National evaluation of healthcare provider attitudes toward organ donation after cardiac death

Healthcare Worker Attitudes to Living Donation Prior to Planned Withdrawal of Care

Background and Aims

This study assesses the attitudes of healthcare practitioners toward Living Donation Prior to Planned Withdrawal of Care (LD-PPW): the recovery of a living donor organ before withdrawal of life-sustaining measures in a patient who does not meet criteria for brain death, but for whom medical care toward meaningful recovery is deemed futile.

Methods

An electronic survey was administered to 1735 members of the American Society of Transplant Surgeons mailing list with 187 responses (10.8%).

Results

Data from this study revealed that 70% of responding practitioners agreed with LD-PPW due to principles of beneficence and autonomy. Also, 65% of participants felt confident in their ability to declare the futility of care and 70% felt that LD-PPW should be added as an option when registering to become an organ donor.

Conclusion

Currently, nearly half of all donation after circulatory determination of death do not proceed to donation. LD-PPW has been proposed as an alternative procedure targeted at increasing the quality and quantity of transplantable organs while respecting the donor's right to donate, though its implementation has been hindered by concerns over public and provider perception. This study revealed support for LD-PPW among healthcare practitioners as an alternative procedure to increase the quality and quantity of transplantable organs while respecting the donor's right to donate.

End-Of-Life Care in the Potential Donor after Circulatory Death: A Systematic Review

Background

Donation after circulatory death (DCD) is becoming increasingly common, yet little is known about the way potential donors receive end-of-life care.

Purpose

The aims of this systematic review are to describe the current practice in end-of-life care for potential donors and identify metrics that are being used to assess discomfort among these patients.

Research design and Study Sample

This review encompasses published literature between June 1, 2000 and June 31, 2020 of end-of-life care received by potential DCD patients. The population of interest was defined as patients eligible for Maastracht classification III donation after circulatory death for a solid organ transplantation. Outcomes examined included: analgesic or palliative protocols, and surrogates of discomfort (eg dyspnea, agitation).

Results

Among 141 unique articles, 27 studies were included for full review. The primary reason for exclusion was lack of protocol description, or lack of reporting on analgesic medications. No primary research studies specifically examined distress in the DCD eligible population. Numerous professional guidelines were identified. Surveys of critical care practitioners identified concerns regarding the impact of symptom management on hastening the dying process in the DCD population as a potential barrier to end-of-life palliative treatment.

Conclusions

There is a paucity of empirical evidence for end-of-life symptom assessment and management for DCD patients. Key evidence gaps identified for DCD include the need for: i) a multidisciplinary structure of treatment teams and preferred environment for DCD, ii) objective tools for monitoring of distress in this patient population, and iii) evidence guiding the administration of analgesic medications following withdrawal of life sustaining therapy.

"A Delicate balance"-Perceptions and Experiences of ICU Physicians and Nurses Regarding Controlled Donation After Circulatory Death. A Qualitative Study

Controlled donation after circulatory death (cDCD) is considered by many as a potential response to the scarcity of donor organs. However, healthcare professionals may feel uncomfortable as end-of-life care and organ donation overlap in cDCD, creating a potential barrier to its development. The aim of this qualitative study was to gain insight on the perceptions and experiences of intensive care units (ICU) physicians and nurses regarding cDCD. We used thematic analysis of in-depth semi-structured interviews and 6-month field observation in a large teaching hospital. 17 staff members (8 physicians and 9 nurses) participated in the study. Analysis showed a gap between ethical principles and routine clinical practice, with a delicate balance between end-of-life care and organ donation. This tension arises at three critical moments: during the decision-making process leading to the withdrawal of life-sustaining treatments (LST), during the period between the decision to withdraw LST and its actual implementation, and during the dying and death process. Our findings shed light on the strategies developed by healthcare professionals to solve these ethical tensions and to cope with the emotional ambiguities. cDCD implementation in routine practice requires a shared understanding of the tradeoff between end-of-life care and organ donation within ICU.

Predicting Time to Death After Withdrawal of Life-Sustaining Measures Using Vital Sign Variability: Derivation and Validation

To develop a predictive model using vital sign (heart rate and arterial blood pressure) variability to predict time to death after withdrawal of life-supporting measures.

Survey of public attitudes towards imminent death donation in the United States

Imminent death donation (IDD) is described as living organ donation prior to a planned withdrawal of life-sustaining care in an imminently dying patient. Although IDD was ethically justified by United Network for Organ Sharing, the concept remains controversial due to presumed lack of public support. The aim of this study was to evaluate the public's attitudes towards IDD. A cross-sectional survey was conducted of US adults age >18 years (n = 2644). The survey included a case scenario of a patient with a devastating brain injury. Responses were assessed on a 5-point Likert scale. Results showed that 68% - 74% of participants agreed or strongly agreed with IDD when posed as a general question and in relation to the case scenario. Participants were concerned about "recovery after a devastating brain injury" (34%), and that "doctors would not try as hard to save a patient's life" (33%). Only 9% of participants would be less likely to trust the organ donation process. In conclusion, our study demonstrates strong public support for IDD in the case of a patient with a devastating brain injury. Notably, participants were not largely concerned with losing trust in the organ donation process. These results justify policy change towards imminent death donation.

Ethical and logistical concerns for establishing NRP-cDCD heart transplantation in the United States

Controlled heart donation after circulatory determination of death (cDCD) is well established internationally with good outcomes and could be adopted in the United States to increase heart supply if ethical and logistical challenges are comprehensively addressed. The most effective and resource-efficient method for mitigating warm ischemia after circulatory arrest is normothermic regional perfusion (NRP) in situ. This strategy requires restarting circulation after declaration of death according to circulatory criteria, which appears to challenge the legal circulatory death definition requiring irreversible cessation. Permanent cessation for life-saving efforts must be achieved to assuage this concern and ligating principal vessels maintains no blood flow to the brain, which ensures natural progression to cessation of brain function. This practice-standard in some countries-raises unique concerns about prioritizing life-saving efforts, informed authorization from decision-makers, and the clinician's role in the patient's death. To preserve public trust, medical integrity, and respect for the donor, the donation conversation must not take place until after an un-coerced decision to withdraw life-sustaining treatment made in accordance with the patient's treatment goals. The decision-maker(s) must understand cDCD procedure well enough to provide genuine authorization and the preservation/procurement teams must be kept separate from the clinical care team.

Donation after circulatory determination of death in western Canada: a multicentre study of donor characteristics and critical care practices

PURPOSE

Donation after circulatory determination of death (DCD) has been performed in Canada since 2006. Numerous aspects of donor management remain controversial.

