Explaining brain death: a critical feature of the donation process

What Is the Effect of Organ Donation Authorization Rates When Utilizing a Standardized Effective Request Process?

To determine if implementation of a standardized effective request process (ERP) can increase organ donation authorization rates.

DESIGN

A retrospective, observational study was performed using data acquired from the Midwest Transplant Network. chi-square test was used to analyze categorical data, with p value of less than 0.05 deemed significant.

SETTING

The Midwest Transplant Network located in Westwood, KS from January 1, 2013 to June 30, 2017.

PATIENTS

A total of 1,391 consecutive patients were identified as potential donors based on medical evaluation of the patient's neurologic status, organ function, and established age criteria.

INTERVENTIONS

An ERP was used when discussing donation with 733 patients (53%), compared with no ERP usage with 658 patients (47%).

MEASUREMENTS AND MAIN RESULTS

A significant increase (30%) in donation rates was observed when an ERP was used. A comparative decrease in donation rates was observed whenever a breakdown in any of the four identified steps occurred.

LIMITATIONS

The data analyzed was gathered retrospectively. Due to the retrospective nature of our study, there is no way to determine delay in authorization times versus no delay. Although most population data information about the authorized donors was known, this information was limited in patients who declined.

CONCLUSIONS

With proper preparation and planning, the implementation of a standardized ERP may improve organ donation rates and increase the number of life-saving organs for transplant.

Formal Training Improves Resident Understanding and Communication Regarding Brain Death/Death by Neurologic Criteria

OBJECTIVE

Residents often are involved in discussions with families regarding brain death/death by neurologic criteria (BD/DNC); however, they receive no standardized training on this topic. We hypothesized that residents are uncomfortable with explaining BD/DNC and that formal didactic and simulated training will improve residents' comfort and skill in discussions surrounding BD/DNC.

DESIGN

We partnered with our organ procurement organization (OPO) to create an educational program regarding BD/DNC consisting of a didactic component, and role-play scenarios with immediate individualized feedback. Residents completed pre- and post-training surveys.

SETTING

This study included participants from 16 academic and community institutions across New Jersey, Pennsylvania, and Delaware that are within our OPO's region.

PARTICIPANTS

Subjects were recruited using convenience sampling based on the institution and training programs' willingness to participate. A total of 1422 residents at participated in the training from 2009 to 2020.  1389 (97.7%) participants competed the pre-intervention survey, while 1361 (95.7%) completed the post-intervention survey.

RESULTS

Prior to the training, only 56% of residents correctly identified BD/DNC as synonymous with death. Additionally, 40% of residents had explained BD/DNC to families at least once, but 41% of residents reported never having been taught how to do so. The biggest fear reported in discussing BD/DNC with families was being uncomfortable in explaining BD/DNC (48%). After participating in the training, 99% of residents understood the definition of BD/DNC and 92% of residents felt comfortable discussing BD/DNC with families.

CONCLUSIONS

Participation in a standardized curriculum improves residents' understanding of BD/DNC and their comfort in discussing BD/DNC with families.

Teleneurology-Enabled Determination of Death by Neurologic Criteria After Cardiac Arrest or Severe Neurologic Injury

OBJECTIVE

To determine whether providing teleneurology (TN) consultations aiding in determination of death by neurologic criteria (DNC) to a bedside intensivist is feasible and whether timely access and expert input increase the quality of the DNC examination and identification of potential organ donors, we reviewed retrospective data related to outcomes of such consultations.

METHODS

Between November 2017 and March 2019, TN consults were requested for sequential comatose patients in the intensive care unit (ICU). We recorded patients' demographic information, causes leading to coma or suspected DNC, and the results of TN consultations. We obtained data on the number of referrals to the organ bank and number of organ donors.

RESULTS

Ninety-nine consults were performed with a median time from request to start of the consult of 20.2 minutes (interquartile range 5.4-65.3 minutes). Eighty consults were requested for determination of prognosis, whereas 19 consults were requested for supervision of the DNC examination. In 1 of 80 (1.2%) prognostication consults, the patient was determined by the neurologist to require assessment of DNC and was found to meet DNC criteria; determination of DNC occurred in 11 of the 19 (57.9%) consultations for a supervised DNC examination. In a comparison of the pre-TN (94 months) and post-TN (17 months) periods, there was 2.56-fold increase in the proportion of patients meeting DNC criteria who were medically suitable for donation (pre-TN 8.9% vs post-TN 21.1%, p = 0.02) and a 2.12-fold increase in the proportion of donors (pre-TN 6.14% vs post-TN 13.1%, p = 0.14).

