Organ Donation Policies Research Articles

Is informed consent required for the diagnosis of brain death regardless of consent for organ donation?

In the half-century history of clinical practice of diagnosing brain death, informed consent has seldom been considered until very recently. Like many other medical diagnoses and ordinary death pronouncements, it...

When Lone Wolf Defectors Undermine the Power of the Opt-Out Default

High levels of cooperation are a central feature of human society, and conditional cooperation has been proposed as one proximal mechanism to support this. The counterforce of free-riding can, however, undermine cooperation and as such a number of external mechanisms have been proposed to ameliorate the effects of free-riding. One such mechanism is setting cooperation as the default (i.e., an opt-out default). We posit, however, that in dynamic settings where people can observe and condition their actions on others’ behaviour, ‘lone wolf’ defectors undermine initial cooperation encouraged by an opt-out default, while ‘good shepherds’ defeat the free-riding encouraged by an opt-in default. Thus, we examine the dynamic emergence of conditional cooperation under different default settings. Specifically, we develop a game theoretical model to analyse cooperation under defaults for cooperation (opt-out) and defection (opt-in). The model predicts that the ‘lone wolf’ effect is stronger than the ‘good shepherd’ effect, which – if anticipated by players – should strategically deter free-riding under opt-out and cooperation under opt-in. Our experimental games confirm the existence of both ‘lone wolf’ defectors and ‘good shepherd’ cooperators, and that the ‘lone wolf’effect is stronger in the context of organ donation registration behaviour. We thus show a potential ‘dark side’ to conditional cooperation (‘lone wolf effect’) and draw implications for the adoption of an opt-out organ donation policy.

Comparing different risk factors associated with delisting of hepatocellular carcinoma patients candidates for liver transplantation

Abstract Background Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide, with more than 1 million new cases diagnosed every year. Liver transplantation (LT) has been used as a curative treatment for patients with HCC. In countries where the liver allograft allocation is based on the Model for End-Stage Liver Disease (MELD) system, patients with HCC within the Milan criteria (MC) receive exception points, preventing dropout from the list. Objective The aim of this study is to analyse the different risk factors leading to delisting in liver transplant patients with hepatocellular carcinoma. Methods This study was a retrospective cohort study which had been carried out during the period between January 2017 to June 2018. During it, 48 patients were listed for LDLT at Ain Shams Center for Organ Transplantation (ASCOT) at Ain Shams Specialized Hospital till liver transplantation. By the end of this period 29 patients were delisted due to several reasons while 12 got transplanted and 7 were still on the waiting list. The study protocol was approved by the medical ethics committee of Ain Shams University. Results Regarding this study’s results, 25% were transplanted, 60.42% were delisted and 14.58% remained on the waiting list. 51.72% of patients in this study were delisted due to unavailability of related donor. In this center only related donors were allowed to donate as it follows Egypt’s organ donation policies, there are no organ allocation systems and deceased donor liver transplantation is illegal limiting availability of donors. Conclusion At the end of this study we can conclude that, age and tumour classification were independent predictors of delisting HCC patients candidates for liver transplantation.

Solid organ donation after death in the United States: Data-driven messaging to encourage potential donors.

US deceased donor solid organ transplantation (dd-SOT) depends upon an individual's/family's altruistic willingness to donate organs after death; however, there is a shortage of deceased organ donors in the United States. Informing individuals of their own lifetime risk of needing dd-SOT could reframe the decision-making around organ donation after death. Using United Network for Organ Sharing (UNOS) data (2007-2016), this cross-sectional study identified (1) deceased organ donors, (2) individuals waitlisted for dd-SOT (liver, kidney, pancreas, heart, lung, intestine), and (3) dd-SOT recipients. Using US population projections, life tables, and mortality estimates, we quantified probabilities (Pr) of (1) becoming deceased organ donors, (2) needing dd-SOT, and (3) receiving dd-SOT. Lifetime Pr (per 100000 US population) for males and females of becoming deceased organ donors were 212 and 146, respectively, and of needing dd-SOT were 1323 and 803, respectively. Lifetime Pr of receiving dd-SOT was 50% for males, 48% for females. Over a lifetime, males were 6.2 and females 5.5 times more likely to need dd-SOT than to become deceased organ donors. Organ donation is traditionally contextualized in terms of charity toward others. Our analyses yield a new tool, in the form of quantifying an individual's own likelihood of needing dd-SOT, which may assist with reframing motivations toward deceased donor organ donation.

