Organ Procurement Organization Staff Research Articles

Dual Advocates in Deceased Organ Donation: The Potential for Moral Distress in Organ Procurement Organization Staff.

AbstractOrgan procurement organization (OPO) staff play an essential role in the facilitation of organ donation as they guide family members and loved ones of dying patients through the donation process. Throughout the donation process, OPO staff must assume the role of a dual advocate, considering both the interests of the donor (which often include the wishes of the donor's family) and the interests of potential recipient(s). The benefits of this role are well established; however, minimal literature exists on the ways this role can cause moral distress in OPO staff, who frequently face scenarios in which adhering to the wishes of a donor family may compromise donation potential but failing to honor donor family requests may result in further emotional burden for the family. Given the frequency with which these ethically complex situations exist during donation, OPO staff are at heightened risk for experiencing moral distress and burnout, yet they are seldom acknowledged in the existing moral distress literature. As a result, it is unclear whether the current practices available to mitigate moral distress are beneficial for this population.

The Role of Procurement Biopsies in Kidney Acceptance Decision Making and Kidney Discard: Perceptions of Physicians, Nurse Coordinators, and OPO Staff and Directors.

Background.Procurement biopsies suffer from challenges with quality and reproducibility and are linked to kidney discard. Nonetheless, procurement biopsies are obtained for the majority of kidneys in the United States, and biopsy findings are commonly relied upon in kidney acceptance decisions.Methods.We conducted in-depth, semistructured interviews with 30 surgeons, nephrologists, nurse coordinators, and organ procurement organization (OPO) staff and directors to assess perceptions of factors contributing to kidney discard and strategies to reduce kidney discard, with a focus on the role of procurement biopsies. Thematic analysis was used to analyze qualitative data.Results.Three main themes emerged: (1) participants emphasized the importance of biopsy findings in making acceptance decisions but expressed concerns about a lack of standardization and quality control; (2) participants reported large variations in the level of importance placed on biopsy findings, the level of reliance on glomerulosclerosis in particular, and the cutoffs used; and (3) participants disagreed about how often procurement biopsies should be taken, with some supporting stricter limits on which kidneys are biopsied and others preferring a biopsy for most kidney offers.Conclusions.These findings support the development of standard practices for which kidneys require biopsy, how the biopsy material is prepared, and how the biopsy is interpreted. Variability in kidney acceptance practices across centers and the use of biopsy findings in guiding recipient selection also lend support to policies to allocate kidneys with suboptimal histological findings to the centers that are willing to use such kidneys and the patients who could most benefit from such offers.

Machine Learning Prediction of Liver Allograft Utilization From Deceased Organ Donors Using the National Donor Management Goals Registry.

Several machine learning classifiers were trained to predict transplantation of a liver graft. We utilized 127 variables available in the DMG dataset. We included data from potential deceased organ donors between April 2012 and January 2019. The outcome was defined as liver recovery for transplantation in the operating room. The prediction was made based on data available 12-18 h after the time of authorization for transplantation. The data were randomly separated into training (60%), validation (20%), and test sets (20%). We compared the performance of our models to the Liver Discard Risk Index. Of 13 629 donors in the dataset, 9255 (68%) livers were recovered and transplanted, 1519 recovered but used for research or discarded, 2855 were not recovered. The optimized gradient boosting machine classifier achieved an area under the curve of the receiver operator characteristic of 0.84 on the test set, outperforming all other classifiers. This model predicts successful liver recovery for transplantation in the operating room, using data available early during donor management. It performs favorably when compared to existing models. It may provide real-time decision support during organ donor management and transplant logistics.

Potential donor characteristics and decisions made by organ procurement organization staff: Results of a discrete choice experiment.