METHODS

We performed a multicentre cohort study involving potential DCD donors in western Canada (2008-2017), as well as recipients of their organs, to describe donor characteristics and critical care practices, and their relation to one-year recipient and graft survival.

RESULTS

There were 257 patients in four provinces that underwent withdrawal of life-sustaining therapies (WLST) in anticipation of possible DCD. The proportion of patients that died within two hours of WLST ranged from 67% to 88% across provinces (P = 0.06), and was predicted by deeper coma (P = 0.01), loss of pupillary light or corneal reflexes (P = 0.02), and vasopressor use (P = 0.01). There were significant differences between provinces in time intervals from onset of hypotension to death (9-11 min; P = 0.02) and death to vascular cannulation (7-10 min; P < 0.001). There was inconsistency in pre-mortem heparin administration (82-96%; P = 0.03), including timing (before vs after WLST; P < 0.001) and dose (≥ 300 vs < 300 units·kg-1; P < 0.001). Donation after circulatory death provided organs for 321 kidney, 81 liver, and 50 lung transplants. One-year recipient and graft survival did not differ among provinces (range 85-90%, P = 0.45). Predictors of death or graft failure included older recipient age (odds ratio [OR] per year, 1.04; 95% confidence interval [CI],1.01 to 1.07) and male donor sex (OR, 3.35; 95% CI, 1.39 to 8.09), but not time intervals between WLST and cannulation or practices related to heparin use.

CONCLUSION

There is significant variability in critical care DCD practices in western Canada, but this has not resulted in significant differences in recipient or graft survival. Further research is required to guide optimal management of potential DCD donors.

Attitudes and self-reported end-of-life care of Australian and New Zealand intensive care doctors in the context of organ donation after circulatory death

The incidence of organ donation after circulatory death (DCD) in Australia and New Zealand (ANZ) has steadily increased in recent years. Intensive care doctors are vital to the implementation of DCD and healthcare professionals' attitudes to DCD can influence their participation. In order to determine ANZ intensive care doctors' attitudes to DCD, to explore if demographic characteristics influence attitude to DCD and to assess if attitude to DCD can predict palliative prescription rationale at the end of life of DCD donors, a cross-sectional online survey was distributed to ANZ intensive care doctors and responses collected between 29 April and 10 June 2016. Exploratory factor analysis was used to define various attributes of attitude to DCD. Results were subjected to comparative statistical analyses to examine the relation between demographic data and attitude to DCD. Multiple regression models were used to examine if attitude to DCD could predict intensive care doctors' palliative prescription rationales at the end of life of DCD donors. One hundred and sixty-one intensive care doctors responded to the survey with 69.4% having worked in intensive care for ten years or more. Respondents responded positively to the support of and perceived importance of DCD in helping those who would benefit from the donations (constructive attributes)(mean composite factor score = 3.84, standard deviation [SD] 0.83), they positively perceived that conducive and facilitative orchestration of DCD helps families cope (mean composite factor score = 3.94, SD 0.72) and that they would manage a DCD donor similar to any patient at the end of their life (mean score = 3.94, SD 0.72). Respondents responded negatively to having concerns that the circulatory death of potential DCD donors does not occur within the specified time frame (mean score = 2.28, SD 1.02). There was an association between organ donation professional education courses, familiarity with national guidelines and positive attitudes to certain attributes of attitude to DCD. Regression models demonstrated the attitude to DCD may predict intensive care doctors' palliative medication prescription rationales at the end of life of the DCD donor. Intensive care doctors in ANZ adopt a morally neutral attitude to DCD where they recognise the importance of organ donation, and support and conduct DCD as a part of good end-of-life care.

Heart transplantation after the circulatory death; The ethical dilemma

Donors after brain death (DBD) have been the major source of organ donation due to good perfusion of the organs. However, owing to the mismatch in demand and supply of the organ donors and recipients, donors after circulatory death (DCDDs) has increased recently all over the world. Kidneys, liver, and lungs are being used for transplantation from DCDDs. Recently, heart transplantation from DCDDs has been started, which is under the firestorm of scrutiny by the ethicists. The ethical dilemma revolves around the question whether the donors are actually dead when they are declared dead by cardiocirculatory death criteria for organ procurement. The subsequent literature review addresses all the perspectives by differentiating between the donation methods known as DBDs and DCDDs, explaining the implications of the dead-donor rule on the organ donation pool, and categorizing the determinants of death leading to separation of the arguments under the two methods of donations.

Barriers and Enablers to Organ Donation After Circulatory Determination of Death: A Qualitative Study Exploring the Beliefs of Frontline Intensive Care Unit Professionals and Organ Donor Coordinators

Background

A shortage of transplantable organs is a global problem. The purpose of this study was to explore frontline intensive care unit professionals' and organ donor coordinators' perceptions and beliefs around the process of, and the barriers and enablers to, donation after circulatory determination death (DCDD).

Methods

This qualitative descriptive study used a semistructured interview guide informed by the Theoretical Domains Framework to interview 55 key informants (physicians, nurses, and organ donation coordinators) in intensive care units (hospitals) and organ donation organizations across Canada.

Results

Interviews were analyzed using a 6-step systematic approach: coding, generation of specific beliefs, identification of themes, aggregation of themes into categories, assignment of barrier or enabler and analysis for shared and unique discipline barriers and enablers. Seven broad categories encompassing 29 themes of barriers (n = 21) and enablers (n = 4) to DCDD use were identified; n = 4 (14%) themes were conflicting, acting as barriers and enablers. Most themes (n = 26) were shared across the 3 key informant groups while n = 3 themes were unique to physicians. The top 3 shared barriers were: (1) DCDD education is needed for healthcare professionals, (2) a standardized and systematic screening process to identify potential DCDD donors is needed, and (3) practice variation across regions with respect to communication about DCDD with families. A limited number of differences were found by region.

Conclusions

Multiple barriers and enablers to DCDD use were identified. These beliefs identify potential individual, team, organization, and system targets for behavior change interventions to increase DCDD rates which, in turn, should lead to more transplantation, reducing patient morbidity and mortality at a population level.

Decision-making in end of life care. Are we really playing together in the same team?

BACKGROUND

Limitation of life-sustaining treatment is increasingly common in critical care units, and controlled donation after circulatory death is starting to be included as an option within patient care plans. Lack of knowledge and misunderstandings can place a barrier between healthcare professionals.

OBJECTIVE

To determine the perceptions, knowledge and attitudes of physicians and nurses working in intensive care units regarding Limitation of life-sustaining treatment and controlled donation after circulatory death.

