Why relatives do not donate organs for transplants: 'sacrifice' or 'gift of life'?

Do ethical views of end-of-life patients' family members impact organ donation decisions?

Background: The relatives of patients who decide to donate their loved one's organs experience dilemmas about organ donation and are affected by culture, religion, and individual views.Aim: The aim of this study was to determine the relationship between the ethical position and personal characteristics of the family members of the patients receiving end-of-life care and their thoughts about organ donation in Turkey.Research design and participants: The study was completed with 158 family members. For data collection, a personal information form and the Ethics Position Questionnaire were used.Ethical considerations: This study was obtained from the ethics committee of the faculty of medicine in Turkey. It was based on voluntary participation, informed consent, confidentiality, and anonymity.Results: All participants in the study shared the same faith and were Muslims. The idealism and relativism tendencies of the participants tended to be high. The number of children, the participants have, participants' status of waiting for an organ transplant, the view that the clergy and health personnel will increase interest in organ donation were identified as factors associated with idealism tendencies. Participants' status of having children, the number of children participants have, participants' status of organ transplant waiting, the view that the health personnel will increase interest in organ donation were identified as factors associated with relativism tendencies (p < 0.0.5).Conclusion: The results of this study demonstrated a relationship between participants' idealism and relativism tendencies, among those with a large number of children, waiting for organ donation, advocating for clergy guidance to increase organ donations, and believing healthcare professionals need not guide to increase organ donations. In light of this finding, it may be recommended to establish a multidisciplinary team, including healthcare professionals and clergy, and to inform the society with accurate information to increase the number of organ donations.

What determinants impact deceased organ donation consent in the adult intensive care unit? An integrative review exploring the perspectives of staff and families

BACKGROUND

Deceased organ donation saves lives. Donation processes in New Zealand operate under an opt-in system, which requires consent from families of patients diagnosed with brain death or circulatory death while in the intensivecare unit. The donation demand and supply mismatch is a global phenomenon.

OBJECTIVES

The objective of this study was to understand the determinants of deceased organ donation decisions in the adult intensive care setting from the perspectives of staff and families.

METHODS

An integrative review based on Whittemore and Knafl's approach searched literature through databases CINAHL Plus, SCOPUS, Proquest Medline Ovid, and manual ancestry searches. Inclusion/exclusion criteria screened for pertinent literature, which were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Selected studies were appraised using a generic scoring tool, and data were systematically extracted and coded onto spreadsheets using inductive, thematic analysis.

RESULTS

A total of 21 studies (12 qualitative, seven quantitative, two mixed methods) were included. Publication dates ranged from 1993 to 2021 from multiple countries (18 opt-in, three opt-out systems). Four overarching themes pertaining to families and staff were generated. Important knowledge related to families' knowledge deficits around brain death, the purpose of ventilation, donation procedures, patients' wishes, and staffs' lack of training. Challenging communication highlighted miscommunications due to language choices and interrupted continuity of care during staff-family interactions. Internal determinants explored the cultural, spiritual, and emotional perspectives of families, while staff faced a sense of burden and conflicting values in delivering care between donors and recipients. External determinants related to the clinical environment impacting on grieving families, while for the staff, it explained concerns around resources and organisational processes.

CONCLUSIONS

Factors underpinning deceased organ donation are multifaceted and complex. Staff actions and families' decisions are inextricably intertwined. Modifiable factors include a lack of formal training and communicational skills and environmental limitations of an intensive care setting.

Death determination by neurologic criteria-what do families understand?

PURPOSE

Currently, there is little empirical data on family understanding about brain death and death determination. The purpose of this study was to describe family members' (FMs') understanding of brain death and the process of determining death in the context of organ donation in Canadian intensive care units (ICUs).

METHODS

We conducted a qualitative study using semistructured, in-depth interviews with FMs who were asked to make an organ donation decision on behalf of adult or pediatric patients with death determination by neurologic criteria (DNC) in Canadian ICUs.

RESULTS

From interviews with 179 FMs, six main themes emerged: 1) state of mind, 2) communication, 3) DNC may be counterintuitive, 4) preparation for the DNC clinical assessment, 5) DNC clinical assessment, and 6) time of death. Recommendations on how clinicians can help FMs to understand and accept DNC through communication at key moments were described including preparing FMs for death determination, allowing FMs to be present, and explaining the legal time of death, combined with multimodal strategies. For many FMs, understanding of DNC unfolded over time, facilitated with repeated encounters and explanation, rather than during a single meeting.

CONCLUSION

Family members' understanding of brain death and death determination represented a journey that they reported in sequential meeting with health care providers, most notably physicians. Modifiable factors to improve communication and bereavement outcomes during DNC include attention to the state of mind of the family, pacing and repeating discussions according to families' expressed understanding, and preparing and inviting families to be present for the clinical determination including apnea testing. We have provided family-generated recommendations that are pragmatic and can be easily implemented.

Gift Discourse in Transplant and Its Implications in Anonymous Living Liver Donation

The Gift of Life metaphor is prevalent in pro-donation dialogue, aiming to promote transplant programs and conceptualize the act of organ donation. To obtain a better understanding of living donor perceptions on the term Gift of Life, we analyzed thematic views presented by anonymous living donors (ALLDs). Twenty-six ALLDs completed a semi-structured qualitative interview consisting of questions regarding their motivations, experiences, and perceptions on donation. The following 5 major themes relating to the Gift of Life terminology were elucidated: (1) Complete agreement with the term and its relevance to donation. (2) Their donation did not represent a Gift of Life. (3) The term was too grandiose. (4)A belief that the term has more meaning for the recipient rather than donor. (5 )That the "gift" goes both ways, with the donor also benefiting from the experience.