CONCLUSIONS

It is feasible to perform TN consultations for patients with severe neurologic damage and to allow expert supervision for DNC examination. Having a teleneurologist as part of the ICU assessment team helped differentiate severe neurologic deficits from DNC and was associated with increase in organ donation.

Qualitative Research Process Applied to Organ Donation

The family interview for organ donation continues to be one of the main concerns of transplant coordinators. We approach the family because we need to know the opinion of the person who has just died about the donation of his or her organs. The objective of this article is to describe how the application of the qualitative methodology has been followed to perceive what the relatives live in the moment in which they are informed of the death of their relative and they are offered the option of organ donation. Phenomenology is a philosophy that deals with the granting of meanings. It can simply describe or try to interpret them. Our informants were selected from among donor families until the 11 families were obtained. We use the Giorgi method because it allows us to identify the essence of a phenomenon and transform the lived experience into a textual expression of its essence. The unit of analysis was, each of the statements of the discourse that describes and interprets a reality, what we call "essence" or "meaning units." It must be the minimum expression of an episode and the experience in relation to it. We have detected 24 themes of the meaning units are most important for families in our area. Families agree on talking about donation, mourning, death, consolation from the donation, and the importance of the support received. Phenomenology is adequate to deepen into the feelings and interests of families in the process of donation.

Investigation of Public Perception of Brain Death Using the Internet

BACKGROUND

Brain death is a difficult concept for the public to comprehend, resulting in a reliance on alternative resources for clarity. This study aims to understand the public's perception of brain death via analysis of information on the Internet, determine the accuracy of that information, and understand how its perception affects the physician-patient relationship.

METHODS

We conducted a prospective cross-sectional study to evaluate information available to the public about brain death. The top 10 Google websites were analyzed for language complexity and accuracy in describing brain death. The top 10 YouTube videos were examined for content and the comments qualitatively analyzed for themes.

RESULTS

Inaccuracies describing brain death inconsistent with national guidelines were prevalent amongst 4 of 10 Google websites, 6 of 10 YouTube videos, and 80% of YouTube comments. On average, Google websites were written at a 12th grade level and 90% mentioned organ donation. Videos were frequently emotional (78%); 33% included negative comments toward physicians, of which 50% mentioned organ donation. All videos included clarification comments questioning the differences between brain death, death, coma, and persistent vegetative states.

CONCLUSIONS

The study revealed a significant amount of inaccurate information about brain death, affecting the public's understanding of the concept of brain death and resulting in negative emotions specifically toward physicians, and the link between brain death and organ donation. The medical community can improve understanding through consistent, simplified language, dissociating brain death from organ donation, and recognizing the emotions tied to discussions of brain death.

Communication, Leadership, and Decision-Making in the Neuro-ICU

The Neuro-ICU is a multidisciplinary location that presents peculiar challenges and opportunities for patients with life-threatening neurological disease. Communication skills are essential in supporting caregivers and other embedded providers (e.g., neurosurgeons, advanced practice providers, nurses, pharmacists), through leadership. Limitations to prognostication complicate how decisions are made on behalf of non-communicative patients. Cognitive dysfunction and durable reductions in health-related quality of life are difficult to predict, and the diagnosis of brain death may be challenging and confounded by medications and comorbidities. The Neuro-ICU team, as well as utilization of additional consultants, can be structured to optimize care. Future research should explore how to further improve the composition, communication and interactions of the Neuro-ICU team to maximize outcomes, minimize caregiver burden, and promote collegiality.

Corneal blindness and current major treatment concern-graft scarcity

According to World Health Organization, the global prevalence of blindness in 2010 was 39 million people, among which 4% were due to corneal opacities. Often, the sole resort for visual restoration of patients with damaged corneas is corneal transplantation. However, despite rapid developments of surgical techniques, instrumentations and immunosuppressive agents, corneal blindness remains a prevalent global health issue. This is largely due to the scarcity of good quality corneal grafts. In this review, the causes of corneal blindness, its major treatment options, and the major contributory factors of corneal graft scarcity with potential solutions are discussed.

Brain death and management of a potential organ donor in the intensive care unit

The concept of brain death developed with the advent of mechanical ventilation, and guidelines for determining brain death have been refined over time. Organ donation after brain death is a common source of transplant organs in Western countries. Early identification and notification of organ procurement organizations are essential. Management of potential organ donors must take into consideration specific pathophysiologic changes for medical optimization. Future aims in intensive and neurocritical care medicine must include reducing practice variability in the operational guidelines for brain death determination, as well as improving communication with families about the process of determining brain death.

