Decision solution, data manipulation and trust: The (un-)willingness to donate organs in Germany in critical times

Toward Equity in Global Access to SoHO-based Therapies: Recommendations for Action

Therapies derived from substances of human origin (SoHOs) such as organs, cells, and tissues provide life-saving or life-changing treatment for millions of people worldwide each year. However, many people lack timely access to SoHO-based therapies because of insufficient supplies of these exceptional health resources and/or broader barriers in access to healthcare. Despite well-established governmental commitments to promote health equity in general and equity of access to SoHOs in particular, information about inequities in access to most SoHO-based therapies is scarce. Furthermore, the issue of equitable allocation of SoHO-based therapies has received little attention from policymakers and ethicists, except in the context of organ allocation for transplantation. Consequently, the extent and nature of potential inequities within and between countries are largely unknown, and few sources of guidance are available to support progress toward equity in global access to SoHO-based therapies. We present here the findings of an international ethics working group convened in preparation for the 2023 Global Summit on Convergence in Transplantation, organized in Santander, Spain. The group sought to assess potential gaps in knowledge about inequities involving SoHO-based therapies, to elucidate systemic factors that may influence access to these therapies, and to consider how policies and frameworks governing access to and allocation of SoHO-based therapies may promote equity when it is necessary to define boundaries in access because of insufficiency of supply. In discussing these challenges, we also outline several recommendations for action by governments and health authorities.

Mapping trust relationships in organ donation and transplantation: a conceptual model

The organ donation and transplantation (ODT) system heavily relies on the willingness of individuals to donate their organs. While it is widely believed that public trust plays a crucial role in shaping donation rates, the empirical support for this assumption remains limited. In order to bridge this knowledge gap, this article takes a foundational approach by elucidating the concept of trust within the context of ODT. By examining the stakeholders involved, identifying influential factors, and mapping the intricate trust relationships among trustors, trustees, and objects of trust, we aim to provide a comprehensive understanding of trust dynamics in ODT. We employ maps and graphs to illustrate the functioning of these trust relationships, enabling a visual representation of the complex interactions within the ODT system. Through this conceptual groundwork, we pave the way for future empirical research to investigate the link between trust and organ donation rates, informed by a clarified understanding of trust in ODT. This study can also provide valuable insights to inform interventions and policies aimed at enhancing organ donation rates.

Effekte des Organspendeskandals 2012 auf die Gewebespende am Institut für Rechtsmedizin München

Hintergrund

Der Organspendeskandal (OSS) 2012 führte zu einem dramatischen Einbruch der Spendebereitschaft. Im Zeitraum nach dem OSS verantwortete die Rechtsmedizin München 2013–2015 mit 51 muskuloskeletalen, 145 Cornea- und 38 Herzklappenentnahmen zahlreiche Gewebespenden im süddeutschen Raum.

Fragestellung

Die Ziele dieser Studie waren die Bestimmung des Einflusses des OSS auf die Gewebespende sowie die Auswirkung des ärztlichen Aufklärungsgespräches auf das Entscheidungsverhalten der Angehörigen.

Material und Methoden

Die Protokolle der Aufklärungsgespräche mit den Angehörigen im Zeitraum von Juli 2012 bis Dezember 2015 wurden auf Diskussionen, Erwähnungen sowie Entscheidungsverhalten im Zusammenhang mit dem OSS evaluiert. Zudem erfolgte im Jahresabstand nach der Spende eine retrospektive Evaluation des Aufklärungsgespräches durch die Angehörigen anhand eines Fragenkatalogs mit 9 Items.

Ergebnisse

Bei 388 potenziellen Spendern lag die Zustimmung bei 54,9 %. In 40 Fällen war der OSS Diskussionspunkt und resultierte in 15 Fällen in Ablehnung. Davon wurde in 6 Fällen ein Spendeausweis zuvor vom Verstorbenen aufgrund des OSS vernichtet, wobei in 4 Fällen nach Diskussion mit den Angehörigen eine Zustimmung erreicht wurde. Insgesamt bewerteten 142 Angehörige das Aufklärungsgespräch als positiv und die Spende als sinnstiftend. Die Entscheidungen waren zu 100 % stabil.