DESIGN, SETTINGS AND PARTICIPANTS

Cross-sectional study carried out in 13 Spanish hospitals by means of an ad hoc questionnaire.

METHODS

Contingency tables, Pearson's chi-squared test, Student's t-test and the Mann-Whitney u-test were used to carry out descriptive, bivariate and multivariate statistical analyses of responses.

RESULTS

Although Limitation of life-sustaining treatment is a widespread practice, the survey revealed that nurses feel excluded from the development of protocols and the decision-making process, whilst the perception of physicians is that they have greater knowledge of the topic, and decisions are reached in consensus.

CONCLUSIONS

Multi-disciplinary training programmes can help critical healthcare providers to work together with greater coordination, thus benefitting patients and their next of kin by providing excellent end-of-life care.

Attitudes of intensive care and emergency physicians in Australia with regard to the organ donation process: A qualitative analysis

Specialized hospital physicians have direct capacity to impact Australia’s sub-optimal organ donation rates because of their responsibility to identify and facilitate donation opportunities. Australian physicians’ attitudes toward this responsibility are examined. A total of 12 intensive care unit and three emergency department physicians were interviewed using a constructionist grounded theory and situational analysis approach. A major theme emerged, related to physicians’ conflicts of interest in maintaining patients’/next-of-kin’s best interests and a sense of duty-of-care in this context. Two sub-themes related to this main theme were identified as follows: (1) discussions about organ donation and who is best to carry these out and (2) determining whether organ donation is part of end-of-life care; including the avoidance of non-therapeutic ventilation; and some reluctance to follow clinical triggers in the emergency department. Overall, participants indicated strong support for organ donation but would not consider it part of end-of-life care, representing a major obstacle to the support of potential donation opportunities. Findings have implications for physician education and training. Continued efforts are needed to integrate the potential for organ donation into end-of-life care within intensive care units and emergency departments.

Measuring Critical Care Providers' Attitudes About Controlled Donation After Circulatory Death

INTRODUCTION

Unfavorable attitudes and insufficient knowledge about donation after cardiac death among critical care providers can have important consequences for the appropriate identification of potential donors, consistent implementation of donation after cardiac death policies, and relative strength of support for this type of donation. The lack of reliable and valid assessment measures has hampered research to capture providers' attitudes. Design and Research Aims: Using stakeholder engagement and an iterative process, we developed a questionnaire to measure attitudes of donation after cardiac death in critical care providers (n = 112) and examined its psychometric properties. Exploratory factor analysis, internal consistency, and validity analyses were conducted to examine the measure.

RESULTS

A 34-item questionnaire consisting of 4 factors (Personal Comfort, Process Satisfaction, Family Comfort, and System Trust) provided the most parsimonious fit. Internal consistency was acceptable for each of the subscales and the total questionnaire (Cronbach α > .70). A strong association between more favorable attitudes overall and knowledge ( r = .43, P < .001) provides evidence of convergent validity. Multivariable regression analyses showed that white race ( P = .002) and more experience with donation after cardiac death ( P < .001) were significant predictors of more favorable attitudes.

CONCLUSION

Study findings support the utility, reliability, and validity of a questionnaire for measuring attitudes in critical care providers and for isolating targets for additional education on donation after cardiac death.

Impact of training on intensive care providers' attitudes and knowledge regarding limitation of life-support treatment and organ donation after circulatory death

The limitation of life-sustaining treatment is common practice in critical care units, and organ donation after circulatory death has come to be included as an option within this care plan. Lack of knowledge and misunderstandings can raise barriers between health-care providers (e.g., confusion about professional roles, lack of collaboration, doubts about the legality of the process, and not respecting patients' wishes in the decision-making process). The aim of the present study was to determine the knowledge and attitudes of intensive care physicians and nurses before and after a multidisciplinary online training program. A cross-sectional study was performed, and comparisons between the two groups were made using a χ² -test for categorical data and unpaired t-test or Mann-Whitney rank sum test for continuous data according to its distribution. Training benefited both professional categories, helping nurses to be more open-minded and willing to collaborate, while physicians became more aware of nurses' presence and the need to collaborate with them.

Use of Lung Allografts From Donation After Cardiac Death Donors: A Single-Center Experience

BACKGROUND

Lung transplantation remains the only treatment for end-stage lung disease. Availability of suitable lungs does not parallel this growing trend. Centers using donation after cardiac death (DCD) donor lungs report comparable outcomes with those from brain-dead donors. Donor assessment protocols and consistent surgical teams have been advocated when considering using the use of DCD donors. We present our experience using lungs from Maastricht category III DCD donors.

METHODS

Starting 2007 to July 2016, 73 DCD donors were assessed, 44 provided suitable lungs that resulted in 46 transplants. A 2012 to October 2016 comparative cohort of 379 brain-dead donors were assessed. Recipient and donor characteristics and primary graft dysfunction (PGD) and survival were monitored.

RESULTS

Seventy-three DCD (40% dry run rate) donors assessed yielded 46 transplants (23 double, 6 right, and 17 left). Comparative cohort of 379 brain-dead donors yielded 237 transplants (112 double, 43 right, and 82 left). One- and 3-year recipient survival was 91% and 78% for recipients of DCD lungs and 91% and 75% for recipients of lungs from brain-dead donors, respectively. PGD 2 and 3 in DCD recipients at 72 hours was 4 of 46 (9%) and 6 of 46 (13%), respectively. Comparatively, brain-dead donor recipient cohort at 72 hours with PGD 2 and 3 was 23 of 237 (10%) and 41 of 237 (17%), respectively.

CONCLUSIONS

Our experience reaffirms the use of lungs from DCD donors as a viable source with favorable outcomes. Recipients from DCD donors showed equivalent PGD rate at 72 hours and survival compared with recipients from brain-dead donors.

A Comparison of Request Process and Outcomes in Donation After Cardiac Death and Donation After Brain Death: Results From a National Study

Available literature points to healthcare providers' discomfort with donation after cardiac death (DCD) and their perception of public reluctance toward the procedure. Using a national sample, we report on the communication content of actual DCD and donation after brain death (DBD) approaches by organ procurement organization (OPO) requesters and compare family decision makers' (FDMs') experiences of both modalities. We recruited 1601 FDMs using a validated protocol; 347 (21.7%) were of potential DCD donors. Semistructured telephone interviews yielded FDMs' sociodemographic data, donation attitudes, assessment of approach, final outcomes, and substantiating reasons. Initial analysis consisted of bivariate analyses. Multilevel mixture models compared groups representing authorization outcome and DCD/DBD status. No significant differences in family authorization were found between DCD and DBD cases. Statistically significant associations were found between sociodemographic characteristics and authorization, with white FDMs more likely to authorize DCD or DBD than black FDMs. FDMs of both modalities had similar evaluations of requester skills, topics discussed, satisfaction, and refusal reasons. The findings suggest that the DCD/DBD distinction may not be notable to families. We recommend the use of similar approach strategies and communication skills and the development of education campaigns about the public's acceptance of DCD.