A narrative review of the empirical evidence on public attitudes on brain death and vital organ transplantation: the need for better data to inform policy

Vital organ transplantation is premised on 'the dead donor rule': donors must be declared dead according to medical and legal criteria prior to donation. However, it is controversial whether individuals diagnosed as 'brain dead' are really dead in accordance with the established biological conception of death-the irreversible cessation of the functioning of the organism as a whole. A basic understanding of brain death is also relevant for giving valid, informed consent to serve as an organ donor. There is therefore a need for reliable empirical data on public understanding of brain death and vital organ transplantation. We conducted a review of the empirical literature that identified 43 articles with approximately 18,603 study participants. These data demonstrate that participants generally do not understand three key issues: (1) uncontested biological facts about brain death, (2) the legal status of brain death and (3) that organs are procured from brain dead patients while their hearts are still beating and before their removal from ventilators. These data suggest that, despite scholarly claims of widespread public support for organ donation from brain dead patients, the existing data on public attitudes regarding brain death and organ transplantation reflect substantial public confusion. Our review raises questions about the validity of consent for vital organ transplantation and suggests that existing data are of little assistance in developing policy proposals for organ transplantation from brain dead patients. New approaches to rigorous empirical research with educational components and evaluations of understanding are urgently needed.

Family presence during brain death evaluation: a randomized controlled trial*

OBJECTIVE

To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress.

DESIGN

Randomized controlled trial.

SETTING

Four ICUs at an academic tertiary care center.

SUBJECTS

Immediate family members of patients suspected to have suffered brain death.

INTERVENTIONS

Subjects were group randomized to presence or absence at bedside throughout the brain death evaluation with a trained chaperone. All randomized subjects were administered a validated "understanding brain death" survey before and after the intervention. Subjects were assessed for psychological well-being between 30 and 90 days after the intervention.

MEASUREMENTS AND MAIN RESULTS

Follow-up assessment of psychological well-being was performed using the Impact of Event Scale and General Health Questionnaire. Brain death understanding, Impact of Event Scale, and General Health Questionnaire scores were analyzed using Wilcoxon nonparametric tests. Analyses were adjusted for within family correlation. Fifty-eight family members of 17 patients undergoing brain death evaluation were enrolled: 38 family members were present for 11 brain death evaluations and 20 family members were absent for six brain death evaluations. Baseline understanding scores were similar between groups (median 3.0 [presence group] vs 2.5 [control], p = 0.482). Scores increased by a median of 2 (interquartile range, 1-2) if present versus 0 (interquartile range, 0-0) if absent (p < 0.001). Sixty-six percent of those in the intervention group achieved perfect postintervention "understanding" scores, compared with 20% of subjects who were not present (p = 0.02). Median Impact of Event Scale and General Health Questionnaire scores were similar between groups at follow-up (Impact of Event Scale: present = 20.5, absent = 23.5, p = 0.211; General Health Questionnaire: present = 13.5, absent = 13.0, p = 0.250).

CONCLUSIONS

Family presence during brain death evaluation improves understanding of brain death with no apparent adverse impact on psychological well-being. Family presence during brain death evaluation is feasible and safe.

Experiences of donor families after consenting to organ donation: a qualitative study

AIM

The aim of this study was to investigate the experience of Norwegian donor families during organ donation after brain death.

METHODS

This was a qualitative study using personal interviews. Twenty donor-family members from thirteen different situations were interviewed about their experience of being a close relative in an organ donation situation. The principles of qualitative content analysis were used.

FINDINGS

An experience of strain caused by the organ donation situation was identified. Lack of comprehension and awareness of the process of organ donation contributed to this, and continuing information after the consent was given appeared to be necessary. Reconciliation with the decision of organ donation and the subsequent situation was gained through understanding the organ donation process, through recognition of the increased strain and through satisfaction resulting from the contribution made by organ donation. Healthcare personnel were key persons in contributing to such understanding and recognition.

CONCLUSION

When attending to families in an organ donation situation, the focus must be on ensuring comprehension of the situation both through information provided in the hospital and during follow-up. It seems essential to arrange for a period of parting that can contribute to reconciliation, and to offer follow-up according to individual needs.

Do medical students understand brain death? A survey study

BACKGROUND

A lack of understanding of brain death has been demonstrated among physicians, and may stem from knowledge deficits at the medical school level. The authors sought to evaluate current understanding of brain death and knowledge gaps among U.S. medical students at a single center.