Diskussion

Die guten Resultate der Evaluation sowie der dieses Spendeprojekt nur gering beeinflussende OSS beruhen vor allem auf der mit Empathie und Erfahrung durchgeführten Aufklärung. Zum Vertrauensaufbau der Bevölkerung benötigt es ärztlicherseits ein aktives Informationsangebot und lückenlose Transparenz.

How Implementing a Quality Management System at the LIONS Eye Bank Saar-Lor-Lux, Trier/Western Palatinate from 2006 to 2016 Impacted the Rate and Reasons for Discarding Human Organ-Cultured Corneas

BACKGROUND

The aim of this study was to explore how the implementation of the quality management system (QM; according to DIN EN ISO 9001 : 2008) at the LIONS Eye Bank impacted the rate and reasons for discarding donated corneas. The QM system was introduced in November 2010.

MATERIAL AND METHODS

The rate of and reasons for discarding cornea tissues at the LIONS Eye Bank Saar-Lor-Lux,Trier/Western Palatinate from 2006 to 2016 were analysed retrospectively. 4,140 corneas from 2,084 donors were analysed. 1,640 corneas were processed before the QM system had been introduced and 2,500 corneas thereafter. Main reasons for discarding cornea tissues were endothelial quality, contamination of the medium and a positive conjunctival swab. The data was extracted from clinical files and data filing systems, entered into a Microsoft Access database and analysed statistically with SPSS.

OUTCOME

Following the implementation of a QM system, the discard rate decreased significantly from 50.1% to 39.7% (p < 0.0001). Prior to the implementation of the QM system, 493 (30.1%) cornea tissues had been discarded due to endothelial quality, while this figure improved significantly to 604 (24.2%) after the QM system had been implemented (p < 0.0001). Contamination was the reason for discarding tissue in 173 (10.5%) cases before implementation of the QM system, and in 124 (5.0%) cases thereafter (p < 0.0001). Positive conjunctival swab was the reason for discarding tissue in 10 (0.6%) cases before the QM system had been implemented, and in 53 (2.1%) cases thereafter (p < 0.0001).

CONCLUSION

Implementation of a QM system significantly reduced the rate of discarded donor tissue in the LIONS Eye Bank. Better management of contamination as a reason for discarding cornea tissues can be attributed to improved standards, protocols and training that are part of this QM system.

Improving quality of withdrawal of life-sustaining measures in organ donation: a framework and implementation toolkit

BACKGROUND

Donation after circulatory determination of death (DCD) is responsible for the largest increase in deceased donation over the past decade. When the Canadian DCD guideline was published in 2006, it included recommendations to create standard policies and procedures for withdrawal of life-sustaining measures (WLSM) as well as quality assurance frameworks for this practice. In 2016, the Canadian Critical Care Society produced a guideline for WLSM that requires modifications to facilitate implementation when DCD is part of the end-of-life care plan.

METHODS

A pan-Canadian multidisciplinary collaborative was convened to examine the existing guideline framework and to create tools to put the existing guideline into practice in centres that practice DCD.

RESULTS

A set of guiding principles for implementation of the guideline in DCD practice were produced using an iterative, consensus-based approach followed by development of four implementation tools and three quality assurance and audit tools.

CONCLUSIONS

The tools developed will aid DCD centres in fulsomely adapting the Canadian Critical Care Society Withdrawal of Life-Sustaining Measures guideline.

Attitudes and knowledge about post-mortem organ donation among medical students, trainee nurses and students of health sciences in Germany

Objective

In 2018 Germany had the lowest rate of post-mortem organ donation in the Eurotransplant network. Healthcare trainees and students will be important advisors on organ donation for patients in the future. This study aimed to examine 1) attitudes and knowledge about post-mortem organ donation, 2) how past transplantation scandals have affected those attitudes and 3) how satisfied respondents were with the knowledge provided on the courses.

Methods

A cross-sectional study was conducted between 20 March and 8 July 2019 at a university hospital and nursing schools in Berlin and Potsdam, Germany. Study participants were 209 medical students, 106 health sciences students and 67 trainee nurses.