THE INFLUENCE OF INFORMATION AND RELIGION ON ORGAN DONATION, AS SEEN BY SCHOOL TEACHERS IN BOSNIA AND HERZEGOVINA

Introduction:

Transplantation of organs is the treatment of choice for severe organ failure worldwide.

Aim:

The aims of the present study were to determine the influence of religion on attitudes towards organ donation among staff at schools in Tuzla.

Material and Methods:

In the Tuzla region there are 42 schools and 1580 school staff. A total of 21 schools were selected randomly, which were stratified by geographical location. 499 employees were invited to participate in the study, and 475 agreed to participate. According to the definition of their attitude towards religion the subjects were divided into three groups: non-religious, only religious and practical believers.

Results:

None of the subjects possesses a donor card. To the question whether the subjects support the idea of organ transplantation, most replied that they support the idea of donating organs both during life and after death. Regarding this question there is a significant difference between the groups (p = 0.0063). To the question whether they are prepared to donate an organ of a deceased family member, most replied that they would consent to donating an organ, whilst a significant number also replied that they were not sure. The results show that there is no significant difference between the replies given by the groups (p = 0.7694). To the question regarding to whom they were prepared to donate an organ, most said they were prepared to donate one to a member of their family, then to a close relative, whilst the least would donate to a stranger. The results show that there is a significant difference between the groups (p = 0.0002).

Conclusion:

In order to reduce the wide disparity between the need and organ donation amongst other things a more active relationship is necessary between health workers, religious officials and school staff.

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.

Lung Quality and Utilization in Controlled Donation After Circulatory Determination of Death Within the United States

Although controlled donation after circulatory determination of death (cDCDD) could increase the supply of donor lungs within the United States, the yield of lungs from cDCDD donors remains low compared with donation after neurologic determination of death (DNDD). To explore the reason for low lung yield from cDCDD donors, Scientific Registry of Transplant Recipient data were used to assess the impact of donor lung quality on cDCDD lung utilization by fitting a logistic regression model. The relationship between center volume and cDCDD use was assessed, and the distance between center and donor hospital was calculated by cDCDD status. Recipient survival was compared using a multivariable Cox regression model. Lung utilization was 2.1% for cDCDD donors and 21.4% for DNDD donors. Being a cDCDD donor decreased lung donation (adjusted odds ratio 0.101, 95% confidence interval [CI] 0.085-0.120). A minority of centers have performed cDCDD transplant, with higher volume centers generally performing more cDCDD transplants. There was no difference in center-to-donor distance or recipient survival (adjusted hazard ratio 1.03, 95% CI 0.78-1.37) between cDCDD and DNDD transplants. cDCDD lungs are underutilized compared with DNDD lungs after adjusting for lung quality. Increasing transplant center expertise and commitment to cDCDD lung procurement is needed to improve utilization.

Neonatal and Pediatric Organ Donation: Ethical Perspectives and Implications for Policy

The lifesaving processes of organ donation and transplantation in neonatology and pediatrics carry important ethical considerations. The medical community must balance the principles of autonomy, non-maleficence, beneficence, and justice to ensure the best interest of the potential donor and to provide equitable benefit to society. Accordingly, the US Organ Procurement and Transplantation Network (OPTN) has established procedures for the ethical allocation of organs depending on several donor-specific and recipient-specific factors. To maximize the availability of transplantable organs and opportunities for dying patients and families to donate, the US government has mandated that hospitals refer potential donors in a timely manner. Expedient investigation and diagnosis of brain death where applicable are also crucial, especially in neonates. Empowering trained individuals from organ procurement organizations to discuss organ donation with families has also increased rates of consent. Other efforts to increase organ supply include recovery from donors who die by circulatory criteria (DCDD) in addition to donation after brain death (DBD), and from neonates born with immediately lethal conditions such as anencephaly. Ethical considerations in DCDD compared to DBD include a potential conflict of interest between the dying patient and others who may benefit from the organs, and the precision of the declaration of death of the donor. Most clinicians and ethicists believe in the appropriateness of the Dead Donor Rule, which states that vital organs should only be recovered from people who have died. The medical community can maximize the interests of organ donors and recipients by observing the Dead Donor Rule and acknowledging the ethical considerations in organ donation.

Increasing organ donation after cardiac death in trauma patients

BACKGROUND

Organ donation after cardiac death (DCD) is not optimal but still remains a valuable source of organ donation in trauma donors. The aim of this study was to assess national trends in DCD from trauma patients.

METHODS

A 12-year (2002 to 2013) retrospective analysis of the United Network for Organ Sharing database was performed. Outcome measures were the following: proportion of DCD donors over the years and number and type of solid organs donated.

RESULTS

DCD resulted in procurement of 16,248 solid organs from 8,724 donors. The number of organs donated per donor remained unchanged over the study period (P = .1). DCD increased significantly from 3.1% in 2002 to 14.6% in 2013 (P = .001). There was a significant increase in the proportion of kidney (2002: 3.4% vs 2013: 16.3%, P = .001) and liver (2002: 1.6% vs 2013: 5%, P = .041) donation among DCD donors over the study period.

CONCLUSIONS

DCD from trauma donors provides a significant source of solid organs. The proportion of DCD donors increased significantly over the last 12 years.

Non-therapeutic intensive care for organ donation

Background and Purpose:

Providing non-therapeutic intensive care for some patients in hopeless condition after cerebrovascular stroke in order to protect their organs for possible post-mortem organ donation after brain death is an effective but ethically tricky strategy to increase organ grafting. Finding out the feelings and opinion of the involved healthcare professionals and assessing the training needs before implementing such a strategy is critical to avoid backlash even in a presumed consent system.

Participants and methods:

A single-centre opinion survey of healthcare professionals was conducted in 2013 in the potentially involved wards of a French University Hospital: the Neurosurgical, Surgical and Medical Intensive Care Units, the Stroke Unit and the Emergency Department. A questionnaire with multiple-choice questions and one open-ended question was made available in the different wards between February and May 2013.

Ethical considerations:

The project was approved by the board of the Lorraine University Diploma in Medical Ethics.