METHODS

Using a validated "Understanding Brain Death" survey tool, the authors surveyed the student body at an accredited four year medical school. A score of 5/5 on this scale indicated an expert level of understanding. The investigators identified areas of knowledge gaps, and compared brain death expertise throughout the curriculum progression.

RESULTS

The overall response rate was 69% (212 of 306 students). Mean scores were 3.1, 3.9, 4.1, and 4.0 (out of 5) among first through fourth year classes respectively. Understanding of brain death differed across the medical school classes (p <0.0001). 33% (N=70) of all students attained scores of 5 indicating an expert level of understanding brain death. By class; 18% of first year students demonstrated expert levels of understanding, compared to 31% of second year students, 48% of third year students, and 39% of fourth year students.

CONCLUSIONS

The level of understanding of brain death is low among the student body in a four year accredited U.S. medical school. This knowledge gap persists among graduating students as most do not attain an expert understanding of brain death. A more comprehensive brain death curriculum should be implemented in order to adequately equip physicians with this fundamental knowledge.

ICU nurses' perceptions of responsibilities and organisation in relation to organ donation--a phenomenographic study

OBJECTIVES

According to the Istanbul declaration, health services should create better routines for identifying potential donors. A previous study involving 702 intensive and critical care (ICU) nurses revealed that only 48% trusted clinical diagnosis of brain death without a confirmatory cerebral angiography. The aim was to study ICU nurses' perceptions of their experiences of professional responsibilities and organisational aspects in relation to organ donation and how they understand and perceive brain death.

METHODS

A phenomenographic method was chosen. Data collection (interviews) took place in Sweden and included fifteen nurses; one man and fourteen women, from six hospitals serving different geographic areas.

RESULTS

The findings pertain to three domains: ICU nurses' perceptions of (1) their professional responsibility, (2) the role of the organisation regarding organ donation and (3) death and the diagnosis of brain death.

CONCLUSION

The ambiguity and various perceptions of brain death diagnosis seem to be a crucial aspect when caring for a brain dead patient. The lack of structured and sufficient organisation also appears to be a limiting factor. Both these aspects are essential for the ICU nurses' opportunities to fulfil their professional responsibility during the organ donation process.

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.

Deal breakers in the organ donation request process

Organ donation consent rates have stagnated at about 50%, while the need for transplantable organs continues to increase. This article focuses on consent rates of families who make a donation decision for a deceased loved one, and how social marketing efforts to increase organ donation can be enhanced by better understanding the decision-making process these families use. Three categories of factors bear significantly on that decision which, if not addressed properly, will very likely result in a refusal to donate. These "deal breaker" categories include (1) family predisposition and family care, (2) requestor characteristics, and (3) request dynamics. Recommendations are made toward developing best practices protocols which roughly parallel promotion activities and the selling process utilized in commercial marketing for overcoming these barriers.

Aggressive organ donor management protocol

As of August 2007, 96 900 people are awaiting organ transplantation in the United States, while only 28 930 transplants were performed in 2006. With such a large gap between organ need and organ availability, it is inevitable that many will die while awaiting transplantation. This organ shortage has become a national public health crisis, and as a response, the United States Department of Health and Human Services launched the Organ Donation Breakthrough Collaborative, an ambitious campaign to dramatically increase the number of transplantable organs. One of the suggested strategies involves maximizing the number of organs obtained from the available cadaveric "brain dead'' donor pool by using donor management protocols that optimize and treat the profound physiological disturbances that are associated with brain death. The use of these standardized and aggressive donor management protocols has been shown to increase the number of transplanted organs and prevent the number of donors lost due to medical failures. A protocol-driven approach by a dedicated organ donor management team should be considered a key component of any program designed to bridge the gap between organ supply and demand.

Signs of life and signs of death: brain death and other mixed messages at the end of life

Brain death is a medical, legal and cultural category constructed to fill an important need created by evolving medical technologies and practices. However, managing life and death via organ transplants and brain death criteria is not without controversy; there remains much confusion and ambivalence in both lay and medical populations regarding both organ donation and the diagnostic category of brain death. By way of a case study of cranial trauma taken from a larger study of bereaved parents, this article discusses how, from a parent's perspective, brain death and organ donation are neither morally nor medically straightforward concepts. The case study presented in this article demonstrates the necessity for more research and clinical training in communication issues regarding brain death and end-of-life care with families in critical care situations.

Why relatives do not donate organs for transplants: 'sacrifice' or 'gift of life'?

AIM

This paper is a report of a study to explore the reasons family members declined organ donation from a deceased relative.

