The instability of organ donation decisions by next-of-kin and factors that predict it

Hospital-Related Determinants of Refusal of Organ Donation in France: A Multilevel Study

In a worldwide context of organ shortage, refusal of organ donation remains the main reason for the non-procurement of organs from deceased donors. Many studies have characterized the clinical or psychological factors of refusal but not organizational and structural factors in healthcare centers. We used multilevel logistic regression models with hospitals as a random effect to analyze organ procurement among 6734 potential brain-dead donors recorded in the national register in France in 2018 and 2019. According to the opt-out law, 29% of the potential donors refused to donate. Among hospital-related factors, low probability of refusal was related to hospitals audited for the organ donation process by the national program (adjusted odds ratio [aOR] 0.74, 95% confidence interval [CI]: 0.58-0.94), hospitals with high inpatient satisfaction scores for care (aOR 0.95, 95% CI 0.92-0.99) and facilities with a high ratio of nurse donor coordinators to donors (aOR: 0.78; 95% CI: 0.64-0.95). Among clinical factors, the odds of refusal were associated with age younger than 65 years (18-49 years; aOR 1.58, 95% CI 1.37-1.83) and donors with blood group B (aOR 1.32, 95% CI: 1.10-1.59). Hospital-related factors are just as important as individual factors in the procurement of organs from potential brain-dead donors.

Bereaved family members' perspectives of their organ donation decision at 3 months post death of the donor-eligible patient in critical care: A dual-method study

BACKGROUND

Offering organ donation is part of routine end-of-life care in critical care. Families describe feeling emotionally overwhelmed, which reduces their ability to understand complex medical information necessary to make informed decisions about organ donation. Late decisional regret is more common among families who decline donation. Thus, it is vital to investigate whether the organ donation decision choices that families make in hospital endure unchanged and what factors affect their perspectives.

OBJECTIVES

The objective of this study was to explore family members' perspectives of their final organ donation decision in hospital, either to consent or to decline donation, at around 90 d later.

METHODS

This dual-method study comprised semistructured interviews of family members of donor-eligible patients who experienced care in seven metropolitan teaching hospitals, a tertiary paediatric hospital, and a major regional hospital in New South Wales, Australia. Interviews were audio recorded and transcribed verbatim. Descriptive quantitative analysis and thematic analysis were used.

FINDINGS

Participants overwhelmingly agreed that their organ donation decision remained unchanged at 3 months after the death of their relative (n = 127, 97%). The remainder (n = 3, 2%) were unsure or stated "possibly not" (n = 1, 1%); in these cases, the eligible donor was certified dead via circulatory criteria. Five themes were synthesised in relation to the organ donation decision: Knowledge of the donor-eligible patient's prior wishes, Family members' prior decision to donate their own organs, Solace in the decision, Altruism, and Reality of the process.

CONCLUSIONS

The organ donation decision choice remained unchanged for the large majority. Further research is required to ascertain how people can be assisted to understand the organ donation process, particularly in the setting of certification of death by circulatory criteria, and how best to positively influence consent rates.

CLINICAL TRIAL REGISTRY NUMBER

Australian and New Zealand Clinical Trial Registration ACTRN12613000815763.

Gender disparity in living organ donation: a qualitative analysis of experiences and perceptions of female donors in Pakistan

OBJECTIVES

This study aims to explore and analyse the interplay of sociocultural, psychological and institutional factors, gender roles and power dynamics in shaping the decision-making processes and experiences of living kidney and liver donors in Punjab, specifically focusing on women.

DESIGN

This study employed a qualitative approach, using in-depth interviews to delve into the narratives and experiences of living kidney and liver donors in Punjab.

SETTING

Punjab Human Organ Transplantation Authority (PHOTA), Lahore, Punjab, Pakistan.

PARTICIPANTS

17 participants registered at the PHOTA for kidney or liver donation.

RESULTS

Interviews with living donors at PHOTA, Lahore, provided qualitative data, which was then systematically coded and analysed to identify recurring themes that explore the underlying social and cultural reasons for the observed gender disparity. The qualitative research yielded 17 interviews to include in the analysis, representing the voices of living kidney and liver donors. The study resulted in the following themes emerging: (1) female donation as a consequence of economic vulnerability; (2) comorbidities impacting donor eligibility; (3) altruism among female donors; (4) social and self-benefit of the donors and (5) social obligation on the female donors. These themes transcended the medical considerations and highlighted the interplay between social norms, family dynamics and gendered expectations surrounding caregiving and self-sacrifice.

CONCLUSION

The findings of this study underscore the significant relationship between gender roles, economic pressures and social expectations in the context of living organ donation. The study's results highlight the urgent need for targeted interventions to address the gender gap in living kidney and liver donation. By acknowledging the influence of social and economic factors, strategies to create a more equitable landscape for living kidney and liver donors can be created.

"I'm standing next to him, I'm supporting him"-Supporting a loved one with brain cancer to donate their brain: A qualitative study

Background

Brain cancer is a devastating and incurable disease that places a high burden of care on next of kin (NOK). NOK can play a core role in supporting end-of-life planning, including the decision to donate one's brain after death. Postmortem brain donation is crucial to research. As postmortem programs develop it is important to understand the experiences of NOK as they support a loved one in the donation decision.

Methods

Thirteen qualitative interviews were completed with NOK of people who had consented to donate their brains to the Mark Hughes Foundation (MHF) Biobank. A thematic analysis was carried out on the transcribed interviews.

Results

Four central themes were identified: (i) The carer role has additional responsibilities and psychological benefits when brain donation is being considered; (ii) Supporting a loved one to donate requires mutual trust, understanding, and a commitment to honor agency; (iii) Increasing awareness of brain donation is a priority for NOK, and (iv) Brain donation is seen as a natural continuation of the donor's altruistic values.

