Should We Promote Organ Donor Registries When So Few Registrants Will End Up Being Donors?

Organ and Tissue Donation Consent Model and Intent to Donate Registries: Recommendations From an International Consensus Forum

Consent model and intent to donate registries are often the most public facing aspects of an organ and tissue donation and transplantation (OTDT) system. This article describes the output of an international consensus forum designed to give guidance to stakeholders considering reform of these aspects of their system.

Methods

This Forum was initiated by Transplant Québec and cohosted by the Canadian Donation and Transplantation Program partnered with multiple national and international donation and transplantation organizations. This article describes the output of the consent and registries domain working group, which is 1 of 7 domains from this Forum. The domain working group members included administrative, clinical, and academic experts in deceased donation consent models in addition to 2 patient, family, and donor partners. Topic identification and recommendation consensus was completed over a series of virtual meetings from March to September 2021. Consensus was achieved by applying the nominal group technique informed by literature reviews performed by working group members.

Results

Eleven recommendations were generated and divided into 3 topic groupings: consent model, intent to donate registry structure, and consent model change management. The recommendations emphasized the need to adapt all 3 elements to the legal, societal, and economic realities of the jurisdiction of the OTDT system. The recommendations stress the importance of consistency within the system to ensure that societal values such as autonomy and social cohesion are applied through all levels of the consent process.

Conclusions

We did not recommend one consent model as universally superior to others, although considerations of factors that contribute to the successful deployment of consent models were discussed in detail. We also include recommendations on how to navigate changes in the consent model in a way that preserves an OTDT system's most valuable resource: public trust.

Three-in-1,000 and dynamic norms: A mixed-method investigation of novel appeals for influencing organ donor registration

The current research investigated two rarely used appeals for increasing organ donor registration-both with the potential to backfire. The three-in-1000 appeal explains that less than one percent of people will die in such a way that their organs can be donated. This appeal could heighten awareness that donor registration is needed, but it can also convey that registering is futile. The dynamic norms appeal emphasizes the increasing number of people who are becoming registered donors. This appeal could increase the perceived normative nature of registration, but doing so can also lead potential donors to conclude that enough people are already registered. In Studies 1 and 2, participants recruited from Amazon's Mechanical Turk were randomly assigned to either one of these appeals, and their attitudes toward donor registration and intentions to register as a donor were compared to participants in a no-message control group. Study 2 included a qualitative component where participants were asked to describe their perceptions as to why the message was or was not influential. In both experiments, intentions to register were higher for those in both messaging conditions compared to the control group. Positive attitudes toward organ donation were higher in the three-in-1000 condition compared to the control group for both studies. Those in the dynamic norms condition reported more positive attitudes than the control group in Study 1, but not Study 2. In both studies, there was scant evidence of the messages backfiring. In the qualitative component of Study 2, self-reported reasons for the influence of each method provided insight into how and why these appeals were influential, and indicated signs of underdetection for the dynamic norms message.

A Randomized Trial of Theory-Informed Appeals for Organ Donor Registration Using Internet Advertisements

Introduction

Many people do not register as organ donors. We developed 5 different brief appeals for organ donation that were disseminated online. The content was informed by theories of behavior change and studies of the specific cognitive barriers to organ donor registration.

Methods

One message was a persuasive narrative about a transplant recipient. Another message promoted the idea that organ donor registration is a social norm. The knowledge-based message communicated that 1 donor could improve the lives of 50 people. The message on reciprocity offered a free organ donation wristband, whether or not the participant registered as a donor. The message on control simply encouraged organ donation. Using Google AdWords, the messages were deployed randomly as banners of different sizes on diverse online sites and carried a link to an organ donor registration site. We measured clicks, page visits, and organ donor registrations.

Results

There were 5,156,048 impressions and 25,001 total clicks, a click-through rate of 0.49%. The messages on control and reciprocity both had the highest click-through rates of 0.51%. A total of 152 unique individuals requested wristbands and there were 52 total organ donor registration events. The message on reciprocity had the highest number of organ donor registrations (n = 18).