Results:

Of a total of 340 healthcare professionals, 51% filled the form. Only 21.8% received a specific education on brain death, and only 18% on potential donor’s family approach and support. Most healthcare professionals (93%) think that non-therapeutic intensive care is the continuity of patient’s care. But more than 75% of respondents think that the advance patient’s consent and the consent of the family must be obtained despite the presumed consent rule regarding post-mortem organ donation in France.

Conclusion:

The acceptance by healthcare professionals of non-therapeutic intensive care for brain death organ donation seems fairly good, despite a suboptimal education regarding brain death, non-therapeutic intensive care and families’ support. But they ask to require previously expressed patient’s consent and family’s approval. So, it seems that non-therapeutic intensive care should only remain an ethically sound mean of empowerment of organ donors and their families to make post-mortem donation happen as a full respect of individual autonomy.

Donation after circulatory death: a national survey of current practice in England in 2012

OBJECTIVE

In recent years, England has seen renewed interest in donation after circulatory death. Many national and local initiatives have been implemented to encourage and support donation after circulatory death. To assess whether practice is in line with published guidance, we conducted a national survey with regard to current donation after circulatory death practices, local guidelines, and views on the need to further develop a national standardized protocol for donation after circulatory death.

DESIGN

Online survey.

SUBJECTS

Lead physicians for intensive care or organ donation for every acute National Health Service trust in England delivering adult care between April and June 2012.

INTERVENTIONS

Physicians were e-mailed a link to a structured online questionnaire regarding their experience and practice of donation after circulatory death, including local protocols, use of organ optimization, and the need for a national protocol.

MEASUREMENTS AND MAIN RESULTS

We received replies from 119 of 156 eligible trusts (76.3%) in England. Of these, 112 trusts (94%) have performed donation after circulatory death. Ninety-three trusts (78.1%) have a local donation after circulatory death protocol, and 89 trusts (74.7%) felt there should be a national donation after circulatory death protocol. All responding transplant centers had performed donation after circulatory death, 14 of 17 (82.3%) had a donation after circulatory death protocol with 14 of 17 respondents (82.3%) supporting a national protocol. Regarding organ optimization, 92 institutions (77.3%) used vasoactive drugs to achieve a target mean arterial blood pressure with 82 centers (68.9%) employing positive end-expiratory pressure and FIO2 to optimize oxygenation. Eight centers (6.7%) used heparin premortem compared with two of 17 transplant centers (11.8%). Two centers have used phentolamine to facilitate organ retrieval, with another five centers (4.2%) cannulating vessels premortem.

CONCLUSIONS

Our survey revealed varying approaches and views toward donation after circulatory death across England. A greater than expected percentage use premortem cannulation, heparinization, and phentolamine despite current guidance in England to the contrary. The majority of institutions practicing donation after circulatory death with protocols in place favor the development of national guidelines, particularly with respect to organ optimization. We believe that such a protocol would help to address potential barriers to donation after circulatory death, which may lead to increased donation rates and improved outcomes.

Exploring Australian intensive care physicians clinical judgement during Donation after Cardiac Death: an exploratory qualitative study

BACKGROUND

Donation after Cardiac Death (DCD) is one possible solution to the world wide organ shortage. Intensive care physicians are central to DCD becoming successful since they are responsible for making the clinical judgements and decisions associated with DCD. Yet international evidence shows health care professionals have not embraced DCD and are often reluctant to consider it as an option for patients.

PURPOSE

To explore intensive care physicians' clinical judgements when selecting a suitable DCD candidate.

METHODS

Using interpretative exploratory methods six intensive care physicians were interviewed from three hospital sites in Australia. Following verbatim transcription, data was subjected to thematic analysis.

FINDINGS

Three distinct themes emerged. Reducing harm and increasing benefit was a major focus of intensive care physicians during determination of DCD. There was an acceptance of DCD if there was clear evidence that donation was what the patient and family wanted. Characteristics of a defensible decision reflected the characteristics of sequencing, separation and isolation, timing, consensus and collaboration, trust and communication to ensure that judgements were robust and defensible. The final theme revealed the importance of minimising uncertainty and discomfort when predicting length of survival following withdrawal of life-sustaining treatment.

CONCLUSION

DCD decisions are made within an environment of uncertainty due to the imprecision associated with predicting time of death. Lack of certainty contributed to the cautious and collaborative strategies used by intensive care physicians when dealing with patients, family members and colleagues around end-of-life decisions, initiation of withdrawal of life-sustaining treatment and the discussion about DCD. This study recommends that nationally consistent policies are urgently needed to increase the degree of certainty for intensive care staff concerning the DCD processes.

Incidence and distribution of transplantable organs from donors after circulatory determination of death in U.S. intensive care units

RATIONALE

All U.S. acute care hospitals must maintain protocols for recovering organs from donors after circulatory determination of death (DCDD), but the numbers, types, and whereabouts of available organs are unknown.

OBJECTIVES

To assess the maximal potential supply and distribution of DCDD organs in U.S. intensive care units.

METHODS

We conducted a population-based cohort study among a randomly selected sample of 50 acute care hospitals in the highest-volume donor service area in the United States. We identified all potentially eligible donors dying within 90 minutes of the withdrawal of life-sustaining therapy from July 1, 2008 to June 30, 2009.

MEASUREMENTS AND MAIN RESULTS

Using prespecified criteria, potential donors were categorized as optimal, suboptimal, or ineligible to donate their lungs, kidneys, pancreas, or liver. If only optimal DCDD organs were used, the deceased donor supplies of these organs could increase by up to 22.7, 8.9, 7.4, and 3.3%, respectively. If optimal and suboptimal DCDD organs were used, the corresponding supply increases could be up to 50.0, 19.7, 18.5, and 10.9%. Three-quarters of DCDD organs could be recovered from the 17.2% of hospitals with the highest annual donor volumes-typically those with trauma centers and more than 20 intensive care unit beds.

CONCLUSIONS

Universal identification and referral of DCDD could increase the supply of transplantable lungs by up to one-half, and would not increase any other organ supply by more than one-fifth. The marked clustering of DCDD among a small number of identifiable hospitals could guide targeted interventions to improve DCDD identification, referral, and management.

Does uncontrolled cardiac death for organ donation raise ethical questions? An opinion survey

BACKGROUND

Organ donation after uncontrolled cardiac death raises complex ethical issues. We conducted a survey in a large hospital staff population, including caregivers and administrators, to determine their ethical viewpoints regarding organ donation after uncontrolled cardiac death.

METHODS

Multicenter observational survey using a questionnaire, including information on the practical modalities of the procedure. Respondents were asked to answer 15 detailed ethical questions corresponding to different ethical issues raised in the literature. Ethical concerns was defined when respondents expressed ethical concerns in their answers to at least three of nine specifically selected ethical questions.

