room. We compared these groups versus the successful donation group in terms of average age, male-to-female ratio, average body mass index, pace of brain death occurrence, and days of hospitalization. Results showed that age, body mass index, and cause of brain death are important predictive factors in differentiating successful and failed donations, whereas sex and days of hospitalization are not so decisive.

CONCLUSIONS

Special precautions must be considered before transfer of brain dead donors who are overweight, are of older age, and have nonhemorrhagic causes of brain death. Stricter criteria are needed to control psychologic and financial burdens of failed transfers of deceased donors to the organ procurement unit.

A web-based education program to encourage organ donation registration among lower-educated adolescents in the Netherlands: study protocol for a cluster randomized controlled trial

BACKGROUND

The gap between the supply and demand of organ donors is substantial, causing patients to suffer from long waiting times. Moreover, the lack of registrations places a burden on family members and medical professionals when an unregistered individual dies. This article describes a cluster randomized controlled trial (CRCT) study to assess the effectiveness and quality of implementation of a web-based program aimed at encouraging lower-educated adolescents to register a well-informed choice about organ donation, regardless of it being as a donor or not.

METHODS/DESIGN

The program will be delivered by teachers at schools for Intermediate Vocational Education in the Netherlands. The effectiveness will be assessed in a CRCT design with post-test only using self-administered questionnaires for the primary outcome (i.e. intention to register). Classes will be matched to improve equivalence of groups. From each pair of matched classes, one class will be randomly assigned to the experimental condition, and the other assigned to the control condition. Students in the control groups will fill in the questionnaire before receiving the program, while the experimental groups will do this afterwards. A post-test design prevents the risk of testing bias. The required sample size is 14 schools, with 10 classes per school and 13 unregistered students per class. The questionnaire assesses demographics, behavioural determinants (attitude, self-efficacy, knowledge and social outcomes), intention to register (as a donor) and registration status. Six months after delivery, registration status will be assessed again. Additionally, a process evaluation will be conducted to evaluate the quality of implementation using both qualitative (i.e. semi-structured interviews) and quantitative (i.e. logbooks, questionnaires, Google Analytics to track user behaviour at the website) methods.

DISCUSSION

Findings of the study can help to further improve the program and serve as a basis for a solid dissemination plan. Moreover, the study will provide insight into (change in) determinants of registration and donorship and the translation of research into practice of school-based health promotion interventions, which can serve as an example for others.

TRIAL REGISTRATION

The Dutch Trial Register, NTR6771 . Registered on 24 October 2017. This is version 2 of the protocol (5 November 2017).

Complexity of Organ Donation Registration: Determinants of Registration Behavior Among Lower-educated Adolescents

BACKGROUND

Registration rates are low for organ donation among lower educated adolescents in The Netherlands. This could be improved by preparing them for making a decision regarding donation when they become 18 years old. To do so, more insight is needed into their beliefs about organ donation and registration.

METHODS

A cross-sectional quantitative study was conducted among students in intermediate vocational education schools. Data were gathered my means of self-administrated questionnaires. The outcome measurements included current registration status, being an organ donor, intention to register, and intention to become a donor. Correlation coefficients were used to assess the strength of associations between beliefs and each of the 4 outcome measurements.

RESULTS

A total of 405 participants (mean age, 18.86 years) were included, of whom 26.6% had already registered a decision. Most beliefs showed a significant correlation with one or more of the outcomes. In general, the correlations were of small to medium size and participants scored around the middle of the scales on the beliefs.

CONCLUSION

Means and correlations need to be combined to gain insight into the importance of certain beliefs for future interventions. However, it is plausible that, in addition to these explicit beliefs, implicit factors play a role in registration behavior. This could be explored in future research. Results could support intervention development for increasing registration rates.

Knowledge and Attitude Regarding Organ Donation among Medical Students

Introduction. All over the world people on organ transplant waiting lists die due to shortage of donor organs. The success of organ donation program needs education of the population regarding organ donation for which healthcare professionals are most suitable. The present study was taken up to assess the knowledge and attitude of 1st, 2nd and 3rd year medical students about organ donation. Methods. A specially designed self-administered questionnaire was distributed amongst all willing 1st, 2nd and 3rd year medical students at our Medical College and later analyzed statistically. Results. A total of 157, 145 and 92 students from each year of medical education respectively gave their consent for participation in the study. Awareness regarding organ donation was found to be 98.7-100%, 69.4% claimed television as their source of information regarding organ donation and 46.7% stated that it is possible for patient to recover from brain death. The awareness regarding eye, liver, heart and kidney donations was found to be 92.4%, 87%, 87% and 97.8%, respectively. 87% of medical students were aware of need for legal supervision, and awareness regarding the existing laws was found to be 57.6%. Conclusion. Medical students had a high level of awareness and a positive attitude towards organ donation. However, knowledge regarding “brain-death”, organs and tissues donated, legislation and ethical issues was poor. A teaching intervention designed to specifically address these issues could help increase the confidence of the health-care professionals and may result finally in increased organ procurement rates.

Intensive care practices in brain death diagnosis and organ donation

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24 h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤ 8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥ 15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Organ donation as transition work: Policy discourse and clinical practice in The Netherlands

An increasing number of patients become eligible for organ transplants. In the Netherlands, at the level of policy discourse, growing waiting lists are often referred to as a persistent “shortage” of organs, producing a “public health crisis.” In this way, organ donation is presented as an ethical, social, and medical necessity. Likewise, policy discourse offers a range of seemingly unambiguous solutions: improving logistical infrastructure at the level of hospitals, developing organizational and legal protocols, as well as public information campaigns. Instead of taking these problem and solution definitions as given, we critically examine the relationship between policy discourse and clinical practice. Based on a historical review, first, we trace the key moments of transformation where organ donation became naturalized in Dutch policy discourse, particularly in its altruistic connotation. Second, based on in-depth interviews with medical professionals, we show how those involved in organ donation continue to struggle with the controversial nature of their clinical practice. More specifically, we highlight their use of different forms of knowledge that underlie clinicians’ “transition work”: from losing a patient to “gaining” a donor.