Conclusions

When a person with brain cancer decides to donate their brain to research, their NOK can experience additional burdens and benefits as the NOK-patient relationship evolves. Understanding this evolution and recognizing the importance of trust, advocacy, and altruism provides a guide for the integration of brain donation programs into clinical pathways and a basis for normalizing brain donation as an extension of organ donation frameworks.

'I think both of us drew strength from it': qualitative reflections from next of kin following the death and post-mortem brain donation of a loved one with brain cancer

Background

Glioblastoma, a high-grade primary brain cancer, has a median survival of approximately 14 months. Post-mortem brain donation provides insight to pathogenesis along with spatial and temporal heterogeneity. Post-mortem brain biobanking programs are increasing in number and the need to understand and improve the associated human experience is pressing. This study aims to qualitatively explore the experiences of next of kin (NOK) following the death and brain donation of a loved one and to understand the impact such programs have on NOK carers.

Method

We interviewed 29 NOK following the death of their loved one and subsequent brain donation. Thematic analysis was conducted on the transcribed, qualitative interviews.

Results

Four themes were identified; (1) Brain donation is a straightforward decision grounded in altruism and pragmatism; (2) Supporting donors is a source of comfort, pride and empowerment; (3) Brain donation can provide meaning for suffering and tragedy and (4) Perceptions of procedures and processes when supporting a loved one to donate. Insights into areas for improvement, for example transporting donors following a home death and the role of the body bag were also noted.

Conclusion

Supporting a loved one to donate their brain can be a positive experience providing a source of hope, empowerment and purpose for NOK. Data indicating areas for consideration are broadly relevant for improving the delivery of brain donation programs for future donors and their loved ones.

Organ Donation Organization Architecture: Recommendations From an International Consensus Forum

This report contains recommendations from 1 of 7 domains of the International Donation and Transplantation Legislative and Policy Forum (the Forum). The purpose is to provide expert guidance on the structure and function of Organ and Tissue Donation and Transplantation (OTDT) systems. The intended audience is OTDT stakeholders working to establish or improve existing systems.

Methods

The Forum was initiated by Transplant Québec and co-hosted by the Canadian Donation and Transplantation Program partnered with multiple national and international donation and transplantation organizations. This domain group included administrative, clinical, and academic experts in OTDT systems and 3 patient, family, and donor partners. We identified topic areas and recommendations through consensus, using the nominal group technique. Selected topics were informed by narrative literature reviews and vetted by the Forum's scientific committee. We presented these recommendations publicly, with delegate feedback being incorporated into the final report.

Results

This report has 33 recommendations grouped into 10 topic areas. Topic areas include the need for public and professional education, processes to assure timely referral of patients who are potential donors, and processes to ensure that standards are properly enforced.

Conclusions

The recommendations encompass the multiple roles organ donation organizations play in the donation and transplantation process. We recognize the diversity of local conditions but believe that they could be adapted and applied by organ donation organizations across the world to accomplish their fundamental objectives of assuring that everyone who desires to become an organ donor is given that opportunity in a safe, equitable, and transparent manner.

Reviewing next of kin regrets in surgical decision-making: cross-sectional analysis of systematically searched literature

BACKGROUND

Decision-making concerning relatives undergoing surgery is challenging. It remains unclear to what extent implicated next of kin eventually regret their decisions and how this regret is assessed. Our aim was to systematically review the literature on decisional regret of next of kin and to describe the assessment tools used and the surgical populations studied.

METHODS

We included interventional or observational, quantitative or qualitative studies reporting the measurement of decisional regret of next of kin concerning relatives undergoing surgery. We searched a variety of databases without restriction on publication year. We assessed the quality of reporting of quantitative studies using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and of qualitative studies using the Critical Appraisal Skills Program Checklist.

RESULTS

Thirteen cross-sectional, five prospective cohorts and five qualitative studies matched our inclusion criteria. In 18 studies (78%), patients were children, in five (22%), young or middle-aged adults. No study included elderly or frail patients. Thirteen studies (57%) used the original Decision Regret Scale which was validated for patients, but not for next of kin. Only 3 of the 18 (17%) quantitative studies and only one of the 4 (25%) qualitative studies were rated as "good" in the quality assessment.

CONCLUSION

None of the retrieved studies used validated tools to assess the decisional regret of next of kin and none of them examined this issue in elderly or frail surgical patients.

How to improve results after DCD (donation after circulation death)

The shortage of organs for transplantation has led health professionals to look for alternative sources of donors. One of the avenues concerns donors who have died after circulatory arrest. This is a special situation because the organs from these donors are exposed to warm ischaemia-reperfusion lesions that are unavoidable during the journey of the organs from the donor to the moment of transplantation in the recipient. We will address and discuss the key issues from the perspective of team organization, legislation and its evolution, and the ethical framework. In a second part, the avenues to improve the quality of organs will be presented following the itinerary of the organs between the donor and the recipient. The important moments from the point of view of therapeutic strategy will be put into perspective. New connections between key players involved in pathophysiological mechanisms and implications for innate immunity and injury processes are among the avenues to explore. Technological developments to improve the quality of organs from these recipients will be analyzed, such as perfusion techniques with new modalities of temperatures and oxygenation. New molecules are being investigated for their potential role in protecting these organs and an analysis of potential prospects will be proposed. Finally, the important perspectives that seem to be favored will be discussed in order to reposition the use of deceased donors after circulatory arrest. The use of these organs has become a routine procedure and improving their quality and providing the means for their evaluation is absolutely inevitable.

Organ Donation Decision in Families With Brain-Dead Patients: An Evolutionary Concept Analysis

BACKGROUND AND AIM

Organ donation decision is a complicated process for bereaved families; however, its attributes and associated factors are not clear. Accordingly, the purpose of this study was to analyze the concept of organ donation decision in families with brain-dead patients.

