Opting-out systems: no guarantee for higher donation rates

Organ Donation Awareness among Family Members of ICU Patients

Background and Objectives: With one of the lowest donation rates in the European Union, Romania faces challenges in organ donation from brain death donors, within an opt-in system. This study aims to measure the attitudes and knowledge of ICU patient's relatives toward organ donation. Materials and Methods: A descriptive cross-sectional study was conducted in the intensive care unit of the Emergency Clinical County Hospital of Oradea, Romania. A 24-item self-administered questionnaire (N = 251) was used to collect data on knowledge about organ and tissue donation and transplantation, as well as the willingness to donate. Results: A high degree of awareness and willingness for organ donation and transplantation was recorded. The main positive predictor of willingness to donate was the perception of helping others by donating their organs after brain death (β = 0.537, OR = 1.711, p < 0.05), and the main negative predictor was the idea that the whole body should be buried intact (β = -0.979, OR = 0.376, p < 0.01). Conclusions: A basic understanding of organ donation and transplantation and favorable attitudes toward organ donation were registered. Families' interviews for organ donation consent may be affected due to extreme emotional distress.

Randomized intervention to assess the effectiveness of an educational video on organ donation intent among Hispanics in the New York metropolitan area

BACKGROUND

The Hispanic community has a high demand for organ donation but a shortage of donors. Studies investigating factors that could promote or hinder organ donation have examined emotional video interventions. Factors acting as barriers to organ donation registration have been classified as: (1) Bodily integrity; (2) medical mistrust; (3) “ick”-feelings of disgust towards organ donation; and (4) “jinx”-fear that registration may result in one dying due to premeditated plans. We predict that by providing necessary information and education about the donation process via a short video, individuals will be more willing to register as organ donors.

AIM

To determine perceptions and attitudes regarding barriers and facilitators to organ donation intention among Hispanic residents in the New York metropolitan area.

METHODS

This study was approved by the Institutional Review Board at Northwell Health. The approval reference number is No. 19-0009 (as presented in Supplementary material). Eligible participants included Hispanic New York City (NYC) residents, 18 years of age and above, who were recruited voluntarily through Cloud Research and participated in a larger randomized survey study of NYC residents. The survey an 85-item Redcap survey measured participant demographics, attitudes, and knowledge of organ donation as well as the intention to register as an organ donor. Attention checks were implemented throughout the survey, and responses were excluded for those who did fail. Participants were randomly assigned two-between subject conditions: To view a short video on organ donation and then proceed to complete the survey (i.e., video first) and view the same video at the end of the survey (video last). No intra-group activities were conducted. This study utilized an evidenced-based emotive educational intervention (video) which was previously utilized and was shown to increase organ donation registration rates at the Ohio Department of Motor Vehicles. Results were analyzed using Jamovi statistical software. Three hundred sixty-five Hispanic individuals were included in the analysis. Once consent was obtained and participants entered the survey (the survey sample is presented in Supplementary material), participants were asked to report on demographic variables and their general impression of organ donation after death. The video depicted stories regarding organ donation after death from various viewpoints, including from the loved ones of a deceased person who died waiting for a transplant; from the loved ones of a deceased person whose organs were donated upon death; and, from those who were currently waiting for a transplant.

RESULTS

Using a binomial logistic regression, the analysis provides information about the relationship between the effects of an emotive video and the intention to donate among Hispanic participants who were not already registered as donors. The willingness to go back and register was found to be significantly more probable for those who watched the emotive video before being asked about their organ donation opinions (odds ratio: 2.05, 95% confidence interval: 1.06-3.97). Motivations for participation in organ donation were also captured with many stating the importance of messages coming from “people like me” and a message that highlights “the welfare of those in need”. Overall, the findings suggest that using an emotive video that addresses organ donation barriers to prompt organ donation intentions can be effective among the Hispanic populous. Future studies should explore using targeted messaging that resonates with specific cultural groups, highlighting the welfare of others.

CONCLUSION

This study suggests that an emotive educational intervention is likely to be effective in improving organ donation registration intent among the Hispanic population residing in NYC.

