Family Refusal Research Articles

Awareness, Beliefs and Barriers of Organ Donation among Saudis in Madinah City, Saudi Arabia

Background: Although organ transplantation is considered as the only preferable treatment for end-stage organ disease, there are not many organ donors among Saudis. Objectives: To assess knowledge and attitude of Saudis in Madinah, Saudi Arabia, towards organ donation and to determine factors intervene with willingness of family to donate a member’s organ. Methods: A cross-sectional study, data were collected through a valid structured interview questionnaire from 290 participants during organ donation campaign in May 2015. The questionnaire included socio-demographicdata and data about participants’ awareness and knowledge on organ donation. Data were analyzed and compared by participants’ sex using appropriate statistical tests. Results: Of the interviewed 385 Saudis, 290 agreed to participate in the study with a response rate of 76.3%. The mean age of the participants was 27.2 ± 8.8 years. The study revealed 74.1% of the participants were willing to donate their organs with no significant differences between males and females, although only 2.7% of them reported to have a donation card. Religion, money, and age of the recipient appeared to have no role in their willing of organ donation. However, lack of awareness (21.7%), family refusal (20.6%) and fear of unknown (19.7%) were the most important barriers of organ donation. Conclusions: The study showed a considerable number of participants were willing to donate their organs that religion and financial reasons were not factors. More organ donation campaigns are needed to maximize public positive beliefs.

Awareness and Attitudes toward Organ Donation in Rural Puducherry, India.

Background:For many of the end-stage organ diseases, organ transplantation is the most preferred treatment. The need for the organ transplantation is higher than the availability. For the transplantation program to be successful, awareness regarding organ donation is needed and people must have a positive attitude toward donating organs.Aim:This study aims to assess the awareness and attitudes regarding organ donation among the rural population and to evaluate the sociodemographic factors associated with their awareness.Subjects and Methods:This community-based cross-sectional study was conducted among 360 people living in 4 villages of Puducherry. Face-to-face interviews were carried out using pretested questionnaire, which included the sociodemographic data. Data were entered into Excel and analyzed using Statistical Package for Social Sciences.Results:Of 360 participants, 88% (317/360) were aware of organ donation. Among these 317 participants, awareness was highest in the age group 18–30 years 98.8% (87/88), male 91% (147/161), higher secondary and above 100% (58/58), and Class 1 socioeconomic status 92% (13/14). Source of awareness about organ donation was primarily through media 83% (263/317). The majority of the participants 88% (281/317) felt that the purpose of organ donation was to save life. Most of the participants 91% (290/317) said that all healthy adults are eligible organ donors and 87% (275/317) of the participants said that monetary benefits could not be accepted for organ donation. Most of the participants 70% (223/317) were willing to donate their organs after death. Among the participants who refused to donate their organs, family refusal 57% (25/44) was the most common reason.Conclusion:This study shows that there is a high level of awareness about organ donation among rural people and most of the participants are willing to donate their organs.

Limiting Factors of Brain Donation in Neurodegenerative Diseases: The Example of French Memory Clinics.

Postmortem neuropathological examination of the brain is essential in neurodegenerative diseases, to ensure accurate diagnosis, to obtain an a posteriori critical assessment of the adequacy of clinical care, and to validate new biomarkers, but is only rarely performed. The purpose of this study was to assess factors limiting brain donation, such as reluctance of physicians to seek donation consent, opposition from patients and families, and organizational constraints. We conducted a survey across French memory clinics and major neuropathological centers. Few postmortem examinations were performed annually, as less than one third of the centers had performed at least five autopsies, and 41% had performed none. The main limiting factor was the lack of donation requests made by physicians, as half of them never approach patients for brain donation. Reasons for not seeking donation consent often include discomfort broaching the subject and lack of awareness of the medical and scientific benefit of postmortems (77%), organizational constraints (61%), and overestimation of families' negative reaction (51%). Family refusals represented a second major obstacle, and were often caused by misconceptions. Identifying and addressing these biases early could help improve physicians' rate of making requests and the public's awareness about the importance of brain donation.