Organ procurement organizations (OPOs) evaluate referrals for deceased organ donation in the United States. Efforts to expand the donor pool, such as the HIV organ policy equity (HOPE) Act that permits transplants from HIV-positive donors to HIV-positive recipients, can only succeed if OPOs pursue referrals. However, relatively little is known about how OPO staff evaluate referrals. To better understand this process, OPO staff completed a discrete choice experiment to quantify the relative importance of seven donor characteristics on the decision to pursue a theoretical donor. Relative importance was defined by Partworth utility using a hierarchical Bayesian conditional logit model. There were 51 respondents from 36 of 58 OPOs in the United States. Of the seven attributes, organ and tissue potential were the most influential, followed by age, type of death, HIV status, donor registration, and Hepatitis C status. To be preferred to an HIV-negative donor, an HIV-positive donor needed to have the potential to donate two additional organs. These data provide insight into the preferences of OPO referral staff and may help explain the lower than expected number of HIV-positive transplants performed since the passage of the HOPE Act.

Barriers experienced by organ procurement organizations in implementing the HOPE act and HIV-positive organ donation

In the seven years since the HIV Organ Policy Equity (HOPE) Act made HIV-positive organ donation to HIV-positive recipients legally permissible in the United States, there have been fewer HIV-positive organ donations than expected. Organ procurement organizations (OPOs) play a key role in the transplant system and barriers at OPOs may be partly responsible for the relatively low number of HIV-positive donors. To understand potential OPO barriers, we conducted semi-structured interviews with 20 OPO staff members. Interviews were recorded, transcribed, and analyzed using a conventional content analytic approach with two coders. OPO staff had high levels of knowledge about HOPE. Many had evaluated referrals of HIV-positive donors and approached families for authorization. Barriers to HIV-positive organ recovery identified included obtaining authorization for donation, potentially disclosing HIV status to next-of-kin, and fear of HIV infection among those engaged in organ recovery. Strategies to overcome these barriers include providing continuing education about the specific tasks required to procure organs from HIV-positive donors, implementing targeted interventions to reduce fear of infection, and developing partnerships with HIV advocacy and care organizations. Given the central role OPOs play, HIV-positive donations are unlikely to occur in significant numbers unless these barriers can be overcome.

Vascularized composite allotransplantation: Knowledge and attitudes of a national sample of organ procurement organization professionals.

With the emergence of vascularized composite allografts (VCAs) for transplantation, donation professionals' ability to obtain authorization for these anatomical gifts has become paramount for its continued practice. Our national study examines the experience of organ procurement organization (OPO) professionals responsible for presenting the opportunity to donate VCAs to families of deceased donor-eligible patients. Semi-structured telephone interviews conducted with 157 OPO staff assessed experience with VCA discussions, VCA knowledge, and comfort, confidence, and feeling prepared with discussions about different VCA types. Standard procedures were used to code and analyze the qualitative data and summarize the quantitative data. Most respondents (70.1%) never held a VCA donation discussion, but those with experience reported overall low levels of knowledge, comfort, and confidence talking with families about VCA. Although 44.4% of the sample had VCA-related training, many felt unprepared, with most (75.0%) stating the training was insufficient. Participants without experience indicated even lower ratings of the aforementioned constructs. Findings support extant work demonstrating that no standardized procedures exist for VCA donation discussions; however, donation professionals are willing to adopt new VCA-related skills. This report concludes that sustained and content-specific training will elevate donation professionals' ability to augment the supply of VCAs available for transplantation.