METHODS

Concept analysis was performed using Rodgers' evolutionary method. For this purpose, PubMed, OVID, Scopus, and ProQuest databases were searched in English from 1985 to 2019. In total, 54 articles were analyzed using the thematic analysis to identify the attributes, antecedents, and consequences of the concept. The validity of the data was provided by examining the analysis process by 2 independent researchers.

FINDINGS/CONCLUSIONS

Organ donation decision in these families is a complicated and conflicting process of vicarious decision-making that begins with an organ donation request: a difficult, painful, and critical experience that requires extensive interpersonal interactions and is ultimately influenced by various factors, leading to the acceptance or refusal. The antecedents include deceased-related factors, family-related factors, the quality of organ donation request, and the quality of health care professionals' interactions. The consequences include the positive outcomes (grief solace, gift of life, and promoting human values) and negative outcomes (ambiguity, doubt and regret, and psychological inconsistency). The results of this concept analysis led to a better understanding of the complexity of an organ donation decision in these families. In this way, in addition to knowledge development, it assists the health care staff to support families in making the organ donation decision.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Although case managers rarely participate in organ donation, they definitely need to understand the concepts related to organ donation decision while advocating for the patients or families. The results of this concept analysis can broaden the case managers' and other health care professionals' knowledge about families' organ donation decision and help them take more effective interventions for management of this process. Case managers and the health care team can use the information of this article for informing families about brain death, negotiating with families for organ donation, preparing information, and caring and facilitating the families in making the clear and unconflicted decision.

Ethical reflection support for potential organ donors' relatives: A narrative review

BACKGROUND

Even in countries with an opt-out or presumed consent system, relatives have a considerable influence on the post-mortem organ harvesting decision. However, their reflection capacity may be compromised by grief, and they are, therefore, often prone to choose refusal as default option. Quite often, it results in late remorse and dissatisfaction. So, a high-quality reflection support seems critical to enable them to gain a stable position and a long-term peace of mind, and also avoid undue loss of potential grafts. In practice, recent studies have shown that the ethical aspects of reflection are rarely and often poorly discussed with relatives and that no or incomplete guidance is offered. No review of the literature is available to date, although it could be of value to improve the quality of the daily practice.

OBJECTIVES

The objective was to review and synthesize the main concepts and approaches, theories and practices of ethical reflection support of the relatives or surrogates of potential post-mortem organ donors.

RESEARCH DESIGN

A narrative review was performed in the medical, psychological and ethical fields using PubMed, PsycArticles and Web of Science databases (1980-2020).

RESULTS

Out of 150 papers, 25 were finally retained. Four themes were drawn: the moral status of the potential post-mortem organ donor, the principlistic approach with its limits and critics, the narrative approach and the transcendental approach.

DISCUSSION

This review suggests an extension of psychological support towards ethical reflection support. The process of helping relatives in their ethical exploration of post-mortem organ donation is psychologically and morally characterized. The need for specialized professionals educated and experienced both in clinical psychology and in health ethics to carry out this task is discussed.

PRACTICAL IMPACT

This review could contribute to optimize the quality of the ethical reflection support by initiating an evolution from an empirical, partial and individual-dependent support to a more systematized, professionalized and exhaustive support.

Family Refusal to Consent Donation: Retrospective Quantitative Analysis of Its Increasing Tendency and the Associated Factors Over the Last Decade at a Spanish Hospital

BACKGROUND

Organ and tissue recovery remains limited by several factors. This study retrospectively analyzes the factors associated with family refusal to consent to donation at a high-donor-volume Spanish hospital.

METHODS

Data regarding the annual number of potential donors and family refusal rates at hospital and regional levels were retrieved from 2008 to 2017. Descriptive, bivariate, and multivariate analyses were performed to detect those factors independently associated with family refusal. Results were cross-validated using the data from years 2018 and 2019 as the validation group. To explore potential inter-relations between factors a Multiple Correspondence Analysis was performed.

RESULTS

A total of 601 family interviews for petition of consent were conducted between 2008 and 2017, 531 (88.4%) resulted in acceptance and 70 (11.6%) resulted in refusal of the donation. Lesser experience of the interviewers (odds ratio [OR], 2.980; P = .001), donation after brain death (OR, 2.485; P = .013), number of interviews conducted per family (OR, 1.892; P < .001), age of the main decision maker (OR, 1.025; P = .045), and high or middle attributed cultural levels (OR, 0.142; P < .001 and OR, 0.199; P < .001 respectively) were observed to be independently associated with the family final decision. The logistic regression model displayed good predictive power for both derivation and validation cohorts, with an overall predictive accuracy of 80.9% (95% confidence interval, 0.747-0.870; P < .001) and 74.4% (95% confidence interval, 0.635-0.854; P = .001), respectively.

CONCLUSIONS

Transplant coordination team members having a thorough knowledge of the family decision mechanisms may be a key factor in donation process optimization.

Experiences of Families Following Organ Donation Consent: A Qualitative Systematic Review

OBJECTIVE

This systematic review synthesizes qualitative evidence on the experiences of donor families after consent to organ donation.

METHODS

This robust, qualitative systematic review included an exhaustive search of electronic databases, including PubMed, Scopus, EBSCO PsycINFO, and CINAHL Complete. Manual searches of reference lists and gray literature were conducted to achieve a comprehensive identification of all relevant research. A qualitative study design served to capture the experiences of donor families after organ donation consent.

RESULTS

A total of 6 articles that met the eligibility criteria were identified and included in this review. Three key themes emerged from the primary research: 1. family members were ambivalent about consent due to the ambiguity of brain death; 2. conversations about donation requirements proved uncomfortable; and 3. support is needed after donation.