Excavating the social representations and perceived barriers of organ donation in China over the past decade: A hybrid text analysis approach

Background

Organ donation has been claimed as a prosocial behavior to prolong the recipient's life and deliver great love. However, the supply-demand ratio of organs in China is highly unbalanced. Being entangled with multiple factors derived from individual and supra-individual levels, organ donation in China is important but sensitive. Previous scholars usually depended on obtrusive approaches to explore the facilitators and hindrances of organ donation, which is hard to discover genuine perceptions toward organ donation. Besides, relatively limited scholarly attention has been paid to what hampers organ donation in China.

Objective

We intended to excavate the diversified social representations and perceived barriers to organ donation in China over the past decade.

Method

Two kinds of text analysis methods-semantic network analysis and conventional content analysis, were applied to 120,172 posts from ordinary users on the Sina Weibo platform to address the research questions.

Results

Regarding social representations, the "hope, understanding, and acceptance" of organ donation was the most pronounced one (34% of the whole semantic network), followed by "family story" (26%), "the procedure of organ donation in NGOs" (15%), "the practical value of organ donation" (14%), and "organ donation in the medical context" (11%). Regarding perceived barriers, a four-layer framework was constructed, including (1) the individual level, mainly about the fear of death and postmortem autopsy; (2) the familial level, which refers to the opposition from family members; (3) the societal level, which alludes to distrust toward medical institutions and the general society; (4) the cultural level, which covers religious-cultural concerns about fatalism.

Conclusion

In concordance with prior works on social representations regarding organ donation, the current study also uncovered the coexistence of antithetical representations about organ donation-the longing for survival and the fear of death. This representation pair serves as the foundation of Chinese people's ambivalence. Besides, family-related narratives were dispersed over various representations, demonstrating the critical position of family support in organ donation. Moreover, the four-layer framework concerning donation barriers affords a reference for future empirical studies. The practical implications of this work are further discussed.

Effekte des Organspendeskandals 2012 auf die Gewebespende am Institut für Rechtsmedizin München

Hintergrund

Der Organspendeskandal (OSS) 2012 führte zu einem dramatischen Einbruch der Spendebereitschaft. Im Zeitraum nach dem OSS verantwortete die Rechtsmedizin München 2013–2015 mit 51 muskuloskeletalen, 145 Cornea- und 38 Herzklappenentnahmen zahlreiche Gewebespenden im süddeutschen Raum.

Fragestellung

Die Ziele dieser Studie waren die Bestimmung des Einflusses des OSS auf die Gewebespende sowie die Auswirkung des ärztlichen Aufklärungsgespräches auf das Entscheidungsverhalten der Angehörigen.

Material und Methoden

Die Protokolle der Aufklärungsgespräche mit den Angehörigen im Zeitraum von Juli 2012 bis Dezember 2015 wurden auf Diskussionen, Erwähnungen sowie Entscheidungsverhalten im Zusammenhang mit dem OSS evaluiert. Zudem erfolgte im Jahresabstand nach der Spende eine retrospektive Evaluation des Aufklärungsgespräches durch die Angehörigen anhand eines Fragenkatalogs mit 9 Items.

Ergebnisse

Bei 388 potenziellen Spendern lag die Zustimmung bei 54,9 %. In 40 Fällen war der OSS Diskussionspunkt und resultierte in 15 Fällen in Ablehnung. Davon wurde in 6 Fällen ein Spendeausweis zuvor vom Verstorbenen aufgrund des OSS vernichtet, wobei in 4 Fällen nach Diskussion mit den Angehörigen eine Zustimmung erreicht wurde. Insgesamt bewerteten 142 Angehörige das Aufklärungsgespräch als positiv und die Spende als sinnstiftend. Die Entscheidungen waren zu 100 % stabil.

Diskussion

Die guten Resultate der Evaluation sowie der dieses Spendeprojekt nur gering beeinflussende OSS beruhen vor allem auf der mit Empathie und Erfahrung durchgeführten Aufklärung. Zum Vertrauensaufbau der Bevölkerung benötigt es ärztlicherseits ein aktives Informationsangebot und lückenlose Transparenz.

Collaboration between the intensive care unit and organ donation agency to achieve routine consideration of organ donation and comprehensive bereavement follow-up: an improvement project in a quaternary Australian hospital

Objective Routine family follow-up after bereavement in the intensive care unit (ICU) and routine consideration of organ and tissue donation at end of life are both integral to good health care delivery, yet neither is widely achieved. This study evaluated an initiative to efficiently deliver these outcomes in an Australian setting through a novel collaboration between DonateLife South Australia (DLSA) and the ICU of the Royal Adelaide Hospital. Methods A Plan-Do-Study-Act method of quality improvement was used in the Royal Adelaide Hospital ICU between February 2018 and February 2019. The ICU clinical team identified adult patients and family members at medical consensus of end of life to donation specialist nursing coordinators, who assessed potential for donation and enrolled patients and family members into a bereavement follow-up program. After death, family members received bereavement information and details of a structured telephone follow-up conversation that took place 6-8 weeks later. Results Of 241 deaths, 216 were enrolled in the project. Follow-up telephone calls were completed with 124 of 201 (62%) family members, with 77 (38%) family members not contactable. Follow-up telephone interviews yielded practical suggestions to improve end-of-life care. Donation was considered in all patients enrolled in the project, and referral through DLSA increased from 24% to 90% of all ICU deaths. Associated with the collaborative initiative, consent to organ donation recorded a 63% increase on the 10-year average (from 19 to 31 donors). Corneal donation referral increased by 625%. The initiative required an additional 0.4 full-time equivalent registered nurse. Family members valued the opportunity to debrief their experience. Conclusions Collaboration between DLSA and the Royal Adelaide Hospital ICU achieved universal consideration of organ donation and high rates of structured bereavement follow-up. Follow-up calls were valued with areas for improvement identified. What is known about this topic? Death in the ICU is associated with significant psychopathology among bereaved family members, and bereavement follow-up is widely recommended. Opportunities to consider organ and tissue donation are commonly missed due to lack of consideration at end of life. What does this paper add? Collaboratively exploring donation and performing bereavement follow-up is feasible with a minimal added resource. Such comprehensive approach to good end-of-life care helps identify aspects of care that could be improved and is associated with an increase in organ and tissue donation rates. What are the implications for practitioners? Collaboration between the ICU and DonateLife achieved mutually beneficial outcomes of understanding the end-of-life experience for family members and timely consideration of organ and tissue donation. This timely consideration potentially identified some missed organ donors and then allowed family members to give feedback on their experience.

