Attitude of healthcare professionals: a major limiting factor in organ donation from brain-dead donors

Outcome analysis of brain-death referral to NOD-Lb: A retrospective chart review of a single hospital experience over 3 years

BACKGROUND

Organ donation shortage and in particular organ procurement is an international concern as the gap between the number of donors and recipients is steadily growing. Organ procurement is a chain of steps with donor identification and referral (ID&R) as the very first link in this chain. Failure of this step hinders the progress in the organ transplantation program.

OBJECTIVES

Our study was conducted to evaluate and highlight the gap between the national system and the practice at the identification and referral (ID&R) step of the organ procurement chain in a single tertiary-care academic health center in Beirut: the Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), and to appraise the literature for challenges at this step and for possible interventions for improvement based on the international experience.

MATERIALS AND METHODS

This retrospective study was a descriptive case series of ICU and ED deceased patients at a single tertiary-care university hospital in Beirut. Patients' characteristics were collected from medical records for all patients who died between 2017 and 2019 while in the ICU or the ED and shared with the National Organization for Organ and Tissue Donation and Transplantation (NOD-Lb), for each subject separately, to decide on the donor status. All data collected from the patient cohort was analyzed using R version 3.6.1. Wilcoxon signed-rank test, chi-squared, and fisher-exact tests were used to compare differences in clinical characteristics in terms of donor status when appropriate.

RESULTS

This study served as 3 years audit of a single hospital experience, and it demonstrates failure to make any referrals to NOD-Lb and zero actual organ and tissue donations over the study period. The review of 295 deceased subjects' charts demonstrates 295 missed alerts to NOD-Lb and the overall missing of 5 organ and tissue donors and 24 cornea donors assuming the organ procurement chain of steps will continue uninterrupted after ID&R.

CONCLUSION

The data gathered suggests the presence of an inefficient identification and referral system that is translated into a complete failure of reporting to NOD-Lb from LAUMC-RH. A systematic evidence-based approach to evaluate for the most cost-effective intervention to increase identification and referral rates is needed with a serious effort to examine and account for any inefficient implantation.

Attitudes Toward and Knowledge of Brain Death and Deceased Organ Donation Among Anesthesiologists in the Northeastern Region of Poland

BACKGROUND

Because in Poland transplant of organs from deceased donors is the predominant form of transplant, anesthesiology and intensive care specialists play a key role in the process. Insight into the work organization in intensive care units, anesthesiologists' and intensivists' level of knowledge and expertise, as well as personal opinions regarding declaring brain death and critical care of potential donors may be helpful in increasing transplant rates.

AIM OF THE STUDY

The objective of this survey was to identify factors and challenges influencing donation rates in intensive care units of hospitals of various reference levels in region.

METHODS

An anonymous, 31-question survey was sent to anesthesiology and intensive care specialists working in hospitals in one of the regions of eastern Poland. The survey was completed by 133 physicians, and a quantitative analysis was conducted on the data collected from submitted answers.

RESULTS

The average age of responders was 46 years (±10.24 years). Anesthesiology and intensive care specialists made up 80.45% of respondents. A vast majority of respondents (97%) expressed positive attitude toward transplant and are willing to donate their organs after death (92.19%). Meanwhile, more than 50% of them admit their lack of sufficient knowledge when it comes to declaring brain death. More than 53% of surveyed physicians have never had the opportunity to participate in training in methodology in performing brain death provided by their hospital or know about such training taking place. A vast majority of respondents (94.76%) see the need for workshops in potential organ donor care and brain death determination and would like to attend them.

CONCLUSIONS

This study shows a positive outlook toward organ donation and transplant but at the same time reveals a lack of knowledge and expertise among doctors working in intensive care units. That is why implementing education tools for identification, declaration, and maintenance of brain-dead donors could be one of the keys to enhancing donation.

The Suitability of Potential Organ Donors Using Real Case-Scenarios; Do we Need to Create a "Donor Board" Process for Donors Perceived as Unlikely Suitable?

Introduction: Despite availability of selection criteria, different interpretations can lead to variability in the appreciation of donor eligibility with possible viable organs missed. Our primary objective was to test the perception of feasibility of potential organ donors through the survey of a small sample of external evaluators.