Ethical Solutions to the Problem of Organ Shortage

Organ shortage is a major survival issue for millions of people worldwide. Globally 1.2 million people die each year from kidney failure. In this paper, we critically examine and find lacking extant proposals for increasing organ supply, such as opting in and opt out for deceased donor organs, and parochial altruism and paired kidney exchange for live organs. We defend two ethical solutions to the problem of organ shortage. One is to make deceased donor organs automatically available for transplant without requiring consent from the donor or their relatives. The other is for society to buy nonvital organs in a strictly regulated market and provide them to people in need for free.

A Randomized Intervention to Assess the Effectiveness of an Educational Video on Organ Donation Intent

Background

The primary objective of this study was to evaluate the effectiveness of an emotive educational video on organ donation intent in New York City. The secondary study objective was to determine if the educational video affected various factors associated with organ donation.

Methods

New York City residents were recruited via a crowdsourcing online platform and randomized to one of two groups, with exposure to viewing (1) an educational video before completing an 81 question survey on organ donation (“video first” condition) or (2) after completing the survey (“video last” condition). Logistic regression analysis compared organ donation intent (i.e., “how likely are you to become an organ donor”) between the two groups. Additional variables related to organ donation (e.g., religious beliefs, financial incentives) were also evaluated between the two groups. Analyses were adjusted for organ donation registration status.

Results

In total, 1905 participants were randomized. We observed a statistically significant increased odds of organ donation intent among those randomized to the video first condition compared with those randomized to the video last condition (odds ratio [OR], 1.70; 95% confidence interval [95% CI], 1.29 to 2.24). Differences regarding both educational effect on nondonors and racial differences such that there was a decreased odds of organ donation intent among those who identified as Black compared with those who were White (OR, 0.66; 95% CI, 0.47 to 0.92). Black participants were also more likely to report bodily integrity and differential treatment by doctors compared with White participants.

Conclusion

Our findings suggest that future interventions to increase organ donation registration among ethnically diverse populations could be effective if sufficient information is presented before decision making to addresses potential concerns.

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.

Comparison of organ donation and transplantation rates between opt-out and opt-in systems

Studies comparing opt-out and opt-in approaches to organ donation have generally suggested higher donation and transplantation rates in countries with an opt-out strategy. We compared organ donation and transplantation rates between countries with opt-out versus opt-in systems to investigate possible differences in the contemporary era. Data were analysed for 35 countries registered with the Organisation for Economic Co-operation and Development (17 countries classified as opt-out, 18 classified as opt-in) and obtained organ donation and transplantation rates for 2016 from the Global Observatory for Donation and Transplantation. Compared to opt-in countries, opt-out countries had fewer living donors per million population (4.8 versus 15.7, respectively) with no significant difference in deceased donors (20.3 versus 15.4, respectively). Overall, no significant difference was observed in rates of kidney (35.2 versus 42.3 respectively), non-renal (28.7 versus 20.9, respectively), or total solid organ transplantation (63.6 versus 61.7, respectively). In a multivariate linear regression model, an opt-out system was independently predictive of fewer living donors but was not associated with the number of deceased donors or with transplantation rates. Apart from the observed difference in the rates of living donation, our data demonstrate no significant difference in deceased donation or solid organ transplantation activity between opt-out versus opt-in countries. This suggests that other barriers to organ donation must be addressed, even in settings where consent for donation is presumed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Organ donation in Australia

Organ donation in Australia has undergone a series of important changes in the past 3 years. An ethically complex and emotionally profound subject, important questions are being raised about the approach to organ donation by the government, by health-care professionals and also by the public. This paper highlights some of the changes within the Australian organ donation community and explores several controversies that accompany the widespread implementation of measures aimed at significantly improving organ donation throughout the country.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Imagining the impact of different consent systems on organ donation: the decisions of next of kin

Next of kin play an important role in organ donation. The aim of this study was to assess the extent to which explicitness of consent to organ donation by the deceased impacts the likelihood that next of kin will agree to organ donation of the deceased by using hypothetical cases. Results indicate that that people say they are more willing to agree to donate organs of those who explicitly consented to donate than those whose permission to donate is presumed. The degree of explicitness for the consent to donate by the deceased appears to influence the next of kin's decision about whether to agree to donation. This variation might explain the absence of differences in efficiency between various types of consent systems.