AUTOMATED ELECTRONIC REFERRALS ARE CHANGING DONATION

Introduction: It is broadly understood and supported by previous studies that disruptive inefficiencies exist in the hospital to Organ Procurement Organization (OPO) donor referral process, including failure to notify the OPO and delayed referrals. Without a reliable and timely donor referral, life-saving organs cannot be procured and transplanted. A secure direct and automatic electronic donor referral interface was collaboratively developed and implemented to confront the issue of inefficient donor referrals by 1) eliminating the need for nurses to step away from patient care and place the phone call; and 2) automating the donor referral trigger with the goals of increasing referrals and donations while also reducing critical time spent by the hospital and OPO. Materials and Methods: The multi-disciplinary team collaborated to create a secure technical interface directly connecting the OPO and Hospital systems, as well as design seamless donor referral triggers within the Hospital EMR. These triggers automatically deliver electronic donor referrals from the Hospital to the OPO upon staff entry of pre-determined clinical data into the EMR, greatly reducing the need for donation knowledge and decision making by the hospital staff. The interface includes an additional manual trigger for staff to utilize in cases such as early family mention of donation and other exceptional situations. Upon receipt of the initial electronic referral, the OPO can quickly retrieve critical details for donation screening without pulling the hospital staff away from their critical duties of care. The above described interface has been successfully implemented in all 4 facilities in the hospital system. Results and Discussion: The interface has led to a significant increase in referrals and donations. Comparing the data from previous (2018) and following years (2019), during which time the only major process change at the hospital was the implementation of the electronic interface, there was a 49% increase in donor referrals (389 to 579) and a 333% increase in organ donors (3 to 13). Over the same period, over 190 hours of staff time were saved by the hospital and the OPO, regardless of the increase in referrals. There are several case studies of the OPO receiving an automatically triggered donor referral when the nurse was unable to connect on a phone call due to duties in a busy ICU. OPO staff were then able to retrieve the appropriate data directly from the EMR, allowing them to mobilize and ultimately recover organs and tissue which likely would have otherwise timed out. Conclusion: The results demonstrate increased efficiency in the donation referral process and project goals fulfillment by significant increase in referrals and donations as well as reduced burdens on both the Hospital and OPO through time savings. The initiative has been successful due to both the electronic interface and automating the donor referral trigger, leading to more donation and transplantation.

A Comparison of the Content and Quality of Organ Donation Discussions with African American Families Who Authorize and Refuse Donation

This study compares the experiences of African American (AA) families who authorized organ donation with those who refused. Large administrative datasets were obtained from 9 partnering Organ Procurement Organizations (OPO). Initial analyses used these data to assess authorization among African American families (n = 1651). Subsequent analyses were performed using a subsample of interview data of AA family decision makers (n = 276). Initial bivariate analyses tested differences in study variables by authorization status (donor/nondonor). Two separate multilevel logistic regressions examined associations between independent variables and family authorization. Analyses of the administrative datasets found that refusal was more likely when the patient was older, female, a DCD case, and not referred in a timely manner; refusal was less likely when families initiated donation conversations. Interview data revealed that families who refused donation were less likely to respond favorably to initial donation requests and reported less satisfaction with the overall approach, amount of time with OPO staff, and how questions were handled. Refusing families were also more likely to feel pressured, had less comprehensive donation discussions, and rated the OPO requesters' communication skills lower. No significant differences in organ donation attitudes were found between families who authorized donation and those refusing to donate. The study suggests that AA families making decisions about organ donation would benefit from culturally appropriate discussions. Clinical Trial Notation: NCT02138227.

342.1: Successful delivery of a healthy infant with subsequent recovery and transplant of organs from a brain dead mother following 105 days of maternal somatic support: A case study.

