The living donor advocate: a team approach to educate, evaluate, and manage donors across the continuum

Challenges in decision-making support processes regarding living kidney donation: A qualitative study

BACKGROUND

Previous studies on decision-making of living kidney donors have indicated issues regarding donors' autonomy is inherent in decision-making to donate their kidney. Establishing effective decision-making support that guarantees autonomy of living kidney donor candidates is important.

OBJECTIVES

The aim of this study was to identify the difficulties in the decision-making support when clinical transplant coordinators advocating for the autonomy of donor candidates of living donor kidney transplantation and to identify the methods to deal with these difficulties.

DESIGN

A qualitative descriptive study.

PARTICIPANTS

Ten clinical transplant coordinators supporting living kidney donors.

APPROACH

Semi-structured interviews were conducted using an interview guide. The modified grounded theory approach was utilised to analyse.

RESULTS

Three categories related to difficulties were as follows: issues inherent to the interaction between coordinators, donor candidates and their families; issues regarding the environment and institutional background in which coordinators operate; and emotional labour undertaken by coordinators in the decision-making support process. Additionally, five categories related to methods were as follows: assessing the autonomy of donor candidates based on the coordinators nursing experience; interventions for the donor candidates and their family members based on the coordinators nursing experience; smooth coordination with medical staff; clarifying and asserting their views as coordinators; and readiness to protect the donor candidates.

CONCLUSION

The involvement of highly experienced coordinators with excellent and assertive communication skills as well as the ability to reflect on their own practices is essential. Moreover, we may need to fundamentally review the transplant community, where power domination is inherent.

Developing an ethics framework for living donor transplantation

Both living donor transplantation and human subjects research expose one set of individuals to clinical risks for the clinical benefits of others. In the Belmont Report, the National Commission for the Protection of Human Subjects of Biomedical and Behavior Research (National Commission) articulated three principles to serve as the basis for a research ethics framework: respect for persons, beneficence and justice. In contrast, living donor transplantation lacks a framework. In this manuscript, we adapt the three principles articulated in the Belmont Report to serve as the foundation for an ethics framework for living donor transplantation which we supplement with the principles of vulnerability and responsibility. The National Commission supported additional protections for vulnerable groups of potential research participants. In 2001, Kenneth Kipnis effectively argued that the concept of vulnerable groups failed to explore in what ways particular groups of people were vulnerable, thereby risking unnecessary protections for some and inadequate protections for others. He proposed a taxonomy that explored different types of vulnerabilities that all research participants may experience to provide a more robust framework for human subjects protections, which we adapt to living donors. Robert Goodin claims that health professionals, who stand in special relationship with patients, are responsible for promoting and protecting their well-being. In living donor transplantation, the donor transplant team is responsible for empowering prospective donors to address their vulnerabilities and/or for protecting those who cannot by disqualifying them from donation.

Living Donor Kidney Transplantation: Improving Efficiencies in Live Kidney Donor Evaluation--Recommendations from a Consensus Conference

The education, evaluation, and support of living donors before, during, and after donation have historically been considered the roles and responsibilities of transplant programs. Although intended to protect donors, ensure true informed consent, and prevent coercion, this structure often leaves referring nephrologists unclear about the donor process and uncertain regarding the ultimate outcome of potential donors for their patients. The aim of this article is to help the referring nephrologist understand the donor referral and evaluation process, help the referring nephrologist understand the responsibilities of the transplant program, and offer suggestions about how the referring nephrologist can help to improve efficiencies in the process of donor education and evaluation. A partnership between referring nephrologists and transplant programs is an important step in advancing living kidney donation. The referring nephrologists are the frontline providers and are in a unique position to offer education about living donation and improve efficiencies in the process. Understanding the donor referral and evaluation process, the responsibilities of the transplant program, and the potential role referring nephrologists can play in the process is critical to establishing such a partnership.

The independent living donor advocate: a guidance document from the American Society of Transplantation's Living Donor Community of Practice (AST LDCOP)

The independent living donor advocate (ILDA) serves a mandated and supportive role in the care of the living organ donor, yet qualifications and role requirements are not clearly defined. Guidance comes from Centers for Medicare and Medicaid Services (CMS) Conditions for Transplant Center Participation and interpretive guidelines, Organ Procurement and Transplantation Network (OPTN) Policy and CMS and OPTN site surveys, yet interpretation of regulations varies. Herein, the AST Living Donor Community of Practice (LDCOP) offers seven recommendations to clarify and optimize the ILDA role: (a) the ILDA must have a certain skill set rather than a specific profession, (b) the ILDA must be educated and demonstrate competence in core knowledge components, (c) the ILDA's primary role is to assess components of informed consent, (d) centers must develop a transparent system to define ILDA independence, (e) the ILDA should have a reporting structure outside the transplant center, (f) the ILDA's role should be integrated throughout the donor care continuum, (g) the ILDA role should include a narrow "veto power." We address controversies in ILDA implementation, and offer pathways to maximize benefits and minimize limitations of approaches that may each meet regulatory requirements but confer different practice benefits. We propose a research agenda to explore the impact of the ILDA.