BACKGROUND

In the United Kingdom family members' consent is usually sought before organ donation from their deceased relative can proceed. Knowledge of the concerns that may influence families' decision-making could be helpful to nurses supporting bereaved family members.

METHOD

A convenience sample of 26 family members, who declined donation of their deceased relatives' (n = 23) organs, were recruited via three media campaigns in large conurbations and from four intensive care units in the United Kingdom. Data were collected in 2005 using interviews.

FINDINGS

Donation decisions depended on a number of converging factors in a particular situation and not necessarily on the views of relatives about donation, or the reported wishes of the deceased in life, except if the person had stated that they did not wish to be an organ donor. Therefore, reported pro-donation views held by the family, or the deceased in life, did not guarantee donation. Protecting the dead body, which related to keeping the body whole and intact was the most frequently-recurring theme, being reported in 15 interviews.

CONCLUSION

Families' wishes to protect the dead body may stimulate tension between the notions of 'gift of life' as supported by transplant policy and 'sacrifice' of the body, which must be made if organ donation is to proceed. This could account for the decision of participants to decline donation even if their deceased relative previously held positive views about organ donation.

Two perspectives on organ donation: experiences of potential donor families and intensive care physicians of the same event

The aim was to explore how relatives and physicians understood cases where organ donation had been requested and what factors were salient for the decision on donation. Physicians of 25 deceased patients and 20 relatives were interviewed. The material was analyzed using qualitative methods. Eleven patients had declared their wishes on donation before death; in 14 cases the relatives had to decide. Half of these relatives accepted donation and half refused. The donation request was of secondary importance to the families; they were totally occupied by the death and initially tried to avoid the request by regarding "no" as a nonresponse. They needed support to relieve their immediate reactions of uneasiness, start rational thought processes, and reach well-grounded answers. The basis for requesting donation was good; relatives, with regard to circumstances, had been well prepared for the death by continuous information from the physicians and had confidence in staff, accepted that the question was raised, and understood the death criteria. However, about half the physicians experienced conflicts regarding prerequisites of procuring organs and dealing with relatives. Three different approaches were displayed: prodonation, neutral, and ambivalent. Only physicians with a prodonation approach received acceptance for donation.

Organ donation decision: comparison of donor and nondonor families

Family members continue to play a prominent role in donation decisions at time of death. This study examined the relative influence of donor and next-of-kin factors, requestor characteristics, communication processes and satisfaction with the health care team on the donation decision. Data were gathered via structured telephone interview with 285 next-of-kin of donor-eligible deceased individuals who had been approached by coordinators from one organ procurement organization (OPO) in the southeastern USA from July 2001 to February 2004. Univariate and multivariate analyses showed that several variables were associated with the donation decision. Subsequent logistic regression analyses revealed that donation was more likely when the deceased was younger, white (OR = 3.20, CI = 1.3, 5.7) and had made his/her donation intentions known (OR = 4.35, CI = 2.6, 7.3), and when the next-of-kin had more favorable organ donation beliefs (OR = 8.72, CI = 5.2, 14.7), was approached about donation by an OPO coordinator (OR = 3.74, CI = 2.2, 6.4), viewed the requestor as sensitive to their needs (OR = 2.70, CI = 1.6, 4.5) and perceived the timing of the request as optimal (OR = 6.63, CI = 3.6, 12.1) (total regression model, chi square = 133.2, p < 0.001, 92.7% of cases correctly predicted). Findings highlight the need for continued public education efforts to maximize positive beliefs about organ donation, to share and document donation decisions and to improve communication processes among the OPO personnel, hospital staff and prospective donor families.

A Qualitative Examination of the Needs of Families Faced With the Option of Organ Donation

Fewer than half of families approached about organ donation provide consent. Identifying specific support needs of family members in these situations is critical to help them cope and for improving consent rates. This focus group study retrospectively investigated donor and non-donor family members' perceived social support needs while facing the death of their loved one. Implications for nursing care and other interventions are discussed for interested healthcare providers.

Do New Drivers Equal New Donors? An Examination of Factors Influencing Organ Donation Attitudes and Behaviors in Adolescents

Adolescent and parent organ donation attitudes, knowledge, communications, and donor card signing rates were assessed. Parent-adolescent dyads (N = 137) were recruited at a Department of Motor Vehicles (DMV). Using discriminant analysis, attitude, knowledge, and communication variables adequately classified adolescent donor status. Overall, adolescent positive attitude toward donation was the most powerful variable discriminating between donors and nondonors. Examining only participants who had discussed donation with parents, the nature of parent-adolescent discussions about organ donation became the most important variable in donor classification. Adolescent donors reported significantly more positive and less negative attitudes, had parents with more positive and less negative attitudes, and had engaged in more frequent and more positive communications with parents about organ donation.