Background: A 27 year-old pregnant woman (17 weeks gestation) suffered an anoxic brain injury status post hanging. She was diagnosed brain dead on day 8 of hospitalization; all days listed herein are from admission (day 1) as she was on full ventilator support and under acute critical care from the date of admission. Case Progression: The family expressed a desire for the patient to be an organ donor. Hospital Staff (HS) made an early referral to the organ procurement organization (OPO) on day 4 at the family’s request after they were made aware of the grave prognosis. The OPO, patient’s physician (MD), HS, and ethics huddled to evaluate options for fulfilling the family’s wishes. During initial conversations with the family, the MD made the family aware ethics would need to be involved regarding any decisions to withdraw care or support. Family considered all options including withdrawal of support before ultimately choosing to pursue donation. A literature search revealed that while a brain dead mother had been supported for up to 110 days to achieve a live birth, the longest that such a mother had been supported with the end result of both a live birth and organ donation had been 64 days. The OPO collaborated with the family and a dedicated multidisciplinary hospital staff to develop a strategy to pursue the family’s goals. At a minimum there was daily communication between HS/MD and OPO staff; numerous OPO staff role types were involved. The donor’s water broke on day 19. On day 35 (22 weeks gestation), HS informed OPO staff that if the donor went into labor, it would not be stopped. At 30 weeks gestation, a date was set for a planned Caesarian-section. A huddle was conducted and infectious disease testing was performed. Results: On day 104, a healthy baby was delivered weighing 2212 g at 31.5 weeks gestation. OPO staff then began organ evaluation and on day 105 of maternal somatic support and 98 days after declaration of brain death, 4 organs (kidneys, liver, pancreas) were recovered and successfully transplanted into 3 recipients. All recipients are alive with normal organ function 200 days post-transplant. The newborn infant was discharged home 33 days after delivery with no disability. Conclusions: This landmark case represents the third longest reported case of life support for a brain dead mother to deliver a viable infant. It also represents the longest duration to both deliver a viable infant and provide organs for transplant, exceeding the previous record by 41 days. This case demonstrates that careful collaboration between the OPO and donor hospital can allow families to both achieve delivery of a viable infant and save lives through organ donation. The OPO’s and hospital’s lifesaving mission was met as four individuals (one newborn child and three recipients) are alive 200 days later. Further cases of this type should be carefully evaluated and pursued as an opportunity to support the grieving family and to save lives.

116.2: Electronic hospital donor referrals have arrived.

Background: The Centers for Medicare and Medicaid Services in the United States and additional regulatory organizations require that hospitals refer all potential organ, tissue and/or eye donors to their designated Organ Procurement Organization (OPO). To replace the current time-consuming and error-prone telephonic referral process, one OPO, its software system partner, a Hospital clinical team and their Electronic Medical Record (EMR) team successfully collaborated to implement the first-ever secure direct and automatic electronic donor referral interface between a Hospital EMR system and an OPO donor management system. The goals of the interface include: (1) increase the number and timeliness of referrals (and thus transplantable organs); (2) reduce Hospital and OPO resource costs; and (3) reduce risk of error due to human verbal communication and transcription risk. Methods: The multi-disciplinary team collaboratively created a secure technical interface directly connecting the OPO and Hospital systems. The team designed seamless donor referral triggers within the Hospital EMR which expanded upon existing Best Practice Advisory (BPA) notifications that previously instructed the EMR user to call in the referral, and now automatically deliver electronic donor referrals from the Hospital to the OPO. Immediately upon receipt, the OPO’s electronic donor management system creates a new referral that is auto-populated with actionable patient information and delivers real-time notifications alerting OPO staff of the new referral. The interface automatically returns the associated OPO referral ID number to the patient’s EMR. This interface was successfully launched in the Hospital ICU in October 2018. In April 2019 (six months later), the Hospital successfully rolled out the interface to additional units and facility locations, and numerous additional interface discussions and implementations are currently underway. Results: Immediately, the monthly referral count from the Hospital ICU to the OPO quadrupled (October 2017 = 18; October 2018 = 72). Since the launch, the OPO has been able to convert on a total of 36 organ, tissue, and eye donors across the facility. The use of an existing BPA resulted in minimal change to Standard Operating Procedures and reduced the need for clinical team training. Successfully transmitted referrals contained zero (0) errors in data transmission. Higher levels of awareness of organ donation potential in the units was observed. Conclusions: The current results were successful in the following measures: 1) increased number of referrals; 2) reduction in resource cost; and 3) decreased errors. The interface was established using standard interoperability technology connecting widely-adopted OPO donation software and Hospital EMR Systems to allow for scalable expansion. There is unlimited potential for streamlining the referral process through this electronic interface, ultimately leading to more donors and transplantations.