Non–Heart-Beating Donor Program: Results After 3 Years of Experience

BackgroundNon–heart-beating donation (NHBD) is a useful way to obtain organs and tissues. Therefore, since 2012 we have had an NHBD protocol in the metropolitan area of Seville. The aim of this work was to present the results obtained after 3 years of program. MethodsProspective observational study carried out from 2012 to 2014. We included all patients with an extrahospitalary sudden death who did not survive despite cardiopulmonary resuscitation, becoming a potential donors (PD). Variables included number of consultations, PD, allowed donor (AD), real donor (RD), and family or legal refusals; minutes of out-hospital care, in-hospital care, cannulation, and perfusion of the RD; and number of organs and tissues removed and viable proportion. Nonallowed donors were grouped according to the discarding cause. ResultsWe received 97 consultations, of which 40 were performed as PD. Of these, 24 were AD (60%) and 22 RD (55%). There were only 2 family refusals. In 2012, 10 patients were donors, 5 in 2013, and 7 in 2014. The out-hospital median time was 71 (interquartile range [IQR] 60–76) minutes, in-hospital 29 (26–34) minutes, cannulation 28 (24–33) minutes, and perfusion 135 (105–177) minutes. Eighteen tissues and 43 organs were extracted, of which 32 were implanted (75%), with kidneys (96%) being more frequent. Nonallowed donors numbered 12 in 2012, 4 in 2013, and 1 in 2014, and out-hospital causes were the most frequent discard reason. ConclusionsNHBD is a useful program in our city with a low refusal rate (8%), an average of 1.45 organs per donor, and kidney the most frequent organ.

Barriers to goals of care discussions with patients with advanced cancer and their families: A multicenter survey of oncologists.

15 Background: Early documentation of end-of-life (EOL) preferences in patients with advanced cancer is associated with less aggressive EOL care, however, several barriers to having these discussions exist. Evaluating practitioner-level barriers in the ambulatory oncology setting by adapting an existing survey from the critical care and internal medicine contexts was deemed important. Methods: The previously published “DECIDE” survey was modified to the ambulatory oncology setting and pilot tested. Surveys were then distributed to oncologists in Ontario, Canada via paper and secure online methods. The survey asked physicians to rank on a numerical scale the importance of various barriers to having EOL discussions with patients and their families. Trends were established using descriptive statistics. Analysis by respondent demographic was not completed due to small numbers. Results: A total of 30 out of 79 participants responded to the survey, for a response rate of 38%. Respondents generally ranked patient and family related barriers highest. For instance, patient difficulty accepting prognosis or indicating a desire to be “aggressive” was rated by 69% of respondents as an extremely or very important barrier to initiating EOL discussions. Sixty-three percent of respondents also rated patients’ inflated expectations of further cancer treatment benefit as a very or extremely important barrier to discontinuing active cancer-directed therapies. Patient or family refusal for referral was rated by 47% of respondents as a very or extremely important barrier to early palliative care referral. The majority ( > 85%) of respondents were very or extremely willing to initiate, lead, and finalize the EOL discussions with patients and their families. Conclusions: Oncologists in this study ranked patient and family related barriers to having EOL discussions above all other barriers. Further work is required to better understand such perceived barriers, and compare them to patient preferences and perceptions about EOL planning and cancer care at the end of life. Targeted interventions to address these barriers could then be developed.

Medical Students for Tissue Procurement, a 10-Year Experience in a Large University Hospital: An Exportable Model?

ObjectiveThe objective of this study was to describe tissue procurement activity performed during 10 years (2004–2014) by trained medical students in a large university hospital. MethodsIn this study, third to sixth year medical students were trained as in-hospital Tissue Coordinators (Tc) to perform tissue procurement activity on a 24/7 schedule supervised by an on-call senior Transplant Coordinator (sTC) in a large university hospital. Tc duty consisted of detection, initial evaluation of all hospital deaths, donor's family approach for tissue donation, and retrieval logistics organization, including corneal tissue retrieval after training and certification. They also assist sTC in organ procurement activity. ResultsA total of 18,931 deaths were prospectively evaluated, 79% of whom (n = 14,879) presented medical contraindications for tissue donation. Of the remaining 4052 (21%) potential tissue donors (PTD), 2522 (62%) were not converted into real donors, mostly due to family refusal (66%; n = 1650) followed by detection system failure and other logistical issues (34%; n = 872). A total of 2814 corneal units, 225 skin donations, 327 muscleskeletal tissue donations, 91 blood vessels donations, and 177 heart valve donations were obtained from the remaining 1530 (38%) real donors. Tissue potentiality increased from 19% to 43% throughout the study period as a consequence of the fluctuating acceptance criteria used by tissue banks depending on tissue demand. ConclusionsThe tissue donation program performed by trained students was successful in achieving a high and sustainable tissue donation rate in a large university hospital.

