Optimal transplant education for recipients to increase pursuit of living donation

Decision support needs of kidney transplant candidates regarding the deceased donor waiting list: A qualitative study and conceptual framework

BACKGROUND

Kidney transplant candidates face complex decisions about transplant options such as living donation or acceptance of lower quality kidneys. We sought to characterize knowledge and decision support needs regarding kidney transplant outcomes and options.

METHODS

We conducted 10 interviews and four focus groups of 28 adult kidney transplant candidates from two centers in Minnesota. Transcripts were analyzed thematically using a grounded theory approach.

RESULTS

We identified four themes: First, candidates have a limited understanding of treatment options and demonstrate confusion or a lack of awareness about waiting list outcomes and prognosis. Second, candidates desired frank discussions about likely outcomes and individualized prognosis. Third, emotional barriers impact how patients make informed decisions. Finally, participants relied on the support of family and friends to help process information, and many favored the medical community engaging their family and friends in their medical decisions. These findings were incorporated into a conceptual model to support kidney transplant candidates in medical decision making.

CONCLUSIONS

Transplant candidates had limited understanding about treatment options and outcomes on the kidney transplant waiting list. Individualized risk information and cognitive approaches that recognize how patients process information and balance competing risks may improve informed decision making.

A patient navigator and education program for increasing potential living donors: a comparative observational study

BACKGROUND AND OBJECTIVES

Person-centered clinical environments may promote living donation for patients with end-stage renal disease (ESRD). We implemented an observational study design to explore whether a patient navigator (PN) program with person-centered education in nephrology practice settings could increase potential living donors (PLDs) and, subsequently, increase living transplantation.

DESIGN, SETTING, PARTICIPANTS, AND MEASURES

Patients referred to (N = 4621) and/or transplanted at (N = 950) our transplant center during 2007-2012 were eligible for inclusion. Two analytical study populations were derived from propensity score matched patient groups. Outcomes comprised total PLDs per candidate and living vs. deceased transplantation for recipients.

RESULTS

Multivariable generalized estimating equations logistic regression showed that PN practice candidates were significantly more likely to have an initial inquiry PLD (odds ratio [OR] = 1.21, 95% confidence interval [CI] = 1.01-1.44) and a preliminary screening PLD (OR = 1.27, 95% CI = 1.05-1.54), while there were no significant differences observed in evaluated PLD (OR = 0.94, 95% CI = 0.61-1.45).

CONCLUSIONS

Our results suggest that our person-centered PN program stimulated willingness to seek living transplantation and was associated with a trend toward increased LD.

Living Donor Kidney Transplantation: Improving Education Outside of Transplant Centers about Live Donor Transplantation--Recommendations from a Consensus Conference

Living donor kidney transplantation (LDKT) offers better quality of life and clinical outcomes, including patient survival, compared with remaining on dialysis or receiving a deceased donor kidney transplant. Although LDKT education within transplant centers for both potential recipients and living donors is very important, outreach and education to kidney patients in settings other than transplant centers and to the general public is also critical to increase access to this highly beneficial treatment. In June 2014, the American Society of Transplantation's Live Donor Community of Practice, with the support of 10 additional sponsors, convened a consensus conference to determine best practices in LDKT, including a workgroup focused on developing a set of recommendations for optimizing outreach and LDKT education outside of transplant centers. Members of this workgroup performed a structured literature review, conducted teleconference meetings, and met in person at the 2-day conference. Their efforts resulted in consensus around the following recommendations. First, preemptive transplantation should be promoted through increased LDKT education by primary care physicians and community nephrologists. Second, dialysis providers should be trained to educate their own patients about LDKT and deceased donor kidney transplantation. Third, partnerships between community organizations, organ procurement organizations, religious organizations, and transplant centers should be fostered to support transplantation. Fourth, use of technology should be improved or expanded to better educate kidney patients and their support networks. Fifth, LDKT education and outreach should be improved for kidney patients in rural areas. Finally, a consensus-driven, evidence-based public message about LDKT should be developed. Discussion of the effect and potential for implementation around each recommendation is featured, particularly regarding reducing racial and socioeconomic disparities in access to LDKT. To accomplish these recommendations, the entire community of professionals and organizations serving kidney patients must work collaboratively toward ensuring accurate, comprehensive, and up-to-date LDKT education for all patients, thereby reducing barriers to LDKT access and increasing LDKT rates.

Consensus conference on best practices in live kidney donation: recommendations to optimize education, access, and care

Live donor kidney transplantation is the best treatment option for most patients with late-stage chronic kidney disease; however, the rate of living kidney donation has declined in the United States. A consensus conference was held June 5-6, 2014 to identify best practices and knowledge gaps pertaining to live donor kidney transplantation and living kidney donation. Transplant professionals, patients, and other key stakeholders discussed processes for educating transplant candidates and potential living donors about living kidney donation; efficiencies in the living donor evaluation process; disparities in living donation; and financial and systemic barriers to living donation. We summarize the consensus recommendations for best practices in these educational and clinical domains, future research priorities, and possible public policy initiatives to remove barriers to living kidney donation.

Communication self-efficacy, perceived conversational difficulty, and renal patients' discussions about transplantation

OBJECTIVE

Many patients with chronic and end-stage renal disease (ESRD) have reported difficulties initiating and managing discussions about kidney transplantation, particularly live donor transplantation (LDT). Limited communication has demonstrable impact on patients' access to transplantation, the duration of dialysis treatments, and the length of time awaiting a transplantable kidney. This formative study sought to identify the specific communicative and conversational elements impeding ESRD patients' discussions about transplantation to inform the design of an educational program facilitating transplant-related discussions.

METHODS

From March to July 2012, semi-structured telephone interviews (n=63) were conducted with ESRD patients waitlisted for kidney transplantation at one mid-Atlantic transplant center.

