Evaluating the "family veto" of consent for organ donation

Parents' Views on Autopsy, Organ Donation, and Research Donation After Neonatal Death

Importance

Parents who experience neonatal loss have the option to participate in autopsy, organ donation, and research donation. However, clinicians are uncomfortable discussing autopsy and may not be aware of research and organ donation opportunities.

Objective

To capture the perspectives of parents who had experienced neonatal loss about autopsy, organ donation, and research donation.

Design, Setting, and Participants

This qualitative study used virtual focus groups with parents who attended a local bereavement support group in the US. Participants were recruited from Helping After Neonatal Death, a support group with a local chapter. Participants self-selected from an email request if they met the following criteria: aged 18 years or older, English speaking, at least 6 months elapsed since neonatal death, and access to a video conference device with internet. Focus groups took place between April and September 2021. The recorded sessions were analyzed using a grounded theory-informed approach by the research team that included parents with experience of neonatal loss. Data were analyzed from December 2021 through December 2022.

Results

A total of 14 mothers engaged in the focus group; 9 (75%) were aged 30 to 39 years, and 8 (66%) were White. The mothers were overall well educated. The first main theme grew from the lived experience of neonatal loss, specifically the importance of offering all parents the option to donate, rather than prejudging who would or would not be interested. Parents of neonates who die have few opportunities to parent that child and make loving decisions for them. Participants emphasized that the conversation about autopsy, organ donation, and research donation, albeit difficult, can offer a meaningful parenting experience. A second main theme that emerged related to how organ or tissue donation could provide additional meaning to a child's life. These choices contributed to building a legacy to honor their child's memory, which also helped with grief and coping with their loss. A third theme included recommendations to clinicians and health systems for improving communication, including written information for parents and communication training for health care professionals.

Conclusions and Relevance

In this qualitative study, parents who experienced neonatal loss endorsed the importance of offering parents the choice of autopsy, organ donation, or research donation with skillful and empathetic communication. They provided practical recommendations to improve communication and empower families.

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.

Evaluating Organ Donation Decision in ICU Patients’ Families by Analytic Network Process Approach

The imbalance between supply and demand for organs has been a global crisis, despite the efforts of transplant coordinators from healthcare institutions to promote donor registration. Because the patient's family has legal rights over the patient's remains, they can easily undermine any efforts spent on organ procurement by simply refusing the patient's consent before death in practice. Most related studies seldom mention the decision-making on organ donation from patients' families. The objectives of this study are to find what are the priorities of those factors acting as the pillars of organ donation by patients' families. This study applied the analytic network process (ANP) to the prioritization factors contributing toward the willingness of families to donate organs of intensive care unit patients. The purposive sampling method used structured questionnaires and ANP questionnaires to enroll 180 patients' families from five intensive care units who met the criteria in the regional teaching hospital of southern Taiwan. Through the ANP analysis, it was found that when family members made organ donation decisions, the weights of the four domains are as follows: psychology—47.6%, externality—20.3%, spirituality—19.7%, and physiology—12.3%. The main decision-making factors that influenced the weighting factors were “attitude” (31.5%), “physician's experience” (0.88%), “religion” (19.3%), and “organ selection” (31.9%). These results could assist organ donation teams to take the best strategies for persuading people to agree with organ donation and formulating an individual organ donation plan.

Transitions in decision-making authority at the end of life: a problem of law, ethics and practice in deceased donation

Where a person is unable to make medical decisions for themselves, law and practice allows others to make decisions on their behalf. This is common at the end of a person's life where decision-making capacity is often lost. A further, and separate, decision that is often considered at the time of death (and often preceding death) is whether the person wanted to act as an organ or tissue donor. However, in some jurisdictions, the lawful decision-maker for the donation decision (the 'donation decision-maker') is different from the person who was granted decision-making authority for medical decisions during the person's life. To date, little attention has been given in the literature to the ethical concerns and practical problems that arise where this shift in legal authority occurs. Such a change in decision-making authority is particularly problematic where premortem measures are suggested to maximise the chances of a successful organ donation. This paper examines this shift in decision-making authority and discusses the legal, ethical and practical implications of such frameworks.

Family veto in organ donation: the experiences of Organ and Tissue Donation Coordinators in Ontario

PURPOSE

In Ontario, an individual's registered wish for organ donation is legally valid consent following death. Family veto occurs when the deceased donor's substitute decision-maker (SDM) overrides this consent to donate, evoking a legal and ethical conflict. The objective of this study was to examine the experiences of Organ and Tissue Donation Coordinators (OTDCs) working with SDMs who vetoed a deceased donor's consent for organ donation.

METHODS

Qualitative focus groups were conducted with ten OTDCs in Ontario, Canada who reported experience with family veto. An interpretative phenomenological approach informed data analysis. Themes emerged through team consensus and were further refined through collaborative and reflexive engagement.