Intensive care practices in brain death diagnosis and organ donation.

We conducted a multicentre study of 1844 patients from 42 Spanish intensive care units, and analysed the clinical characteristics of brain death, the use of ancillary testing, and the clinical decisions taken after the diagnosis of brain death. The main cause of brain death was intracerebral haemorrhage (769/1844, 42%), followed by traumatic brain injury (343/1844, 19%) and subarachnoid haemorrhage (257/1844, 14%). The diagnosis of brain death was made rapidly (50% in the first 24h). Of those patients who went on to die, the Glasgow Coma Scale on admission was ≤8/15 in 1146/1261 (91%) of patients with intracerebral haemorrhage, traumatic brain injury or anoxic encephalopathy; the Hunt and Hess Scale was 4-5 in 207/251 (83%) of patients following subarachnoid haemorrhage; and the National Institutes of Health Stroke Scale was ≥15 in 114/129 (89%) of patients with strokes. Brain death was diagnosed exclusively by clinical examination in 92/1844 (5%) of cases. Electroencephalography was the most frequently used ancillary test (1303/1752, 70.7%), followed by transcranial Doppler (652/1752, 37%). Organ donation took place in 70% of patients (1291/1844), with medical unsuitability (267/553, 48%) and family refusal (244/553, 13%) the main reasons for loss of potential donors. All life-sustaining measures were withdrawn in 413/553 of non-donors (75%).

Attitudes of Australian neonatologists to resuscitation of extremely preterm infants.

We aimed to investigate how Australian neonatologists made decisions when incompetent patients of different ages needed resuscitation. A survey including vignettes of eight incompetent patients requiring resuscitation was sent to 140 neonatologists. Patients ranged from a very preterm infant to 80 years old. While some had existing impairments, all faced risk of death or neurological sequelae. Respondents indicated whether they would resuscitate, whether they believed resuscitation was in the patients' best interests, whether they would want intervention for a family member and whether they would comply with families' wishes to withhold resuscitation. They were also asked how they would rank the eight patients in a triage situation. Seventy-eight per cent of specialists completed the survey. The majority of respondents gave priority to the resuscitation of children over adults. Less than 40% would agree to withhold resuscitation at families' request for all children except for the preterm infant, where 96% would comply with families' wishes to withhold intensive care despite 77% believing resuscitation to be in the infant's best interest. This study found inconsistencies between physicians' perceptions of the patient's best interest regarding resuscitation and their willingness to comply with families' wishes to withhold resuscitation and give comfort care. Accepting a family's refusal of resuscitation was more marked for the premature infant, even among respondents who thought that resuscitation was in the patient's best interest. These findings are consistent with other international studies.

Application of Spanish quality instruments about organ donation and tranplants validated in pilot hospitals in Santa Catarina.

The need of increasing the number of notifications of potential and actual donors is a worldwide problem. There is still much loss of donors, which can be avoided. To use instruments adapted from the Model of Quality Management of the Spanish National Organization of Transplants in pilot hospitals in Brazil. This was a quantitative research developed in three large hospitals in Santa Catarina, The option by the three institutions is related to the number of Intensive Care Unit (ICU) beds and the number of potential donors notifications Central Catchment Notification and Distribution of Organs and Tissues of State (CNCDO-SC). Data collection was performed in medical records from deceased patients in the units of critical patients using two validated instruments, period of three months, in two steps as directed by ONT. In one of the hospitals, there was a higher percentage of losses due to maintenance problems (17.6%), family refusal (64.3%) and escapes (16.7%), and there also was a lower real effectuation index (29.4%). In 70.3%, losses due to maintenance were associated with irreversible cardiac arrest and hemodynamic instability. Family refusal was associated in 48.4% with the fact that the family was against donation and ample desire to keep the body integrate. Information obtained allows the manager to administer these data and therefore to implement actions of improvement, increasing the number of donator of organs and tissues.

