Intensive care staff, the donation request and relatives' satisfaction with the decision: a focus group study

Barriers to Organ Donation: A Qualitative Study of Intensive Care Nurses' Experiences

BACKGROUND

An increasing number of patients affected by organ failure can be treated with organ transplantation. The need for organs available for transplantation is critical and patients die while on the transplant list. Intensive care unit (ICU) nurses are essential in facilitating organ donation through their ceaseless bedside care for potential organ donors and their families.

AIMS AND OBJECTIVES

The aim of this study was to describe the challenges faced by ICU nurses in the organ donation process.

DESIGN

A descriptive qualitative study design was used.

METHOD

Semistructured individual interviews of 9 ICU nurses from 1 university hospital were performed. Data were analyzed using Malterud's systematic text condensation.

RESULTS

Three themes describe the core of the results: (1) practical tasks, (2) challenging care for the next of kin, and (3) ethical and emotional challenges.

CONCLUSIONS

Practical tasks represent challenges in the organ donation process that are not previously revealed. Actions to address these challenges should be prioritized to promote organ donation. Simulation-based training may optimize practical aspects of the organ donation process and implementation of simulation-based training should be assessed by future research.

Obtaining tissues and organs: empowering actions of nurses in the light of ecosystem thinking

OBJECTIVES

to analyze, in the light of ecosystem thinking, the actions of nurses that stimulate the potential to increase the rates of organ and tissue donation.

METHODS

descriptive, exploratory, mixed method study, of the embedded type, with simultaneous realization and emphasis on the quantitative approach, including 125 nurses from the Intra-hospital Commission for Donation of Organs and Tissues for Transplants in the Southern Region of Brazil. Data were collected using an online survey questionnaire. Quantitative data were analyzed using the Statistical Package for the Social Sciences software; and qualitative, Bardin content analysis.

RESULTS

the identified actions refer to the reception of the family, exclusive dedication and remunerated valorization of the nurses of the commission, media and dissemination campaigns for society in general and educational actions for the training of professionals.

CONCLUSIONS

the results of the actions encourage the possibility of increasing the rates of organ and tissue donation for transplantation.

Physician Experiences with Communicating Organ Donation with the Relatives: A Dutch Nationwide Evaluation on Factors that Influence Consent Rates

Background

The aim of this nationwide observational study is to identify modifiable factors in communication about organ donation that influence family consent rates.

Methods

Thirty-two intensivists specialized in organ donation systematically evaluated all consecutive organ donation requests with physicians in the Netherlands between January 2013 and June 2016, using a standardized questionnaire.

Results

Out of 2528 consecutive donation requests, 2095 (83%) were evaluated with physicians. The questionnaires of patients registered with consent or objection in the national donor registry were excluded from analysis. Only those questionnaires, in which the family had to make a decision about donation, were analyzed (n = 1322). Independent predictors of consent included: requesting organ donation during the conversation about futility of treatment (OR 1.8; p = 0.004), understanding of the term ‘brain death’ by the family (OR 2.4; p = 0.002), and consulting a donation expert prior to the donation request (OR 3.4; p < 0.001).

Conclusions

Our study showed that decoupling the organ donation conversation from the conversation about futility of treatment was associated with lower family consent rates. Comprehension of the concept of brain death by the family and consultation with a transplant coordinator before the organ donation request by the physician could positively influence consent rates.

Electronic supplementary material

The online version of this article (10.1007/s12028-019-00678-8) contains supplementary material, which is available to authorized users.

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.

Barriers to Brain Death Notifications From Emergency Departments

PURPOSE

Emergency departments (EDs) are a new focus of interest in recent years as a possible solution for increasing organ donations, as, EDs are full of missed opportunities. In this study, we aimed to determine the barriers to the identification and referral by emergency medicine physicians (EMPs) of potential brain death (BD) cases.

MATERIALS AND METHODS

The participants of the study consist of 252 EMPs who had answered the questionnaire sent via e-mail.

FINDINGS

The following causes were found in the questionnaire: (1) negative attitudes and lack of knowledge about organ donation in society (63.1%); (2) religious beliefs (57.5%); (3) family refusal (57.1%); (4) disruption of bodily integrity (45.6%); (5) inadequate knowledge of doctors (50.4%); (6) difficulties in predicting the prognosis of the patient and diagnosing BD in EDs (40.1%); (7) fear of negative reactions from relatives of patients (37.7%); (8) the absence of an organ procurement unit (OPU) (36.5%); (9) lack of ideal candidates (27%); (10) increased workload in EDs (23.8%); and (11) fear of legal problems arising (23.8%). Of the participants, 42.9% stated that there was an OPU in their hospital. Of the participants, 15.8% reported that they have good communication with the OPU.