RESULTS

Four themes emerged regarding family veto: 1) the significance of the OTDC role, 2) emotional distress and the "understandable" family veto, 3) barriers contributing to family veto, and 4) strategies towards a culture of organ donation. Findings highlighted the importance of patient advocacy in the OTDC role, while revealing the emotional distress of experiencing family veto. OTDCs identified timing and healthcare providers' perceived ambivalence toward organ donation as critical barriers to family authorization. Value-positive language, role reframing, and increased education were offered as strategies to address these barriers and reduce family veto.

CONCLUSION

This study highlights important considerations about organ donation authorization processes in Ontario. Findings support practice changes towards reducing family veto and further research nationally. Collaborations with key stakeholders are warranted to align healthcare practices, donation policies, and education initiatives towards a shared goal of increasing organ donation.

Defining Quality Criteria for Success in Organ Donation Programs: A Scoping Review

Background

Well-established performance measures for organ donation programs do not fully address the complexity and multifactorial nature of organ donation programs such as the influence of relationships and organizational attributes.

Objective

To synthesize the current evidence on key organizational attributes and processes of international organ donation programs associated with successful outcomes and to generate a framework to categorize those attributes.

Design

Scoping Review using a mixed methods approach for data extraction.

Setting

Databases included PubMed, CINAHL, Embase, LILACS, ABI Business ProQuest, Business Source Premier, and gray literature (organ donation association websites, Google Scholar-first 8 pages), and searches for gray literature were performed, and relevant websites were perused.

Sample

Organ donation programs or processes.

Methods

We systematically searched the literature to identify any research design, including text and opinion papers and unpublished material (research data, reports, institutional protocols, government documents, etc). Searches were completed on January 2018, updated it in May 2019, and lastly in March 2020. Title, abstracts, and full texts were screened independently by 2 reviewers with disagreements resolved by a third. Data extraction followed a mixed method approach in which we extracted specific details about study characteristics such as type of research, year of publication, origin/country of study, type of journal published, and key findings. Studies included considered definitions and descriptions of success in organ donation programs in any country by considering studies that described (1) attributes associated with success or effectiveness, (2) organ donation processes, (3) quality improvement initiatives, (4) definitions of organ donation program effectiveness, (5) evidence-based practices in organ donation, and (6) improvements or success in such programs. We tabulated the type and frequency of the presence or absence of reported improvement quality indicators and used a qualitative thematic analysis approach to synthesize results.

Results

A total of 84 articles were included. Quantitative analysis identified that most of the included articles originated from the United States (n = 32, 38%), used quantitative approaches (n = 46, 55%), and were published in transplant journals (n = 34, 40.5%). Qualitative analysis revealed 16 categories that were described as positively influencing success/effectiveness of organ donation programs. Our thematic analysis identified 16 attributes across the 84 articles, which were grouped into 3 categories influencing organ donation programs' success: context (n = 39, 46%), process (n = 48, 57%), and structural (n = 59, 70%).

Limitations

Consistent with scoping review methodology, the methodological quality of included studies was not assessed.

Conclusions

This scoping review identified a number of factors that led to successful outcomes. However, those factors were rarely studied in combination representing a gap in the literature. Therefore, we suggest the development and reporting of primary research investigating and measuring those attributes associated with the performance of organ donation programs holistically.

Trial Registration

Not applicable.

Survey of Canadian intensivists on physician non-referral and family override of deceased organ donation

PURPOSE

Intensive care physicians play an important role in the identification and referral of potential organ donors in Canada. Nevertheless, little is known about intensivists' attitudes or behaviours in situations where families override previously expressed consent to donate; nor why physicians elect not to refer patients who are potential donors to provincial organ donation organizations (physician non-referral).

METHODS

We integrated questions regarding family override and physician non-referral into an online, self-administered survey of Canadian intensivists. We report results descriptively.

RESULTS

Fifty percent of targeted respondents (n = 550) participated. Fifty-five percent reported having witnessed family override situations and 44% reported having personally not referred patients who were potential donors. Fifty-six percent of respondents stated they would not pursue donation in the face of family override; 2% stated they would continue with the donation process. Fear of loss of trust in the donation system (81%) and obligation to respect the grief and desires of surrogate decision makers (71%) were frequently reported reasons to respect family override requests. Respondents who chose not to refer patients often did so based on organ dysfunction they assumed would preclude donation (59%), or a perception that the family was too distressed to consider donation (42%). No respondents reported that personally held beliefs against organ donation influenced their decision.

CONCLUSION

Physicians caring for patients who are potential organ donors commonly encounter both family override and physician non-referral situations. Knowledge translation of optimal practices in identification and referral could help ensure that physician practices align with legal requirements and practice recommendations.