CONCLUSIONS

Family members demonstrated ongoing ambivalence and distress that lasted for weeks after organ donation due to the ambiguity of brain death. Some family members were unhappy with having been approached for a conversation about organ donation. Donor families were not always able to deal with the difficulties they faced after their decision about organ donation. Health care professionals should provide ongoing care and updated information to family members. This review helped to identify family members' needs for both psychological and financial assistance.

The impact of organ donation specialists on consent rate in challenging organ donation conversations

Background: Consent rates for organ donation conversations (ODCs) vary. We hypothesised that a simple grading system could identify challenging ODCs. We further hypothesised that challenging ODCs would have higher consent rates when conducted by ODC specialists. Objectives: We aimed to study the utility of a grading system for ODCs and test the hypothesis that any training effect would be associated with improved consent rates in ODCs graded as most challenging. Methods: We stratified 2017 Australian DonateLife Audit aggregate consent and donation discussion data into four ODC grades based on Australian Organ Donor Register (AODR) status and person first raising the topic of organ donation. Grade I: "yes" present on AODR and family-raised organ donation; Grade II: "yes" present on AODR, and clinician-raised organ donation; Grade III: no registration on AODR but family-raised organ donation; and Grade IV: no registration on AODR, and clinician-raised organ donation. Results: Grade I ODCs were uncommon 7.7% (109/1420), with a consent rate of 95.4% (104/109). Grade IV ODCs were frequent (60.4%, 857/1420), with a consent rate of 41.4% (355/857). However, in Grade IV ODCs, organ donation specialist consent rate was 53.5% (189/353), significantly greater than for other trained staff at 33.1% (88/266) (P < 0.005; odds ratio [OR], 2.33; 95% CI, 1.68-3.24) or untrained requestors at 32.8% (78/238; P < 0.005; OR, 2.36; 95% CI. 1.68-3.33). Conclusion: The likelihood of consent can be predicted using readily available variables. This allows prospective identification of Grade IV ODCs, which carry low but potentially modifiable likelihood of consent. Involving donation specialists was associated with more consents for organ donation when applied retrospectively to Australian audit data.

Patient-centred and family-centred care of critically ill patients who are potential organ donors: a qualitative study protocol of family member perspectives

INTRODUCTION

In a patient-centred and family-centred approach to organ donation, compassion is paramount. Recent guidelines have called for more research, interventions and approaches aimed at improving and supporting the families of critically ill patients. The objective of this study is to help translate patient-centred and family-centred care into practice in deceased organ donation.

METHODS AND ANALYSIS

This will be a national, qualitative study of family members of deceased organ donors in Canada. We will include family members who had been approached regarding an organ donation decision, including those who agreed and declined, at least 2 months and no later than 3 years after the patients' death. Data collection and analysis is ongoing and will continue until September 2020 to include approximately 250 participants. Family members will be identified and recruited from provincial organ donation organisation databases. Four experienced qualitative researchers will conduct telephone interviews in English or French with audio-recording for subsequent transcription. The research team will develop a codebook iteratively through this process using inductive methods, thus generating themes directly from the dataset.

ETHICS AND DISSEMINATION

Local research ethics boards (REB) at all participating sites across Canada have approved this protocol. The main REB involved is the Ottawa Health Science Network REB. Data collection began in August 2018. Publication of results is anticipated in 2021. Study findings will help improve healthcare provider competency in caring for potential organ donors and their families and improve organ donation consent rates. Findings will also help with the development of educational materials for a competency-based curriculum for critical care residents.

Grief, Stress, Trauma, and Support During the Organ Donation Process

The organ donation process is complex and stressful for the family of the potential donor and members of the multidisciplinary team who may experience grief, ethical dilemmas, vicarious trauma, or compassion fatigue. Several studies each explore the role of a specific healthcare group and the impact of inhospital processes on group members. We conducted a systematic literature search to identify such studies and a qualitative synthesis to consolidate findings and highlight features of the interaction and relationships between role players. Our results suggest that, while healthcare professionals have different roles, attitudes, and views, the experience of stressors and interdisciplinary tension is common. Nevertheless, staff are united by the goal of caring for the patient and family. We therefore propose that, while focusing on bereavement care and other aspects of the family's experience, staff can find other shared goals and develop understanding, trust, empathy, and respect for each other's positions, thereby improving functioning in the complex adaptive system that forms at this time. Education and training can equip staff to facilitate anticipatory mourning, family-led activities, and a meaningful parting from their relative, assisting families with their grief and increasing staff members' efficacy, confidence, and interdisciplinary teamwork. Knowledge of systems thinking and opportunities to share ideas and experiences will enable staff to appreciate each other's roles, while supportive mentors, self-care strategies, and meaningful feedback between role players will foster healthy adjustment and shared learning. A focus on psychosocial outcomes such as family satisfaction with the process, collaboration within the multidisciplinary team, and reduction in the role stress of healthcare professionals will contribute to family well-being as well as personal and professional growth for staff.

Stressors experienced by the family members of brain-dead people during the process of organ donation: A qualitative study

More is known about organ donor recipients than donor families. We explored the stressors experienced by family members of brain-dead people during the process of organ donation. Seventeen family members and five organ procurers were interviewed and the data analyzed through conventional qualitative content analysis. Stressors experienced by family members fell into six themes-perceived threat of loss, decision making under conflict, painful corrosive farewell, feeling of insecurity, complexity of grief, and seeking relief. Findings highlight the necessity of developing and using standard protocols for supporting brain-dead people's family members throughout the process of organ donation and following bereavement.

Family Interview to Enable Donation of Organs for Transplantation: Evidence-based Practice

BACKGROUND

In this study we propose a theoretical and practical basis for the best practices for interviewing relatives of brain-dead eligible organ donors.

METHODS

This investigation was a reflective study of the methodologic factors of the family interview that affect their decision regarding the donation of a deceased patient's organs for transplantation. The articles that formed the empirical basis of the trial were obtained from PubMed, which is a free-access tool of the MEDLINE database of the United States National Library of Medicine. Published articles that allowed us to reflect on evidence-based family interview practice were selected.

