Potential yield of imminent death kidney donation

Moral Injury Among Transplant Providers: Evaluating the Effects of Training in End-of-Life Counseling

Introduction

Ethical issues are pervasive in healthcare, but few specialties rival the moral complexity of transplant medicine. Transplant providers must regularly inform patients that they are no longer eligible to receive a potentially life-saving operation and the stress of these conversations poses a high risk of moral injury. Training in end-of-life counseling (EOLC) has proven to significantly reduce provider stress and burnout. The purpose of this study was to determine whether training in EOLC reduces levels of moral injury among transplant providers.

Methods

This was a mixed methods study. We interviewed 10 patient participants and administered a survey to staff in the solid organ transplant department at the University of Kansas Health System. Respondents indicated whether they had received training in EOLC and completed the standardized Moral Injury Symptom Scale-Healthcare Professionals version (MISS-HP). A two-sample, one-sided t-test compared levels of moral injury between trained and untrained staff. Subsequently, we conducted semi-structured interviews with transplant providers, then performed inductive coding followed by thematic network analysis.

Results

Thirty-seven percent (14/38) of respondents reported a moral injury score at or above the threshold for psychosocial dysfunction associated with moral injury. Analysis revealed no difference in moral injury scores between the trained and untrained groups (p = 0.362, power (1-β) = 0.842). Thematic network analysis demonstrated high-level themes of "challenges", "training", and "stress relief".

Conclusions

Our study demonstrated a concerning prevalence of moral injury among transplant staff and suggested that EOLC training did not significantly mitigate the threat of moral injury.

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.

Living Donation by Individuals with Life-Limiting Conditions

The traditional living donor was very healthy. However, as the supply-demand gap continues to expand, transplant programs have become more accepting of less healthy donors. This paper focuses on the other extreme, asking whether and when individuals who have life-limiting conditions (LLC) should be considered for living organ donation. We discuss ethical issues raised by 1) donation by individuals with progressive severe debilitating disease for whom there is no ameliorative therapy; and 2) donation by individuals who are imminently dying or would die by the donation process itself.