Fourteen Years of Experience in Uncontrolled Organ Donation After Cardio-Circulatory Death

BackgroundSince 1999, a protocol for uncontrolled donation after cardio-circulatory death (DCD) has been carried out in our institution. We aimed at evaluating those 14 years of local experience. MethodsWe reviewed the charts of uncontrolled donors from 1999 till 2013. Potential donors with a no-flow period less than 30 minutes were considered. Kidneys were perfused by the use of a double balloon triple lumen catheter after at least a 2-minute period of no touch. We analyzed grafts outcome and warm and cold ischemia times. ResultsThirty-nine procedures were initiated: 19 were aborted because of family refusal (n = 7), medical reasons (n = 7), or canulation failures (n = 5) and 20 harvesting procedures were completed. Transplantation was considered for 35 kidneys (cold storage [n = 5] and hypothermic preservation system [n = 30]). The causes of withdrawal from transplantation were mostly macroscopic lesions (poor perfusion, macroscopic parenchyma or vascular lesions, or infectious risk). We transplanted 22 kidneys locally and 3 were shipped to another Eurotransplant center. Mean donor age was 40 ± 13 years. Among the 20 donors, 13 came from the emergency unit and 7 from the intensive care unit. Mean no-flow time for out-hospital management was 8.7 ± 3.6 minutes. Mean time of cardiopulmonary resuscitation was 71 ± 46 minutes. Mean cold ischemia time was 19 ± 5 hours. Primary nonfunction and delayed graft function occurred in 1 and 12 cases (4.5% and 54%), respectively. Graft survival was 86% at 1 year. Causes of graft loss during the entire follow-up were graft rejection (n = 3), ischemically damaged kidney (n = 2), and recurrence of focal segmental glomerulosclerosis (n = 1). ConclusionIn our experience, uncontrolled donors represent a valuable source of kidney grafts, with a prognosis of graft function and survival similar to the literature. To increase the number of available DCD organs, new techniques, such as the use of Normothermic ExtraCorporeal Membrane Oxygenation (NECMO), as well as improvement of recruitment of out of hospital potential donors have to be considered.

Improving Deceased Organ Donation in Lebanon: Opinion of the Healthcare Professionals.

Introduction Despite three years of continuous efforts, Lebanon still suffers from a very low deceased organ donation rate (2.5 deceased donors per M Inhabitants, in 2012). Method A series of refresher seminars were conducted for 9 hospitals involved in the organ procurement effort launched by NOOTDT-Lb in 2010. At the end of each seminar the healthcare professionals in attendance were asked to fill out a survey that included questions on the reasons for the low deceased organ donation rate in Lebanon as well as ideas for its improvement. Results Two hundred and twenty-eight (228) healthcare professionals completed the survey. Most of them (72.9%) associated the low donation rate to the family's refusal to donate the organs of a deceased relative. Approximately half the health professionals (52.3%) attributed the low rate to insufficient awareness campaigns while 30.4% considered it to be due to the indifference of the medical community. When asked what would improve this rate, 63.8% endorsed including organ donation in the school curriculum while 49.8% thought increasing awareness was necessary. Around 62% of the respondents understood the importance of collaborating with NOOTDT-Lb through a timely declaration of all potential brain death donors. In the professionals' opinion, the best way to improve personal performance was through seminars and conferences (27.3%) while the best method in which NOOTDT-Lb could help would be through the collaboration with the hospital coordinators (15.9%). Conclusion Education, awareness and collaboration seem to be the focus of most of the suggestions for improvement provided by health care professionals involved in the process of organ donation in Lebanon. These results have enabled NOOTDT-Lb to propose and develop strategies to improve the rate of organ donation namely, including organ donation in the hospital accreditation and in the curriculum of all medical and nursing schools.