RESULTS

Thirty-six scientific articles were used to guide our assessment the family interview, providing evidence for its adequate execution in view of the following prerequisites: When should the family interview be performed? Where should it be done? How many and which people should participate in the interview? Who should perform it? How should it be done?

CONCLUSION

Scientific studies offer evidence to donation and transplantation specialists that can help them in their daily work regarding their interactions with relatives in the process of decisionmaking and family consent.

A novel approach to studying co-evolution of understanding and research: Family bereavement and the potential for organ donation as a case study

A novel approach to data extraction and synthesis was used to explore the connections between research priorities, understanding and practice improvement associated with family bereavement in the context of the potential for organ donation. Conducting the review as a qualitative longitudinal study highlighted changes over time, and extraction of citation-related data facilitated an analysis of the interaction in this field. It was found that lack of 'communication' between researchers contributes to information being 'lost' and then later 'rediscovered'. It is recommended that researchers should plan early for dissemination and practice improvement to ensure that research contributes to change.

An exploration of the relationship between families of deceased organ donors and transplant recipients: A systematic review and qualitative synthesis

Following deceased organ donation and transplantation, the narratives of families of donors and organ recipients become connected. This is acknowledged when parties receive anonymous information from donation agencies and transplant centres, when they exchange correspondence or when they meet in person. This article reviews literature describing the experience from the points of view of donor families, recipients, and other stakeholders to explore the dynamic system that evolves around this relationship. Findings highlight a link between identity development and ongoing adjustment and will assist those supporting donor families and recipients to make decisions that fit meaningfully.

Tools for the Measurement of Psychological Aspects of Organ Donation among the Families of Brain-dead People

BACKGROUND

According to the basic ethical principle of non-maleficence, organ procurement systems need to be accountable to donor families. As organ donation can be potentially traumatic, donor families are at risk of developing psychological damage. Appropriate measurement tools are needed to diagnose such disorders and develop appropriate treatment measures.

OBJECTIVE

To examine the appropriateness of measurement tools and approaches used in previous studies for assessing donor families' psychological well-being.

METHODS

A structured online search was conducted in electronic databases namely ScienceDirect, PubMed, ProQuest, Scopus, Ovid, and Web of Science. The main inclusion criterion was the use of psychological assessment tools for data collection.

RESULTS

10 studies were included in which different tools had been used for measuring donor families' psychological well-being in the following 5 dimensions: stress, depression, grief, general health, and positive legacy of trauma. The major pitfalls of the reviewed studies were failure to specifically assess complicated grief and differentiating it from other psychological disorders, diversity of the tools used for psychological well-being assessment, and lack of clear definitions of donor families' psychological well-being and its dimensions.

CONCLUSION

Donor families' psychological well-being is a complex and multidimensional concept and the existing measurement tools cannot accurately assess it. Therefore, the concept needs to be clearly explored and defined. Developing a comprehensive measurement tool or a set of scales is necessary for the early diagnosis of any impairment in donor families' psychological well-being.

The development of a narrative describing the bereavement of families of potential organ donors: A systematic review

Families of potential post-mortem organ donors face various challenges in the unfamiliar hospital context and after returning home. This review of sources published between 1968 and 2017 seeks to understand their journey as a bereavement experience with a number of unique features. Grief theory was used to identify ways that staff can assist family members to tolerate ambiguities and vulnerabilities while contributing to an environment characterised by compassion and social inclusion. Staff can guide families and create opportunities for meaningful participation, building resilience and developing bereavement-related skills that could assist them in the months that follow.

Outcomes of organ donation in brain-dead patient's families: Ethical perspective

Background:

The families of brain-dead patients have a significant role in the process of decision making for organ donation. Organ donation is a traumatic experience. The ethical responsibility of healthcare systems respecting organ donation is far beyond the phase of decision making for donation. The principles of donation-related ethics require healthcare providers and organ procurement organizations to respect donor families and protect them against any probable harm. Given the difficult and traumatic nature of donation-related experience, understanding the outcomes of donation appears crucial.

Objective:

The aim of this study was to explore the outcomes of organ donation for the families of brain-dead patients.

Methods:

This was a qualitative descriptive study to which a purposeful sample of 19 donor family members were recruited. Data were collected through holding in-depth semi-structured interviews with the participants. Data analysis was performed by following the qualitative content analysis approach developed by Elo and Kyngäs.

Findings:

The main category of the data was “Decision to organ donation: a challenge from conflict to transcendence.” This main category consisted of 10 subcategories and 3 general categories. The general categories were “challenging outcomes,” “reassuring outcomes,” and “transcending outcomes.”

Ethical considerations:

The study was approved by the regional ethical review board. The ethical principles of informed consent, confidentiality, and non-identification were used.

Conclusion:

Donor families experience different challenges which range from conflict and doubtfulness to confidence, satisfaction, and transcendence. Healthcare providers and organ procurers should not discontinue care and support provision to donor families after obtaining their consent to donate because the post-decision phase is also associated with different complexities and difficulties with which donor families may not be able to cope effectively. In order to help donor families achieve positive outcomes from the tragedy of significant loss, healthcare professionals need to facilitate the process of achieving confidence and transcendence by them.

Development of a Canadian deceased donation education program for health professionals: a needs assessment survey

PURPOSE

The purpose of this survey was to determine how Canadian healthcare professionals perceive their deficiencies and educational requirements related to organ and tissue donation.