RESULTS

One thousand one hundred ninety-six questionnaires were received, and 1057 could be analysed. According to our definition, 573 respondents out of 1057 (54%) had ethical concerns with regard to donation after cardiac death and 484 (46 %) had no ethical concerns. Physicians (55%) and particularly junior intensivists (65%) tended to have more ethical issues than nurses (52%) and hospital managers (37%). Junior intensivists had more ethical issues than senior intensivists (59%), emergency room physicians (46%) and transplant specialists (43%).

CONCLUSION

Only 46% of hospital-based caregivers and managers appear to accept easily the legitimacy of organ donation after cardiac death. A significant number of respondents especially intensivists, expressed concerns over the dilemma between the interests of the individual and those of society. These results underline the need to better inform both healthcare professionals and the general population to help to the development of such procedure.

An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death

RATIONALE

Donation after circulatory determination of death (DCDD) has the potential to increase the number of organs available for transplantation. Because consent and management of potential donors must occur before death, DCDD raises unique ethical and policy issues.

OBJECTIVES

To develop an ethics and health policy statement on adult and pediatric DCDD relevant to critical care and transplantation stakeholders.

METHODS

A multidisciplinary panel of stakeholders was convened to develop an ethics and health policy statement. The panel consisted of representatives from the American Thoracic Society, Society of Critical Care Medicine, International Society for Heart and Lung Transplantation, Association of Organ Procurement Organizations, and the United Network of Organ Sharing. The panel reviewed the literature, discussed important ethics and health policy considerations, and developed a guiding framework for decision making by stakeholders.

RESULTS

A framework to guide ethics and health policy statement was established, which addressed the consent process, pre- and post mortem interventions, the determination of death, provisions of end-of-life care, and pediatric DCDD.

CONCLUSIONS

The information presented in this Statement is based on the current evidence, experience, and clinical rationale. New clinical research and the development and dissemination of new technologies will eventually necessitate an update of this Statement.

Views of pediatric intensive care physicians on the ethics of organ donation after cardiac death

OBJECTIVE

Donation after cardiac death has been endorsed by professional organizations, including the American Academy of Pediatrics as a means of increasing the supply of transplantable organs. However, ethical concerns have been raised about donation after cardiac death, especially in children. This study explores the views of pediatric intensive care physicians on the ethics of pediatric donation after cardiac death.

DESIGN

Internet survey.

SUBJECTS

Physician members of the American Academy of Pediatrics Section of Critical Care.

INTERVENTIONS

Physicians were emailed an anonymous survey consisting of four demographic items and 16 items designed to assess their views on the ethics of pediatric donation after cardiac death. Responses to ethics items were rated on a 5-point scale ranging from strongly disagree to strongly agree. Physicians were also given the opportunity to provide free-text comments regarding their views.

MEASUREMENTS AND MAIN RESULTS

Of the 598 eligible physicians, 264 (44.1%) responded to the survey. Of these, 193 (73.4%) were practicing in a transplant center and 160 (60.6%) participated in at least one donation after cardiac death procedure at the time of survey completion. Two hundred twenty (83.4%) agreed or strongly agreed that regarding donation after cardiac death, parents should be able to make decisions based on the best interests of their child. Two hundred twenty-two (84.1%) agreed or strongly agreed that it is not acceptable to harvest organs from a child before the declaration of death, consistent with the Dead Donor Rule. However, only 155 (59.1%) agreed or strongly agreed that the time of death in donation after cardiac death can be conclusively determined. Twenty-nine (11.0%) agreed or strongly agreed that the pediatric donation after cardiac death donor may feel pain or suffering during the harvest procedure.

CONCLUSIONS

Most pediatric intensive care physicians agree that the Dead Donor Rule should be applied for donation after cardiac death and that donation after cardiac death can be consistent with the best interest standard. However, concerns about the ability to determine time of death for the purpose of organ donation and the possibility of increasing donor pain and suffering exist.

Systematic review of attitudes toward donation after cardiac death among healthcare providers and the general public

OBJECTIVE

Organ donation after cardiac death (DCD) is one promising possibility of combating the organ shortage, but it raises ethical issues that differ from those raised in donation after brain death (DBD). Also, DCD may be perceived differently than DBD by medical staff and the public. The aim of this article is to systematically review empirical studies on attitudes of medical personnel and the public toward DCD and to discuss the findings from an ethical perspective. Our study was conducted in accordance with a seven-step approach for systematic reviews of empirical studies in bioethics.

DATA SOURCES

The authors chose PubMed, EMBASE, CINAHL, PSYCINFO, and PSYNDEX, thus attempting to cover biomedical, sociological and ethical articles on the subject.

STUDY SELECTION

A search algorithm using controlled vocabulary of the respective databases (where applicable) was created, and criteria for the relevance assessment of the articles were established. Article quality was assessed using the Critical Appraisal Skills Programme tool.

DATA EXTRACTION AND SYNTHESIS

The authors took an integrative approach to the data, combining it for further analysis. Qualitative data were synthesized by means of thematic analysis, and a spectrum of relevant themes was identified. Then the authors extracted the quantitative data that corresponded with the identified themes. Quantitative data on common subjects were juxtaposed and presented later.

CONCLUSIONS

Identified themes were the levels of support for DBD vs. DCD, attitudes toward postmortem measures without previous consent, lack of knowledge about DCD, concerns about the Dead Donor Rule, the potential for conflict of interest, making donation happen, and the call for standardized DCD protocols. All of these issues are of ethical relevance and merit further discussion. We conclude that deep-rooted concerns about DCD exist among medical personnel and the general public. These need to be taken seriously in order to maintain or foster trust in the transplantation system.

Controversies in defining and determining death in critical care

Circulatory-respiratory or brain tests are widely accepted for definition and determination of death, but have several controversial issues. Both determinations have been stimulated by organ donation, but must be valid independently of this process. Current controversies in brain death include whether the definition is conceptually coherent, whether the whole-brain or brainstem criterion is correct, whether one neurological examination or two should be required, and when to conduct the examination following therapeutic hypothermia. Controversies about the circulatory determination of death include the minimum duration of asystole that is sufficient for death to be declared, and whether the distinction between permanent and irreversible cessation of circulatory functioning is important. In addition, the goal of organ donation raises issues such as the optimal way to time and conduct the request conversation with family members of the patient, and whether the Dead Donor Rule should be abandoned.