Reasons for Family Refusal of Ocular Tissue Donation

IntroductionCorneal donations do not fill the transplant demand. The waiting list had 5512 individuals in Brazil and 143 in Rio Grande do Sul in December 2012. The aim of this study was to identify the reasons for family refusal of ocular tissues donation. MethodsThis retrospective study analyzed interview records for ocular tissue procurement performed in a general, public university hospital located in Southern Brazil between January 2008 and December 2012. It identified the reasons of family refusal for ocular tissue donation. ResultsA total of 1010 interviews for ocular tissues procurement were performed. From these, 513 (50.79%) refused donation with the following reasons: 60 (11.69%) family members were unaware of the desire of the potential donor, 153 (29.82%) of potential donors spoke against donation in life, 113 (22.02%) family members were undecided about the donation, 156 (30.40%) family members were against donation, 3 (0.58%) family members were unhappy with the service, 11 (2.14%) family members were afraid of body release delay, 6 (1.16%) families expressed religious convictions against donation, and 11 (2.14%) family members wanted to keep the body intact. ConclusionThere are many reasons for ocular tissues donation refusal, and the knowledge provides better strategies for family interviews. In this study, most of the reasons, around 90%, can be related to lack of information or communication about the subject. Greater awareness of the population about the subject can be a good way to increase ocular tissue procurement indexes.

Potential of organ donation from deceased donors: study from a public sector hospital in India.

Deceased donor organ programme is still in infancy in India. Assessing deceased donation potential and identifying barriers to its utilization are required to meet needs of patients with organ failure. Over a 6-month period, we identified and followed all presumed brainstem dead patients secondary to brain damage. All patients requiring mechanical ventilation with no signs of respiratory activity and dilated, fixed and nonreacting pupils were presumed to be brainstem dead. All events from suspicion of brainstem death (BSD) to declaration of BSD, approach for organ donation, recovery and transplants were recorded. Subjects were classified as possible, potential and effective donors, and barriers to donation were identified at each step. We identified 80 presumed brainstem dead patients over the study period. The mean age of this population was 35.9years, and 67.5% were males. When formally asked for consent for organ donation (n=49), 41 patients' relatives refused. The conversion rate was only 8.2%. The number of possible, potential and effective donors per million population per year were 127, 115.7 and 9.5, respectively. The poor conversion rate of 8.2% suggests a huge potential for improvement. Family refusal in majority of cases reflects poor knowledge and thus warrants interventions at community level.

Barriers to palliative care research for emergency department patients with advanced cancer.

Patients with advanced cancer often visit the emergency department (ED). Little is known about their willingness or ability to engage in palliative care research, although enrollment in clinical trials of other seriously ill ED patients—those with stroke, for example—has been shown to be feasible. To identify barriers to the enrollment of ED patients with advanced cancer in palliative care research. We prospectively tracked factors that affected patient accrual into a trial of palliative care for adults with metastatic solid tumors at an urban, academic ED. Research staff screened the electronic medical records for patients admitted to the hospital with metastatic solid tumors 8-12 hours a day, Monday through Friday. The ED attending of record and the patient's medical oncologist had to agree before research staff invited the patient to participate. Informed consent was obtained at the bedside in the ED, and patients were offered a $20 incentive to participate. Attempts were made to enroll 150 eligible patients in the study, and 73 were enrolled (49% enrollment rate). Barriers to enrollment for the 77 patients who did not participate were deduced from the field notes and placed into the following categories: patient refusal (n = 38, 49%), diagnostic uncertainty regarding cancer stage (n = 11, 14%), symptom burden (n = 9, 12%), family refusal (n = 7, 9%), physician refusal (n = 7, 9%), and/or patient unaware of illness or stage (n = 5, 7%). The findings are descriptive and do not test predetermined hypotheses. Patient refusal, symptom burden, and diagnostic disparities are common barriers encountered when recruiting ED patients with advanced cancer. Despite the barriers, recruitment was feasible for such ED patients. This study was funded by a Mentored Research Scholar Grant from the American Cancer Society (Dr Grudzen), a Medical Student Training in Aging Research Grant from the American Federation on Aging (Mr Kandarian), and by a Mid- Career Investigator Award in Patient Oriented Research (K24 AG022345) from the National Institute on Aging (Dr Morrison).

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.

Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention

To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. Transnational registry in Spain. We included 928 patients aged ≥80years with severe symptomatic AS. Aortic-valve replacement (AVR), transcatheter aortic-valve implantation (TAVI) or conservative therapy. All-cause death. Mean age was 84.2±3.5years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%) and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk [322 (47.1%)], other medical motives [193 (28.2%)], patient refusal [134 (19.6%)] and family refusal in the case of incompetent patients [35 (5.1%)]. The mean time from treatment decision to AVR was 4.8±4.6months and to TAVI 2.1±3.2months, P<0.001. During follow-up (11.2-38.9months), 357 patients (38.5%) died. Survival rates at 6, 12, 18 and 24months were 81.8%, 72.6%, 64.1% and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49-0.93; P=0.016) and AVR HR 0.56 (95% CI 0.39-0.8; P=0.002). Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis.

The Sokoto blind beggars: Causes of blindness and barriers to rehabilitation services

Purpose:To determine the causes of blindness and the barriers to accessing rehabilitation services (RS) among blind street beggars (bsb) in Sokoto, Nigeria.Materials and Methods:A cross-sectional survey of 202 bsb (VA < 3/60) using interviewer administered questionnaire. The causes of blindness were diagnosed by clinical ophthalmic examination.Results:There were 107 (53%) males and 95 (47%) females with a mean age of 49 years (SD 12.2). Most bsb 191 (94.6%) had non-formal education. Of 190 (94.1%) irreversibly bsb, 180/190 (94.7%) had no light perception (NPL) bilaterally. The major causes of blindness were non-trachomatous corneal opacity (60.8%) and trachoma corneal opacity (12.8%). There were 166 (82%) blind from avoidable causes and 190 (94.1%) were irreversibly blind with 76.1% due to avoidable causes. The available sub-standard RS were educational, vocational and financial support. The barriers to RS in the past included non-availability 151 (87.8%), inability to afford 2 (1.2%), unfelt need 4 (2.3%), family refusal 1 (0.6), ignorance 6 (3.5%) and being not linked 8 (4.7%). The barriers to RS during the study period included inability of 72 subjects (35.6%) to access RS and 59 (81.9%) were due to lack of linkage to the existing services.Conclusion:Corneal opacification was the major cause of blindness among bsb. The main challenges to RS include the inadequate services available, societal and users factors. Renewed efforts are warranted toward the prevention of avoidable causes of blindness especially corneal opacities. The quality of life of the blind street beggar should be improved through available, accessible and affordable well-maintained and sustained rehabilitation services.

Commendable Developments in Deceased Organ Donation and Transplantation in Iran

he Regional Perspective Section of Transplantationwishes to focus the attention of the international com-munity on the great strides in organ donation and trans-plantation that are being achieved in Iran.Multiple allografts are now being recovered from morethan 250 deceased donors annually in Tehran. The ShahidBeheshti University of Medical Science Organ ProcurementUnit (OPU) has transferred 281 brain-dead potential organdonors forevaluation (withinTehran and from othercities ofIran) to enable more than 800 organs and 100 tissues to betransplantedsince2004(1).TheShahidBeheshtiUniversityofMedicalScienceOPUisachievinganannualrateof30donorspmp (servicing a population of 10 million within Tehran)with a familyconsentfordonationof93%, asreported by theDirector of the OPU Dr. Katayoun Najafizadeh.The liver transplant center in Shiraz, under the di-rection of Dr. S.A. Malek-Hosseini, is performing more than400 deceased-donor liver transplants each year.The scientific and medical contributions of these de-velopments in Iran are profound. For example, such a ro-bust program of deceased-organ donation enabled the firsthand transplant to be performed from a 24-year-old brain-dead donor by the 15 Khordad Plastic Surgery Team inTehran in February 2013 (2). The Shiraz liver transplantteam has recently reported the association of specific cyto-kines interleukin-6 and tumor necrosis factor-> in thebrain-dead donor with postoperative complications (allo-graft dysfunction) inliver transplant recipients (3). The lungtransplantation program at Masih Daneshvari Hospital iswell established, again under the leadership of pulmonolo-gist Dr. Najafizadeh.An expanded program of deceased donation in Iranpresents an opportunity for the expression of a communitysolidarityVto continue to increase the number of organdonors. The World Health Organization has urged memberstates to achieve a self-sufficiency in organ donation andtransplantation (4). The other Tehran organ procurementorganization, the Iranian Tissue Bank, has recently reporteda reduction in the rate of family refusal from 30.4% to 20%,associated with a more sophisticated donation coordinatorteam (5).Iran has a long-standing history of deceased-donorkidney transplantation but limited until now. The first kid-ney transplant from a cadaveric donor was performed inShiraz in 1968. However, the huge expansion of dialysis andthe cost of patients leaving Iran for a foreign destinationpropelled the widely known living unrelated program. Morerecently, Iranian colleagues have made a candid assessmentthat the national living unrelated program has ethical issuesthat are unacceptable to sustain. In a report from theKhuzestan Province in Southwestern Iran that assessed themotivations of the unrelated kidneydonors, the exploitationof young poor individuals for their kidneys was evident (6).Two hundred ten living kidney vendors were evaluated. Thestudy cohort consisted of approximately 80% men (167);67% (141) of the vendors were less than high school grad-uates, and 20 (9.5%) were illiterate. Not surprisingly, fi-nancial issues were the main motivation for kidney sales inthis regionofIran, butit wasimportantly noted thatmost ofthe vendors were very young and uneducated.Recently, Dr. Mahdavi-Mazdeh has written, again in amost candid manner, that the unrelated program of Iran has‘‘given rise to a black market of brokers and other forms oforgan commercialism only accessible to those with sufficientfinancial resources’’ (7). This article exposes the confronta-tional dynamic between the vendor and the recipient. De-spite an appropriation of compensation to the vendor bygovernment and charity foundations, the initial provision offunds is not the final transaction. The vendor wants more