Requests for somatic support after neurologic death determination: Canadian physician experiences

PURPOSE

Neurologic determination of death (NDD) is legally accepted as death in Canada but remains susceptible to misunderstandings. In some cases, families request continued organ support after NDD. Conflicts can escalate to formal legal challenges, causing emotional, financial, and moral distress for all involved. We describe prevalence, characteristics, and common experiences with requests for continued organ support following NDD in Canada.

METHODS

Mixed-methods design combining anonymous online survey with semi-structured interviews of Canadian critical care physicians (448 practitioners, adult and pediatric).

RESULTS

One hundred and six physicians responded to the survey and 12 participated in an interview. Fifty-two percent (55/106) of respondents had encountered a request for continued organ support after NDD within two years, 47% (26/55) of which involved threat of legal action. Requests for continued support following NDD ranged from appeals for time for family to gather before ventilator removal to disagreement with the concept of NDD. Common responses to requests included: consultation with an additional physician (54%), consultation with spiritual services (41%), and delay of one to three days for NDD acceptance (49%). Respondents with prior experience were less likely to recommend ancillary tests (P = 0.004) or consultation with bioethics services (P = 0.004). Qualitative analysis revealed perceptions that requests for continued organ support were driven by mistrust, tensions surrounding decision-making, and cultural differences rather than a lack of specific information about NDD.

CONCLUSIONS

Family requests for continued somatic support following NDD were encountered by half our sample of Canadian critical care physicians. Mitigation strategies require attention to the multifaceted social contexts surrounding these complex scenarios.

Opt-out policy and the organ shortage problem: Critical insights and practical considerations

The legal shift to an opt-out system of consent for deceased organ donation is now official in England, Wales and Scotland. While it is commendable that national governments across the United Kingdom have publicly signalled their serious engagement with organ donation, it remains questionable that opt-out policy can in and of itself solve the public health issue of organ shortage. Opt-out policy risks becoming a futile solution if it fails to attend to key factors in clinical practice. Thus, this article provides critical insights and practical considerations in order to work towards increasing the availability of organs for transplantation: 1) organ donation specialists on their own are not enough, a collaborative hospital culture of donation is also needed; 2) investment in innovative perfusion technologies is fundamental to increase both the quantity and quality of organs utilised for transplants; and 3) opt-out does not solve the enduring problem of consent or authorization for donation, rather than hoping that opt-out will shift the societal culture of donation and make donation the default choice, it is necessary to acknowledge that families' authorization remains essential and their emotional experience can neither be minimized nor excluded altogether. Importantly, consent rates are not the only factor to account for overall deceased donation rates. The organ shortage cannot be solely attributed to a matter of negative public attitudes reversible by law. Doing that does a disservice to the public and diverts strategic attention and resources from fostering the organizational and technological enablers of organ donation in clinical practice.

Assembling organ donation: situating organ donation in hospital practice

In this article I argue for the need to situate deceased organ donation in and as a hospital practice. This study puts the spotlight on the practical conditions that enable and emplace organ donation in the hospital setting. The analytical move serves the political purpose to inform and interrogate dominant policy framings intended to address the problem of organ shortage. I present an ethnographic investigation that draws upon a Science and Technology Studies (STS) approach to make visible the sociomaterial arrangements that bring together people, things and politics in the assembling of organ donation at a Catalan hospital. A progressive and indeterminate process which might fall through and become disassembled at any given time. This, as I explain, challenges current opt-out policy that unnecessarily reduces donation to an individual choice to be decided upon in life. Instead, and drawing on ethnographic materials, I propose a situated and relational understanding of organ donation: an embedded health care and procurement practice enacted as a collective accomplishment. I conclude that (more) responsible donation policies need to be informed by, and attuned to, the situated practicalities and enduring tensions that condition and constrain the assembling of organ donation at the hospital setting.

The obstacles to organ donation following brain death in Iran: a qualitative study

Background

Organ donation following brain death has become an important way of supplying organs for transplantation in many countries. This practice is less common in Iran for different reasons. Therefore, this study aims to explore the obstacles to organ donation following brain death in Iran.

Methods

This qualitative research was conducted following the conventional content analysis method. The study population consisted of individuals with a history of brain death among their blood relatives who refused to donate the organs. Snowball sampling was employed to select the participants. In-depth semi-structured interviews were conducted for data gathering. Theoretical saturation was achieved through 20 interviews. Data analysis was done following the steps proposed by Graneheim and Lundman. Lincoln and Guba’s criteria were used to ensure data rigor and transferability of the study.

Results

Data analyses revealed 185 codes, 23 categories, and seven themes including, poor knowledge about brain death and organ transplantation from a dead body, cultural beliefs, religious beliefs, deficiencies of requesting process, fear and concerns, inability to make a decision, and social learning.

Conclusion

There were several factors in families’ reluctance to donate organs of a brain-dead patient. Through improving knowledge and changing cultural beliefs in society, it is possible to take large steps towards promoting organ donation from brain-dead patients.