Perceptions of organ donation after circulatory determination of death among critical care physicians and nurses: a national survey

OBJECTIVE

We sought to identify factors related to critical care physicians' and nurses' willingness to help manage potential donors after circulatory determination of death, and to elicit opinions on the presence of role conflict in donors after circulatory determination of death and its impact on end-of-life care.

DESIGN AND SETTING

Randomized trial administered by Web or post of four donors after circulatory determination of death vignettes. Response rates were 31.0% and 44.3%, respectively.

SUBJECTS

Two thousand two hundred and six academic inten-sive care unit physicians and 988 intensive care unit nurses in the United States.

MEASUREMENTS AND MAIN RESULTS

Majorities of intensive care unit physicians (72.5%; 95% confidence interval 69.2-75.9) and nurses (74.3%; 95% confidence interval 70.2-78.5) believed they should help manage potential donors after circulatory determination of death. 14.7% (95% confidence interval 12.0-17.4) of physicians and 14.3% (95% confidence interval 11.0-17.6) of nurses believed that management of donors after circulatory determination of death would create professional role conflicts. 33.8% (95% confidence interval 30.0-37.4) of physicians and 55.1% (95% confidence interval 50.3-59.7) of nurses believed that preserving opportunities for donors after circulatory determination of death could improve end-of-life care. More favorable views of donors after circulatory determination of death were provided by clinicians randomly assigned to vignettes depicting donors with previously denoted preferences for organ donation; similar effects were not introduced by vignettes in which surrogates actively initiated donation discussions.

CONCLUSIONS

These findings suggest that critical care physicians and nurses are generally supportive of managing donors after circulatory determination of death, particularly when patients were registered organ donors. However, minorities of clinicians harbor concerns regarding conflicts of interest, and many are uncertain of the practice's impact on end-of-life care.

Donation after circulatory death

Donation after circulatory death (DCD) describes the retrieval of organs for the purposes of transplantation that follows death confirmed using circulatory criteria. The persisting shortfall in the availability of organs for transplantation has prompted many countries to re-introduce DCD schemes not only for kidney retrieval but increasingly for other organs with a lower tolerance for warm ischaemia such as the liver, pancreas, and lungs. DCD contrasts in many important respects to the current standard model for deceased donation, namely donation after brain death. The challenge in the practice of DCD includes how to identify patients as suitable potential DCD donors, how to support and maintain the trust of bereaved families, and how to manage the consequences of warm ischaemia in a fashion that is professionally, ethically, and legally acceptable. Many of the concerns about the practice of both controlled and uncontrolled DCD are being addressed by increasing professional consensus on the ethical and legal justification for many of the interventions necessary to facilitate DCD. In some countries, DCD after the withdrawal of active treatment accounts for a substantial proportion of deceased organ donors overall. Where this occurs, there is an increased acceptance that organ and tissue donation should be considered a routine part of end-of-life care in both intensive care unit and emergency department.

The case for kidney donation before end-of-life care

Donation after cardiac death (DCD) is associated with many problems, including ischemic injury, high rates of delayed allograft function, and frequent organ discard. Furthermore, many potential DCD donors fail to progress to asystole in a manner that would enable safe organ transplantation and no organs are recovered. DCD protocols are based upon the principle that the donor must be declared dead prior to organ recovery. A new protocol is proposed whereby after a donor family agrees to withdrawal of life-sustaining treatments, premortem nephrectomy is performed in advance of end-of-life management. Since nephrectomy should not cause the donor's death, this approach satisfies the dead donor rule. The donor family's wishes are best met by organ donation, successful outcomes for the recipients, and a dignified death for the deceased. This proposal improves the likelihood of achieving these objectives.

The impact of variation in donation after cardiac death policies among donor hospitals: a regional analysis

The Joint Commission requires all hospitals have a policy regarding donation after cardiac death. To this date however, a quantitative analysis of adult hospital donation after cardiac death (DCD) policies and its impact on transplantation outcomes has not been reported. Specific characteristics for DCD polices were identified from 90 of the 164 (54.9%) hospitals within the New England Organ Bank's donor service area. Forty-five policies (50.0%) allow family members to be present during withdrawal of life-sustaining therapy (WLST) whereas eight (8.9%) prohibit this. Seventeen policies (18.9%) require WLST to occur in the operating room (OR); 20 (22.2%) specify a location outside of the OR. Fifty-six (62.2%) policies fail to state the method of determining death; however, some require arterial line (15 policies, 16.6%) and/or EKG (10 policies, 11.1%). These variables were not associated with organ recovery, utilization or donor ischemia time. Our regional analysis highlights the high degree of variability of hospital DCD policies, which may contribute to misunderstanding and confusion among providers and patients that may influence acceptance of this mode of donation.

Organ donation after circulatory death: vital partnerships

OVERVIEW

The authors present the case of a woman in her mid-50s who sustained extensive brain injury in an accident but wasn't declared brain dead. The case highlights some of the clinical and ethical considerations of organ donation after circulatory death (also known as non-heart-beating donation and donation after cardiac death). It also illustrates the interdisciplinary teamwork necessary for organ donation in such cases, involving nurses and other clinicians in the ICU, palliative care, and the local organ procurement organization, among others.

KEYWORDS

cardiac death, circulatory death, donation after cardiac death, end-of-life care, ethics, non-heart-beating donation, organ donation, organ donation after circulatory death, organ transplantation, palliative care.

Donation after cardiac death: community views about 'decent' intervals

Donation after cardiac death (DCD) offers an alternative pathway to donation for some donors. Successful recovery of organs for transplantation following DCD requires that organ recovery surgery commence as soon as possible after death has occurred. This limits the amount of time that family and friends can spend with the donor prior to surgery. The aim of this study was to identify community views about the timing of organ recovery in DCD. Data were collected from two sources in South Australia: 32 members of the public participated in four focus groups, and 2693 adults participated in a representative population survey. Respondents were asked their views about a decent interval to wait after death prior to organ recovery surgery. Focus group participants identified a tension between preserving organ viability and allowing families time with the deceased. Of the survey respondents, 45.2% selected a timeframe compatible with potentially viable donations; 34.1% selected a timeframe incompatible with viable donations; and 20.8% gave an indeterminate answer. These findings provide information about public perceptions of DCD, can be used to inform educational campaigns about DCD and serve as a baseline for evaluating such campaigns, and identify a number of areas for further investigation.

A hierarchical communication model of the antecedents of health care professionals' support for donations after cardiac death

Using structural equation modeling, the direct and indirect impact of five variables on the support of donation after cardiac death from the perspective of health care professionals were investigated: knowledge, trust in the transplant team, whether patients are in a state of irreversibility, whether health care professionals participate in a patient's death, and perceptions about the brain death versus cardiac death donation process. In total, 10/15 relationships posited in the model had significant pathways. The results provide insight into sequential communication strategies for generating support for donations after cardiac death.