Death and organ procurement: public beliefs and attitudes

While brain death and the dead donor rule (patients must not be killed by organ retrieval) have been clinically and legally accepted in the US as a prerequisite to organ removal, there is little data about public attitudes and beliefs concerning these matters. To examine the public attitudes and beliefs about the determination of death and its relationship to organ transplantation, 1351 Ohio residents >or=18 years were randomly selected and surveyed using random digit dialing (RDD) sample frames. The RDD telephone survey was conducted using computer-assisted telephone interviews. The survey instrument was developed from information provided by 12 focus groups and a pilot study of the questionnaire. Three scenarios based on hypothetical patients were presented: brain dead, in a coma, or in a persistent vegetative state (PVS). Respondents' provided personal assessments of whether the patient in each scenario was dead and their willingness to donate that patient's organs in these circumstances. Over 98% of respondents had heard of the term brain death, but only one-third (33.7%) believed that someone who was brain dead was legally dead. The majority of respondents (86.2%) identified the brain dead patient in the first scenario as dead, 57.2% identified the patient in a coma as dead (Scenario 2), and 34.1% identified the patient in a PVS as dead (Scenario 3). Nearly, a third (33.5%) were willing to donate the organs of patients they classified as alive for at least one scenario, in seeming violation of the dead donor rule. Most respondents were not willing to violate the dead donor rule, although a substantial minority was. However, the majority of respondents were unaware, misinformed or held beliefs that were not congruent with current definitions of brain death. This study highlights the need for more public dialogue and education about brain death and organ donation.

Factors influencing the willingness to donate body parts for transplantation

Three hundred and thirty-six people representing three ethnic groups (White, Asian, and Afro-Caribbean) were asked to rank their preferences concerning various incentives that might induce them to agree to the posthumous donation of their body parts. A conjoint analysis of the responses suggested that 'self centred' options (notably upfront cash payments and priority on waiting lists) were generally more popular than 'altruistic' alternatives. Members of the sample already possessing donor cards were more knowledgeable about the issue of organ transplantation than others, were less squeamish, and had relatives who favoured organ donation. The strength of a person's desire to donate body parts was related positively to self-respect and whether the individual was 'religious'; and negatively to (i) squeamishness and (ii) having relatives who objected to transplantation. Altruistic preferences vis-à-vis organ donation were associated with knowledgeability, self-esteem, family background, low levels of squeamishness, and the extent to which a person experienced 'helper's high.' People who were financially well-off were the most self-centred in the organ donation context. Overall the results imply substantial disparities between public policy and contemporary public opinion regarding transplant donation incentives.

Evaluation of coma and brain death

Coma is a nonspecific sign of widespread central nervous system impairment resulting from various metabolic and structural etiologies. The rapid recognition of this neurologic emergency and results from the history, physical examination, and early investigative studies are key to the identification and treatment of its underlying cause. The prognosis for recovery depends greatly on the underlying etiology as well as on its optimal treatment, which seeks to preserve neurologic function and maximize the potential for recovery by reversing the primary cause of brain injury, if known, and preventing secondary brain injury from anoxia, ischemia, hypoglycemia, cerebral edema, seizures, infections, and electrolyte and temperature disturbances. Brain death must be diagnosed with similar care and precision, and families approached compassionately about the diagnosis and their decisions regarding organ donation.

The physician's role in discussing organ donation with families

Federal Conditions of Participation from the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) introduced in 1998 require that all families be presented the option of organ and tissue donation when death is imminent. The perception that physicians were being excluded from participating in this process led to a resolution at the American Medical Association House of Delegates meeting in December 1999, calling on the American Medical Association Council on Scientific Affairs to review the Conditions of Participation "to ensure that there is no prohibition of physician involvement in the organ donation process..." The number of organs procured for transplantation in the United States is insufficient to meet needs. Families' hospital experiences significantly affect their decisions to donate organs. Discussing severe brain injury, brain death, and organ donation after brain death with families is a specialized form of end-of-life decision-making and care in the intensive care unit; however, the knowledge, skills, and attitudes necessary for physicians and nurses to promote good end-of-life decision-making are widely variable. The federal Conditions of Participation require that those making requests of families for organ donation receive specific training. They do not prohibit physician involvement in initiating organ donation requests, provided these individuals are properly trained. Physicians have an important role in caring for patients and families in these circumstances, and the care they provide is enhanced through training, attention to the special issues involved, and collaboration with organ procurement organization personnel.

