Families who previously refused organ donation would agree to donate in a new situation: a cross-sectional study

Survey of public attitudes towards imminent death donation in the United States

Imminent death donation (IDD) is described as living organ donation prior to a planned withdrawal of life-sustaining care in an imminently dying patient. Although IDD was ethically justified by United Network for Organ Sharing, the concept remains controversial due to presumed lack of public support. The aim of this study was to evaluate the public's attitudes towards IDD. A cross-sectional survey was conducted of US adults age >18 years (n = 2644). The survey included a case scenario of a patient with a devastating brain injury. Responses were assessed on a 5-point Likert scale. Results showed that 68% - 74% of participants agreed or strongly agreed with IDD when posed as a general question and in relation to the case scenario. Participants were concerned about "recovery after a devastating brain injury" (34%), and that "doctors would not try as hard to save a patient's life" (33%). Only 9% of participants would be less likely to trust the organ donation process. In conclusion, our study demonstrates strong public support for IDD in the case of a patient with a devastating brain injury. Notably, participants were not largely concerned with losing trust in the organ donation process. These results justify policy change towards imminent death donation.

A Comparison of the Content and Quality of Organ Donation Discussions with African American Families Who Authorize and Refuse Donation

BACKGROUND

This study compares the experiences of African American (AA) families who authorized organ donation with those who refused.

METHODS

Large administrative datasets were obtained from 9 partnering Organ Procurement Organizations (OPO). Initial analyses used these data to assess authorization among African American families (n = 1651). Subsequent analyses were performed using a subsample of interview data of AA family decision makers (n = 276). Initial bivariate analyses tested differences in study variables by authorization status (donor/nondonor). Two separate multilevel logistic regressions examined associations between independent variables and family authorization.

RESULTS

Analyses of the administrative datasets found that refusal was more likely when the patient was older, female, a DCD case, and not referred in a timely manner; refusal was less likely when families initiated donation conversations. Interview data revealed that families who refused donation were less likely to respond favorably to initial donation requests and reported less satisfaction with the overall approach, amount of time with OPO staff, and how questions were handled. Refusing families were also more likely to feel pressured, had less comprehensive donation discussions, and rated the OPO requesters' communication skills lower. No significant differences in organ donation attitudes were found between families who authorized donation and those refusing to donate.

CONCLUSIONS

The study suggests that AA families making decisions about organ donation would benefit from culturally appropriate discussions.

TRIAL REGISTRATION

Clinical Trial Notation: NCT02138227.

Factors Influencing Families' Decision-Making for Organ Donation in Hunan Province, China

BACKGROUND

In 2010, the Chinese government started a pilot project of donation after Chinese citizens' death. Seeking the consent of the families of potential donors is an important task in the organ donation process.

OBJECTIVE

We aimed to explore the factors that influence the families' decision-making for organ donation.

METHODS

We performed a content analysis of 30 semistructured in-depth interviews with immediate family members who made the decision for an organ donation. The interviewees were asked questions such as how the decision to donate was made, what factors influenced the decision, and whether the decision was rejected by relatives and friends.

RESULTS

The interviewees were the donors' parent (15; 50%), spouse (9; 30%), brother (3; 10%) or son (3; 10%), including 18 men and 12 women, with a mean age of 41.6 (standard deviation, 10.7) years; rural households accounted for 83.3%. Through analyzing the interview notes, 17 factors ware mentioned by interviewees, and 3 types of decision-making in organ donors' families were obtained. Then, the factors affecting the decisions of the donor families were classified into 3 categories and 11 subcategories.

CONCLUSIONS

Factors influencing the families' decision-making for organ donation were analyzed preliminarily in this study.

A few realistic questions raised by organ retrieval in the intensive care unit

Organ transplantation saves the lives of many persons who would otherwise die from end-stage organ disease. The increasing demand for donated organs has led to a renewed interest in donation after circulatory determination of death (CDD). In many countries (including France), terminally ill patients who die of circulatory arrest after a planned withdrawal of life support may be considered as organ donors under certain conditions. While having equal responsibility towards the potential donor and the persons awaiting a transplant, caregivers may experience an ethical dilemma between the responsibility to deliver the best care to the dying, and the need to retrieve the organs. Once it has been established that the patient wishes to be a donor, we assume that end-of-life care and organ donation may have convergent goals when they contribute to transforming a comfortable death into a chance of life for others in need.

"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.

Decision making on organ donation: the dilemmas of relatives of potential brain dead donors

Background

This article is part of a study to gain insight into the decision-making process by looking at the views of the relatives of potential brain dead donors. Alongside a literature review, focus interviews were held with healthcare professionals about their role in the request and decision-making process when post-mortal donation is at stake. This article describes the perspectives of the relatives.

Methods

A content-analysis of 22 semi-structured in-depth interviews with relatives involved in an organ donation decision.

Results

Three themes were identified: ‘conditions’, ‘ethical considerations’ and ‘look back’. Conditions were: ‘sense of urgency’, ‘incompetence to decide’ and ‘agreement between relatives’. Ethical considerations result in a dilemma for non-donor families: aiding people or protecting the deceased’s body, especially when they do not know his/her preference. Donor families respect the deceased’s last will, generally confirmed in the National Donor Register. Looking back, the majority of non-donor families resolved their dilemma by justifying their decision with external arguments (lack of time, information etc.). Some non-donor families would like to be supported during decision-making.

Discussion

The discrepancy between general willingness to donate and the actual refusal of a donation request can be explained by multiple factors, with a cumulative effect. Firstly, half of the participants (most non-donor families) stated that they felt that they were not competent to decide in such a crisis and they seem to struggle with utilitarian considerations against their wish to protect the body. Secondly, non-donor families refused telling that they did not know the deceased’s wishes or contesting posthumous autonomy of the eligible. Thirdly, the findings emphasise the importance of Donor Registration, because it seems to prevent dilemmas in decision-making, at least for donor families.

Conclusion

Discrepancies between willingness to consent to donate and refusal at the bedside can be attributed to an unresolved dilemma: aiding people or protect the body of the deceased. Non-donor families felt incompetent to decide. They refused consent for donation, since their deceased had not given any directive. When ethical considerations do not lead to an unambiguous answer, situational factors were pivotal. Relatives of unregistered eligible donors are more prone to unstable decisions. To overcome ambivalence, coaching during decision-making is worth investigation.