RESULTS

Although 85.7% (n=54) of patients reported holding discussions about transplantation, qualitative analyses of open-ended responses revealed that the majority (66.7%) had limited conversations. Patients reported difficulties managing a variety of logistical and content-related aspects of LDT discussions. Moderate levels of communication self-efficacy were also found (mean=19.2 out of 28); self-efficacy was highest among respondents having held discussions and was significantly related to perceived magnitude of difficulty handling conversational aspects.

CONCLUSION

Results support comprehensive communication skills training for ESRD patients awaiting kidney transplantation.

PRACTICE IMPLICATIONS

Potential topics to be included in such training are discussed.

Comparison of communication and personal characteristics of living kidney donors and a matched quota sample

Deceased organ donation does not meet the need for kidney transplants. Thus, it is important to examine topics relevant to kidney donors such as communication leading to the donation decision and donor characteristics. This study reports personal characteristics and communication leading to the decision to donate among living kidney donors and a demographically matched quota sample. Donors had higher scores for compassion, while non-donors reported more volunteerism. Donors and non-donors did not differ in conversation or conformity orientations of family communication styles. Only 4.7% of donors reported being asked to donate directly. Matched respondents reported feeling more comfortable than unsettled with the idea of being asked directly and indicated a preference to learn of the need directly or indirectly, giving them the option to volunteer. The majority of donors were giving to family members and friends, and the matched sample indicated greater willingness to donate to immediate family members, followed by friends. Practical implications of the findings are offered.

Transplant center provision of education and culturally and linguistically competent care: a national study

Although transplant centers are required to educate patients about kidney transplantation (KT) and living donation (LD), little is known about the educational format, and cultural and linguistic competence necessary for patients to make informed treatment decisions. This study surveyed US transplant administrators about education provided concerning KT and LD and culturally and linguistically competent care. Transplant administrators were invited to participate in an anonymous Internet-based survey about education format, education providers, promoting LD, culturally and linguistically competent care and center characteristics. Most (61%) transplant administrators contacted (N = 280/461) completed the survey. Most administrators (91%) reported that their center provides any type of formal education in their pre-KT evaluation. Education was mostly provided by: nurses (97%), social workers (72%) and surgeons (55%), and predominantly as one-on-one (80%) versus group discussions (60%). Education was primarily delivered through written materials (93%). Written educational materials in Spanish (86%) and the provision of interpreters (82%) were emphasized over educational sessions in Spanish (39%), or employing bilingual (51%) and bicultural staff (39%). Half (55%) promoted LD as the best option. Transplant centers need to take greater efforts to consistently provide appropriate education, promote LD, and provide culturally and linguistically competent care to ensure effective communication with all patients.

Addressing racial and ethnic disparities in live donor kidney transplantation: priorities for research and intervention

One potential mechanism for reducing racial/ethnic disparities in the receipt of kidney transplants is to enhance minorities' pursuit of living donor kidney transplantation (LDKT). Pursuit of LDKT is influenced by patients' personal values, their extended social networks, the health care system, and the community at large. This review discusses research and interventions promoting LDKT, especially for minorities, including improving education for patients, donors, and providers, using LDKT kidneys more efficiently, and reducing surgical and financial barriers to transplant. Future directions to increase awareness of LDKT for more racial/ethnic minorities also are discussed including developing culturally tailored transplant education, clarifying transplant-eligibility practice guidelines, strengthening partnerships between community kidney providers and transplant centers, and conducting general media campaigns and community outreach.

Correlates of support for living donation among African American adults

CONTEXT

Living donation is studied with much less intensity among African Americans than among the general population. Examination of barriers to living donation can lead to effective strategies to educate dialysis patients and their families about this alternative.

OBJECTIVE

To explore the correlates of likelihood of becoming a living donor among community-recruited African American adults.

DESIGN/PARTICIPANTS

Cross-sectional data were gathered via self-administered questionnaire from 425 African American adults, age 18 years and older, who were recruited from 9 churches in Atlanta.

MAIN OUTCOME MEASURES

Self-reported likelihood of becoming a living donor to a close family member, an extended family member or friend, or a stranger.

RESULTS

More than three-quarters of participants were willing to act as living donors to a close family member or spouse and two-thirds to friends or extended family. For likelihood of donating to a friend or extended family member, only willingness to engage in deceased donation was significantly associated; to a stranger, both willingness to engage in deceased donation and attitudes toward donation were significantly associated. Knowledge of and personal experiences with donation and/or transplantation were not significantly associated with likelihood of any type of living donation.

CONCLUSIONS

Findings indicate widespread support for living donation to a close family member or spouse. These findings have important implications for dialysis patients who must decide whether to approach friends and/or family about the possibility of serving as a living donor and emphasize the need for interventions to help facilitate this process.

Avoiding the issue: patients' (non)communication with potential living kidney donors

OBJECTIVE

Kidney transplantation with a living donor has proved to be an effective solution for kidney patients on the waiting list for transplantation. Nevertheless, it may be difficult to find a living kidney donor. The purpose of this explorative study is to investigate how kidney transplant candidates may, or may not, find a living donor in the Netherlands.

METHODS

We compared a group of 42 patients who did not find a living donor with a group of 42 patients who did, using semi-structured interviews.

RESULTS

We found that, although almost all patients recognized the advantages of living kidney donation and were willing to accept the offer of a living kidney donor, many found it very difficult to ask a potential donor directly. This was true for both groups.

CONCLUSION

Patients may gain from professional support to deal with this situation in ways that balance their medical needs and their personal relationships.

PRACTICE IMPLICATIONS

Support programs should be developed to assist patients in developing strategies for discussing living kidney donation with potential donors.