Authorization of tissues from deceased patients for genetic research.

Tissues from deceased donors provide important data for genomic research and Organ Procurement Organizations (OPOs) play a significant role. To understand the decisions of families who donated for transplantation and made decisions about donation to the Genotype-Tissue Expression Project (GTEx), we examined donation decisions of family decision makers (FDMs). 413 families were interviewed by telephone. The OPO staff who made the transplant and research requests completed self-administered surveys; a total of 309 matching surveys from 99 OPO staff were obtained. 76.8% of families donated to the GTEx project. Logistic regression analysis found that FDM consent to GTEx donation was associated with endorsement of policies to promote biobanking (OR=1.35), positive attitudes about medical research (OR=1.1), lack of concern regarding a breach of confidentiality (OR=1.54), comfort with tissue donation (OR=1.24), and prior authorization to solid organ donation (OR=3.17). OPO staff characteristics associated with GTEx donation included being female (OR=3.57), White (OR=4.97), comfort with hospital staff role in donation (OR=1.61), and number of topics discussed with families (OR=57.9). Donor type, FDM attitudes, OPO staff sociodemographics, OPO comfort with the GTEx authorization process, and intensity of discussing research-specific issues were significantly associated with GTEx donation decisions.

Changing Patterns of Organ Donation: Brain Dead Donors Are Not Being Lost by Donation After Circulatory Death.

The clinical characteristics of all New England Organ Bank (NEOB) donors after circulatory death (DCD) donors were analyzed between July 1, 2009, and June 30, 2014. During that 5-year period, there were 494 authorized medically suitable potential DCDs that the NEOB evaluated, constituting more than 30% of deceased donors coordinated annually by the NEOB. From the cohort of 494 authorized potential DCDs, 331 (67%) became actual DCD, 82 (17%) were attempted as a DCD but did not progress to donation, and 81 (16%) transitioned to an actual donor after brain death (DBD). Two hundred seventy-six organs were transplanted from the 81 donors that transitioned from DCD to actual DBD, including 24 heart, 70 liver, 12 single and 14 bilateral lung, and 12 pancreas transplants. When patients with devastating brain injury admitted to the intensive care units are registered donors, the Organ Procurement Organization staff should share the patient's donation decision with the health care team and the patient's family, as early as possible after the comfort measures only discussion has been initiated. The experience of the NEOB becomes an important reference of the successful implementation of DCD that enables an expansion of deceased donation (inclusive of DBD).

Honoring patients' organ donation decisions when family conflict is present: Experience from a single organ procurement organization.

Donor designation refers to the laws and processes for documentation of an individual's wishes regarding organ donation should that person become eligible for donation at death. All 50 states have laws supporting donor designation. Donor-family conflict arises when a designated donor's family attempts to rescind the donor's authorization to donate. Little guidance exists in the current literature to address these situations. Hospital public relations offices and organ procurement organization (OPO) records were queried to assess the incidence of legal action and adverse media coverage. Public legal records were searched for civil actions involving the hospitals at which these conflicts occurred. Fourteen cases of donor-family conflict were identified. Organ procurement proceeded in 9 (64%) of 14. A total of 38 organs were transplanted from these 9 donors. For those nine cases, median follow-up time was 57 months (interquartile range, 52-77 months; range, 38-114 months). The identified reasons for conflict include a belief by the family that they were given a choice in the decision about whether to proceed with donation; misunderstanding and lack of acceptance of the brain death diagnosis; disagreement among family members; concerns about timing/length of the donation process and desire to withdraw ventilator support; next-of-kin anger over cause of death when cause of death was suicide; and challenges to the validity of donor document and stated donor intent. No adverse news items were reported, and no lawsuits were filed in cases of donor-family conflict where organ donation proceeded. In addition, we found no mention of lawsuits brought against hospitals for failure to proceed with organ donation when donor was designated and eligible. The 2006 Anatomical Gift Act compels hospitals and OPOs to pursue donation regardless of family wishes in cases of brain death in designated donors. When a donor's family attempts to rescind the donor's authorization, the donor's wishes, not the families, should be honored. Fears of legal action and adverse media coverage are unfounded. Clinicians, OPO staff, and hospital administrators should strive to understand state donor designation law and create a plan for managing this conflict should it arise. Therapeutic/care management study, level V.