Conclusion

Online organ donation messages rapidly generated substantial attention through clicks, but no message led to a meaningful number of organ donor registrations. Future research may focus on effectively capturing the attention of viewers through social networks or other convenient online venues with less competition for attention than Internet banners.

Estimating the effect of focused donor registration efforts on the number of organ donors

Waiting times for organs in the United States are long and vary widely across regions. Donor registration can increase the number of potential donors, but its effect on the actual number of organ transplants depends upon several factors. First among these factors is that deceased donor organ donation requires both that death occur in a way making recovery possible and that authorization to recover organs is obtained. We estimate the potential donor death rate and donor authorization rate conditional on potential donor death by donor registration status for each state and for key demographic groups. With this information, we then develop a simple measure of the value of a new donor registration. This combined measure using information on donor authorization rates and potential death rates varies widely across states and groups, suggesting that focusing registration efforts on high-value groups and locations can significantly increase the overall number of donors. Targeting high-value states raises 26.7 percent more donors than a uniform, nationwide registration effort. Our estimates can also be used to assess alternative, but complementary, policies such as protocols to improve authorization rates for non-registered potential donors.

A Study of Concerns of Families of Potential Donation After Circulatory Death Donors and Recommendations for Raising Donation Rates

CONTEXT

The request process for donation after circulatory death (DCD) and family concerns about DCD differ in significant ways from the process for, and family concerns about, donation after brain death (DBD). In addition, donation rates for DCDs are typically lower than for DBDs. Although there has been a great deal of research on how the concerns of DBD families impact donation, limited research exists on family concerns and decision-making in the DCD request process.

OBJECTIVE

To determine the concerns of families approached for DCD and explore how those might be addressed to increase DCD donation rates.

DESIGN, SETTING, AND PARTICIPANTS

Written request response forms were completed by organ procurement and family services coordinators from 4 organ procurement organizations in 4 different states. They were filled out as soon as possible after speaking with families about DCD.

MAIN OUTCOME MEASURES

Responses were marked on a 12-item instrument, and anecdotal observations and detailed comments about family concerns, donor registration status, and decisions made were noted.

RESULTS

Family concerns that block DCDs differ in many ways from those that block DBDs. These concerns arise from stresses peculiar to the DCD situation and must be addressed for these types of donations to increase.

PURPOSE OF THE STUDY

The purposes of the study are to identify family concerns about donating organs that are specific to DCD and that may differ from DBD and to distinguish how those concerns might be addressed in ways that increase the likelihood of donation.

Using Voter Registration to Increase Enrollment Into the Organ and Tissue Registry in New York State

CONTEXT

In an effort to increase donation rates, interventions seek to increase the number of residents who are enrolled in the electronic organ and tissue registry. New York State includes an organ and tissue registration field on voter registration forms.

OBJECTIVE

Report the results from voter enrollment drives in New York State seeking to increase voter registration and completed enrollments into the organ and tissue registry.

SETTING

Cosponsored voter/donation drives taking place across in New York State at various public settings.

PARTICIPANTS

New York State residents who completed and submitted voter registration forms at designated campaign sites from fall of 2014 through fall of 2018.

INTERVENTION

Voter/donation drives cosponsored by League of Women Voters New York State with Organ Procurement Organizations and Eye & Tissue Banks in New York State.

MAIN OUTCOME MEASURES

Number of enrollments to organ and tissue donation registry per drive over 4 project years. Calculation of yield as measured by percentage of enrollments to state organ and tissue registry divided by total number of voter registration forms completed.

RESULTS

In all, 754 drives were undertaken over the project period with 6651 residents enrolling into the state organ and tissue registry. The average yield was 27% of completed voter forms resulting in organ and tissue registration; this estimate increased to 34% when prodonation representatives staffed the drives.

CONCLUSION

Use of voter registration form to enroll organ and tissue donors is an effective method to supplement traditional methods to enroll donors.