METHODS

We surveyed 641 intensive care unit (ICU) physicians, 1,349 ICU nurses, 1,561 emergency room (ER) physicians, and 1,873 ER nurses. The survey was distributed by the national organization for each profession (the Canadian Association of Emergency Physicians, the Canadian Association of Critical Care Nurses, and the National Emergency Nurses Association). Canadian Blood Services developed the critical care physician list in collaboration with the Canadian Critical Care Society. Survey development included questions related to comfort with, and knowledge of, key competencies in organ and tissue donation.

RESULTS

Eight hundred thirty-one (15.3%) of a possible 5,424 respondents participated in the survey. Over 50% of respondents rated the following topics as highly important: knowledge of general organ and tissue donation, neurological determination of death, donation after cardiac death, and medical-legal donation issues. High competency comfort levels ranged from 14.7-50.9% for ICU nurses and 8.0-34.6% for ER nurses. Competency comfort levels were higher for ICU physicians (67.5-85.6%) than for ER physicians who rated all competencies lower. Respondents identified a need for a curriculum on national organ donation and preferred e-learning as the method of education.

CONCLUSIONS

Both ICU nurses and ER practitioners expressed low comfort levels with their competencies regarding organ donation. Intensive care unit physicians had a much higher level of comfort; however, the majority of these respondents were specialty trained and working in academic centres with active donation and transplant programs. A national organ donation curriculum is needed.

"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.

COMmunication with Families regarding ORgan and Tissue donation after death in intensive care (COMFORT): protocol for an intervention study

Background

Discussing deceased organ donation can be difficult not only for families but for health professionals who initiate and manage the conversations. It is well recognised that the methods of communication and communication skills of health professionals are key influences on decisions made by families regarding organ donation.

Methods

This multicentre study is being performed in nine intensive care units with follow-up conducted by the Organ and Tissue Donation Service in New South Wales (NSW) Australia. The control condition is pre-intervention usual practice for at least six months before each site implements the intervention. The COMFORT intervention consists of six elements: family conversations regarding offers for organ donation to be led by a “designated requester”; family offers for donation are deferred to the designated requester; the offer of donation is separated from the end-of-life discussion that death is inevitable; it takes place within a structured family donation conversation using a “balanced” approach. Designated requesters may be intensivists, critical care nurses or social workers prepared by attending the three-day national “Family Donation Conversation” workshops, and the half-day NSW Simulation Program. The design is pre-post intervention to compare rates of family consent for organ donation six months before and under the intervention. Each ICU crosses from using the control to intervention condition after the site initiation visit. The primary endpoint is the consent rate for deceased organ donation calculated from 140 eligible next of kin families. Secondary endpoints are health professionals’ adherence rates to core elements of the intervention; identification of predictors of family donation decision; and the proportion of families who regret their final donation decision at 90 days.

Discussion

The pragmatic design of this study may identify ‘what works’ in usual clinical settings when requesting organ donation in critical care areas, both in terms of changes in practice healthcare professionals are willing and able to adopt, and the effect this may have on desired outcomes. The findings of this study will be indicative of the potential benefits of the intervention and be relevant and transferrable to clinical settings in other states and countries.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000815763 (24 July 2013). ClinicalTrials.gov: NCT01922310 (14 August 2013) (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1964-7) contains supplementary material, which is available to authorized users.

Request for organ donation without donor registration: a qualitative study of the perspectives of bereaved relatives

BACKGROUND

In the Netherlands, consent from relatives is obligatory for post mortal donation. This study explored the perspectives of relatives regarding the request for consent for donation in cases without donor registration.

METHODS

A content analysis of narratives of 24 bereaved relatives (14 in-depth interviews and one letter) of unregistered, eligible, brain-dead donors was performed.

RESULTS

Relatives of unregistered, brain-dead patients usually refuse consent for donation, even if they harbour pro-donation attitudes themselves, or knew that the deceased favoured organ donation. Half of those who refused consent for donation mentioned afterwards that it could have been an option. The decision not to consent to donation is attributed to contextual factors, such as feeling overwhelmed by the notification of death immediately followed by the request; not being accustomed to speaking about death; inadequate support from other relatives or healthcare professionals, and lengthy procedures.

CONCLUSION

Healthcare professionals could provide better support to relatives prior to donation requests, address their informational needs and adapt their message to individual circumstances. It is anticipated that the number of consenting families could be enlarged by examining the experience of decoupling and offering the possibility of consent for donation after circulatory death if families refuse consent for donation after brain-death.

Randomised, Double Blind, Controlled Trial of the Provision of Information about the Benefits of Organ Donation during a Family Donation Conversation

Introduction

It is unclear how much information should be provided to families of potential organ donors about the benefits of organ donation. Whilst this information is material to the donation decision, it may also be perceived as coercive.

Methods

Randomised, double blind, controlled trial in which community members watched one of two videos of a simulated organ donation conversation that differed only in the amount of information provided about the benefits of donation. Participants then completed a questionnaire about the adequacy of the information provided and the degree to which they felt the doctor was trying to convince the family member to say yes to donation.

Results

There was a wide variability in what participants considered was the “right” amount of information about organ donation. Those who watched the conversation that included information about the benefits of donation were more likely to feel that the information provided to the family was sufficient. They were more likely to report that the doctor was trying to convince the family member to say yes to donation, yet were no more likely to feel uncomfortable or to feel that the doctor was uncaring or cared more about transplant recipients than he did for the patient and their family.

Conclusions

This study suggests that community members are comfortable with health care staff providing information to family members that may be influential in supporting them to give consent for donation.