Results

Of the respondents 29.3 and 50.8% knew the tasks of the German Organ Transplantation Foundation and Eurotransplant, respectively. All brain death questions were correctly answered by 56.3% of the medical students, 25.7% of the health sciences students and 50.9% of the trainee nurses (Fisher’s exact test p < 0.001, Cramer’s V = 0.242). Transplantation scandals had damaged attitudes towards organ donation for 20.7% of the medical students, 33.3% of the health sciences students and 13.6% of the trainee nurses (χ²-test p = 0.001, Cramer’s V = 0.164). Asked whether post-mortem organ donation was sufficiently addressed in their courses, 39.5% of the medical students, 60.4% of the health sciences students and 51.9% of the trainee nurses said this was not or tended not to be the case (Kruskal-Wallis H-test p < 0.001, Spearman’s rho r = −0.112).

Conclusion

Given the knowledge gaps identified and the respondents’ dissatisfaction with the knowledge they received, organ donation should be better integrated into curricula and training programs.

Public preferences for the allocation of donor organs for transplantation: Focus group discussions

BACKGROUND

Deceased donor organs are scarce resources because of a large supply-and-demand mismatch. This scarcity leads to an ethical dilemma, forcing priority-setting of how these organs should be allocated and whom to leave behind.

OBJECTIVE

To explore public preferences for the allocation of donor organs in regard to ethical aspects of distributive justice.

METHODS

Focus groups were facilitated between November and December 2018 at Hannover Medical School. Participants were recruited locally. Transcripts were assessed with content analysis using the deductive framework method. All identified and discussed criteria were grouped according to the principles of distributive justice and reported following the COREQ statement.

RESULTS

Six focus groups with 31 participants were conducted. Overall, no group made a final decision of how to allocate donor organ; however, we observed that not only a single criterion/principle but rather a combination of criteria/principles is relevant. Therefore, the public wants to allocate organs to save as many lives as possible by both maximizing success for and also giving priority to urgent patients considering the best compatibility. Age, waiting time, reciprocity and healthy lifestyles should be used as additional criteria, while sex, financial status and family responsibility should not, based on aspects of equality.

CONCLUSIONS

All participants recognized the dilemma that prioritizing one patient might cause another one to die. They discussed mainly the unclear trade-offs between effectiveness/benefit and medical urgency and did not establish an agreement about their importance. The results suggest a need of preference studies to elucidate public preferences in organ allocation.

[Knowledge, trust, and the decision to donate organs : A comparison of medical students and students of other disciplines in Germany]

BACKGROUND

Following the organ transplant scandal in Germany in 2011, the willingness to donate organs postmortem decreased dramatically. This was explained by a loss of confidence in the German organ donation system.

OBJECTIVES

The aim of this study was to evaluate the relationship between knowledge, trust, and fear in respect to organ donation and the explicit willingness to potentially act as an organ donor by comparing medical students to students of other disciplines.

MATERIAL AND METHODS

We conducted a Facebook-based online survey (June-July 2013). The participating students were divided into two groups according to their discipline: medical students and other students. Based on questions covering different aspects of organ donation, a knowledge, trust, and fear score was established and calculated. The answers were related to an explicitly expressed decision to donate organs as expressed in a signed organ donor card.

RESULTS

In total, 2484 participants took part in our survey. Of these, 1637 were students, 83.7% (N = 1370) of which were medical students and 16.3% (N = 267) other students. As expected, medical students reached a higher knowledge score regarding organ donation compared with other students (knowledge score 4.13 vs. 3.38; p < 0.001). They also demonstrated more confidence in organ donation, resulting in a higher confidence score (3.94 vs. 3.33; p < 0.001) and expressed less fear towards organ donation as indicated by the lower fear score (1.76 vs. 2.04; p < 0.01). Medical students declared their written willingness to donate organs more often than did other students (78.2% vs. 55.2%; p < 0.001). Entries on organ donation cards did not differ significantly between medical students and other students. Medical students possessing an organ donor card showed a higher knowledge and a higher trust score than did medical students without an organ donor card. In contrast, other students possessing an organ donor card showed a higher trust score but did not show a higher knowledge score.