Success of Opt-In Organ Donation Policy in the United States

Success of Opt-In Organ Donation Policy in the United States

Organ donor registration in the UK: The need for informed consent for ante-mortem interventions to facilitate organ donation

A generic consent model for the organ donation process currently permeates organ donation policy in the United Kingdom. The National Health Service Blood and Transplant’s (NHSBT’s) strategy for increasing organ donation rates in the United Kingdom includes interpreting a person’s registration on the Organ Donor Register (ODR) as justifying changes to the end-of-life care of the ODR registrant once incapacitated. However, individuals registering on the ODR are not currently provided with specific information regarding any ante-mortem procedures that may be carried out to facilitate organ donation. In this article, I argue that a specific consent model for ante-mortem donor optimisation procedures is needed not only to facilitate the achievement of the best interests of ODR registrants once incapacitated but also to fulfil NHSBT’s obligations to ODR registrants under the law on informed consent. I argue that NHSBT owes a duty of care to ODR registrants and that the implications of this duty of care include incorporating informed consent standards into the process of ODR registration.

Does Changing Defaults save Lives? Effects of Presumed Consent Organ Donation Policies

In this review, we examine whether presumed consent organ donation policies save lives. We compare presumed consent defaults (where people are considered organ donors by default but can opt out of donation) with explicit consent defaults (where people are considered nondonors by default but can opt in to be considered donors). Experimental, cross-sectional, and longitudinal evidence indicates that rates of consent, donation, and transplantation are higher under presumed consent policies than under explicit consent policies. The evidence also suggests, however, that presumed consent is one factor among many that determine the number of organs donated and lives saved; policymakers must balance a number of other considerations to ensure that shifting to a presumed consent system will boost donation and transplantation rates. We underscore the importance of investing in health care infrastructure to support organ procurement and transplantation and offer empirically informed recommendations to enable consent policies to save the most lives.

How Does Treating Chronic Hepatitis C Affect Individuals in Need of Organ Transplants in the United Kingdom?

ObjectivesTo estimate the impact of cures for chronic hepatitis C (CHC) infection on organ donation in the United Kingdom. Curing CHC infection reduces the need for liver transplants and enables cured individuals to donate organs of all types. MethodsWe adapted a double-queuing model of organ allocation to estimate the effects of CHC infection cures on liver, lung, heart, and kidney transplants in the United Kingdom. We assumed that cured individuals would donate organs at similar rates as the general population and no longer require liver transplants because of CHC infection. We estimated how curing CHC infection influences waitlist lengths for each organ and the annual net present value to society on the basis of quality-adjusted life-years gained through additional transplants under opt-in and opt-out organ donation policies. ResultsCuring CHC generates the most value for patients on the liver waitlist, because it increases the number of transplantable livers and reduces the need for transplants. Under the current opt-in policy, liver waitlist length falls by 24%, generating £34.3 million of annual net present value. Growth in the number of uninfected lungs, hearts, and kidneys generates an additional £19.2 million annually, with £18.7 million from kidneys. Implementing the opt-out policy, liver waitlist length would decrease by 75%, implying that treating CHC eliminates one-third of the excess liver waitlist due to an opt-in policy. ConclusionsTreating CHC has large positive spillovers to uninfected individuals by reducing the need for liver transplants and allowing cured individuals to donate organs. These spillovers have not been included in traditional value assessments of CHC treatment.

University Students’ vs. Lay People’s Perspectives on Organ Donation and Improving Health Communication in Poland

Given that organ transplant is a standard medical technology admitted in medical practice, and taking into consideration that Polish transplantology is regarded among the most advanced in the world one should expect to find similarly high levels of acceptance in interviewees asked for their opinion on vital organ transplantation and their willingness to donate a paired organ ex vivo, or a vital organ ex mortuo in order to rescue the life of a recipient with a missing vital organ. The paper presents research build on the societal assessment of vital organ donation and transplant policies in Poland with the focus on students. Data have been collected at three different universities (Boratyński et al., Questionnaire on the Bases of Transplantation Medicine 2016/7). Various assessments concerning a vital organ donation have been observed. The authors discuss educational factors contributing to these variety including factual knowledge and ethical issues.