Image-Sharing Bronchoscopy: A Donor Management Advanced Practice Benefits Lung Donation.

Background The feasibility to perform timely fiberoptic bronchoscopy (FOB) and the level of transplant center confidence in report of findings can impact donor care and lung utilization. For solution, selected Organ Procurement Organization (OPO) staff were trained and equipped to perform FOB and capture digital images of airway exam for broad sharing through Donor Net upload. Clinical impact of this OPO initiative is examined relative to conventional FOB practice. Methods FOB curriculum development and training were carried out in collaboration with the American College of Chest Physicians and airway exam performed using the MAF-TM-SET Olympus Airway Mobilscope with integral digital camera and light source. Findings were shared as text reports (hospital performed FOB) or uploaded digital images (OPO performed FOB). The data set was collected from 70 sequential FOBs for each cohort accrued over 8 month periods. Results All 70 OPO FOBs were collectively performed by five trained staff with no adverse events. Outcome between groups is shown [table 1]. Age and gender composition were comparable. The OPO practice was associated with significantly more after-hours procedures, repeat FOB capability (at 20%) for pulmonary toilet, higher level of intent, and cost containment. There were more lung donors and lungs transplanted in the OPO group, but did not reach statistical significance. Table 1. Summary of Bronchoscopy Outcome Hospital (N=70)OPO (N=70)Changep ValueAge (Years)3632 0.082Male (%)37 (53%)43 (61%)6 (8%)0.6743After Hours FOB15 (21%)49 (70%)34 (49%)0.0004Repeat FOB014 (20%)14 (20%)0.0001Intent27 (39%)49 (70%)22 (31%)0.0236OR Decline3960.1337Lung Donors23 (33%)35 (50%)12 (17%)0.2121 Double Lung192670.3949 Single Lung4950.2491 Total Lungs426119 (45%)0.1928FOB Costs$93,590 $16,730 ($76,860)0.0001 Conclusion Image-sharing FOB performed by trained OPO staff is a safe, cost containment practice which permits timely and repeat examination upon need, and is an effective means to permit remote viewing of the donor airway all to support lung donor management and utilization.

Resource Utilization Associated With Procurement of Transplantable Organs From Donors That Do Not Meet OPTN Eligible Death Criteria

The strategy of evaluating every donation opportunity warrants an investigation into the financial feasibility of this practice. The purpose of this investigation is to measure resource utilization required for procurement of transplantable organs in an organ procurement organization (OPO). Donors were stratified into those that met OPTN-defined eligible death criteria (ED donors, n=589) and those that did not (NED donors, n=703). Variable direct costs and time utilization by OPO staff for organ procurement were measured and amortized per organ transplanted using permutation methods and statistical bootstrapping/resampling approaches. More organs per donor were procured (3.66±1.2 vs. 2.34±0.8, P<0.0001) and transplanted (3.51±1.2 vs. 2.08±0.8, P<0.0001) in ED donors compared with NED donors. The variable direct costs were significantly lower in the NED donors ($29,879.4±11590.1 vs. $19,019.6±7599.60, P<0.0001). In contrast, the amortized variable direct costs per organ transplanted were significantly higher in the NED donors ($8,414.5±138.29 vs. $9,272.04±344.56, P<0.0001). The ED donors where thoracic organ procurement occurred were 67% more expensive than in abdominal-only organ procurement. The total time allocated per donor was significantly shorter in the NED donors (91.2±44.9 hr vs. 86.8±78.6 hr, P=0.01). In contrast, the amortized time per organ transplanted was significantly longer in the NED donors (23.1±0.8 hr vs. 36.9±3.2 hr, P<0.001). The variable direct costs and time allocated per organ transplanted is significantly higher in donors that do not meet the eligible death criteria.

