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

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.

"Effective" Requesting: A Scoping Review of the Literature on Asking Families to Consent to Organ and Tissue Donation

BACKGROUND

Families are often asked to consent to the donation of their deceased relative's organs or tissues. These end-of-life conversations are important because they affect consent rates as well as the psychological impact of the decision for families. This scoping review of the literature on requesting family consent was prepared to support of the development of leading practice recommendations for end-of-life conversations with families of potential donors. A scoping review maps research activity in a field across a range of commentary and empirical study designs but does not attempt meta-synthesis of empirical data or quality assessment.

METHODS

We performed a scoping review of the peer-reviewed literature from January 2000 to February 2015 on the questions of what constitutes an "effective" request and the factors that affect consent rates and family satisfaction with their decision and the process. This review includes a final set of 168 articles addressing (a) whether, when, and how to ask families for consent to donation or (b) characteristics of families or decedents that affect families' decisions or family satisfaction with their decisions.

RESULTS

Six main themes were identified: (1) the objectives of requesting and encouraging family consent to donation, (2) the effect of the donation decision on family well-being, (3) the process of requesting family consent, (4) the impact of the quality of the care for the deceased and for the family, (5) the content and manner of the request for family consent, and (6) the characteristics of the family and deceased that affect the request for family consent.

CONCLUSION

This scoping review found that there is a large literature on how to modify the process and manner of the request to increase family consent rates. Another important line of inquiry focuses on the psychological impact of the decision on the family. Although a scoping review does not attempt to synthesize results or draw evidence-based conclusions, the literature generally supports the intuitive expectations that compassionate and respectful care for the deceased and family, listening for and addressing family concerns, and an attitude to donation that is positive (but not solely procurement-focused) and is best for both consent rates and family well-being. Although the presumption is often that the primary objective of asking for family consent is to secure consent and donation, some ethical commentary on requesting consent emphasizes that this objective must be balanced with the parallel obligation to protect the psychological well-being of families. This places some constraints on the approaches used in family consent discussions.

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.