A Department of Motor Vehicle-Based Intervention to Promote Organ Donor Registrations in New York State

CONTEXT

Examination of efficacy of motor vehicle representative educational training and dissemination of promotional materials as a means to promote organ donation enrollments in New York State.

OBJECTIVE

To increase the number of New York State residents who consent to donation through the department of motor vehicle transactions during project period.

SETTING

County-run motor vehicle offices across New York State.

PARTICIPANTS

Customers who present to New York Department of Motor Vehicle offices and the representative who work at designated bureaus.

INTERVENTIONS

point-of-decision materials including promotional posters, brochures, website, and the motor vehicle representative training sessions.

MAIN OUTCOME MEASURES

Reasons for enrollment decision, knowledge/experience with donation, monthly consent rates, enrollment in state organ, and tissue registry.

RESULTS

Customers who elected not to register reported no reason or uncertainty surrounding enrollment. The representatives reported experience with donation, discussion with customers, and need for additional education on organ donation. Enrollment cards were mailed to 799 project staff; counties where offices participated in intervention did not indicate significantly higher monthly enrollments when comparing pre- to postenrollment rates.

CONCLUSIONS

Use of point-of-decision materials and enrollment cards proved inexpensive method to register customers with a 3.6% return rate. Customers report low (27%) enrollment rate and reticence to consent to donation. Educational training sessions with representatives did not yield significant enrollment increases when evaluating data at county-level enrollment.

How African Americans Express Their Intentions to Be Organ Donors

Context

As part of an organ sharing network's outreach, African American adults were interviewed to assess their awareness of the network's efforts and willingness to donate their organs after death.

Objective

To describe (1) the proportion who expressed their intentions to be an organ donor, (2) the means they had used, and (3) sociodemographic characteristics of the participants who used a particular means.

Design

A repeated, cross-sectional, random-digit dialing telephone interview was conducted from July 2005 (start of wave 1) to April 2006 (end of wave 3). Each interview averaged 7 minutes and consisted of 60 items.

Setting

Trained interviewers placed telephone calls to the residences of African Americans who resided in 1 of 4 New Jersey locales: East Orange/Orange, Irvington, Jersey City/Newark, and Trenton.

Participants

One thousand five hundred sixty-seven African Americans, aged 18 to 95 years.

Main Outcome Measures

Five Yes/No items were used to determine if participants had declared their intention to be an organ donor via driver's license application, donor card, donor registry, will/healthcare directive, or discussion with a family member.

Results

Twenty-seven percent of the participants had expressed their intentions to be an organ donor with an organ donor card, driver's license, donor registry, or will/healthcare directive. The participants who had used one or more of these formal means were 14.4 times more likely to have discussed their intention to be an organ donor with a family member than were the participants who had not.

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.

An Effort to Increase Organ Donor Registration Through Intergroup Competition and Electronic Word of Mouth

The effort to increase Web organ donation registrations in Michigan by enhancing 2 types of university campaigns with social media strategies informed by social identity theory is the focus of this research. The two campaigns focused on either ingroup or rivalry outgroup social identification, and each was enhanced with individually focused social media in the first year of the campaign and with electronic word of mouth in Year 2 of the campaign. Results indicated that individually focused social media such as Facebook ads worked well in rivalry campaigns (in which registrations increased two times over baseline) but not in ingroup identification campaigns (in which registrations decreased significantly over baseline when ads were introduced in the first year of each type of campaign). Electronic word-of-mouth strategies worked well in both ingroup identification campaigns (in which registrations increased two times over baseline) and rivalry campaigns (in which registrations rose almost eight times over baseline, when strategies were introduced in the second year of each type of campaign).