Methods: Clinical scenarios summarizing 66 potential donors managed in the first year of our Organ Recovery Center were sent to four critical care physicians to evaluate the feasibility of the potential donors and the probability of organ procurement.

Results: Potential donors procuring at least one organ were identified in 55 of the 66 cases (83%). Unanimity was reached in 38 cases, encompassing 35 out of the 55 converted and 3 of the non-converted donors. The overall agreement was moderate (kappa = 0.60, 95% CI: 0.37–0.82). For the organs finally procured for transplantation, organ donation was predicted for the majority of the cases, but high discrepancy was present with the final outcome of organs not procured (particularly liver and kidney).

Conclusion: The assessment of a potential donor is a complex dynamic process. In order to increase organ availability, standardized electronically clinical data, as well a “donor board” structure of decision might inform future systems.

Results of the European EDITH nephrologist survey on factors influencing treatment modality choice for end-stage kidney disease

BACKGROUND

Access to forms of dialysis, kidney transplantation (Tx) and comprehensive conservative management (CCM) for patients with end-stage kidney disease (ESKD) varies across European countries. Attitudes of nephrologists, information provision and decision-making may influence this access and nephrologists may experience several barriers when providing treatments for ESKD.

METHODS

We surveyed European nephrologists and kidney transplant surgeons treating adults with ESKD about factors influencing modality choice. Descriptive statistics were used to compare the opinions of professionals from European countries with low-, middle- and high-gross domestic product purchasing power parity (GDP PPP).

RESULTS

In total, 681 professionals from 33 European countries participated. Respondents from all GDP categories indicated that ∼10% of patients received no information before the start of renal replacement therapy (RRT) (P = 0.106). Early information provision and more involvement of patients in decision-making were more frequently reported in middle- and high-GDP countries (P < 0.05). Professionals' attitudes towards several treatments became more positive with increasing GDP (P < 0.05). Uptake of in-centre haemodialysis was sufficient to 73% of respondents, but many wanted increased uptake of home dialysis, Tx and CCM. Respondents experienced different barriers according to availability of specific treatments in their centre. The occurrence of barriers (financial, staff shortage, lack of space/supplies and patient related) decreased with increasing GDP (P < 0.05).

CONCLUSIONS

Differences in factors influencing modality choice when providing RRT or CCM to adults with ESKD were found among low-, middle- and high-GDP countries in Europe. Therefore a unique pan-European policy to improve access to treatments may be inefficient. Different policies for clusters of countries could be more useful.

Muslim American physicians' views on brain death: Findings from a national survey

Background

Biotechnology has introduced a new physiological state, "brain death," that continues to attract controversy and confusion. While variability in diagnostic criteria for, and physician practices regarding, "brain death" has been studied, few studies examine physicians' normative views on the significance of "brain death" and how religiosity implicates these views.

Objective

The objective is to assess how Muslim physicians' views on death, and how their religiosity and acculturation, associate with their perceptions of "brain death."

Methods

A randomized national sample of 626 American Muslim physicians completed a mailed questionnaire assessing sociodemographic characteristics, religiosity, and views about death. Measures of religious practice and acculturation were analyzed as predictors of physician views at the bivariate and multivariable levels. In conducting the multivariate analysis, P-values less than 0.05 were deemed statistically significant.

Results

Two-hundred and fifty-five respondents completed the survey (41% response rate). Most participants agreed that death is the irreversible cessation of cardiac and respiratory function (90%), while half agreed or disagreed with other definitions of death, such as loss of personhood or the equivalence of cardiopulmonary and neurological criteria for death. Physicians who scored higher on the religious practice scale had significantly lower odds of agreeing with the statement; "brain death" signifies the departure of the soul from the body [odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.33-0.98]. Those who were born in the US, or immigrated to the US as a child, had greater odds of viewing death as the irreversible loss of personhood and consciousness [OR = 3.52, 95% CI: 1.62-7.63].

Conclusion

Physician characteristics such as religiosity and acculturation appear to influence their views on what constitutes death and how it should be diagnosed. In our sample of Muslim physicians, there appears to be significant reservation toward equating neurological and cardiopulmonary criteria to determine death and disquiet regarding the meaning of "brain death" in general.