Potential donor families' experiences of organ and tissue donation-related communication, processes and outcome

We aimed to describe the experiences of families of potential organ and tissue donors eligible for donation after circulatory death or brain death. Forty-nine family members of potential donors from four Melbourne hospitals were interviewed to assess their experiences of communication, processes and the outcomes of donation. Interviews were recorded, transcribed verbatim and analysed thematically. Families expressed a range of perspectives on themes of communication, hospital processes and care, the processes of consent and donation and reflected on decisions and outcomes. They expressed satisfaction overall with communication when receiving bad news, discussing death and donation. Honest and frank communication and being kept up-to-date and prepared for potential outcomes were important aspects for families, especially those of post circulatory death donors. Participants reported high levels of trust in healthcare professionals and satisfaction with the level of care received. Many donor families indicated the process was lengthy and stressful, but not significantly enough to adversely affect their satisfaction with the outcome. Both the decision itself and knowing others' lives had been saved provided them with consolation. No consenting families, and only some non-consenting families, regretted their decisions. Many expressed they would benefit from a follow-up opportunity to ask questions and clarify possible misunderstandings. Overall, while experiences varied, Australian families valued frank communication, trusted health professionals, were satisfied with the care their family member received and with donation processes, despite some apparent difficulties. Family satisfaction, infrequently assessed, is an important outcome and these findings may assist education for Australian organ donation professionals.

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.

Organ Donation, Brain Death and the Family: Valid Informed Consent

I argue that valid informed consent is ethically required for organ donation from individuals declared dead using neurological criteria. Current policies in the U.S. do not require this and, not surprisingly, current practices inhibit the possibility of informed consent. Relevant information is withheld, opportunities to ensure understanding and appreciation are extremely limited, and the ability to make and communicate a free and voluntary decision is hindered by incomplete disclosure and other practices. Current practices should be revised to facilitate valid informed consent for organ donation.

African American organ donor registration: a mixed methods design using the theory of planned behavior

CONTEXT

A large racial disparity exists in organ donation.

OBJECTIVE

To identify factors associated with becoming a registered organ donor among African Americans in Alabama.

METHODS

Concurrent mixed methods design guided by the Theory of Planned Behavior to analyze African Americans' decisions to become a registered organ donor by using both qualitative (focus groups) and quantitative (survey) methods.

RESULTS

The sample consisted of 22 registered organ donors and 65 non registered participants from 6 focus groups completed in urban (n = 3) and rural (n = 3) areas. Participants emphasized the importance of the autonomy to make one's own organ donation decision and have this decision honored posthumously. One novel barrier to becoming a registered organ donor was the perception that organs from African Americans were often unusable because of the high prevalence of chronic medical conditions such as diabetes and hypertension. Another novel theme discussed as an advantage to becoming a donor was the subsequent motivation to take responsibility for one's health. Family and friends were the most common groups of persons identified as approving and disapproving of the decision to become a donor. The most common facilitator to becoming a donor was information, whereas fear and the lack of information were the most common barriers. In contrast, religious beliefs, mistrust, and social justice themes were infrequently referenced as barriers to becoming a donor.

CONCLUSION

Findings from this study may be useful for prioritizing organ donation community-based educational interventions in campaigns to increase donor registration.

Intensive care staff, the donation request and relatives' satisfaction with the decision: a focus group study

BACKGROUND

Effectiveness of the donation request is generally measured by consent rates, rather than by relatives' satisfaction with their decision. Our aim was to elicit Dutch ICU staffs' views and experiences with the donation request, to investigate their awareness of (dis)satisfaction with donation decisions by relatives, specifically in the case of refusal, and to collect advice that may leave more relatives satisfied with their decision.

METHODS

Five focus groups with a total of 32 participants (IC physicians, IC nurses and transplant coordinators) from five university hospitals in the Netherlands. Transcripts were examined using standard qualitative methods.

RESULTS

Four themes (donation request perceived by ICU staff from the perspective of relatives; donation request perceived by ICU staff from their own perspective; aftercare; donation in society) divided into 14 categories were identified. According to ICU staff, relatives mentioned their own values more frequently than values of the potential donor as important for the decision. ICU staff observed this imbalance, but reacted empathically to the relatives' point of view. ICU staff rarely suggested reconsideration of refusal and did not ask relatives for arguments. ICU staff did not always feel comfortable with a request in the delicate context of brain death. Sometimes the interests of patient, relatives and those on the waiting list were irreconcilable. ICU staff were mostly unaware of relatives' regret following their decisions. Aftercare did not provide this type of information. Donation request by IC physicians was influenced by the way organ donation has been regulated in society (law, donor register, education, media).

CONCLUSIONS

Our findings lead to the hypothesis that giving relatives more time and inviting them to reconsider their initial refusal will lead to a more stable decision and possibly more consent.

Family perspectives on deceased organ donation: thematic synthesis of qualitative studies

A major barrier to meeting the needs for organ transplantation is family refusal to give consent. This study aimed to describe the perspectives of donor families on deceased donation. We conducted a systematic review and thematic synthesis of qualitative studies. Electronic databases were searched to September 2012. From 34 studies involving 1035 participants, we identified seven themes: comprehension of sudden death (accepting finality of life, ambiguity of brain death); finding meaning in donation (altruism, letting the donor live on, fulfilling a moral obligation, easing grief); fear and suspicion (financial motivations, unwanted responsibility for death, medical mistrust); decisional conflict (pressured decision making, family consensus, internal dissonance, religious beliefs); vulnerability (valuing sensitivity and rapport, overwhelmed and disempowered); respecting the donor (honoring the donor's wishes, preserving body integrity) and needing closure (acknowledgment, regret over refusal, unresolved decisional uncertainty, feeling dismissed). Bereaved families report uncertainty about death and the donation process, emotional and cognitive burden and decisional dissonance, but can derive emotional benefit from the "lifesaving" act of donation. Strategies are needed to help families understand death in the context of donation, address anxieties about organ procurement, foster trust in the donation process, resolve insecurities in decision making and gain a sense of closure.

Do trained specialists solicit familial authorization at equal frequency, regardless of deceased donor characteristics?

CONTEXT

The Organ Donor Breakthrough Collaborative recommended high-leverage changes including "master effective requesting.