CONCLUSIONS

Negative attitudes and lack of knowledge about organ donation in society, religious beliefs, inadequate knowledge of EMPs, and the absence of an OPU in hospitals are important barriers to organ donor notification from EDs. Increasing social awareness and increasing of the level of knowledge of EMPs and close cooperation between OPU and EDs will significantly contribute to the increase of organ donor notifications from EDs.

Evaluation of the quality of the communication and emotional support during the donation procedure: The use of the donor family questionnaire (DFQ)

PURPOSE

A multi-centric study in Intensive Care units (ICU) and Emergency departments (ED) was designed to evaluate whether the provided communication and emotional support to the family in the context of organ donation met the international recommendations of the European Donor Hospital Education Program (EDHEP).

MATERIALS AND METHODS

Using a participatory approach and focus groups, a questionnaire was constructed: Donor Family questionnaire (DFQ). The questionnaire was distributed to 203 families. The data were analysed on item level.

RESULTS

Sixty-four families participated, and 89% considered the communication as tactful. Only 24.1% had a separate conversation about passing and donation, which is the recommendation. 88.5% reported they could count on emotional support in the first phase on the ICU/ED. This dropped during the parting phase and the aftercare. The physician is perceived as the most active caregiver in the emotional support during the entire procedure.

CONCLUSIONS

The DFQ is a useful instrument to evaluate the donor procedure. The physician is important in the first phases of the donor procedure for the medical explanation. Other disciplines could be more involved in the following phases to assure enough emotional support, but this issue requires further exploration.

A mixed-methods study of organ donation in the intensive care unit: 22 actionable practices to improve organ donation

PURPOSE

Rates of organ donation vary between otherwise comparable intensive care units (ICUs) suggesting that the process of donation must vary between ICUs. The purpose of this study was to describe the process of organ donation from the perspective of ICU staff, identify important drivers of successful donation, and develop strategies to improve the process of donation.

METHODS

We conducted qualitative interviews with 32 ICU staff, including physicians, nurses, and respiratory therapists, using an interview guide developed from previous studies on organ donation. Using a qualitative descriptive approach, we coded interviews using qualitative content analysis. We integrated findings from the interviews in a mixed-methods analysis with previously published data from a document analysis and cross-sectional survey to identify practices that may enhance organ donation in the ICU.

RESULTS

Five major themes important to the organ donation process emerged from the interviews: i) staff relationship with organ donation coordinators; ii) standardized processes; iii) ICU staff beliefs; iv) integration of donation and high quality end-of-life care; v) feedback and staff support. In the mixed-methods analysis, we identified 22 actionable practices to enhance the process of organ donation in the ICU.

CONCLUSION

Incorporating the perspectives of ICU staff, we were able to identify 22 practice changes that may have a significant cumulative impact on donation outcomes. Future research is required to evaluate whether these findings account for the variability of donation rates between otherwise comparable ICUs.

[Communication with relatives]

BACKGROUND

Communication with relatives is a central part of the decision-making process. In the absence of the patient's direct consent to a potential organ donation, the next of kin must provide information about a potential wish to donate and give permission in the context of an extended consent solution. At the same time, family members must also cope with the death of a loved one.

OBJECTIVE

To determine how relatives can be optimally supported during the decision-making process.

MATERIALS AND METHODS

Narrative review.

RESULTS

In the context of potential or confirmed irreversible brain death, communication with family members or legal representatives serves to deliver bad news as well as to determine whether the patient had a wish to donate his/her organs and to clarify the resultant steps. Communication strategies such as the SPIKES or VALUE models provide emotional and cognitive support for relatives and strengthen clinicians' communication skills. Clinicians' behavior towards patients, deceased, and next of kin may influence relatives' decision-making; respectful and competent behavior seems to contribute towards relatives granting permission for organ donation.

CONCLUSION

Clinicians must be trained and skilled in communication strategies which are used in critical situations to provide emotional support to relatives during the organ donation decision-making process. Relatives are more likely to achieve a satisfying and sustainable decision if a strong relationship exists between clinicians and relatives based on information giving, openness, trust, and empathy.

Changing Attitudes of Medical Students Regarding Organ Donation from a University Medical School in Turkey

Background

Doctors have an important role in increasing the number of organ donors. This study aimed to investigate the changing attitudes of medical students regarding organ donation, from first-year medical students (FYMS) to sixth-year medical students (SYMS) at a university medical school in Turkey.

Material/Methods

One hundred first-year medical students and 100 sixth-year medical students participated in the study. A four-part questionnaire was designed for the study, with a response rate of 66.8%.

Results

Completed study questionnaires showed that organ donation was considered by 46% of first-year medical students and 60% of sixth-year medical students, but an organ donor card was signed by only 8% and 10%, respectively. Information about organ donation had been sought, mainly from social media, by 72% of first-year medical students, and 55% of sixth-year medical students. Regarding their views on organ donation of their relatives, 78% of first-year medical students and 86% of sixth-year medical students were influenced by the opinions of their families and community. When asked about brain death, 50% of first-year medical students and 12% of sixth-year medical students believed it to be a potentially reversible condition, or were uncertain of the definition.

