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

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.

The National Donor Family Council: History, Activities, Achievements, and Legacies

The National Donor Family Council (NDFC) functioned under the sponsorship of the National Kidney Foundation from 1992-2014. Giving voice to the needs and views of donor families, the NDFC had an important impact on the support for those families. This article records significant points in the advocacy of donor families, summarizes the history of the NDFC, highlights the various activities and achievements of the NDFC, and offers some impressions of its legacies.

Patients' Information Needs for Informed Consent to Participate in First-in-Human Pig Kidney Xenotransplant Clinical Trials: A Mixed Methods Study

BACKGROUND

Transplant programs preparing to initiate first-in-human pig kidney xenotransplant clinical trials must be especially careful when obtaining participants' informed consent. Little is known about the kind of information patients want for making an informed decision about trial participation.

METHODS

We conducted semi-structured telephone interviews with waitlisted kidney transplant patients about information needs regarding participating in a first-in-human pig kidney xenotransplant trial, which guided development of a prototype consent form. Subsequent usability testing interviews sought patient feedback on the consent form. We analyzed qualitative data by thematic analysis and quantitative data by descriptive statistics.

RESULTS

Twenty-eight patients participated in semi-structured interviews; 16 patients participated in usability testing interviews. Most interview participants were male (68%, 56%), White (54%, 56%), or Black (36%, 31%), respectively. Interview participants identified five types of information needs: (1) the potential for infection contraction and transmission; (2) risks, benefits, and impact of xenotransplant trials; (3) xenotransplant clinical trial and recipient experience; (4) clinical trial logistics; and (5) the pig and its kidney. Usability testing participants suggested adding details to the prototype. Participants' preparedness to make a decision about participating in a xenotransplant trial increased after reviewing the prototype (12.5% vs. 31.3%, n.s.).

CONCLUSION

We identified multiple unique types of information patients desired to make informed decisions about pig kidney xenotransplant trial participation. Transplant programs initiating xenotransplant trials should be prepared to address patients' information needs to optimize informed decision-making for trial participation. The prototype consent form may support a patient-centered approach to informed consent.

Identity Disclosure Between Donor Family Members and Organ Transplant Recipients: A Description and Synthesis of Australian Laws and Guidelines

INTRODUCTION

The disclosure of information that identifies deceased organ donors and/or organ transplant recipients by organ donation agencies and transplant centres is regulated in Australia by state and territory legislation, yet a significant number of donor family members and transplant recipients independently establish contact with each other.

AIM

To describe and synthesize Australian laws and guidelines on the disclosure of identifying information.

METHOD

Legislation and guidelines relevant to organ donation and transplantation were obtained following a search of government and DonateLife network websites. Information about the regulation of identity disclosure was extracted and synthesised using a process guided by Walt and Gilson's (1994) policy analysis framework.

FINDINGS

Nineteen documents were examined. Six guidelines refer to and were consistent with current legislation. Four documents did not address identity disclosure. All jurisdictions prohibit healthcare professionals from disclosing identifying information. In three states, the prohibition extends to all members of the public including donor family members and transplant recipients.

CONCLUSION

Restrictions on identity disclosure have implications for public promotion of donation and transplantation where sharing of stories and images of organ donors and transplant recipients is common. Further research is required to understand the perspective of donor family members, transplant recipients, and healthcare professionals impacted by the current laws.

The bereavement experiences of families of potential organ donors: a qualitative longitudinal case study illuminating opportunities for family care

OBJECTIVES

To illuminate opportunities for care in the context of deceased organ donation by exploring pre-existing family and healthcare professional characteristics, in-hospital experiences, and ongoing adjustment through the lenses of grief theory, systems theory, meaning-making, narrative, and organ donation literature.

METHOD

Qualitative longitudinal case studies explored individual and family change in five Australian families who had consented to Donation after Circulatory Determination of Death at a single centre. Participants attended semi-structured interviews at four, eight, and twelve months after the death.

FINDINGS

Family values, pre-existing relationships, and in-hospital experiences influenced first responses to their changed lives, understanding of the patient's death, and ongoing family adjustment. Novel behaviour that was conguent with family values was required at the hospital, especially if the patient had previously played a key role in family decision-making. This behaviour and emerging interactional patterns were drawn into family life over the first year of their bereavement.

RECOMMENDATIONS

Training that includes lenses introduced in this study will enable healthcare professionals to confidently respond to individual and family psychosocial needs.

CONCLUSION

The lenses of grief theory and systems thinking highlight opportunities for care tailored to the unique in-hospital context and needs that emerge in the months that follow.

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.

Legislation and Policy Recommendations on Organ and Tissue Donation and Transplantation From an International Consensus Forum

There is a shared global commitment to improving baseline donation and transplantation performance metrics in a manner consistent with ethics and local cultural and social factors. The law is one tool that can help improve these metrics. Although legal systems vary across jurisdictions, our objective was to create expert, consensus guidance for law and policymakers on foundational issues underlying organ and tissue donation and transplantation (OTDT) systems around the world.