Optimizing Organ Donation: Expert Opinion from Austria, Germany, Spain and the U.K

Background

Organ donation-rates using deceased donors and organizational approaches to organ donation differ drastically between countries at a similar level of health care as measured by the Euro Health Consumer Index (EHCI).

Material/Methods

Expert opinions from intensive care nurses, physicians, transplant coordinators and transplant surgeons from Austria, Germany, Spain, and the U.K. were obtained in semi-structured interviews followed by qualitative content analysis. Results were reported back to all interview partners to identify potential controversies and consensus recommendations.

Results

No controversies could be detected. On a variety of beneficial factors an interprofessional consensus between interview partners could be reached: A) The relevance of standardization of the screening for potential donors, the family approach and training; B) standards and best-practice procedures should be regulated and supervised by state authorities; C) full transparency and the prevention of scandals is essential; D) overburdened intensive care unit (ICU) doctors need to be supported by full-time in-house special nurses who organize donor evaluation, transport logistics and pastoral care, if required; E) public awareness campaigns are helpful; F) a broad public consensus on the concept of donation after brain and cardiac death is essential; G) incentives for the reporting of potential organ donors are inappropriate; H) an opt-out system alone is not sufficient.

Conclusions

Expert opinions from different professional backgrounds from different European health care systems reach a broad consensus on the most relevant issues for the improvement of organ donation.

Is there an association between consent rates in Swiss hospitals and critical care staffs' attitudes towards organ donation, their knowledge and confidence in the donation process?

This study investigated the critical care staff’s attitude, knowledge and involvement with donation, skills and confidence with donation-related tasks and their association with consent rates at the hospital level. In 2015, we conducted a cross-sectional survey among critical care staff of hospitals involved in organ donation using an anonymous online questionnaire with a response rate of 56.4% (n = 2799). The hospital level consent rate was obtained from the Swiss Monitoring of Potential Donors database (2013–2015). For each hospital, we calculated a mean score for each predictor of interest of the Hospital Attitude Survey and investigated the association with hospital consent rates with generalized linear mixed-effect models. In univariable analysis, one score point increase in doctors' confidence resulted in a 66% (95% CI: 45%–80%) reduction in the odds to consent, and one score point increase in nurses' attitudes resulted in a 223% (95% CI: 84%–472%) increase in the odds to consent. After simultaneously adjusting for all major predictors found in the crude models, only levels of education of medical and nursing staff remained as significant predictors for hospital consent rates. In Switzerland, efforts are needed to increase consent rates for organ donation and should concentrate on continuous support as well as specific training of the hospital staff involved in the donation process.

The Effect of Transplant Education on Nurses Attitudes Toward Organ Donation and Advocacy for Transplantation

Nurses are the largest group of health-care professionals, yet they are not uniformly educated regarding transplantation and organ donation. The future of transplantation hinges on education of this group. Before meaningful studies can be conducted, an instrument to measure attitudes and commitment to organ transplantation is needed. The purpose of this study was to examine content and construct validity as well as establish internal reliability of an investigator-developed online instrument to measure nurses' attitudes and commitment to organ transplantation by registered nurses. The online instrument was administered to registered nurses enrolled in transplantation electives at the University of Alabama in Huntsville and Vanderbilt University. Exploratory factor analysis revealed 4 components with eigenvalues over 1.0. The components were as follows: (1) desire to work in transplantation, (2) confidence in transplantation advocacy, (3) organ donation advocacy, and (4) procurement. Internal consistency of the revised instrument was established (α = .94). The Transplant-Registered Nurse (TXP-RN) instrument is a new instrument with excellent reliability and validity that can be used to measure attitudes and knowledge of American nurses about organ donation and transplantation. This important step is necessary before educational interventions can be accurately assessed.

Process and barriers to organ donation and causes of brain death in northeast of Iran

Introduction

Organ transplantation is the treatment of choice for some diseases. However, the need for cadaveric organ donation has either plateaued or is on a decreasing trend in some countries, especially in developed ones. In this study, we aimed to identify the barriers to organ donation in brain dead patients, who were referred to the organ procurement organizations (OPO) in northeast Iran.