Does Presumed Consent Save Lives? Evidence from Europe

One policy tool that could affect organ donation rates is legislative defaults. In this study, we examine how presumed consent impacts cadaveric donations and kidney transplantations, using a panel dataset from the EU-27 countries plus Croatia in the period 2000-2010. We find that presumed consent countries have 28% to 32% higher cadaveric donation and 27% to 31% higher kidney transplant rates in comparison to informed consent countries, after accounting for potential confounding factors. After studying willingness to donate one's organs and registering preferences for organ donation, we find that presumed consent could increase cadaveric donation rates, because people fail to register their preferences and many have no preference for organ donation.

Promoting organ donation through challenge campaigns

CONTEXT

Four challenge campaigns in 2012 and 2013 were undertaken to promote organ donor registrations in New York State. Challenge campaigns relied on community advocates statewide to initiate month-long outreach efforts with top teams earning monetary rewards and public recognition.

OBJECTIVE

To significantly increase the number and proportion of New York residents who have consented to donation through the electronic registry.

DESIGN

Four month-long campaigns undertaken in fall and spring of 2012 and 2013.

SETTING

Statewide recruitment efforts organized by New York Alliance for Donation and the 4 organ procurement organizations in New York State.

PARTICIPANTS

Adult residents of New York State.

INTERVENTION

Project staff recruited team leaders across New York State and used online and offline resources to recruit teams, educate team leaders, and bolster outreach efforts.

MAIN OUTCOME MEASURES

Number of completed registration forms within month-long campaign periods. Also investigated were statistics on website use (eg, page views, new visitors) and interviews with team leaders regarding campaign activities after the campaign.

RESULTS

Across 4 campaigns, 107 teams were recruited and 2286 persons registered their consent to donate through the state system. Each team recruited a mean of 21 persons; 40% of teams registered 0 persons.

Promoting Organ Donor Registries Through Public Education: What Is the Cost of Securing Organ Donors?

BACKGROUND

Transplant medicine's impact on America's public health is seriously limited by acute shortage of transplantable organs. Consequently, the United Sates has witnessed considerable investment in the promotion of organ donor registries. Although there is no evidence to support that donor registry promotion alleviates organ shortage, this belief continues to drive investments into registry promotion. In this study, return on investment in donor registry promotion was examined using cost-outcomes analysis.

METHODS

Cost of promoting the donor registry was estimated in US dollars whereas the outcome was measured as the number of individuals who join the registry (registrants) and their value in terms of organ donors. The study was conducted from the perspective of a regional Organ Procurement Organization (OPO). Costs were directly obtained from the OPO. The number of new registrants was obtained from the OPO and the departments of motor vehicles that maintain the donor registry. The value of registrants in terms of organ donors was computed based on a registrant's age-dependent risk of dying and age-dependent probability of becoming an organ donor.

RESULTS

Six thousand seven hundred eight individuals joined the organ donor registry (95% confidence interval [95% CI], 5429-7956) at a cost of $455 per registrant (95% CI, US $383-US $562). These individuals result in 4.2 present-day donors (95% CI, 2.5-6.6) at a cost of US $726 000 (95% CI, US $462000-US $1.2 million).

CONCLUSIONS

Because the cost per registrant and cost per donor is less than society's willingness to pay, donor registry promotion offers positive return on investment. Investment in registry promotion should at the minimum be maintained at current levels.

A Content Analysis of Organ Donation Stories Printed in U.S. Newspapers: Application of Newsworthiness

The current study applied a theory of newsworthiness to the topic of organ donation. Specifically, content analysis of newspaper stories published in the United States (N = 1,988) was performed to identify whether deviance and significance of a story predicted story prominence, measured as story length and placement in the newspaper. Results indicated support for study hypotheses: Longer stories and front-page stories pertaining to organ donation were more deviant and more significant in content. Analyses also indicated stories more negative in nature were more likely given front-page coverage, represented international events, and were high on deviance and significance. Higher circulating newspapers were more likely to publish stories recounting negative events in organ donation. Results indicated organ donation coverage represents a valid application of newsworthiness theory, and implications of study findings are discussed in relation to the agenda-setting function of news stories.