OBJECTIVE

To measure who approaches decedent families to request organ donation and to determine whether trained specialists will solicit authorization at equal frequency regardless of donor characteristics.

METHODS

Retrospective analysis of data from 2006 to 2009 in an organ center's donor database. Decedents were stratified into 2 groups: those that met the Organ Procurement and Transplantation Network's eligible death criteria (ED donors) and those that did not (not eligible death [NED] donors).

RESULTS

Of decedents whose families were approached for authorization, 46% were ED donors and 54% were NED donors. Trained specialists solicited authorization from 76% of the total population but were more likely to solicit authorization from ED donors than NED donors (86% vs 68%, P<.001). Trained specialists were more likely to solicit authorization from donors whose cause of death was overrepresented in ED donors and donors less than 50 years old. Trained specialists were more likely than others to obtain authorization from families of all donors. Multivariable modeling demonstrated that having a trained specialist approach the decedent's family was associated with the highest odds of obtaining authorization.

CONCLUSIONS

Trained specialists approached most families of decedents for authorization, but disproportionately approached fewer families of NED donors. Having a trained specialist approach the decedent family has the strongest impact on obtaining donor authorization. These data suggest that fewer resources are allocated to NED donors, which may adversely affect the supply of deceased donor organs.

When do next-of-kin opt-in? Anticipated regret, affective attitudes and donating deceased family member's organs

This research assessed whether affective factors promote and prevent family members from donating their loved one's organs. Participants (N = 191) imagined that a family member had died and that they had to decide whether or not to donate their organs and body parts for transplantation purposes. The least organs and body parts were donated when the deceased opposed donation. Moreover, participants who were not registered organ donors donated fewer organs than registered donors. This effect was mediated by anticipated regret, disgust and the perceived benefits of donation. Organ donation campaigns should target such factors to increase donor rates.

Providing social support in a persuasive context: forms of social support reported by organ procurement coordinators

Eighty-five organ procurement coordinators (OPCs) completed face-to-face interviews designed to elicit the emotional and instrumental social support strategies communicated to potential donor families throughout the request for deceased organ donation. OPCs identified six forms of emotional support and eight forms of instrumental support, with greater reported use of instrumental support strategies. In terms of instrumental support, OPCs most frequently ensured in-hospital comfort (61.2%) or met the nutritional needs of family members (51.8%). With respect to emotional support, OPCs most often expressed sympathy (31.8%) to families and provided support in the form of physical contact (27.1%) with family members. Identifying the forms of social support used by OPCs is a first step toward understanding the strategies that are more (or less) effective in achieving persuasive and support goals.

The impact of social, cognitive and attitudinal dimensions on college students' support for organ donation

This study investigates how college students can be social support catalysts for organ donation and how social, cognitive and attitudinal dimensions impact organ donor registration. A total of 317 people participated in the exploratory portion of the project and a total of 1800 responses were obtained from an online survey to members of a national student organization. The findings show that perceptions of the benefits of organ donation and altruistic motives had the greatest impact on the support for organ donation while respondents' knowledge about how to register to be an organ donor was the dominant dimension for donor registration status. Social-based communications had the next greatest impact for both support and donor registration. Based on the findings, an 18-month social media campaign was launched with the student organization that had 20 421 website visitors, 4473 Facebook members, 1189 YouTube video submissions with 164 000 views, motivated 19 623 people to go to a state's organ donor registration page, and had 9000 documented organ donor registrations. Within the student organization, organ donor registration increased by 28%. On the basis of these project results, Donate Life America and other sponsors have provided funding for two additional years.

Appointing 'trained donation practitioners' results in a higher family consent rate in the Netherlands: a multicenter study

The consent process for organ and tissue donation is complex, both for families and professionals. To help professionals in broaching this subject we performed a multicenter study. We compared family consent to donation in three hospitals between December 2007 and December 2009. In the intervention hospital, trained donation practitioners (TDP) guided 66 families throughout the time in the ICU until a decision regarding donation had been reached. In the first control hospital, without any family guidance or training, 107 families were approached. In the second control hospital 'hostesses', who were not trained in donation questions, supported 99 families during admittance. A total of 272 families were requested to donate. We primarily compared consent rates, but also asked families about their experiences through a questionnaire. Family consent rate was significantly higher in the intervention hospital: 57.6% (38/66), than in the control hospitals: 34.6% (37/107) and 39.4% (39/99). The 69% response rate to the questionnaire -~5 months after death - showed no confounding variables that could have influenced the consent rate. Appointing TDPs in the intervention hospital to guide families during admittance and the donation decision-making process, results in higher family consent rates.

Perceived support among families deciding about organ donation for their loved ones: donor vs nondonor next of kin

BACKGROUND

Families' experiences in the hospital influence their decisions about donating organs of brain-dead relatives. Meeting families' support needs during this traumatic time is an obligation and a challenge for critical care staff.

OBJECTIVES

(1) To elicit family members' accounts of various types of support received and perceived quality of care for themselves and their loved ones when they made the donation decision, and (2) to examine the relationship between these factors and the families' donation decision.

METHODS

Retrospective telephone interviews of 199 families from different regions of the country were completed. Aside from demographic data, the survey addressed perceptions of informational, emotional, and instrumental support and quality of care.

RESULTS

One hundred fifty-four study participants consented to donation; 45 declined. White next of kin were significantly more likely than African Americans to consent. Specific elements of reported support were significantly associated with consent to donate. Donor and nondonor families had differing perceptions of quality care for themselves and their loved ones. Receiving understandable information about organ donation was the strongest predictor of consent.

CONCLUSIONS

Specific supportive behaviors by staff as recounted by family members of potential donors were significantly associated with consent to donation. These behaviors lend themselves to creative training and educational programs for staff. Such interventions are essential not only for next of kin of brain-dead patients, but also for staff and ultimately for the public as a whole.