Children as donors: a national study to assess procurement of organs and tissues in pediatric intensive care units

A shortage of size-matched organs and tissues is the key factor limiting transplantation in children. Empirical data on procurement from pediatric donors is sparse. This study investigated donor identification, parental consent, and effectuation rates, as well as adherence to the national protocol. A national retrospective cohort study was conducted in all eight Dutch pediatric intensive care units. Records of deceased children were analyzed by an independent donation officer. Seventy-four (11%) of 683 deceased children were found to be suitable for organ donation and 132 (19%) for tissue donation. Sixty-two (84%) potential organ donors had been correctly identified; the parental consent and effectuation rate was 42%. Sixty-three (48%) potential tissue donors had been correctly identified; the parental consent and effectuation rate was 27%. Correct identification increased with age (logistic regression, organs: P = .024; tissues: P = .011). Although an overall identification rate of 84% of potential organ donors may seem acceptable, the variation observed suggests room for improvement, as does the overall low rate of identification of pediatric tissue donors. Efforts to address the shortage of organs and tissues for transplantation in children should focus on identifying potential donors and on the reasons why parents do not consent.

Remarkable changes in the choice of timing to discuss organ donation with the relatives of a patient: a study in 228 organ donations in 20 years

Introduction

We studied whether the choice of timing of discussing organ donation for the first time with the relatives of a patient with catastrophic brain injury in The Netherlands has changed over time and explored its possible consequences. Second, we investigated how thorough the process of brain death determination was over time by studying the number of medical specialists involved. And we studied the possible influence of the Donor Register on the consent rate.

Methods

We performed a retrospective chart review of all effectuated brain dead organ donors between 1987 and 2009 in one Dutch university hospital with a large neurosurgical serving area.

Results

A total of 271 medical charts were collected, of which 228 brain dead patients were included. In the first period, organ donation was discussed for the first time after brain death determination (87%). In 13% of the cases, the issue of organ donation was raised before the first EEG. After 1998, we observed a shift in this practice. Discussing organ donation for the first time after brain death determination occurred in only 18% of the cases. In 58% of the cases, the issue of organ donation was discussed before the first EEG but after confirming the absence of all brain stem reflexes, and in 24% of the cases, the issue of organ donation was discussed after the prognosis was deemed catastrophic but before a neurologist or neurosurgeon assessed and determined the absence of all brain stem reflexes as required by the Dutch brain death determination protocol.

Conclusions

The phases in the process of brain death determination and the time at which organ donation is first discussed with relatives have changed over time. Possible causes of this change are the introduction of the Donor Register, the reintroduction of donation after circulatory death and other logistical factors. It is unclear whether the observed shift contributed to the high refusal rate in The Netherlands and the increase in family refusal in our hospital in the second studied period. Taking published literature on this subject into account, it is possible that this may have a counterproductive effect.

Appointing 'trained donation practitioners' results in a higher family consent rate in the Netherlands: a multicenter study

The consent process for organ and tissue donation is complex, both for families and professionals. To help professionals in broaching this subject we performed a multicenter study. We compared family consent to donation in three hospitals between December 2007 and December 2009. In the intervention hospital, trained donation practitioners (TDP) guided 66 families throughout the time in the ICU until a decision regarding donation had been reached. In the first control hospital, without any family guidance or training, 107 families were approached. In the second control hospital 'hostesses', who were not trained in donation questions, supported 99 families during admittance. A total of 272 families were requested to donate. We primarily compared consent rates, but also asked families about their experiences through a questionnaire. Family consent rate was significantly higher in the intervention hospital: 57.6% (38/66), than in the control hospitals: 34.6% (37/107) and 39.4% (39/99). The 69% response rate to the questionnaire -~5 months after death - showed no confounding variables that could have influenced the consent rate. Appointing TDPs in the intervention hospital to guide families during admittance and the donation decision-making process, results in higher family consent rates.

Higher refusal rates for organ donation among older potential donors in the Netherlands: impact of the donor register and relatives

BACKGROUND

The availability of donor organs is considerably reduced by relatives refusing donation after death. There is no previous large-scale evaluation of the influence of the Donor Register (DR) consultation and the potential donor's age on this refusal in The Netherlands.

METHODS

This study examines 2101 potential organ donors identified in intensive care units between 2005 and 2008 and analyzes the association of DR consultation and subsequent refusal by relatives and the relationship with the potential donor's age.

RESULTS

Of the 1864 potential donor cases where the DR was consulted, the DR revealed no registration in 56%, 20% registration of consent, and 18% objection. In the other 6.5% of cases, where the DR indicated that relatives had to decide, the relatives' refusal rate was significantly lower than in the absence of a DR registration (46% vs. 63%). In 6% of the cases where the DR recorded donation consent, relatives still refused donation. DR registration, objection in the DR, and the relatives' refusal rate if the DR was not decisive increased with donor age.

CONCLUSIONS

Despite the introduction of a DR, relatives still play an equally important role in the final decision for organ donation. The general public should be encouraged to register their donation preferences in the DR and also to discuss their preferences with their families. The higher refusal rate of older potential donors means that this group should receive more information about organ donation, especially because the cohort of available donors is ageing.