Effect of web-based training for Department of Motor Vehicle staff on donor designation rates: results of a statewide randomized trial

On approach to addressing the continual shortage of organ donors is to encourage people to join a state donor registry. Joining the registry saves time and assures family members that organ donation is what their loved one would want. However, fewer than half of adults have taken this step. We tested a brief, web-based training program for department of motor vehicles (DMV) staff that educates them about organ and tissue donation and also models the correct way to interact with customers. The intervention was developed with extensive input and active participation from DMV staff. After a small-scale pilot test, all DMV offices across the state of West Virginia (WV) were randomized to receive the training or serve as a comparison group. The results showed that customers of DMV staff who had received the training were 7.5% more likely to register as organ donors. A conservative estimate is that this generates approximately 800 additional donor designations per month. An important aspect of web-based training is that once it has been deployed, it can continue to be used without incurring additional cost; the state of WV currently requires all new employees to complete the training program. This type of training can be adopted nationwide.

Reasons for (not) Signing the State Registry: Surveying Department of Motor Vehicles Customers in New York State

Context

Prior research examining rationales for enrolling as an organ donor is biased because of its reliance on college student samples and retrospective recall.

Objective

To characterize New York state residents' registry enrollment decisions in close proximity to a registration opportunity.

Design

Surveys were conducted with customers exiting Department of Motor Vehicle offices.

Participants

A total of 1325 customers were surveyed upon exiting 1 of 18 Department of Motor Vehicle offices spanning 9 counties.

Main Outcome Measure

Customers making donation-relevant transactions (ie, license renewal/registration) reported whether they had registered as a donor that day, and all other customers reported whether they had registered as a donor in the past. Customers reported reasons to justify their enrollment decision through short interview questions.

Results

Among current donation-relevant transactions (n = 299), 27% reported enrolling in the registry. Of remaining customers, 39% reported enrolling in the state registry in the past. For those who elected not to enroll, many failed to communicate a reason for their decision, or reported a lack of opportunity to sign or decisional uncertainty. Among enrollees, reasons for registration included the altruistic benefits of donation, prior registration, personal experience with donation, and rational arguments for donation.

Conclusion

The value of point-of-decision survey data are discussed in relation to strategic efforts to promote organ donor registration.

Clarifications on mass media campaigns promoting organ donation: a response to Rady, McGregor, & Verheijde (2012)

The current paper provides readers some clarifications on the nature and goals of mass media campaigns designed to promote organ donation. These clarifications were necessitated by an earlier essay by Rady et al. (Med Health Care Philos 15:229-241, 2012) who present erroneous claims that media promotion campaigns in this health context represent propaganda that seek to misrepresent the transplantation process. Information is also provided on the nature and relative power of media campaigns in organ donation promotion.

Telephone requests for donation: concerns expressed by families and the impact of the donor registry

CONTEXT

The request process for eye and tissue donation is different from the process that families of organ donors experience, but the research into eye/tissue-only decision making has been sparse.

OBJECTIVE

To determine the concerns of families approached over the phone for eye/tissue donations and to study the impact of the donor registry on those decisions.

DESIGN, SETTING AND PARTICIPANTS

Written instrument filled out by family services coordinators while speaking with families about donation via phone in the San Diego, California, area during 2011.Main Outcome Measures-Responses marked on a 21-item instrument, contextual notes, donor registrations, and decisions made.

RESULTS

With a 60% refusal rate, the most common reasons reported for declining donation are that the potential donor said during life he/she did not want to donate (26%) or that the family, not knowing the potential donor's wishes, opted not to donate (13%). Other specific reasons for not donating were as follows: wanting the body buried whole (8%), concerns about age and prior health (7%), and incompatibility with religion or culture (7%). Consenting families had different concerns: worries about delays (36%), the potential donors' age and health (25%), how the body might look for viewing (14%), the amount of paperwork (10%), for-profit status of beneficiaries (9%), international distribution (8%), and family disunity (8%). Registry-related refusals weighted against donations of tissues from registered donors amounted to a deficit of 92 potential donations. When donations lost to faulty assumptions based on public education are added, the deficit increases to 122 lost donations.