Preliminary Development of a Postmortem Bodily Integrity Concerns Scale Among the University Students in Hong Kong

The idea of keeping a body intact has been a major barrier that hinders people from making decision for posthumous organ donation or making consent for their deceased family member. The present research thus attempted to bridge the knowledge gap by conducting an exploratory study to identify the underlying beliefs, and a preliminary validation study to confirm the scale developed thereof. Nineteen university students participated in 5 semistructured focus groups; 115 participated in the exploratory factor analysis, while 96 in the confirmatory factor analysis. An 18-item scale, the Postmortem Bodily Integrity Concerns Scale was developed with 4 subscales: Filial Piety Beliefs, Worries of Organ Removal, Postmortem Mutilation Anxiety, and Detachment to Death. The corresponding measures were established and validated with acceptable psychometric properties and a model of good fit. The findings provided implications for the policymakers to devise plans in dealing with the postmortem bodily integrity issue.

Exploring the impact of terminology differences in blood and organ donor decision making

Because the global shortage of blood and organ donors across all medical markets is a serious concern for health care provision, we aim in this study to better understand decisions (not) to participate in these two forms of medical donation, which can save or prolong another's life. Using unique responses from over 1,000 online survey respondents, we compare the reasons given for the donation decision given by blood and/or registered organ donors versus non-donors. To do so, we categorize responses based on five dimensions of language choice: egocentric (referring to self), social, moral, positively emotional, and negatively emotional. Our results reveal statistically significant differences between blood donors and non-donors in the use of all five categories. With respect to organ donation, we find statistically significant differences between donors and non-donors in the use of social, moral and positive emotional terms but not in the use of egocentric or negatively emotional justifications. Such results suggest that the 'gift of life' terminology used universally to market to potential blood and organ donors may only be relevant in the blood donation market and unlikely to incentivize or change organ donation behaviour.

Grief, Stress, Trauma, and Support During the Organ Donation Process

The organ donation process is complex and stressful for the family of the potential donor and members of the multidisciplinary team who may experience grief, ethical dilemmas, vicarious trauma, or compassion fatigue. Several studies each explore the role of a specific healthcare group and the impact of inhospital processes on group members. We conducted a systematic literature search to identify such studies and a qualitative synthesis to consolidate findings and highlight features of the interaction and relationships between role players. Our results suggest that, while healthcare professionals have different roles, attitudes, and views, the experience of stressors and interdisciplinary tension is common. Nevertheless, staff are united by the goal of caring for the patient and family. We therefore propose that, while focusing on bereavement care and other aspects of the family's experience, staff can find other shared goals and develop understanding, trust, empathy, and respect for each other's positions, thereby improving functioning in the complex adaptive system that forms at this time. Education and training can equip staff to facilitate anticipatory mourning, family-led activities, and a meaningful parting from their relative, assisting families with their grief and increasing staff members' efficacy, confidence, and interdisciplinary teamwork. Knowledge of systems thinking and opportunities to share ideas and experiences will enable staff to appreciate each other's roles, while supportive mentors, self-care strategies, and meaningful feedback between role players will foster healthy adjustment and shared learning. A focus on psychosocial outcomes such as family satisfaction with the process, collaboration within the multidisciplinary team, and reduction in the role stress of healthcare professionals will contribute to family well-being as well as personal and professional growth for staff.

Body Perception and Organ Donation: Bereaved Parents' Perspectives

The view of the body in sociological, psychological, and gender studies may be broadly summarized to three metaphors: (a) the body as a machine, (b) the body as Self, and (c) the body as sacred and sanctified entity. Each of these philosophical views has an impact on organ donation. The current study aimed at revealing body perception of bereaved Israeli parents who agreed to donate organs of their deceased child. A deductive and inductive thematic analysis captured an ongoing perceptual change that bereaved donor parents experienced in their view of the child's body. Parents' ability to move between two positions (the body as Self, the body as a machine) allowed them to agree with and protect their decision to donate as well as to maintain an ongoing bond with their deceased child. The view of the body as scared entity was not evident in the bereaved parents' narratives.

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

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

Perioperative nurses' experiences of caring for donation after cardiac death organ donors and their family within the operating room

Background

Worldwide, operating rooms have seen the re-emergence of donation after cardiac death organ donors to increase the number of available organs. There is limited information on the issues perioperative nurses encounter when caring for donor patients after cardiac death who proceed to organ procurement surgery.

Objectives

The purpose of this paper is to report a subset of findings derived from a larger study highlighting the difficulties experienced by perioperative nurses when encountering donation after cardiac death organ donors and their family within the operating room during organ procurement surgery from an Australian perspective.

Methods

A qualitative grounded theory method was used to explore perioperative nurses’ (n = 35) experiences of participating in multi-organ procurement surgery.

Results

This paper reports a subset of findings of the perioperative nurses’ experiences directly related to donation after cardiac death procedures drawn from a larger grounded theory study. Participants revealed four aspects conceptualised as: ‘witnessing the death of the donation after cardiac death donor’; ‘exposure to family’; ‘witnessing family grief’ and ‘stepping into the family’s role by default’.

Conclusion

Perioperative nurses’ experiences with donation after cardiac death procedures are complex, challenging and demanding. Targeted support, education and training will enhance the perioperative nurses’ capabilities and experiences of caring for the donation after cardiac death donor and their family with the operating room context.

Stressors experienced by the family members of brain-dead people during the process of organ donation: A qualitative study

More is known about organ donor recipients than donor families. We explored the stressors experienced by family members of brain-dead people during the process of organ donation. Seventeen family members and five organ procurers were interviewed and the data analyzed through conventional qualitative content analysis. Stressors experienced by family members fell into six themes-perceived threat of loss, decision making under conflict, painful corrosive farewell, feeling of insecurity, complexity of grief, and seeking relief. Findings highlight the necessity of developing and using standard protocols for supporting brain-dead people's family members throughout the process of organ donation and following bereavement.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Restless Feelings: Desiring Direct Contact After Postmortem Organ Donation

This article investigates the emergence of a growing demand in the Netherlands: the wish of organ donor families and organ recipients to establish contact. Such direct contact transgresses both the anonymity and privacy long considered by many to be fundamental to organ donation. Legislation prescribes that privacy should be safeguarded, but the parties involved increasingly manage to find each other. Research is needed to provide insight into the ramifications of direct contact, which may inform mourning counseling and psychosocial support. Drawing on qualitative interviews with donor's relatives, we analyze the reasons for the desire to have direct contact. We seek to understand how meanings are constructed and contested through organs at the margins of life and death in the individualized and secularized society of the Netherlands. We find that relatives struggle with persistent restless feelings after postmortem organ donation and may develop a level of personal attachment and assign inalienability to human body parts.