Attitudes and acceptance of First Person Authorization

First Person Authorization (i.e., donor designation) legislation makes indicating one's intent to be a posthumous organ donor legally binding, much like a living will or advance directive. Such legislation is the most recent in a long history of organ donation policies in the United States and has received little attention in the literature. This retrospective cohort study recruited nine US organ procurement organizations (OPOs) and their staff who make requests for organ donation as well as family decision makers approached by OPO staff about organ donation. Telephone interviews (N = 1,087) with family decision makers assessed the attitudes, perceptions, and behaviors regarding the request for organ donation of families of designated donors as compared with those of patients who did not formally designate themselves as donors. Almost two thirds (65.7%) of the families of registered donors were aware of the decedent's decision to register as a posthumous donor. Family decision makers who authorized donation and those of designated donors exhibited greater knowledge of organ donation and more positive attitudes than decision makers who refused to donate. Families of designated donors had more favorable perceptions of the request for organ donation and were more satisfied with both the time spent discussing donation and the request process; fewer donor designation families were surprised at the request for donation. The enactment of First Person Authorization legislation increases the likelihood of familial authorization and satisfaction with the final donation outcome. As compared with other families approached about the option of organ donation, families of designated donors report having a more positive experience with the organ donation request process overall and greater comfort and satisfaction with the donation decision. Epidemiologic study, level II.

Interim Results of a National Test of the Rapid Assessment of Hospital Procurement Barriers in Donation (RAPiD)

Organ donation remains a major public health challenge with over 114 000 people on the waitlist in the United States. Among other factors, extant research highlights the need to improve the identification and timely referral of potential donors by hospital healthcare providers (HCPs) to organ procurement organizations (OPOs). We implemented a national test of the Rapid Assessment of hospital Procurement barriers in Donation (RAPiD) to identify assets and barriers to the organ donation and patient referral processes; assess hospital-OPO relationships and offer tailored recommendations for improving these processes. Having partnered with seven OPOs, data were collected at 70 hospitals with high donor potential in the form of direct observations and interviews with 2358 HCPs. We found that donation attitudes and knowledge among HCPs were high, but use of standard referral criteria was lacking. Significant differences were found in the donation-related attitudes, knowledge and behaviors of physicians and emergency department staff as compared to other staff in intensive care units with high organ donor potential. Also, while OPO staff were generally viewed positively, they were often perceived as outsiders rather than members of healthcare teams. Recommendations for improving the referral and donation processes are discussed.

Authors' response to letter re: The Rapid Assessment of Hospital Procurement Barriers in Donation: Assessing Hospitals for Change

