Corneal donation within palliative care: a review of the literature

Views of admitted palliative care patients and their clinicians on corneal donation discussions: a qualitative content analysis of semi-structured interviews

BACKGROUND

There is a severe shortage of corneas for donation, globally, for transplantation and research purposes. One group of individuals who could potentially be donors are those who die within the inpatient palliative care unit. The aim of the study was to understand clinician and patient perceptions of corneal donations and discussion of donation in palliative care units.

METHODS

A qualitative design was utilised with data collected through semi-structured interviews and analysed using qualitative content analysis. A total of 46 interviews were undertaken involving inpatient palliative care unit patients (19) and clinicians (27) in three major inpatient palliative care units in South Australia.

RESULTS

Very few patient participants reported being asked about corneal donations during their time in palliative care. Most inpatient palliative care unit clinicians did not raise the topic as they felt other areas of care took precedence. Inpatient palliative care unit patients thought if inpatient palliative care unit clinicians did not raise the topic, then it was not important. There were some differences between patient and clinician views, such as preference about who raises the possibility of donation and when the discussion might occur.

CONCLUSIONS

Findings suggest that patients are receptive to discussing corneal donations, but clinicians are not initiating these. This is a missed opportunity for donors and potential recipients. We recommend that clinicians routinely discuss eye donation as part of palliative care.

Eye donation from palliative and hospice care contexts: the EDiPPPP mixed-methods study

Background

Over 2 million people in the United Kingdom are living with sight loss with costs to the United Kingdom economy reported as £4.34 billion annually. Conditions that lead to sight loss and impaired vision can be treated if eye tissue is available for corneal transplantation, reconstructive surgery and research into eye diseases. Supply of eye tissue (only available via eye donation) is currently insufficient to meet demand; therefore, new routes are needed. Hospice and hospital-based Palliative Care Services have been reported as potential donation sources of this tissue.

Objectives

To: (1) scope the size and clinical characteristics of the potential eye donation population from research sites; (2) map the donation climate of each research site; (3) identify factors that enable or challenge service providers to consider the option of eye donation from a local and national perspective; (4) identify service users' views regarding the option of eye donation and the propriety of discussing eye donation; and (5) develop and pilot an empirically based intervention designed to change behaviours in relation to eye donation.

Design

A 36-month mixed-methods, multicentre study undertaking three work packages.

Settings

Three hospice care and three hospital-based palliative care services situated in the North, Midlands and the South of England (one service of each type per region).

Participants

Work package 1 - 105 service providers. Work package 2 - 62 service users, and 156 service providers in the national survey. Work package 3 - 21 expert consultees (patient and public involvement, cross discipline).

Data sources

Scoping review, retrospective note review, qualitative interviews/focus groups, participant observation, secondary analysis of primary data, national survey, transparent expert consultation.

Results

Potential: The retrospective notes review demonstrated that of 1199 deceased patients' notes, 553 (46%) patients met the criteria for eye donation (56%, n = 337 in hospice care service settings and 36%, n = 216 in hospital palliative care service). Practice: Less than 4% of all cases agreed as eligible for donation had been approached or referred for eye donation. Eye donation is not currently an embedded practice at local and national levels. Perceptions: Service providers were motivated to discuss eye donation but lacked opportunity and capability. Service users were willing and able to hold conversations about eye donation but were not aware of the option and had not had the option discussed with them. Preferences: Service users wanted to be offered the option of eye donation, and service providers wanted bespoke education and training related to eye donation. Evaluation of the developed intervention STEPS - Support Toolkit for Eye donation in Palliative care Settings will follow implementation of the full intervention (expected to begin in October 2022).

Limitations

Due to the significant impact of the COVID-19 pandemic on clinical sites, partner organisations and national service providers, only two elements of the developed intervention have been pilot tested for proof of concept and the response rate to the national survey was low (8%).

Conclusions

Significant potential exists for eye donation from hospice care and hospital palliative care services; however, individual and organisational behaviour as well as information system-based changes are needed to maximise this potential.

Future work

Evaluation of the STEPS - Support Toolkit for Eye donation in Palliative care Settings; Research exploring the wider public knowledge and views regarding eye donation; research exploring the use of language by National Health Service Blood and Transplant-Tissue and Eye Services in their public-facing infographics, communications and campaigns (specifically the use of the term eye donation).

Trial registration

This trial is registered as ISRCTN14243635: Eye donation from palliative care and hospice care settings.

Funding details

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (17/49/42) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 20. See the NIHR Journals Library website for further project information.

Why is corneal donation so rare in children's hospices? A survey of multidisciplinary team members attitudes, knowledge, practice, and experience

BACKGROUND

Corneal donation is a rare event among pediatric patients dying in children's hospices in Italy. Previous research suggests that lack of knowledge and negative attitude of Health Care Professionals (HCPs) are the most relevant factors for low donation rates in hospice, rather than patient ineligibility or public refusal. We conducted a national survey to explore children's hospice staff's knowledge and attitude toward corneal donation, to survey HCPs confidence in discussing the subject with patients and families, to investigate whether staff members receive specific training about corneal donation and its potential impact on the willingness to raise the topic with patients and families.

METHODS

An anonymous web-based survey with multiple-choice responses was delivered to the team members of seven Italian children's hospices to test their knowledge and attitude about corneal donation.