What factors influence a family's decision to agree to organ donation? A critical literature review

Background:There is a shortage of organs for transplantation in the UK. However, whilst 82% of the population consider donating their organs, only 35% of people have joined the NHS Organ Donor Register. Although the Human Tissue Acts (2004, 2006) and Human Transplantation (Wales) Act (2013) state that the wishes of the deceased cannot be vetoed, it is unlikely that healthcare teams will continue with the retrieval process without the family's agreement to proceed.Aim:To understand what influences the decision of families to donate in order to guide clinical practice, education, training and increase donation rates to 80% in line with the NHS Blood and Transplant - Taking Organ Donation to 2020 strategy. Method: A literature review of published research. Results: Seven papers met the inclusion criteria. Several significant factors were identified that influence family decisions, including prior knowledge of the deceased's wishes (e.g. carrying a donor card), presence at the time of the donor's injury, understanding of brain stem death testing, 'personal realisation' of death and hospital related factors (e.g. information, communication and care). These were organised to form the acronym DONATE that serves as a useful mnemonic to guide the requester prior to discussing organ donation. Conclusions: Rates of donation of organ donation may increase through understanding family decision-making.

Generosity and compliance: Recruitment-work and the pathways to participation in bone marrow donation

This study examines challenges involved in recruiting bone marrow donors. Data comes from participant observation with a recruitment organization in the United States. Findings reveal that recruiters try to express bone marrow donation with common "gift of life" messaging, which emphasizes a singular event involving generosity. Potential recruits, however, respond by focusing on pain and time commitments. These concerns draw attention to the many stages and requirements involved in bone marrow donation and make issues of compliance salient. The juxtaposition of generosity and compliance creates practical difficulties for recruiters. The study contributes to existing literature, by illustrating how logistics shape altruism and gift arrangements involved in medical donation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Increasing organ donation rates by revealing recipient details to families of potential donors

Many families refuse to consent to donation from their deceased relatives or over-rule the consent given before death by the patient, but giving families more information about the potential recipients of organs could reduce refusal rates. In this paper, we analyse arguments for and against doing so, and conclude that this strategy should be attempted. While it would be impractical and possibly unethical to give details of actual potential recipients, generic, realistic information about the people who could benefit from organs should be provided to families before they make a decision about donation or attempt to over-rule it.

Bereaved donor families' experiences of organ and tissue donation, and perceived influences on their decision making

PURPOSE

To elicit bereaved families' experiences of organ and tissue donation. A specific objective was to determine families' perceptions of how their experiences influenced donation decision-making.

METHODS

Retrospective, qualitative interviews were undertaken with 43 participants of 31 donor families to generate rich, informative data. Participant recruitment was via 10 National Health Service Trusts, representative of five regional organ donation services in the UK. Twelve families agreed to DBD, 18 agreed to DCD, 1 unknown. Participants' responses were contextualised using a temporal framework of 'The Past', which represented families' prior knowledge, experience, attitudes, beliefs, and intentions toward organ donation; 'The Present', which incorporated the moment in time when families experienced the potential for donation; and 'The Future', which corresponded to expectations and outcomes arising from the donation decision.

RESULTS

Temporally interwoven experiences appeared to influence families' decisions to donate the organs of their deceased relative for transplantation.

CONCLUSIONS

The influence of temporality on donation-decision making is worthy of consideration in the planning of future education, policy, practice, and research for improved rates of family consent to donation.

A novel approach to studying co-evolution of understanding and research: Family bereavement and the potential for organ donation as a case study

A novel approach to data extraction and synthesis was used to explore the connections between research priorities, understanding and practice improvement associated with family bereavement in the context of the potential for organ donation. Conducting the review as a qualitative longitudinal study highlighted changes over time, and extraction of citation-related data facilitated an analysis of the interaction in this field. It was found that lack of 'communication' between researchers contributes to information being 'lost' and then later 'rediscovered'. It is recommended that researchers should plan early for dissemination and practice improvement to ensure that research contributes to change.

An exploration of the relationship between families of deceased organ donors and transplant recipients: A systematic review and qualitative synthesis

Following deceased organ donation and transplantation, the narratives of families of donors and organ recipients become connected. This is acknowledged when parties receive anonymous information from donation agencies and transplant centres, when they exchange correspondence or when they meet in person. This article reviews literature describing the experience from the points of view of donor families, recipients, and other stakeholders to explore the dynamic system that evolves around this relationship. Findings highlight a link between identity development and ongoing adjustment and will assist those supporting donor families and recipients to make decisions that fit meaningfully.

The development of a narrative describing the bereavement of families of potential organ donors: A systematic review

Families of potential post-mortem organ donors face various challenges in the unfamiliar hospital context and after returning home. This review of sources published between 1968 and 2017 seeks to understand their journey as a bereavement experience with a number of unique features. Grief theory was used to identify ways that staff can assist family members to tolerate ambiguities and vulnerabilities while contributing to an environment characterised by compassion and social inclusion. Staff can guide families and create opportunities for meaningful participation, building resilience and developing bereavement-related skills that could assist them in the months that follow.