Laura A. Siminoff, Heather M. Marshall TrainoTo the Editor:In their letter to the editor (this issue), Ve-rheijde, Potts, Rady, and Shewmon (2010)equate implementation of the Rapid Assess-ment of hospital Procurement barriers inDonation (RAPiD) with compromising the ba-sic principle upon which the U.S. organdonation system is founded—voluntariness.Specifically, the authors contend that theRAPiD infringes upon healthcare providers’right to ‘‘opt out’’ of or ‘‘conscientiously ob-ject’’ to engaging in ‘‘health serviceprogram[s] or research activit[ies]’’ that are‘‘contrary to his [or her] religious beliefs ormoral convictions’’ (Public Health Service Act42 USC ‰ 300a-7 (d)) (Office of the Law Re-vision Counsel U.S. House of Representatives,1973). The authors seem to overlook the factthat health practitioners’ employment withinany healthcare organization constitutes partic-ipation in neither a ‘‘health service program’’nor a ‘‘research activity.’’ Employees in health-care organizations, such as hospitals, arecontractually obligated to adhere to the poli-cies and procedures of that organization,whether codes of dress or conduct, or policiesrelated to the identification and referral of do-nor-eligible patients to regional organprocurement organizations (OPO). Moreover,these policies are in response to federal andstate regulations.Hospitals’ organ donation policies are theproduct of national regulatory efforts to in-crease the supply of transplantable organs. Inthe late 1970s, it became apparent that thoseon the transplant waiting list far exceeded thenumber of organs available. Some arguedAmericans wanted to donate and that the or-gan shortage reflected a failure on the part ofhospital staff to approach families and ask fordonation. These assumptions resulted in a se-ries of new state and federal laws intended toincrease the supply of transplantable organs.These laws, commonly called ‘‘required re-quest,’’ were designed to encourage healthcareprofessionals to speak with families about or-gan donation (Caplan, Siminoff, Arnold, V however, this didnot happen. After an initial modest increase,donations leveled off to no more than 5,000donors per year. One problem was that at least50% of all requests for organ donation to fam-ilies of brain dead patients were met withdenial (Siminoff, Arnold, Caplan, Virnig, S Cohen, 1992; Kappel, Whitlock, Parks-Thomas, Hong, & Freedman, 1993). ‘‘Re-quired notification’’ was enacted in 2001 toattempt to address this concern. This policyobligates hospitals to report all deaths to a localOPO to determine patient eligibility for organdonation. The purpose of routine notificationis to try to increase OPO involvement in thepatient identification process so as to improvethe request process (Health Care FinancingAdministration, 1998). Siminoff, Gordon, Hew-lett, and Arnold (2001) and Evanisko et al.,(1998) have demonstrated that OPO staff arebest qualified to discuss this option with fam-ilies.Thus, healthcare organizations are federallymandated to report all potential donor-eligiblepatients to regional OPOs in a timely manner.A timely referral is made within 1hr of a pa-tient meeting the clinical triggers for referral,that is the absence of brain stem reflexes, aGlascow Coma Score45 or the considerationof withdrawal of care (Ehrle, 2006). Hospitalpolicies concerning the identification and re-Vol. 32 No. 3 May/June 2010 45

Understanding the antecedents of the acceptance of donation after cardiac death by healthcare professionals*

A 3-yr study funded by the U.S. Department of Health and Human Services was conducted to identify potential barriers to and opportunities for increasing the number hospitals with donation after cardiac death (DCD) protocols, the support of DCD by individuals involved in the donation request process, and the number DCD donors recovered. This study reports the qualitative findings. Methods used included an advisory committee and an extensive array of key informant interviews and focus groups. Hospitals and telephone contact. Discussions with nurses, physicians, social service staff, clergy, administrators, and organ procurement organization staff. A total of 216 people participated. Collection and analysis of information regarding perceptions of DCD, potential barriers and opportunities, and strategies for gaining support. Key barriers included a lack of knowledge about DCD, psychological barriers for DCD vs. brain death, concerns about whether death has been reached, saving vs. killing patients, trust in the organ procurement organization, moving from saving patients to being a donation advocate, and concerns with the DCD process. Opportunities included education initiatives, well-trained requesters, a cultural shift, a consistent DCD protocol separating care from recovery, process monitoring, and a strong sense of teamwork. Our findings provide a better understanding of healthcare professionals' knowledge, attitudes, and behaviors regarding DCD. Understanding these issues is critical to the implementation of strategic plans for DCD programs. One of the biggest barriers to overcome is a lack of knowledge of DCD, which leads to misperceptions, which in turn contribute to negative attitudes and/or discomfort by healthcare professionals. Communication efforts that are able to educate healthcare professionals and eliminate misperceptions will increase support for DCD. Key to future success requires confident and well-trained DCD requesters.

Organ Donation Breakthrough Collaborative

Organ Donation Breakthrough Collaborative