From attitude formation to behavioral response in organ donation: using marketing to increase consent rates

This article presents a theoretical analysis of attitude formation and the relationship to stated behavioral intentions as it relates to the decision to donate organs. This analysis reveals the presence of three distinct paths to behavior of potential donors, groups differing in their involvement with organ donation. Promotional objectives and campaign strategies designed to influence attitudes and behaviors should differ according to the behavioral path in operation and the involvement of the audience. Mass media campaigns are likely to reach high involvement groups only. Therefore, personal selling, underutilized in previous donation campaigns, should be brought into the donation strategy to appeal to low involvement groups. By recognizing differences in audience involvement and implementing different strategies, overall donation rates could substantially increase.

Organ donation and family decision-making within the Spanish donation system

This study analyses the variables associated with the decisions made by families of potential organ donors to give or deny consent for the extraction of organs. Different indicators were recorded in 68 cases of family interview for petition of consent carried out in 13 Spanish hospitals. Those variables showing the strongest relation with family decision (donation/refusal of consent) are knowledge shown by the family about the deceased's wishes with regard to donation (p<0.001), family relationship climate (p<0.01), expression of family's satisfaction level with medical attention received (p<0.01) and number of relatives present at the consent request interview (p<0.01). Logistic regression on family decision with considered variables correctly predicted relatives' final choice in 98.4% of cases. In turn, multivariate exploratory analysis highlights a potential association between the expression of the deceased's wishes and several concurrent variables in the process (satisfaction with personal treatment and medical attention received, emotional reactions in the interviews of notification of death and consent request). It also shows that patterns of reaction and family participation in this process may vary according to the sex of the deceased relative. Results suggest that both educational efforts devoted to promoting a positive attitude toward donation in the general population and the training of health professionals involved in the generation of organs may be key factors in reducing organ shortage.

Care of the potential pediatric organ donor

Although all of this information may create the impression that caring for a potential organ donor is an exceedingly complex task, in the authors' experience, this often is not true, and much energy can--and should--be devoted to the care of the bereaved family. Of crucial importance are the early recognition of brain death and the consequent radical switch of the treatment goal from preservation of the patient's brain and life to preservation of organs for the lives of others. Care for the donor is the natural extension of care for a critically ill or injured patient. During the foregoing discussion, the authors had to stress the absence of sound evidence on many points. Because many reports originate from transplant centers dedicated to a specific organ, gaining a comprehensive view on management options in the ICU further is hampered. Thus, this situation leaves another field in which investigations originating from pediatric intensivists could provide evidence urgently needed to make optimal choices. The next decade should see the thyroid hormone controversy solved by at least one controlled prospective study and the differential applicability of inotropic, vasoactive, or fluid-centered strategies. It seems self-evident that only graft survival and related parameters can form adequate endpoints for future studies.

Commodified kin: death, mourning, and competing claims on the bodies of organ donors in the United States

A pronounced disjunction characterizes symbolic constructions of the cadaveric donor body in the United States, where procurement professionals and surviving donor kin vie with one another in their desires to honor this unusual category of the dead. Of special concern is the medicalized commodification of donor bodies, a process that shapes both their social worth and emotional value. Among professionals, metaphorical thinking is key: death and body fragmentation are cloaked in ecological imagery that stresses renewal and rebirth. Such objectification also obscures the origins of transplantable organs, renders individual donors anonymous, and silences kin who mourn their dead. In response, donor kin have grown increasingly assertive, generating alternative public mortuary forms that exclude professional mediators. In so doing, they challenge the medical assumption that anonymity is central to transplantation's continued success. Through donor quilts and Web cemeteries, they proclaim the personal identities of donors who, at times, may speak beyond the grave, offering critiques of donation as socio-medical process in the United States.

Organ donation in children: role of the pediatric intensive care unit

OBJECTIVES

Children waiting for organ transplants continue to die because of the shortage of available organs. Studies of organ donation in children are scarce. The evaluation of the organ donation experience in a pediatric tertiary care hospital may identify factors that influence actual organ donation rates and lead to strategies to improve pediatric organ donation.

DESIGN

Retrospective study.

SETTING

Pediatric intensive care unit in a Canadian pediatric referral center.