Patterns of organ donation among resuscitated patients at a regional cardiac arrest center

IntroductionAs organ demand outpaces supply in the United States, donation after cardiac death (DCD) is increasing, and the leading cause of death among donors is now cardiovascular/cerebrovascular disease. Selected patients resuscitated from cardiac arrest may be an under-recognized donor pool. Regional cardiac arrest centers are expected to address organ donation, but there are few guidelines available and the yield from this population is not fully known. MethodsWe characterized the progression of resuscitated cardiac arrest patients at a regional cardiac arrest center and transplant center from organ procurement organization (OPO) referral through procurement. We determined characteristics associated with donation, assessed temporal trends in referral and donation, and calculated the yield of organs from this cohort. ResultsOf 991 patients admitted between 2005 and 2011, 560 did not survive to hospital discharge. Of these, 530 (94.6%) were referred to the OPO and 75 (13.4%) had organs procured. Family refusal of otherwise suitable candidates precluded 71 procurements. Age, sex, arrest location, designated donor status, and family consent were associated with donation. The absolute number of admissions, referrals, and donors increased over the study period. The probability of OPO referral did not change, but the probability of donation increased. The overall yield was 1.8 solid organs and 1.3 eyes per donor, with the majority being transplanted. ConclusionsPost-cardiac arrest patients represent a potential donor pool to help fill the widening gap between organ supply and demand in the United States. Formal multi-modal neurologic assessment may expedite referral to an organ procurement organization. These components should be considered as cardiac arrest center designation criteria.

A More Than 20% Increase in Deceased-Donor Organ Procurement and Transplantation Activity After the Use of Donation After Circulatory Death

BackgroundOrgan procurement and transplant activity from controlled donation after circulatory death (DCD) was evaluated over an 11-year period to determine whether this program influenced the transplant and donation after brain death (DBD) activities. Material and MethodsDeceased donor (DD) procurement and transplant data were prospectively collected in a local database for retrospective review. ResultsThere was an increasing trend in the potential and actual DCD numbers over time. DCD accounted for 21.9% of the DD pool over 11 years, representing 23.7% and 24.2% of the DD kidney and liver pool, respectively. The DBD retrieval and transplant activity increased during the same time period. Mean conversion rate turning potential into effective DCD donors was 47.3%. Mean DCD donor age was 54.6 years (range, 3–83). Donors ≥60 years old made up 44.1% of the DCD pool. Among referred donors, reasons for nondonation were medical contraindications (33.7%) and family refusals (19%). Mean organ yield per DCD donor was 2.3 organs. Mean total procurement warm ischemia time was 19.5 minutes (range, 6–39). In 2012, 17 DCD and 37 DBD procurements were performed in the Liege region, which has slightly >1 million inhabitants. ConclusionsThis DCD program implementation enlarged the DD pool and did not compromise the development of DBD programs. The potential DCD pool might be underused and seems to be a valuable organ donor source.