Methods

Using the nominal group technique, a group composed of legal academics, a transplant coordinator/clinician, and a patient partner identified topic areas and recommendations on foundational legal issues. The recommendations were informed by narrative literature reviews conducted by group members based on their areas of expertise, which yielded a range of academic articles, policy documents, and sources of law. Best practices were identified from relevant sources in each subtopic, which formed the basis of the recommendations contained herein.

Results

We reached consensus on 12 recommendations grouped into 5 subtopics: (i) legal definitions and legislative scope, (ii) consent requirements for donation' (iii) allocation of organs and tissue' (iv) operation of OTDT systems' and (v) travel for transplant and organ trafficking. We have differentiated between those foundational legal principles for which there is a firm basis of support with those requiring further consideration and resolution. Seven such areas of controversy are identified and discussed alongside relevant recommendations.

Conclusions

Our recommendations encompass some principles staunchly enshrined in the OTDT landscape (eg, the dead donor rule), whereas others reflect more recent developments in practice (eg, mandatory referral). Although some principles are widely accepted, there is not always consensus as to how they ought to be implemented. As the OTDT landscape continues to evolve, recommendations must be reconsidered for the law to keep pace with developments in knowledge, technology, and practice.

Barrett's Power Theory: Re-Conceptualizing the Pediatric Organ Donation Experience With Letter Writing

Pediatric organ donation is often a time of reported turbulence and isolation for both families involved. Communication through letter writing is a way for those families to connect and heal, if they choose to participate. Barrett's Power as Knowing in Participation in Change Theory, with its accompanying health patterning, is applicable to this experience by facilitating awareness, choices, freedom to act intentionally, and involvement in the change process related to the pediatric organ donation process. Two families' experiences connected through organ donation and letter writing, as conceptualized through the lens of Barrett's Power Theory, supported future use of patterning of knowing participation in change for families.

Willingness to Donate Organs After Death

Abstract. Background: Despite the growing number of organ transplants, there is still a significant difference between the number of donated organs and the number of people waiting for them. Knowing the reason people decide to donate is the first step to increasing organ donation rates. Aims: The main aim of the present study was to develop and validate a new scale for organ donation. Method: In three studies, 3,585 participants ranging in age between 14 and 89 years were selected through systematic random sampling. In the first study, we created a scale following the organ donation model theoretical framework and submitted the scale to exploratory factor analysis. In the second study, we performed a confirmatory factor analysis to cross-validate the hypothesized factor structure. In the third study, the scale was related to some important variables involved in organ donation. Results: Exploratory factor analysis and confirmatory factor analysis with a good fit index and acceptable levels of validity and reliability guarantee the quality of the scale and stable factor solution. Limitations: The main limitations are connected to social desirability, the presence of systematic bias of the population that refused to take part in the study, and the use of the Caucasian population. Conclusion: The resulting scale consists of 21 items in a seven-factor model (bodily integrity, fear of death, familial beliefs, altruism, medical mistrust, trust in the health institution, and emotional support). We also observed the relationship between scale factors, religiosity, and knowledge of organ donation with the willingness to donate organs.

An Inventory of Deceased Donor Family Care and Contact Between Donor Families and Recipients in 15 European Countries

Families of organ donors play an important role in the deceased organ donation process. The aim of this study was to gain insight into donor family care by creating an inventory of practice in various European countries. A questionnaire about donor family care and contact between donor families and recipients was developed. Representatives of the organ donor professionals of 15 European countries responded (94%). The donor coordinator plays a key role in care for the donor family. All countries provide information about the donation results to the families, although diminished due to privacy laws. Anonymous written contact between donor families and recipients is possible in almost all countries and direct contact in only a few. Remembrance ceremonies exist in most countries. Half of the respondents thought the aftercare could improve. This first inventory shows that differences exist between countries, depending on the organisation of the donation process, the law and the different role of the professionals. Direct contact between donor families and recipients is rarely supported by the donation organisation. To date there has been limited research about the experience of donor family aftercare and we would urge all donation organisations to consider this as a priority area.

Hauntological dimensions of heart transplantation: the onto-epistemologies of deceased donation

The practice of human organ transplantation studies is shot through with questions concerning the concepts of selfhood and identity that continually reach out towards transmigration, displacement and haunting. In particular, heart transplantation is the site at which the parameters of human life and death are tested to their limits, not simply for the recipient but for the donor too. In conventional biomedicine, the definition and therefore the moment of death is a matter of ongoing and disturbing dispute between two major channels of thought. Should we understand life to end at the point of cessation of cardiac function, or alternatively that of the brainstem? That whole logic is predicated, however, on the familiar binary of life/death that fails to address urgent concerns in three arenas: social-cultural imaginaries, postmodernist philosophy and increasingly exploratory bioscience. If there is always something about death that is uncanny, that exceeds rationalist thought, then we need to queer the concept and ask whether there are more sensitive ways of thinking the process of dying. The very concept of extended life for the recipient is no simple outcome, and the question of whose life has been prolonged is far from clear. My contribution touches on the idea of thinking transplantation in the mode of parasitism but will suggest an alternative Deleuzian way forward.