PATIENTS

All children with brain death over an 8-yr period (1990-1997).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 199 children who fulfilled the criteria for brain death, 153 were medically suitable for organ donation. Families were approached for consent to organ donation in 128 (84%) of the 153 suitable cases. Consent was obtained in 63% (81/128) of those asked. Brain death caused by acute neurosurgical lesions was highly correlated to medical suitability and consent. Families identified as ethnic minorities were significantly more likely to refuse. After consent was granted, organs were procured from 63 (78%) of 81 donors, for an average of 3.6 organs transplanted per donor. There was a failure to procure organs in 22% (18/81) of cases after consent had been granted, primarily as a result of cardiocirculatory instability while in the intensive care unit.

CONCLUSIONS

Despite an encouraging 63% consent rate for organ donation when families are approached, only 41% of potential donors proceeded to actual donation. Strategies for a prospective pediatric study should focus on mandatory request, multicultural issues, and aggressive postconsent medical management and procurement. The pivotal role of the pediatric intensive care unit practitioner should be emphasized.

Fears and concerns expressed by families in the donation discussion

Previous research has identified specific fears and concerns among the general public about organ and tissue donation. However, little to none of that research has dealt with fears and concerns at the time of the donation discussion. In this study, 180 experienced coordinators ranked the fears and concerns most commonly heard during the donation discussion. They further classified the fears and concerns according to the ease with which they can be addressed. Subsequently, the fears and concerns were classified in 4 groups: often heard and easy to deal with, often heard and hard to deal with, seldom heard and easy to deal with, seldom heard and hard to deal with. The results can be used to stimulate further research on family fears and concerns, to train and retrain coordinators to address those concerns in the donation discussion, and to improve existing strategies for increasing organ and tissue donation.

Cadaveric donotransplantation: nurses' attitudes, knowledge and behaviour

Human organ transplantation is an important treatment for certain medical conditions, and for irreversible organ failure. There is a shortfall in the number of organs required for transplantation. The close and continuous proximity of nurses to potential donors and their families make them critical links in the organ donation process. Therefore, success in organ procurement may depend on nurses' awareness and integration of knowledge about donotransplantation (the process of organ/tissue donation and transplantation). Postal questionnaires were distributed throughout the United Kingdom (UK) to 2465 registered nurses, to assess their personal attitudes, knowledge and behaviour regarding cadaveric donotransplantation. One thousand, three hundred and thirty-three questionnaires were returned, a response rate of 54%. Overall, nurses held positive attitudes to donotransplantation, with 78% agreeing with organ donation and only 10% clearly being opposed. However, nurses were found to share ambivalent attitudes of altruism and fear which appear to surround decisions about donation. Factor analysis was used to further explore nurses' attitude structure. Six factors were confirmed providing a non-significant likelihood ratio fit (P = 0.468) and a well reproduced correlation matrix. The factors related to: (1) the value and contribution made by donotransplantation; (2) the unique idea of having another's tissue in one's own body; (3) the importance of organ donation; (4) the individual's moral, and nurses' professional rejection of the responsibility for organ/tissue donation; (5) the post-mortem mutilation of the body; and, (6) the potential distress donation may cause a bereaved family. Comparisons were made between certain of nurses' specialist groups and significant differences were found. Comparisons of factor scores between certain specialist groups or other strata were assessed by analysis of variance. Nurses working in renal units were significantly more in favour of donotransplantation than any other group of nurses.

Ethical analysis of organ recovery denials by medical examiners, coroners, and justices of the peace

CONTEXT

Despite its pivotal nature, until the early 1990s the role of medical examiners, coroners, and justices of the peace was largely ignored in discussions of the critical shortage of organs for transplantation in the United States. These officials have the right to determine, from a medico-legal perspective, whether a deceased person can be an organ donor. Thus, they play an important role in the donation process. Using a principles-based ethical framework, this article examines the problem of nonrecovery of life-saving organs for transplantation in the United States because a medical examiner or other official denies recovery.

OBJECTIVE

The goals of organ donation and the collection of forensic evidence are not mutually exclusive. An analysis of the ethical principles and obligations of beneficence, respect for autonomy, and justice reveals that medical examiners and other officials could probably, after appropriate review, release all cases under their jurisdiction for organ donation.

CONCLUSION

Medical examiners, coroners, and justices of the peace could assume a leadership role, working together on public policy with medical, social, and legal groups, spearheading efforts to stop the loss of organs due to official denials, up to and including state and federal regulation and legislation. Beyond their professional obligations, as agents of a social institution, medical examiners and other officials have the more general ethical responsibility of promoting the public health and welfare and of reinforcing societal consensus that transplantation is a social good which should be optimized through formal and informal activities.