The start of the transplant journey: referral for pediatric solid organ transplantation

The focus of the majority of the psychosocial transplant literature is on post-transplant outcomes, but the transplant journey starts much earlier than this, at the point when transplantation is first considered and a referral for transplant evaluation is made. In this review, we cover information regarding the meaning of the referral process for solid organ transplantation. We discuss various factors of the referral for transplantation including the impact of referral on the pediatric patient and the family, potential expectations and misconceptions held by pediatric patients and parents, the role of health literacy, decision-making factors, and the informational needs of pediatric patients and parents. We elucidate steps that providers can take to enhance transplant referral and provide suggestions for much needed research within this area.

The development of practice guidelines for independent living donor advocates

The practice recommendations discussed here are based on the findings of the national survey as well as the opinions of the authors. The recommendations that are proposed here are not exhaustive and are aspirational in intent and are likely to evolve with time. Practice guidelines are recommended for legal and regulatory issues (e.g., state or federal laws), consumer or public benefit (e.g., improving service delivery, avoiding harm to the patient, decreasing disparities in underserved or vulnerable populations), and for professional guidance (e.g., new role, professional risk management issues, advances in practice). Without such practice guidelines, donors, and indirectly the candidates, may be at increased risk for possible bias or undue harm.

How young is too young to be a living donor?

Assessing people in adolescence and early adulthood who wish to become living organ donors (LDs) provides unique challenges. In several Canadian provinces, 16-year-old can legally consent to living organ donation. While the World Health Organization states that adolescence corresponds roughly to the ages of 10-19 years, parts of the brain associated with judgment continue to develop into the mid-20s. Therefore, it is legally possible for some young people to donate organs before their capacity to judge the benefits and risks of surgery has fully matured. Potential young living donors (YLDs) may be financially and/or psychologically dependent on their recipients (e.g. parents), which can make it difficult to determine if the YLD's donation is voluntary. This paper suggests ways to manage three ethical challenges in the use of young people as LDs: (1) determining the YLD's ability to appreciate the consequences of living organ donation, (2) determining whether the YLD's donation is voluntary and (3) evaluating the unique risks and benefits to the YLD. We conclude that there are compelling ethical reasons to offer the opportunity of living donation to selected young people. A thorough and fair evaluation process can address social, emotional and developmental issues associated with YLDs.

A national survey of independent living donor advocates: the need for practice guidelines

In 2000, representatives of the transplant community convened for a meeting on living donation in an effort to provide recommendations to promote the welfare of living donors. One key recommendation included in the consensus statement was that all transplant centers which have performed living donor surgeries have an independent living donor advocate (ILDA) "whose only focus is on the best interest of the donor." The aims of this study were to begin to understand the sociodemographic characteristics, selection and training, and clinical practices of ILDAs. All US transplant centers performing living donor surgeries were contacted to identify the ILDA at their center. One hundred and twenty ILDAs completed an anonymous survey. Results indicated considerable variability with regard to the sociodemographic characteristics of ILDAs, how the ILDA was selected and trained, and the ILDAs' clinical practices, particularly ethical challenges encountered by ILDAs. The variability observed may result in differential selection of donors and could have a potential negative impact on the lives of both donors and transplant candidates. The variability in the background, training, and practice of ILDAs suggests the need for strategies, such as practice guidelines, to standardize the interaction between ILDAs and living donors.

What the medical excuse teaches us about the potential living donor as patient

Since the inception of living donor kidney transplantation, physicians have expressed concern about the voluntariness of the donors and their ability to recuse themselves. The literature from the late 1960s and early 1970s reveals the practice of offering a false medical excuse, although more recent comments seem to focus more on a 'general statement of lack of suitability' or 'a blameless explanation'. Simmerling et al. argue that the provision of a medical excuse rests on deception, which is wrong on deontological grounds (that physicians should hold to a principle of veracity) and on consequential grounds (deception threatens to damage trust and the doctor-patient relationship and deception may have adverse impact on the donor's relationship with his family). In this paper I examine and reject these objections. I argue that a false medical excuse is morally unjustifiable, but the medical excuse understood as a 'general statement of lack of suitability' is morally permissible because it promotes donor autonomy (the donor's right to decide whether or not to donate), and protects and preserves the donor's rights to privacy and confidentiality (by affirming the donor as an independent patient).