CONCLUSIONS

The higher level of knowledge and trust demonstrated by the medical students was associated with a higher rate of written decisions to donate organs. In contrast, the lower level of knowledge and trust observed in the non-medical students was associated with a lower rate of organ donor cards. Interestingly, in the group of non-medical students, the decision regarding organ donation was associated with a higher level of trust, but not with a higher level of knowledge. It would appear that knowledge, trust, and the decision to donate organs are closely related. In cases of a low level of knowledge, confidence is even more important. Therefore, organ donation campaigns should focus on increasing knowledge and fostering trust.

'Saying no to organ donation': an empirical typology of reluctance and rejection

In Germany, as well as in other countries, organ shortages are usually explained by a relative unwillingness to donate among a population which is assumed to be caused by a lack of information and mistrust of the system. As we can see in the data of our qualitative research (focus groups and interviews), lack of information or mistrust are not the only reasons for people to be reluctant to agree to the donation of their organs after death. In fact we can identify four positions: (1) information deficit; (2) mistrust; (3) no killing; and (4) bodily integrity. The first and second are the two prominent explanations in the public discourse about low donation rates. The third and the fourth instead have neither been adequately articulated nor been discussed as a proper argument. Therefore, by means of sociology of critique, we discuss their contribution to the discourse as comprehensible reasons for reluctance and present them as credible positions of criticism: These two positions illuminate fundamental and universal values of the inviolability of the person and human dignity. Thus, both positions are consistent and morally justifiable and should be addressed with sensitivity.

Trends in corneal transplantation at the University Eye Hospital in Tübingen, Germany over the last 12 years: 2004 - 2015

Purpose

This study aimed to investigate the trends in the surgical methods and leading indications for corneal transplantations carried out over the last 12 years.

Methods

The data from the corneal graft waiting list and from all keratoplasties carried out between 2004 and 2015 at the University Eye Hospital in Tübingen were retrospectively analyzed.

Results

A total of 1,185 keratoplasties were performed between 2004 and 2015 at this hospital. The most common surgical indications for corneal transplantation were Fuchs’ endothelial corneal dystrophy (35.2%) and keratoconus (18.9%) with keratoconus being the leading cause during early years (from 2004 to 2009) and Fuch’s dystrophy being the leading cause from 2010 to 2015. Overall, the total count of performed keratoplasties increased, from 385 corneal transplantations during the first 6-year period to 800 corneal transplantations during the second 6-year period (P = 0.008, using Mann-Whitney test). The Descemet’s membrane endothelial keratoplasty has become the favored surgical method for endothelial disorders with the number of Descemet’s membrane endothelial keratoplasties increasing significantly from 2008 to 2015. This increasing trend was statistically significant (P < 0.001 using multivariate adaptive regression splines (MARS). A decreasing trend was also noted for the rate of penetrating keratoplasty since 2008 (P < 0.001 using MARS).

Conclusions

This research showed major changes in the preferred corneal transplantation techniques and leading indications for keratoplasty over the last 12 years. More importantly, it seems that the rapid development and implementation of endothelial keratoplasty, especially the Descemet’s membrane endothelial keratoplasty, has had a profound effect on and begun a new era in corneal transplantation.

Organ transplantation scandal influencing corneal donation rate

In the majority of countries, there is a shortage of donor corneas for corneal transplantations. This study investigated the impact of organ transplantation scandals on corneal donation rate at the University Hospital Tübingen. Each deceased patient was considered as a potential corneal donor. An ophthalmic resident handled with stable methods of procedures the corneal donor procurement from 2009 to 2015. The rates of corneal donation were examined and analyzed. Among the 5712 hospital deaths, consent for corneal donation was obtained in 711 cases. The mean annual corneal donation rate was 12.4%. Since 2009, the donation rate per year could be increased with exception of 2013 and 2015. In the end of 2012 and 2014 two huge organ donation scandals were known in Germany. In the following years 2013 and 2015 corneal donation rate decreased significantly (P=0.0181 and P=0.0006). We concluded that transplantation scandals have a significant impact on corneal donation rate. Improving professional's performance through full transparency and honesty is very important to earn trust of potential donors and their families.