The role of specialist nurses for organ donation: A solution for maximising organ donation rates?

To explore the role that Donor Transplant Co-ordinators have played and the future potential of Specialist Nurses for Organ Donation (SN-ODs), within organ donation strategies in the UK and other countries. Organ donation and transplantation rates vary extensively around the world. However, there is a universal shortage of deceased donors, prompting different approaches to increase transplantation rates. Within the UK, the Clinical Lead for Organ Donation and Specialist Nurse in Organ Donation undertake a key role in the implementation of the Organ Donation Strategy. The Human Transplantation (Wales) Act 2015 is a recent development which facilities a deemed (presumed) consent approach to organ donation, the Specialist Nurse in Organ Donation undertakes a major role identifying the potential donor in this situation by confirming the deemed consent status of the donor and supporting bereaved relatives. UK governments in England and Scotland are currently seeking legislative changes to an opt-out system of organ donation, in line with the Wales change. This discursive paper explores the role from Donor Transplant Co-ordinator to Specialist Nurse in Organ Donation (SN-OD) within organ donation policy in different settings, but with a specific focus on the UK. The paper clarifies the current and future potential of nurses working with bereaved families when requesting authorisation for donation. The current scope and future potential of Donor Transplant Co-ordinator and Specialist Nurse in Organ Donation roles need better recognition. Little empirical data exist about the key role that these nurses play in the organ donation process, especially in relation to gaining authorisation to proceed to donation. There is a need to clarify the role of the Specialist Nurse in Organ Donation and their impact on improving rates of organ donation.

Xenotransplantation in Asia

The organ shortage crisis affects most of the world today. In Asia, rates of deceased organ donation are extremely low due to sociocultural factors. In this context, implementing new organ donation policies is not enough; xenotransplantation remains the most promising way to solve the organ crisis. Most of the early research on xenotransplantation was conducted in the US and Europe. Today, however, Asia has caught up on its Western counterparts partly due to the increasing demand for organ transplants. Given the growing influence of countries such as China, South Korea, and Japan in xenotransplantation, this article provides the reader with an essential global understanding of the scientific and ethical issues currently at stake. Furthermore, it sheds light on the beliefs and values that shape the response of the Asian public to both organ donation and xenotransplantation.

Does changing defaults save lives? Effects of presumed consent organ donation policies

In this review, we examine whether presumed consent organ donation policies save lives. We compare presumed consent defaults (where people are considered organ donors by default but can opt out of donation) with explicit consent defaults (where people are considered nondonors by default but can opt in to be considered donors). Experimental, cross-sectional, and longitudinal evidence indicates that rates of consent, donation, and transplantation are higher under presumed consent policies than under explicit consent policies. The evidence also suggests, however, that presumed consent is one factor among many that determine the number of organs donated and lives saved; policymakers must balance a number of other considerations to ensure that shifting to a presumed consent system will boost donation and transplantation rates. We underscore the importance of investing in health care infrastructure to support organ procurement and transplantation and offer empirically informed recommendations to enable consent policies to save the most lives.

The role of altruism in an organ donation policy

Summary Globally, the two most common systems for managing organ procurement are opt-in and opt-out. Within the United Kingdom, organ procurement in England, Scotland and Northern Ireland is managed via an opt-in system. The United States also practises an opt-in system; individuals can express their intentions to donate by enrolling on a national or state registry and/or signifying their wishes on a driver's license . In 2015, Wales introduced a deemed consent: soft opt-out system for organ procurement in order to address the chronic shortage of organs for transplant. Early statistical evidence suggests that this has had a positive impact on cadaveric organ donation. Such a system for procurement has previously been dismissed by the Organ Donation Taskforce, who suggested that it could potentially undermine the concept of donated organs as gifts , resulting in a negative impact upon the numbers of organs offered for transplant. Considerable weight was placed upon the need to retain the altruistic gift element associated with an opt-in system. This paper will consider the role of altruism in an organ procurement policy and how it may be accommodated in a policy which acquires the maximum number of organs and is consistent with a society's values.