RESULTS

Of the seven children's hospices approached, four agreed to participate with a response rate of 48.5%. Among respondents, 70% declared that they had not received specific training about corneal donation. Results of statistical analysis showed that there were no significant differences in responses between trained and non-trained staff and among the different professionals (nurses, doctors, psychologists, AND social workers) regarding confidence in discussing the subject with patients and families.

CONCLUSIONS

In our sample of HCPs working in Italian children's hospices, there was no difference in self-reported trust between professionals who reported receiving specific cornea donation training and those who did not. It is remarkable that training on corneal donation was endorsed by a minority of the sample.

A qualitative study using semi-structured interviews of palliative care patients' views on corneal donation and the timing of its discussion

BACKGROUND

Corneal transplantation can lead to sight restoration, but globally there is a donor shortage. Many palliative care patients can donate their corneas but think they are ineligible due to comorbidities. Healthcare professionals are reluctant to broach the topic, but studies have shown that relatives would be upset if they were not offered this chance. There is no existing research involving patients.

AIM

To understand the views and feelings of patients in palliative care settings towards corneal donation and explore their opinions regarding the timing of its discussion.

DESIGN

This is an exploratory study based at one UK palliative care unit. A census sampling method was used. Nine participants took part in semi-structured interviews and thematic analysis was undertaken.

RESULTS

Themes found included altruistic motivation and the value of sight. Family views were important, but the influence on final decisions varied. The timing of discussion relative to the illness trajectory was important; patients want to be able to engage fully in conversations and had concerns about not being able to think clearly when closer to death. Participants also associated discussion of donation as an indication of a poor prognosis. Patients prefer face-to-face discussions with someone whom they had a close rapport. Many had misconceptions about eligibility.

CONCLUSION

This is the first study to engage directly with palliative care patients and to establish their views on the timing of corneal donation discussions. Patients are willing to discuss donation, and further exploration of patient views in this area should be undertaken.

Family and Staff Responses to a Scripted Introduction to Tissue Donation for Hospice Inpatients on Admission

Purpose

To implement and evaluate a change in practice regarding the timing of introducing donation for inpatient hospice staff and families whereby scripted information about tissue/organ donation was given by the nurse upon admission as part of the normal admission process and then repeated at the time of death per usual protocol.

Methods

Data were collected from staff for 6 months (January to June 2006). The hospice staff agreed to complete a donor services comment log at the admission and at the death of each patient to relay any concerns with the change in practice rather than just writing down complaints as was the previous practice. Data were supplemented with staff input during regular meetings. Donation rates were compiled as usual for 6 months and compared with the preceding 6 months.

Results

Data were analyzed from the written interactions. Trends identified were limited by the small sample size. The results confirmed that both nursing staff and potential donor families supported the change in practice. No families or staff called the organ procurement organization with complaints during the 6-month period. Corneal donations increased from 2 to 7, a 250% increment for the 6-month period.

Conclusion

The assumption that discussing donation when hospice patients are admitted will lead to a decrease in donation is not supported by the results of this study. The findings suggest the need for a methodologically rigorous, theoretically driven examination of hospice donor families' reactions to the introduction of donation at admission and the subsequent decrease in stress and increase in donation rates.

Obstacles to corneal donation amongst hospice inpatients: a questionnaire survey of multi-disciplinary team member's attitudes, knowledge, practice and experience

BACKGROUND

Corneal donation is a sight restoring procedure. Internationally demand exceeds supply. It is a tissue that palliative care patients may be able to donate, yet donation rates from this group are low.

AIM

To explore the attitudes, knowledge, practice, and experience of corneal donation from hospice staff with direct clinical contact with patients.

DESIGN

Anonymous paper questionnaire with fixed response and free text components.

SETTING/PARTICIPANTS

Questionnaires were delivered to 704 clinical multi-disciplinary team members in 12 hospices within the Yorkshire Palliative Medicine Regional Learning Group, UK.

RESULTS

434 completed questionnaires were received. Most respondents believed that corneal donation is a rewarding opportunity of which patients and families should be aware, but over 90% of respondents rarely or never raised the topic, and only 33% felt that it was part of their role. Key reasons for not engaging in discussions were: concerns about the impact of the discussion on patients and families, a belief held by hospice staff that they lacked essential knowledge, negative experiences of corneal donation, concern about enucleation, a perception that donation is not part of hospice culture, low levels of training and the personal significance of eyes.

CONCLUSIONS

Despite positive staff attitudes towards corneal donation, many barriers to discussing donation were identified, which may reduce donation rates. This could be improved by local policies encompassing further education, prompts in documentation and availability of leaflets.

Eye donation in Sydney metropolitan palliative care units

Organ donation is generally accepted within the medical profession as a beneficial practice with demand continuing to exceed supply. For patients who are dying from cancer opportunities for organ donation are generally limited to eye donation. Between July 1, 2006 and 30 June 2007 over 2000 deaths occurred in nine palliative care units (PCUs) in metropolitan Sydney. Of these deaths only 50 patients became eye donors. Donors came from only four of the nine inpatient PCUs. Of these four, two provided nearly 90% of the eye donations. Only two PCUs in the Sydney metropolitan area provide significant numbers of eye donations. There are likely to be a number of factors contributing to the low rate of eye donation from PCUs and these are discussed in detail.