Presumed Consent to Organ Donation in Three European Countries

United Kingdom Transplant reported that, during 2007—2008, a total of 7655 people were awaiting a transplant; however, only 3235 organs were available via the current `opt in' approach. To address this shortfall, new UK legislation sought to increase the number of organs available for donation. The Chief Medical Officer for England and Wales supports the adoption of `presumed consent' legislation, that is, an `opt out' approach, as used in much of Europe. Little research, however, has explored the impact on bereaved relatives, nurses and medical staff of introducing presumed consent legislation. Adopting a phenomenological approach, this study used responses to an initial questionnaire combined with selected interviews with health care professionals to capture their direct experience of presumed consent legislation in three European countries: Portugal, Norway and Belgium.

The impact of donor policies in Europe: a steady increase, but not everywhere

BACKGROUND

Transplantable organs are scarce everywhere. Therefore, countries have developed policies to support the efficient use of potential donors. Nevertheless, the shortage of organs remains. Were these policies in vain? The aim of this study is to assess the impact of donor policies on donor procurement in 10 Western European countries from 1995 to 2005.

METHOD

To assess the impact of the donor policies we studied the conversion of potential donors into effectuated donors. 80% of the donors died from CVAs or a (traffic) accident. We considered these mortality rates to be a good proxy for potential donors. Here we call the conversion of potential donors into actual donors 'the donor efficiency rate by proxy'.

RESULTS

The mortality rates for CVA and (traffic) accidents have decreased in the countries under study. At the same time, in most countries the donor efficiency rates have steadily increased. The variance in donor efficiency rates between countries has also increased from 1995 to 2005. Four countries introduced a new consent system or changed their existing system, without (visible) long-term effects.

CONCLUSION

The overall increase in donor efficiency means that the efforts to improve donor policies have paid off. However, substantial differences between countries were found. The success of donor policies in terms of the number of absolute donors is blurred by the success of policies on traffic safety and CVA treatment. It remains unclear which specific policy measures are responsible for the increase in donor efficiency rates. This increase is not related to having a presumed consent system. Furthermore, an analysis of countries that introduced a new consent system or changed their system showed no effect on donor efficiency.

Is presumed consent the answer to organ shortages? No

The supply of donor organs cannot keep up with demand. Veronica English argues that assuming people want to donate unless there is contrary evidence will increase availability, but Linda Wright believes the problem is more complex

How large is the organ donor potential in Germany? Results of an analysis of data collected on deceased with primary and secondary brain damage in intensive care unit from 2002 to 2005

The number of potential organ donors depends on various factors, among which the number of deceased with primary or secondary brain damage is the most decisive. In the north-east donor region of Germany with 7.69 million inhabitants, 2019 cases of deceased with primary or secondary brain damage were reported by 136 intensive care units during 2002-2005. In a study, 64% of these deceased were identified as potential donors. This represents 40.7 potential donors per million inhabitants. It can be concluded that in the other donor regions of Germany a comparable number of potential donors exists, yet not all possible donors are being detected and referred. The conversion rate (percentage of potential donors who become effective donors) in the years 2002-2005 was 47%. The main reason for the conversion rate being so low was the large number of relatives who declined an organ donation (73%). More than 90% of the relatives in the north-east region did not know the deceased's will in the acute situation. From our point of view the high refusal rate can be decreased mainly by two measures: improvement of the family approach and integrating the topic of organ donation into schools' curricula.

Explaining differences between hospitals in number of organ donors

The shortage of donor organs calls for a careful examination of all improvement options. In this study, 80 Dutch hospitals were compared. They provided 868 donors in a 5-year period, constituting 91% of all donors in that period in The Netherlands. Multilevel regression analysis was used to explain the differences between hospitals. Potential explanatory variables were hospital-specific mortality statistics, donor policy and structural hospital characteristics. Of all donors, 81% came from one quarter of the hospitals, mainly larger hospitals. A strong relationship was found between the number of donors and hospital-specific mortality statistics. Hospitals with a neurosurgery department had additional donors. Seven hospitals systematically underperformed over a period of 5 years. If these hospitals were to increase their donor efficiency to their expected value, it would lead to an increase of 10% in the number of donors. Most donors are found in large hospitals, implying that resources to improve donor-recruitment should be channelled to larger hospitals. This study presents an efficient strategy toward a benchmark for hospitals of their organ donation rates. Some larger hospitals performed less well than others. This suggests that there is still room for improvement. There is no evidence for large undiscovered and unused pools of donor organs.