Family Attitudes, Actions, Decisions and Experiences Following Implementation of Deemed Consent and the Human Transplantation Act (Wales) 2013

Family Attitudes, Actions, Decisions and Experiences Following Implementation of Deemed Consent and the Human Transplantation Act (Wales) 2013

Organ donation in the ICU: A document analysis of institutional policies, protocols, and order sets

ObjectiveTo better understand how local policies influence organ donation rates. Research methodology/designWe conducted a document analysis of our ICU organ donation policies, protocols and order sets. We used a systematic search of our institution’s policy library to identify documents related to organ donation. We used Mindnode software to create a publication timeline, basic statistics to describe document characteristics, and qualitative content analysis to extract document themes. SettingDocuments were retrieved from Hamilton Health Sciences, an academic hospital system with a high volume of organ donation, from database inception to October 2015. FindingsWe retrieved 12 active organ donation documents, including six protocols, two policies, two order sets, and two unclassified documents, a majority (75%) after the introduction of donation after circulatory death in 2006. Four major themes emerged: organ donation process, quality of care, patient and family-centred care, and the role of the institution. These themes indicate areas where documented institutional standards may be beneficial. ConclusionFurther research is necessary to determine the relationship of local policies, protocols, and order sets to actual organ donation practices, and to identify barriers and facilitators to improving donation rates.

Physician perceptions about living organ donation in patients with Amyotrophic Lateral Sclerosis

ObjectivesPatients with Amyotrophic Lateral Sclerosis (ALS) have expressed desire to become living organ donors but are unable to do so with current organ donation policies. Our objective is to assess ALS patient’s interest in organ donation, and perceived concerns of this practice by ALS neurologists. Patients and methodsAn electronic survey was administered to ALS neurologists across the United States regarding living organ donation in ALS patients prior to respiratory failure. Results52 complete responses were received from 121 invites. 67% (35/52) of neurologists expressed no concerns about living organ donation in ALS patients, and 33% had concerns. The concerns related to respiratory failure, anesthesia exposure and renal dysfunction. With their concerns addressed, 71% of neurologists reported that they would endorse living organ donation.49% of neurologists reported being asked by a patient for information regarding living organ donation. ALS neurologists felt that 22.8% of ALS patients (median 19%) would be interested in learning more about organ donation, while only 6% of neurologists broach this subject with their patients. ConclusionOur results indicate that 1 in every 4 ALS patients may be interested in exploring options for living organ donation, and this topic is not routinely addressed by ALS clinics. These results indicate an unexplored area of patient interest. To honor a patient’s wishes to donate, the transplant community will have to accommodate living organ donation from terminally ill patients, and address neurologist concerns. Such a practice could benefit two groups of patients.

Preferences for Policy Options for Deceased Organ Donation for Transplantation: A Discrete Choice Experiment.

Despite broad public support for organ donation, there is a chronic shortage of deceased donor organs. We sought to identify community preferences for features of organ donation policies. A discrete choice study was conducted using an online panel of Australian community respondents older than 18 years. Respondents were presented with scenarios comparing a "new" policy to the current policy. Tradeoffs between 8 policy aspects were quantified using mixed logit and latent class models: registration system, extent of donor family involvement, ease of registration, frequency of confirmation of intent, direct payment, and funeral expense reimbursement, priority for donor's family, and formal recognition of donation. There were 2005 respondents (mean, 44.6 years). We found a strong preference for a new policy. Overall, respondents favored a policy that included: some involvement of the donor's family in the final decision, simple registration processes, less frequent reconfirmation of donation intent, direct payment or funeral expense reimbursement, and formal recognition of donation. However, there was significant preference heterogeneity across respondents, with various respondent groups valuing policy mechanisms differently. Respondents who viewed policy change negatively were also those who would be unlikely to be organ donors anyway, because they tended to hold negative views toward organ donation. Our results suggest that the Australian community are open to alternative organ donation policies including changes to: registration systems, family involvement, and financial and nonfinancial mechanisms. Future policy discussions should not be limited by preconceived notions of what is acceptable to the community, rather informed by actual community values and preferences.