Click to “Like” Organ Donation: The Use of Online Media to Promote Organ Donor Registration

Context

Efforts to promote organ donation have traditionally relied on mass-mediated or interpersonal communication to promote donor registration. Despite its popularity, the use of online media has yet to be carefully evaluated as a platform to promote organ donation.

Objective

To describe results of an intervention to promote donor registration that relies solely on online media to communicate to target audiences.

Design

For 3 years, 6 campaigns were implemented in 3 different online media formats.

Setting

Online media formats included (1) traditional online advertising, (2) student seeders' social networking sites campaigns, and (3) challenge campaigns.

Participants

Online media campaigns primarily targeted college-aged individuals.

Intervention

Each campaign directed individuals to the dedicated project website, where they could access educational material about donation and request a donor registration card.

Main Outcome Measures

Unique website visitors, webpages viewed per site visit, time spent on site, and organ donor cards requested/received were tracked in relation to each online media format.

Results

Traditional online advertising offered greater message exposure but failed to result in a higher proportion of website visitors who registered their donation intentions. Use of student seeders (ie, motivated students who promote donation by using social networking sites) and challenge campaigns resulted in greater attention to the project website, donor card requests, and subsequent returns. Additional research is recommended to reveal the effect of combining 2 or more varying online media formats within a single campaign.

Addressing the Unintended Adverse Consequences of First-Person Consent and Donor Registries

One of the most common reasons given for the refusal to donate in both the United States and the United Kingdom is that the potential donor, in his lifetime, said he did not want to be a donor. This objection has not always been given by families refusing to donate and appears to be an unintended consequence of donation strategies based on public education, donor registries, and first-person consents. A history of the objection is given, possible meanings are explored, and strategies for dealing with it are suggested.

Difficult communication: compliance-gaining strategies of organ procurement coordinators

Organ procurement coordinators (OPCs) face a formidable communication task when making familial requests for consent to organ donation, because they must provide social support for grieving family members while seeking compliance to the donation request. Structured interviews were conducted with 102 OPCs, representing 16 organ procurement organizations (OPOs) (27.6% of national organizations) across the United States. Responses were transcribed and content-analyzed along four domain areas: (a) establishing credibility, (b) message strategies, (c) timing/setting of requests, and (d) adaptation of messages to diverse families. OPO conversion rates were used as a criterion factor for OPCs' persuasive communication success and regressed onto self-reported strategy use. Results indicate message strategies varied at the OPC level of analysis and 7 techniques significantly predicted 32% of the variance in conversion rates. Two strategies (i.e., gaining early intervention, approaching with additional support) positively influenced conversion rates, whereas 5 strategies (e.g., discussing benefits as a persuasive strategy, emphasizing the need for donation in particular racial/ethnic groups) negatively influenced conversion rates. Future research is recommended to validate the study findings toward the goal of improving OPCs' communication strategies.

A peer-to-peer campaign to promote organ donation among racially diverse college students in New York City

PURPOSE

Due to the documented disparities in organ transplantation, individuals from racially diverse backgrounds are encouraged to register as donors and communicate their donation intentions to family. The present study reports an intervention aimed at addressing students' fears and misconceptions related to organ transplantation on college campuses with racially diverse student enrollments. The intervention uses peer-to-peer campaigns at colleges in New York City in an attempt to increase declarations of intent to donate and to educate students about transplantation.

PROCEDURES

Six campuses in the New York City area participated in the intervention. Students participating in the college campaign intervention were educated about donation through active learning methods and implemented campus-wide campaigns to recruit fellow students as donors.

RESULTS

Student campaigners reported increases in topic salience and self-efficacy from precampaign to postcampaign activities. In addition, rates of donor registration and family communication improved over time. Across 6 campuses, campaigners were able to recruit 1019 students as registered donors.

CONCLUSIONS

Participation in the campaign course increases students' vested interest in donation and has proven effective at increasing donor registration among racially diverse groups.