Family attitudes, actions, decisions and experiences following implementation of deemed consent and the Human Transplantation (Wales) Act 2013: mixed-method study protocol

INTRODUCTION

The Human Transplantation (Wales) Act 2013 (the Act) introduced a 'soft opt-out' system of organ donation on 1 December 2015. Citizens are encouraged to make their organ donation decision known during their lifetime. In order to work, the Act and media campaign need to create a context, whereby organ donation becomes the norm, and create a mechanism for people to behave as intended (formally register their decision; consider appointing a representative; convey their donation decision to their families and friends or do nothing-deemed consent). In addition, family members/appointed representatives need to be able to put their own views aside to support the decision of their loved one. The aim of this study is to evaluate initial implementation, outcomes and impact on families and appointed representatives who were approached about organ donation during the first 18 months.

METHODS AND ANALYSIS

Prospective mixed-method coproductive study undertaken with National Health Service Blood and Transplant (NHSBT), and multiple patient/public representatives. The study is designed to collect information on all cases who meet specified criteria (≥18 years, deceased person voluntarily resident in Wales and died in Wales or England) whose family were approached between 1 December 2015 and 31 June 2017). Data for analysis include: NHSBT routinely collected anonymised audit data on all cases; Specialist Nurse in Organ Donation (SNOD) completed anonymised form for all cases documenting their perception of the families' understanding of the Act, media campaign and outcome of the donation approach; questionnaires and depth interviews with any family member or appointed representative (minimum 50 cases). Additional focus groups and interviews with SNODs. Anonymised donation outcomes and registration activity reports for Wales provide additional context.

ETHICS AND DISSEMINATION

Approved by NHSBT Research, Innovation and Technology Advisory Group on 23 October 2015; Wales Research Ethics Committee 5 (IRAS190066; Rec Reference 15/WA/0414) on 25 November 2015 and NHSBT R&D Committee (NHSBT ID: AP-15-02) on 24 November 2015.

REGISTRATION

The protocol is registered on the Health and Care Research Wales Clinical Research Portfolio. Study ID number 34396, www.ukctg.nihr.ac.uk.

"Effective" Requesting: A Scoping Review of the Literature on Asking Families to Consent to Organ and Tissue Donation

BACKGROUND

Families are often asked to consent to the donation of their deceased relative's organs or tissues. These end-of-life conversations are important because they affect consent rates as well as the psychological impact of the decision for families. This scoping review of the literature on requesting family consent was prepared to support of the development of leading practice recommendations for end-of-life conversations with families of potential donors. A scoping review maps research activity in a field across a range of commentary and empirical study designs but does not attempt meta-synthesis of empirical data or quality assessment.

METHODS

We performed a scoping review of the peer-reviewed literature from January 2000 to February 2015 on the questions of what constitutes an "effective" request and the factors that affect consent rates and family satisfaction with their decision and the process. This review includes a final set of 168 articles addressing (a) whether, when, and how to ask families for consent to donation or (b) characteristics of families or decedents that affect families' decisions or family satisfaction with their decisions.

RESULTS

Six main themes were identified: (1) the objectives of requesting and encouraging family consent to donation, (2) the effect of the donation decision on family well-being, (3) the process of requesting family consent, (4) the impact of the quality of the care for the deceased and for the family, (5) the content and manner of the request for family consent, and (6) the characteristics of the family and deceased that affect the request for family consent.

CONCLUSION

This scoping review found that there is a large literature on how to modify the process and manner of the request to increase family consent rates. Another important line of inquiry focuses on the psychological impact of the decision on the family. Although a scoping review does not attempt to synthesize results or draw evidence-based conclusions, the literature generally supports the intuitive expectations that compassionate and respectful care for the deceased and family, listening for and addressing family concerns, and an attitude to donation that is positive (but not solely procurement-focused) and is best for both consent rates and family well-being. Although the presumption is often that the primary objective of asking for family consent is to secure consent and donation, some ethical commentary on requesting consent emphasizes that this objective must be balanced with the parallel obligation to protect the psychological well-being of families. This places some constraints on the approaches used in family consent discussions.

Ethical Challenges and the Donation Physician Specialist: A Scoping Review

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

Fresh osteochondral allografts-procurement and tissue donation in Europe

Fresh osteochondral allografts are a well-established treatment for large, full-thickness cartilage defects. The clinical outcome for carefully selected patients is very favorable, especially for the young and active and graft survival up to 25 years has been described in the literature. Furthermore, a high patient satisfaction rate has been reported, but the biggest obstacle to overcome is the availability of tissue for transplantation. Large fresh bone allografts for cartilage damage repair only can be harvested from organ donors following organ removal or cadaveric donors, preferably in the setting of an operation room to minimize possible contamination of the tissue. Apart from the logistic challenges this entails, an experienced recovery team is needed. Furthermore, the public as well as medical staff is much less aware of the possibility and requirements of tissue donation than organ donation and families of deceased are rarely approached for bone and cartilage donation. This review aims to highlight the current situation of organ and tissue donation in Europe with special focus on the processing of bones and possible safety and quality concerns. We analyze what may prevent consent and what might be done to improve the situation of tissue donation.

Organ donation agency: A discourse analysis of correspondence between donor and organ recipient families

Studies about the psychosocial issues concerning organ donation and transplantation tend to focus on the experiences of donor or recipient families. Little is known about the part played by correspondence exchanged between these two groups; in particular how they perceive the agency of organ donation. This is the first analysis to address the representation of the act of donation from the viewpoint of both donor and recipient families through interrogation of archived correspondence data, using linguistic techniques. The data was drawn from a collection of letters, from four USA organ procurement organisations, exchanged between donor and transplant recipient families. Donor families consistently linguistically ascribed agency and accountability for donation to the person who died, the donor. For the recipient families, on the other hand, the 'giver' was mainly implied, ambiguous or ascribed to the donor family.

Randomised, Double Blind, Controlled Trial of the Provision of Information about the Benefits of Organ Donation during a Family Donation Conversation

Introduction

It is unclear how much information should be provided to families of potential organ donors about the benefits of organ donation. Whilst this information is material to the donation decision, it may also be perceived as coercive.