Can evidence-based health policy from high-income countries be applied to lower-income countries: considering barriers and facilitators to an organ donor registry in Mumbai, India

BackgroundOrgan transplantation has become an effective means to extend lives; however, a major obstacle is the lack of availability of cadaveric organs. India has one of the lowest cadaver organ donation rates in the world. If India could increase the donor rate, the demand for many organs could be met. Evidence from high-income countries suggests that an organ donor registry can be a valuable tool for increasing donor rates. The purpose of this study is to determine whether the implementation of an organ donor registry is a feasible and appropriate policy option to enhance cadaver organ donation rates in a lower-income country.MethodsThis qualitative policy analysis employs semi-structured interviews with physicians, transplant coordinators, and representatives of organ donation advocacy groups in Mumbai. Interviews were designed to better understand current organ donation procedures and explore key informants’ perceptions about Indian government health priorities and the likelihood of an organ donor registry in Mumbai. The 3-i framework (ideas, interests, and institutions) is used to examine how government decisions surrounding organ donation policies are shaped.ResultsFindings indicate that organ donation in India is a complex issue due to low public awareness, misperceptions of religious doctrines, the need for family consent, and a nation-wide focus on disease control. Key informants cite social, political, and infrastructural barriers to the implementation of an organ donor registry, including widely held myths about organ donation, competing health priorities, and limited hospital infrastructure.ConclusionsAt present, both the central government and Maharashtra state government struggle to balance international pressures to improve overall population health with the desire to also enhance individual health. Implementing an organ donor registry in Mumbai is not a feasible or appropriate policy option in India’s current political and social environment, as the barriers, identified through the 3-i framework lens, may be too difficult to overcome. Despite the evidence supporting the use of donor registries as a means to enhance organ donation rates, it is clear that context is critical and that it is not always practical to apply evidence-based policy solutions from high-income countries to lower-income settings.Electronic supplementary materialThe online version of this article (doi:10.1186/s12961-016-0075-6) contains supplementary material, which is available to authorized users.

Identifying context and cause in small-N settings: a comparative multilevel analysis

Qualitative small-N comparisons face the challenge to detect context-bound causality under conditions of limited empirical diversity. Rather than treating context as a causal factor, we test the usefulness of the novel method of comparative multilevel analysis (CMA) to identify and understand the role of context as a contingent necessary condition that enables a causal relationship to unfold. Combining CMA with pairwise comparisons, we assess how organ donation policies in Switzerland and Spain affect relatives’ refusal rates in a small-N setting exhibiting multiple contextual levels. To tackle limited diversity systematically, we suggest to refine the CMA methodology by accounting for several contexts and referring to higher-order constructs. Applying CMA with these refinements, we find voluntary information measures only affect refusal rates in contexts of a credible state explicitly supporting organ donation. The fact that CMA can easily be combined with other analytical and conceptual approaches makes it an effective technique to identify contextual effects in small-N research.

Declining liver graft quality threatens the future of liver transplantation in the United States.

National liver transplantation (LT) volume has declined since 2006, in part because of worsening donor organ quality. Trends that degrade organ quality are expected to continue over the next 2 decades. We used the United Network for Organ Sharing (UNOS) database to inform a 20-year discrete event simulation estimating LT volume from 2010 to 2030. Data to inform the model were obtained from deceased organ donors between 2000 and 2009. If donor liver utilization practices remain constant, utilization will fall from 78% to 44% by 2030, resulting in 2230 fewer LTs. If transplant centers increase their risk tolerance for marginal grafts, utilization would decrease to 48%. The institution of "opt-out" organ donation policies to increase the donor pool would still result in 1380 to 1866 fewer transplants. Ex vivo perfusion techniques that increase the use of marginal donor livers may stabilize LT volume. Otherwise, the number of LTs in the United States will decrease substantially over the next 15 years. In conclusion, the transplant community will need to accept inferior grafts and potentially worse posttransplant outcomes and/or develop new strategies for increasing organ donation and utilization in order to maintain the number of LTs at the current level.