Methods

In this cross-sectional study during 2006 to 2013, data were collected from medical records of brain dead patients. Demographic information, cause of brain death, the process of obtaining informed consent, and the reasons for declining organ donation were obtained from the OPO records. The data were analyzed using chi-square test by SPSS 13 software.

Results

Of 1034 brain dead patients, 751 cases (72.6%) were eligible for organ donation, and, ultimately, 344 cases underwent organ donation. The rate of organ donation increased during the course of the study; medical and legal reasons as well as family refusal to authorize donation were the main barriers to the process.

Conclusion

Based on the pattern of mortality, the need for living donors in developing countries, such as Iran and other countries in the Mediterranean region, can be reduced by improving the quality of healthcare, efficient identification of brain death, and obtaining consent with appropriate strategies.

An institutional study of awareness of brain-death declaration among resident doctors for cadaver organ donation

Background and Aims:

Brain death is defined as irreversible and complete cessation of all brain function including that of the brainstem. The aim of this study was to assess the level of knowledge and awareness about brain-death declaration among resident doctors.

Methods:

This was an observational questionnaire-based study conducted in single institute in which 112 junior residents and 46 senior resident doctors in various medical specialities were included by universal sampling method. A prevalidated questionnaire consisting of questions related to knowledge, attitude and performance of brain-death declaration were distributed among residents as per the inclusion criteria to fill in the time limit of 30 min. Statistical tools used were mean and standard deviation, proportion and Chi-square test.

Results:

A total 87 resident doctors consisting of 71.26% males and 28.73% females responded to the questionnaire. About 91.95% correctly defined it as complete cessation of brain activity including brainstem reflexes. Most of the resident doctors (80.45%) knew about the documentation of absence of brainstem reflexes at 6 h intervals and 64.36% were aware about positive apnoea test. When asked about whether there is legal sanction for disconnecting life support in India, 56.32% said no, and 43.67% said yes. Only 12.64% of resident doctors were aware about a panel of 4 physicians are mandatory to declare brain death in India.

Conclusion:

Awareness and attitude towards the identification of brain death and possible deceased donor organ transplantation were lacking amongst resident doctors.

Organ donation protocols

Organ transplantation improves survival and quality of life in patients with end-organ failure. Waiting lists continue to grow across the world despite remarkable advances in the transplantation process, from the creation of public engagement campaigns to the development of critical pathways for the timely identification, referral, approach, and treatment of the potential organ donor. The pathophysiology of dying triggers systemic changes that are intimately related to organ viability. The intensive care management of the potential organ donor optimizes organ function and improves the donation yield, representing a significant step in reducing the mismatch between organ supply and demand. Different beliefs and cultures reflect diverse legislations and donation practices amongst different countries, creating a challenge to standardized practices. Maintaining public trust is necessary for continued progress in organ donation and transplantation, hence the urge for a joint effort in creating uniform protocols that ensure transparent practices within the medical community.

Training, work, and lifestyle of transplant physicians and surgeons in Germany

BACKGROUND

International data on training, work, and lifestyle of transplant physicians and surgeons are scarce. Such data might help in development of uniform education paths and provide insights for young clinicians interested in this field. This study aimed at the evaluation of these data in all transplant-associated medical disciplines.

METHODS

A survey on professional and academic training, workload, and lifestyle was generated. The questionnaire was distributed to all members of the German Transplant Association (DTG), utilizing the tool SurveyMonkey(®) .

RESULTS

A total of 127 members of the DTG responded (male/female 66.1%/33.9%, 45.8±10.3 years). The majority had been working in transplant medicine for more than 10 years (61.9%). Fifteen respondents (11.8%) obtained an official European certification (European Union of Medical Specialists). A total of 57 (48.3%) respondents worked full time on research during training. The research focus was clinical for most respondents (n=72, 61.5%). An average working time of 62±1.5 h/wk was reported. Fifty-eight percent of all respondents complained of inadequate remuneration and 50% reported inadequate acknowledgment of their professional performance.

CONCLUSION

This is the first study reporting characteristics of training, work, and lifestyle in an interdisciplinary cohort of German transplant physicians and surgeons. Enormous efforts in clinical and research work were reported, associated with high rates of professional and financial dissatisfaction.