Methods

Randomised, double blind, controlled trial in which community members watched one of two videos of a simulated organ donation conversation that differed only in the amount of information provided about the benefits of donation. Participants then completed a questionnaire about the adequacy of the information provided and the degree to which they felt the doctor was trying to convince the family member to say yes to donation.

Results

There was a wide variability in what participants considered was the “right” amount of information about organ donation. Those who watched the conversation that included information about the benefits of donation were more likely to feel that the information provided to the family was sufficient. They were more likely to report that the doctor was trying to convince the family member to say yes to donation, yet were no more likely to feel uncomfortable or to feel that the doctor was uncaring or cared more about transplant recipients than he did for the patient and their family.

Conclusions

This study suggests that community members are comfortable with health care staff providing information to family members that may be influential in supporting them to give consent for donation.

Increasing the acceptability and rates of organ donation among minority ethnic groups: a programme of observational and evaluative research on Donation, Transplantation and Ethnicity (DonaTE)

Background

Black, Asian and minority ethnic (BAME) groups have a high need for organ transplantation but deceased donation is low. This restricts the availability of well-matched organs and results in relatively long waiting times for transplantation, with increased mortality risks.

Objective

To identify barriers to organ donor registration and family consent among the BAME population, and to develop and evaluate a training intervention to enhance communication with ethnic minority families and identify impacts on family consent.

Methods

Three-phase programme comprising (1) community-based research involving two systematic reviews examining attitudes and barriers to organ donation and effective interventions followed by 22 focus groups with minority ethnic groups; (2) hospital-based research examining staff practices and influences on family consent through ethics discussion groups (EDGs) with staff, a study on intensive care units (ICUs) and interviews with bereaved ethnic minority families; and (3) development and evaluation of a training package to enhance cultural competence among ICU staff.

Setting

Community focus group study in eight London boroughs with high prevalence of ethnic minority populations. Hospital studies at five NHS hospital trusts (three in London and two in Midlands).

Participants

(1) Community studies: 228 focus group participants; (2) hospital studies: 35 nurses, 28 clinicians, 19 hospital chaplains, 25 members of local Organ Donation Committees, 17 bereaved family members; and (3) evaluation: 66 health professionals.

Data sources

Focus groups with community residents, systematic reviews, qualitative interviews and observation in ICUs, EDGs with ICU staff, bereaved family interviews and questionnaires for trial evaluation.

Review methods

Systematic review and narrative synthesis.

Results

(1) Community studies: Organ Donor Register – different ethnic/faith and age groups were at varying points on the ‘pathway’ to organ donor registration, with large numbers lacking knowledge and remaining at a pre-contemplation stage. Key attitudinal barriers were uncertainties regarding religious permissibility, bodily concerns, lack of trust in health professionals and little priority given to registration, with the varying significance of these factors varying by ethnicity/faith and age. National campaigns focusing on ethnic minorities have had limited impact, whereas characteristics of effective educational interventions are being conducted in a familiar environment; addressing the groups’ particular concerns; delivery by trained members of the lay community; and providing immediate access to registration. Interventions are also required to target those at specific stages of the donation pathway. (2) Hospital studies: family consent to donation – many ICU staff, especially junior nurses, described a lack of confidence in communication and supporting ethnic minority families, often reflecting differences in emotional expression, faith and cultural beliefs, and language difficulties. The continuing high proportion of family donation discussions that take place without the collaboration of a specialist nurse for organ donation (SNOD) reflected consultants’ views of their own role in family consent to donation, a lack of trust in SNODs and uncertainties surrounding controlled donations after circulatory (or cardiac) death. Hospital chaplains differed in their involvement in ICUs, reflecting their availability/employment status, personal interests and the practices of ICU staff. (3) Evaluation: professional development package – a digital versatile disc-based training package was developed to promote confidence and skills in cross-cultural communication (available at:www.youtube.com/watch?v=ueaR6XYkeVM&feature=youtu.be). Initial evaluation produced positive feedback and significant affirmative attitudinal change but no significant difference in consent rate over the short follow-up period with requirements for longer-term evaluation.

Limitations

Participants in the focus group study were mainly first-generation migrants of manual socioeconomic groups. It was not permitted to identify non-consenting families for interview with data regarding the consent process were therefore limited to consenting families.

Conclusions

The research presents guidance for the effective targeting of donation campaigns focusing on minority ethnic groups and provides the first training package in cultural competence in the NHS.

Future work

Greater evaluation is required of community interventions in the UK to enhance knowledge of effective practice and analysis of the experiences of non-consenting ethnic minority families.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Grief and loss for patients before and after heart transplant

OBJECTIVES

The purpose of the study was to examine the loss and grief experiences of patients waiting for and living with new hearts.

BACKGROUND

There is much scholarship on loss and grief. Less attention has been paid to these issues in clinical transplantation, and even less on the patient experience.

METHODS

Part of a qualitative inquiry oriented to the work of Merleau-Ponty, a secondary analysis was carried out on audiovisual data from interviews with thirty participants.

RESULTS

Patients experience loss and three forms of grief. Pre-transplant patients waiting for transplant experience loss and anticipatory grief related to their own death and the future death of their donor. Transplanted patients experience long-lasting complicated grief with respect to the donor and disenfranchised grief which may not be sanctioned.

CONCLUSIONS

Loss as well as anticipatory, complicated and disenfranchised grief may have been inadvertently disregarded or downplayed. More research and attention is needed.