Conclusions

During six years of training in a university medical school in Turkey, there was only a slight increase in the number of students who were willing to become organ donors and there was a lack of formal education regarding organ donation. Therefore, urgent improvements are required in the education of doctors and society regarding organ donation.

What do people agree to when stating willingness to donate? On the medical interventions enabling organ donation after death

Purpose of the study

The purpose of this study is to explore donor relatives’ experiences of the medical interventions enabling organ donation, as well as to examine the donor relatives’ attitudes towards donating their own organs, and whether or not their experiences have influenced their own inclination to donate.

Methods

The experiences of donor relatives were explored via in-depth interviews. The interviews covered every step from the deceased family member being struck by a severe bleeding in the brain till after the organ recovery, including the medical interventions enabling organ donation. The interviews were analysed through qualitative and quantitative content analysis.

Results

Brain death and organ donation proved to be hard to understand for many donor relatives. The prolonged interventions provided after death in order to enable organ donation misled some relatives to believe that their family member still was alive. In general, the understanding for what treatment aimed at saving the family member and what interventions aimed at maintaining organ viability was low. However, most donor relatives were either inspired to, or reinforced in their willingness to, donate their own organs after having experienced the loss of a family member who donated organs.

Conclusions

There is a need for greater transparency regarding the whole chain of events during the donation process. Yet, having experienced the donation process closely did not discourage the donor relatives from donating their own organs–but rather inspired a willingness to donate. This indicates an acceptance of the medical procedures necessary in order to enable organ donation after death.

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.

Organ donation and transplantation: Awareness and roles of healthcare professionals-A systematic literature review

AIMS AND OBJECTIVES

To examine the role of healthcare professionals in the organ donation and transplantation process.

BACKGROUND

Globally, there remains a perennial disequilibrium between organ donation and organ transplantation. Several factors account for this disequilibrium; however, as healthcare professionals are not only strategically positioned as the primary intermediaries between organ donors and transplant recipients, but also professionally situated as the implementers of organ donation and transplantation processes, they are often blamed for the global organ shortage.

DESIGN

Mixed-method systematic review using the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols 2015 checklist.

METHODS

Databases were searched including CINAHL, MEDLINE, Web of Science and EMBASE using the search terms "organ donation," "healthcare professionals," "awareness" and "roles" to retrieve relevant publications.

RESULTS

Thirteen publications met the inclusion criteria. The global organ shortage is neither contingent upon unavailability of suitable organs nor exclusively dependent upon healthcare professionals. Instead, the existence of disequilibrium between organ donation and transplantation is necessitated by a web of factors. These include the following: healthcare professionals' attitudes towards, and experience of, the organ donation and transplantation process, underpinned by professional education, specialist clinical area and duration of professional practice; conflicts of interests; ethical dilemmas; altruistic values towards organ donation; and varied organ donation legislations in different legal jurisdictions.

CONCLUSION

This review maintains that if this web of factors is to be adequately addressed by healthcare systems in different global and legal jurisdictions, there should be sufficient organs voluntarily donated to meet all transplantation needs.

RELEVANCE TO CLINICAL PRACTICE

There is a suggestion that healthcare professionals partly account for the global shortage in organ donation, but there is a need to examine how healthcare professionals' roles, knowledge, awareness, skills and competencies might impact upon the organ donation and transplantation process.

Potential donor families' experiences of organ and tissue donation-related communication, processes and outcome

We aimed to describe the experiences of families of potential organ and tissue donors eligible for donation after circulatory death or brain death. Forty-nine family members of potential donors from four Melbourne hospitals were interviewed to assess their experiences of communication, processes and the outcomes of donation. Interviews were recorded, transcribed verbatim and analysed thematically. Families expressed a range of perspectives on themes of communication, hospital processes and care, the processes of consent and donation and reflected on decisions and outcomes. They expressed satisfaction overall with communication when receiving bad news, discussing death and donation. Honest and frank communication and being kept up-to-date and prepared for potential outcomes were important aspects for families, especially those of post circulatory death donors. Participants reported high levels of trust in healthcare professionals and satisfaction with the level of care received. Many donor families indicated the process was lengthy and stressful, but not significantly enough to adversely affect their satisfaction with the outcome. Both the decision itself and knowing others' lives had been saved provided them with consolation. No consenting families, and only some non-consenting families, regretted their decisions. Many expressed they would benefit from a follow-up opportunity to ask questions and clarify possible misunderstandings. Overall, while experiences varied, Australian families valued frank communication, trusted health professionals, were satisfied with the care their family member received and with donation processes, despite some apparent difficulties. Family satisfaction, infrequently assessed, is an important outcome and these findings may assist education for Australian organ donation professionals.

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.