Outcome measures in solid organ donor management research: a systematic review

AIM

We systematically reviewed published outcome measures across randomised controlled trials (RCTs) of donor management interventions.

METHODS

The systematic review was conducted in accordance with recommendations by the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. We searched MEDLINE, Embase, CENTRAL, Web of Science, and trial databases from 1980 to February 2021 for RCTs of donor management interventions.

RESULTS

Twenty-two RCTs (n=3432 donors) were included in our analysis. Fourteen RCTs (63.6%) reported a primary outcome relating to a single organ only. Eight RCTs primarily focused on aspects of donor optimisation in critical care. Thyroid hormones and methylprednisolone were the most commonly evaluated interventions (five and four studies, respectively). Only two studies, focusing on single organs (e.g. kidney), evaluated outcomes relating to other organs. The majority of studies evaluated physiological or biomarker-related outcomes. No study evaluated recipient health-related quality of life. Only one study sought consent from potential organ recipients.

CONCLUSIONS

The majority of RCTs evaluating donor management interventions only assessed single-organ outcomes or effects on donor stability in critical care. There is a need for an evaluation of patient-centred recipient outcomes and standardisation and reporting of outcome measures for future donor management RCTs.

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.

Legislative proposal in Italy to facilitate contacts between deceased organ donor families and transplant recipients

Contacts between organ donors and recipients might be possible in the near future in Italy. As suggested by The Italian Committee of Bioethics "anonymity is requested by the Italian National Transplant Centre" before transplantation anonymity shall be strict in order to grant privacy, gratuity, justice, solidarity and benefits and avoids organ trafficking. Following a period that is ethically correct and justifiable, organ donor families and recipients can meet after signing a valid declaration of consent, expressed on a template valid for the whole country. A third party within the body of the National Health Systems shall control the validity of the consent. The opinion stresses that contacts are not a right but a possibility justifiable on ethical grounds if the procedure is followed appropriately. A legislative proposal has been presented before the Chamber of deputies incorporating all suggestions made by the National Committee of Bioethics. The agreement between parties might be signed a year after transplantation. This is a long enough period of time for the recipients to fully appreciate the benefits of the procedure and for the donor families to see the effects of their decision (the opinion and the Law proposal hit the Zeitgeist, and keep Italy in the regulation of European Union).

Pure Altruistic Gift and the Ethics of Transplant Medicine

The article argues that altruistic giving based on anonymity, which is expected to promote social solidarity and block trade in human body parts, is conceptually defective and practically unproductive. It needs to be replaced by a more adequate notion which responds to the human practices of giving and receiving. The argument starts with identification of the main characteristics of the anonymous altruistic donation: social separation of the organ donor (or donor family) from the recipient, their mutual replaceability, non-obligatoriness of donation, and non-obligatoriness of reciprocation on the recipient's part. Since these characteristics are also central to typical market relations, anonymous altruistic donation not only cannot promote solidarity but may encourage proposals for (regulated) markets of transplantable organs. Thus, transplant ethics needs to be reframed. It needs to be rooted in, rather than promote, the practices of giving and receiving known to human societies. As the basis for such reframing, the idea of sharing in another's misfortune is proposed. It relies on the human practices of giving and receiving and, with appropriate regulatory safeguards, can provide a better conceptual basis for blocking commercial exchanges of human body parts.

A simple segmentation and quantification method for numerical quantitative analysis of cells and tissues

BACKGROUND

Microscopic image analysis based on image processing is required for quantitative evaluation of decellularization. Existing methods are not widely used because of expensive commercial software, and machine learning-based techniques lack generality for decellularization because many high-resolution image data has to be processed.

OBJECTIVE

In this study, we developed an image processing algorithm for quantitative analysis of tissues and cells in a general microscopic image.

METHODS

The proposed method extracts the color images obtained by the microscope into reference images consisting of grayscale, red (R), green (G), and blue (B) information and transforms each into a binary image. The transformed images were extracted by separating the cells and tissues through outlier noise elimination, logical multiplication and labeling. In order to verify the method, decellularization of porcine arotic valve was performed by the electrical method. Slice samples were obtained by time and the proposed method was applied.

RESULTS

The experimental results show that the segmentation of cells and tissues, and quantitative analysis of the number of cells and changes in tissue area during the decellularization process was possible.

CONCLUSIONS

The proposed method shows that cell and tissue extraction and quantitative numerical analysis were possible in different brightness of microscopic images.