Can evidence-based health policy from high-income countries be applied to lower-income countries: considering barriers and facilitators to an organ donor registry in Mumbai, India

Background

Organ transplantation has become an effective means to extend lives; however, a major obstacle is the lack of availability of cadaveric organs. India has one of the lowest cadaver organ donation rates in the world. If India could increase the donor rate, the demand for many organs could be met. Evidence from high-income countries suggests that an organ donor registry can be a valuable tool for increasing donor rates. The purpose of this study is to determine whether the implementation of an organ donor registry is a feasible and appropriate policy option to enhance cadaver organ donation rates in a lower-income country.

Methods

This qualitative policy analysis employs semi-structured interviews with physicians, transplant coordinators, and representatives of organ donation advocacy groups in Mumbai. Interviews were designed to better understand current organ donation procedures and explore key informants’ perceptions about Indian government health priorities and the likelihood of an organ donor registry in Mumbai. The 3-i framework (ideas, interests, and institutions) is used to examine how government decisions surrounding organ donation policies are shaped.

Results

Findings indicate that organ donation in India is a complex issue due to low public awareness, misperceptions of religious doctrines, the need for family consent, and a nation-wide focus on disease control. Key informants cite social, political, and infrastructural barriers to the implementation of an organ donor registry, including widely held myths about organ donation, competing health priorities, and limited hospital infrastructure.

Conclusions

At present, both the central government and Maharashtra state government struggle to balance international pressures to improve overall population health with the desire to also enhance individual health. Implementing an organ donor registry in Mumbai is not a feasible or appropriate policy option in India’s current political and social environment, as the barriers, identified through the 3-i framework lens, may be too difficult to overcome. Despite the evidence supporting the use of donor registries as a means to enhance organ donation rates, it is clear that context is critical and that it is not always practical to apply evidence-based policy solutions from high-income countries to lower-income settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0075-6) contains supplementary material, which is available to authorized users.

Interactions between health care personnel and parents approached for organ and/or tissue donation: influences on parents' adjustment to loss

CONTEXT

The effect of loss on those approached for organ and/or tissue donation, particularly in the years thereafter, has received little attention.

OBJECTIVE

To assess whether adjustment of a parent to loss of a child is influenced by interactions with health care personnel.

METHODS

A self-administered questionnaire was completed by the parents of 216 decedents. Interactions in the hospital were assessed by examining the experience in the hospital, physical separation from the child, and the relationship with health care professionals. Adjustment to loss was defined by 4 components: grief, personal growth after loss, meaning of life after loss, and the meaning of organ donation.

RESULTS

A positive experience in the hospital was significantly associated with the meaning of donation. Increased satisfaction with the separation process was associated with better adjustment on all components. Finally, a better relationship with health care professionals was associated with less grief and with greater personal growth. These results were characterized after adjustment for time since loss, which was from 6 months to 27 years.

CONCLUSIONS

Interactions in the hospital appear to influence adjustment to loss significantly. Appropriate interventions may aid parents in their adjustment to life.

Decision making on organ donation: the dilemmas of relatives of potential brain dead donors

Background

This article is part of a study to gain insight into the decision-making process by looking at the views of the relatives of potential brain dead donors. Alongside a literature review, focus interviews were held with healthcare professionals about their role in the request and decision-making process when post-mortal donation is at stake. This article describes the perspectives of the relatives.

Methods

A content-analysis of 22 semi-structured in-depth interviews with relatives involved in an organ donation decision.

Results

Three themes were identified: ‘conditions’, ‘ethical considerations’ and ‘look back’. Conditions were: ‘sense of urgency’, ‘incompetence to decide’ and ‘agreement between relatives’. Ethical considerations result in a dilemma for non-donor families: aiding people or protecting the deceased’s body, especially when they do not know his/her preference. Donor families respect the deceased’s last will, generally confirmed in the National Donor Register. Looking back, the majority of non-donor families resolved their dilemma by justifying their decision with external arguments (lack of time, information etc.). Some non-donor families would like to be supported during decision-making.

Discussion

The discrepancy between general willingness to donate and the actual refusal of a donation request can be explained by multiple factors, with a cumulative effect. Firstly, half of the participants (most non-donor families) stated that they felt that they were not competent to decide in such a crisis and they seem to struggle with utilitarian considerations against their wish to protect the body. Secondly, non-donor families refused telling that they did not know the deceased’s wishes or contesting posthumous autonomy of the eligible. Thirdly, the findings emphasise the importance of Donor Registration, because it seems to prevent dilemmas in decision-making, at least for donor families.

Conclusion

Discrepancies between willingness to consent to donate and refusal at the bedside can be attributed to an unresolved dilemma: aiding people or protect the body of the deceased. Non-donor families felt incompetent to decide. They refused consent for donation, since their deceased had not given any directive. When ethical considerations do not lead to an unambiguous answer, situational factors were pivotal. Relatives of unregistered eligible donors are more prone to unstable decisions. To overcome ambivalence, coaching during decision-making is worth investigation.

Understanding Australian Families’ Organ Donation Decisions

Numbers of deceased organ donors in Australia have increased, but rates of consent to donation remain at around 60%. Increasing family consent is a key target for the Australian Organ and Tissue Authority. Reasons for donation decisions have been reported in the international literature, but little is known of reasons for Australian families’ decisions. Potential organ donors in four Melbourne hospitals were identified and 49 participants from 40 families (23 consenting and 17 non-consenting) were interviewed to understand reasons for consent decisions. Themes for consent to organ donation included that: donation was consistent with the deceased's explicit wishes or known values, the desire to help others or self—including themes of altruism, pragmatism, preventing others from being in the same position, consolation received from donation and aspects of the donation conversation and care that led families to believe donation was right for them. Themes for non-consent included: lack of knowledge of wishes, social, cultural and religious beliefs; factors related to the donation process and family exhaustion; and conversation factors where negative events influenced decisions. While reasons for consent were similar to those described in international literature, reasons for non-consent differed in that there was little emphasis on lack of trust of the medical profession, concerns regarding level of care provided to the potential donor, preserving the deceased's body, fears of body invasion or organ allocation fairness.