Exploring the experiences and perspectives of substitute decision-makers involved in decisions about deceased organ donation: a qualitative study protocol

INTRODUCTION

In Canada, deceased organ donation provides over 80% of transplanted organs. At the time of death, families, friends or others assume responsibility as substitute decision-makers (SDMs) to consent to organ donation. Despite their central role in this process, little is known about what barriers, enablers and beliefs influence decision-making among SDMs. This study aims to explore the experiences and perspectives of SDMs involved in making decisions around the withdrawal of life-sustaining therapies, end-of-life care and deceased organ donation.

METHODS AND ANALYSIS

SDMs of 60 patients admitted to intensive care units will be enrolled for this study. Ten hospitals across five provinces in Canada in a prospective multicentre qualitative cohort study. We will conduct semistructured telephone interviews in English or French with SDMs between 6 and 8 weeks after the patient's death. Our sampling frame will stratify SDMs into three groups: SDMs who were not approached for organ donation; SDMs who were approached and consented to donate and SDMs who were approached but did not consent to donate. We will use two complementary theoretical frameworks-the Common-Sense Self-Regulation Model and the Theoretical Domains Framework- to inform our interview guide. Interview data will be analysed using deductive directed content analysis and inductive thematic analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Centre Hospitalier de l'Université de Montréal Research Ethics Board. The findings from this study will help identify key factors affecting substitute decision-making in deceased organ donation, reasons for non-consent and barriers to achieve congruency between SDM and patient wishes. Ultimately, these data will contribute to the development and evaluation of tools and training for healthcare providers to support SDMs in making decisions about organ donation.

TRIAL REGISTRATION NUMBER

NCT03850847.

The Role of the Family in Deceased Organ Procurement: A Guide for Clinicians and Policymakers

Families play an essential role in deceased organ procurement. As the person cannot directly communicate his or her wishes regarding donation, the family is often the only source of information regarding consent or refusal. We provide a systematic description and analysis of the different roles the family can play, and actions the family can take, in the organ procurement process across different jurisdictions and consent systems. First, families can inform or update healthcare professionals about a person's donation wishes. Second, families can authorize organ procurement in the absence of deceased's preferences and the default is not to remove organs, and oppose donation where there is no evidence of preference but the default is to presume consent; in both cases, the decision could be based on their own wishes or what they think the deceased would have wanted. Finally, families can overrule the known wishes of the deceased, which can mean preventing donation, or permitting donation when the deceased refused it. We propose a schema of 4 levels on which to map these possible family roles: no role, witness, surrogate, and full decisional authority. We conclude by mapping different jurisdictions onto this schema to provide a more comprehensive understanding of the consent system for organ donation and some important nuances about the role of families. This classificatory model aims to account for the majority of the world's consent systems. It provides conceptual and methodological guidance that can be useful to researchers, professionals, and policymakers involved in organ procurement.

Family veto in organ donation in Canada: framing within English-language newspaper articles

BACKGROUND

Because organ transplantation relies on public support for donation, an analysis of public discourse around organ donation is essential. We investigated the portrayal of family veto - when a family overrides the deceased person's prior legally executed wishes to donate - in Canadian news media.

METHODS

Using the Canadian Newsstream database, we identified articles published in English-language newspapers addressing family veto between 2000 and 2016. Guided by the theoretical perspectives of framing of media effects, we conducted a systematic content analysis of the articles to examine how the Canadian media framed family veto. An initial in-depth analysis of the data set in which themes and patterns were captured and recorded identified coding categories, including primary framing of family veto, prevalence, reasons, ethical or legal concerns and overall tone of the article. Two coders analyzed the data set to ensure intercoder reliability.

RESULTS

A total of 133 relevant articles were identified. Family veto was framed predominantly as something that should not be allowed (81 articles [60.9%]) and as a reality that is little understood outside the transplantation community (45 [33.8%]). One-quarter of the articles (32 [24.1%]) highlighted ethical principles of autonomy and justice associated with family veto. Family veto was represented as a stumbling block in the present organ donation system, with most publications (107 [80.4%]) calling for change. There were differing interpretations of organ donation legislation, with 82 articles (61.6%) erroneously stating or suggesting that existing legislation permits family veto.

INTERPRETATION

Family veto in organ donation was portrayed predominantly negatively. Many publications reflected a misunderstanding of the law concerning this issue. Although the framing of family veto highlighted important ethical and legal concerns as well as practice and policy considerations, research is needed to enhance the understanding of family veto in organ donation.

Ethical Challenges and the Donation Physician Specialist: A Scoping Review

Deceased donation medicine involves unique ethical challenges. Physicians who are focused on deceased donation medicine as part of their practice can expect to encounter these challenges. The goal of this review is to identify and describe these challenges, highlight existing guidelines and policy regarding the management of these challenges and to describe how the donation physician role might promote ethical practice in deceased donation medicine. Themes of discussion include: communication with families, interprofessional conflict, donation physician personal characteristics, donation clinical processes, health resource allocation, research and education, and remuneration. The information presented in this review can be used to inform development of recommendations and guidelines for the management of ethical challenges encountered by donation physicians.