The impact of country and culture on end-of-life care for injured patients: results from an international survey

BACKGROUND

Up to 20% of all trauma patients admitted to an intensive care unit die from their injuries. End-of-life decision making is a variable process that involves prognosis, predicted functional outcomes, personal beliefs, institutional resources, societal norms, and clinician experience. The goal of this study was to better understand end-of-life processes after major injury by comparing clinician viewpoints from various countries and cultures.

METHODS

A clinician-based, 38-question international survey was used to characterize the impacts of medical, religious, social, and system factors on end-of-life care after trauma.

RESULTS

A total of 419 clinicians from the United States (49%), Canada (19%), South Africa (11%), Europe (9%), Asia (8%), and Australasia (4%) completed the survey. In America, the admitting surgeon guided most end-of-life decisions (51%), when compared with all other countries (0-27%). The practice structure of American respondents also varied from other regions. Formal medical futility laws are rarely available (14-38%). Ethical consultation services are often accessible (29-98%), but rarely used (0-29%), and typically unhelpful (<30%). End-of-life decision making for patients with traumatic brain injuries varied extensively across regions with regard to the impact of patient age, Glasgow Coma Scale score, and clinician philosophy. Similar differences were observed for spinal cord injuries (age and functional level). The availability and use of "donation after cardiac death" also varied substantially between countries.

CONCLUSIONS

In this unique study, geographic differences in religion, practice composition, decision-maker viewpoint, and institutional resources resulted in significant variation in end-of-life care after injury. These disparities reflect competing concepts (patient autonomy, distributive justice, and religion).

Family initiated discussions about organ donation at the time of death

Some family members initiate organ donation discussions before being approached by donor coordinators or healthcare providers. We examined differences between families that did vs. did not initiate organ donation discussions and factors predicting donation consent among those families that self-initiated the discussion. Next-of-kin of donor-eligible individuals (147 donors, 138 non-donors) from one organ procurement organization completed a telephone interview. Seventy-three families (25.6%) first mentioned organ donation, and 54 (74%) of them consented to donation. Several characteristics of the deceased and next-of-kin were associated with whether family members initiated the donation discussion with donation coordinators or healthcare providers. Moreover, family mention of donation was more likely to yield consent when the deceased was younger (OR=0.95, CI=0.92-0.99), next-of-kin was a registered donor (OR=3.86, CI=2.84-6.76), and when family was more satisfied with the healthcare team (OR=1.20, CI=1.04-1.39). Knowing the deceased's donation intentions and being exposed to positive organ donation messages are more likely to trigger families to raise donation with providers. Organ procurement organizations (OPOs) and healthcare providers should work collaboratively to develop strategies for how best to respond to families who initiate this conversation.

Families' reflections on the process of brain donation following coronial autopsy

This study aims to explore families' reflections on their decision to donate brain tissue to the NSW Tissue Resource Centre (NSW TRC), Australia. Specifically, the study aims to investigate respondents' initial reactions to the request for donation, primary reasons for their decision, and subsequent satisfaction levels. Participants were next-of-kin (NOK) contacted between May 2002 and May 2008, on the day of their relative's autopsy, who agreed to donate brain tissue to the NSW TRC for medical research. All 111 NOK were invited to participate, and those who agreed completed an anonymous questionnaire. Fifty completed questionnaires were received. Results showed that 74% of respondents were not upset by the donation call and 98% were satisfied with their decision to donate. Of the 22% who reported having been upset, many indicated that their distress was partly related to their circumstances. When asked the main reason for their donation, 66% had wanted to help others, or help research, while 24% stated their primary reason as a belief that they were respecting the wishes of their deceased relative. These findings show that NOK are not further distressed by being asked to donate brain tissue, give altruistic reasons for consent and are satisfied with the decision they made. In both this study and previous literature, the importance of discussion about organ donation amongst relatives is a recurring theme. Knowledge about a relative's wishes is likely to help facilitate decision-making, overcoming at least one crucial barrier to lifting rates of organ donation for transplantation and research.

Ethical controversies at end of life after traumatic brain injury: defining death and organ donation

Death is more than a mere biological occurrence. It has important legal, medical, and social ramifications that make it imperative that those who are responsible for determination of death be accurate and above suspicion. The medical and legal definitions of death have evolved to include consideration of such concepts as loss of integration of the whole organism, loss of autonomy, and loss of personhood. Development of the concept of brain death coincided with advances in medical technology that facilitated artificial ventilation and organ transplantation. More recently, the process of "timed" death with subsequent organ donation (controlled donation after cardiac death transplantation) has raised controversial questions having to do with the limits of treatments that facilitate organ transplant but might hasten death, and the duration of cardiac arrest necessary for declaration of death and the commencement of organ procurement. In this review, we discuss the background and ethical ramifications of the concepts of brain death, and of controversies involved in controlled donation after cardiac death organ transplantation.

Scientific, legal, and ethical challenges of end-of-life organ procurement in emergency medicine

AIM

We review (1) scientific evidence questioning the validity of declaring death and procuring organs in heart-beating (i.e., neurological standard of death) and non-heart-beating (i.e., circulatory-respiratory standard of death) donation; (2) consequences of collaborative programs realigning hospital policies to maximize access of procurement coordinators to critically and terminally ill patients as potential donors on arrival in emergency departments; and (3) ethical and legal ramifications of current practices of organ procurement on patients and their families.

DATA SOURCES

Relevant publications in peer-reviewed journals and government websites.

RESULTS

Scientific evidence undermines the biological criteria of death that underpin the definition of death in heart-beating (i.e., neurological standard) and non-heart-beating (i.e., circulatory-respiratory standard) donation. Philosophical reinterpretation of the neurological and circulatory-respiratory standards in the death statute, to avoid the appearance of organ procurement as an active life-ending intervention, lacks public and medical consensus. Collaborative programs bundle procurement coordinators together with hospital staff for a team-huddle and implement a quality improvement tool for a Rapid Assessment of Hospital Procurement Barriers in Donation. Procurement coordinators have access to critically ill patients during the course of medical treatment with no donation consent and with family or surrogates unaware of their roles. How these programs affect the medical care of these patients has not been studied.

CONCLUSIONS

Policies enforcing end-of-life organ procurement can have unintended consequences: (1) erosion of care in the patient's best interests, (2) lack of transparency, and (3) ethical and legal ramifications of flawed standards of declaring death.