Donation Request Research Articles

Organ Procurement After Euthanasia: Belgian Experience

Euthanasia was legalized in Belgium in 2002 for adults under strict conditions. The patient must be in a medically futile condition and of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident. Between 2005 and 2007, 4 patients (3 in Antwerp and 1 in Liège) expressed their will for organ donation after their request for euthanasia was granted. Patients were aged 43 to 50 years and had a debilitating neurologic disease, either after severe cerebrovascular accident or primary progressive multiple sclerosis. Ethical boards requested complete written scenario with informed consent of donor and relatives, clear separation between euthanasia and organ procurement procedure, and all procedures to be performed by senior staff members and nursing staff on a voluntary basis. The euthanasia procedure was performed by three independent physicians in the operating room. After clinical diagnosis of cardiac death, organ procurement was performed by femoral vessel cannulation or quick laparotomy. In 2 patients, the liver, both kidneys, and pancreatic islets (one case) were procured and transplanted; in the other 2 patients, there was additional lung procurement and transplantation. Transplant centers were informed of the nature of the case and the elements of organ procurement. There was primary function of all organs. The involved physicians and transplant teams had the well-discussed opinion that this strong request for organ donation after euthanasia could not be waived. A clear separation between the euthanasia request, the euthanasia procedure, and the organ procurement procedure is necessary.

The Instability of Organ Donation Decisions by Next-of-Kin and Factors That Predict It

We examined the instability of organ donation decisions made by next-of-kin and factors that predict whether nondonors wish they had consented to donation. Next-of-kin of donor-eligible individuals from one organ procurement organization participated in a semistructured telephone interview. Participants were asked if they would make the same decision if they had to make it again today. Of the 147 next-of-kin donors, 138 (94%) would make the same decision again, 6 (4%) would not consent to donation and 3 (2%) were unsure. Of the 138 next-of-kin nondonors, 89 (64%) would make the same decision again, 37 (27%) would consent to donation and 12 (9%) were unsure. Regret among nondonors was more likely when the next-of-kin had more favorable transplant attitudes (OR = 1.76, CI = 1.15, 2.69), had the first donation discussion with a non-OPO professional (OR = 0.21, CI = 0.13, 0.65), were not told of their loved one's death before this discussion (OR = 0.23, CI = 0.10, 0.50), did not feel they were given enough time to make the decision (OR = 0.25, CI = 0.11, 0.55), had not discussed donation with family members (OR = 0.30, CI = 0.13, 0.72) and had not heard a public service announcement about organ donation (OR = 0.29, CI = 0.13, 0.67). Organ procurement organizations (OPOs) should consider targeting these variables in educational campaigns and donation request approaches.

Family, Patients, and Organ and Tissue Donation: Who Decides?

Objective To identify who is responsible for the decision to donate organs and tissues from a deceased donor. Methods This cross-sectional study was performed with 69 family members of deceased donors, identified by the Organ Procurement Organization. Results The decision of the family regarding the request for donation took place after they had enough time to reflect on the matter (81.8%). The decision was made by the family (43.5%), by both family and donor (76.8%), by the family with previous knowledge about their deceased relative's wish (63.2%), or only by the donor (11.6%). There was familial conflict after the decision in about 7.2% of donations; 63.2% of the families were aware of their deceased relative's wish, and 90.5% were aware that their relative's wish helped them make the decision. Women were most frequently responsible for the decision to donate (55%). Conclusion The donation process is experienced by all the family, regardless of who signs the consent form. At times, it is precisely the discussion about what is conflicting that will enable the familial decision. The donor's autonomy alone was shown to be a poor indicator, as the ones who decide about the donation are the family. This, therefore, legitimizes the alteration made to Law No. 9,434/97, which gives family members the responsibility for the decision about organ and tissue donation from their deceased relatives.

Social Comparison and prosocial behavior: An applied study of social identity theory in community food drives

Social Identity Theory and the concept of social comparison have inspired research on individuals, addressing effects of personal and environmental factors in directing social attention. The theory's conceptual origins, however, suggest that social comparison may have behavioral implications as well. Such behaviors may include attempts by an individual to enhance the relative status of his ingroup on a salient dimension of comparison. Such behavior is referred to as "social competition." In two studies, the effects of social comparison and social competition were measured in the real-world environment of community food drives. Participants were aggregated by household; 600 households in upper middle-class neighborhoods in Eugene and Salem, Oregon, were contacted. In Study 1 of 300 households, it was hypothesized that inclusion of a social competition cue in requests for donation would significantly increase the likelihood of donation. This hypothesis was supported. Study 2 was done to clarify the possible role in a social comparison of perceived ingroup inferiority in the prior observed increase in donations. The inclusion of a social comparison cue in the donation request significantly increased donations in households of the second study. The findings suggest that researchers should expand study of the theory's behavioral implications, including the role of social comparison in prosocial behavior.

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.

Parents' Commitment to Participation in Mesenchymal Stem Cell Donation and Research Demonstrates Extensive Altruism to Other Patients.

Mesenchymal stem cells (MSC's) can be used in the experimental transplant setting for treatment of life threatening GvHD or to improve engraftment. Presently, the European MSC Consortium has three ethically approved multi center clinical protocols in use. MSC's expanded ex vivo from donor bone marrow are mostly of parental origin. We reviewed donation data from two participating centers, to establish donor commitment, donation and procedural related complications. Parents of children undergoing haploidentical PBSCT or a cord blood transplant were asked to donate 50 cc of bone marrow 4–5 weeks prior to HSCT. Parents of children with non-steroid responsive aGvHD (grade III-IV) were asked at the time of treatment failure. Bone marrow was aspirated either under general or local anesthesia. Haploidentical PBSC donors received in addition 5 days of G-CSF immediately before stem cell harvest. Donors were asked to consider consent for additional MSC's to be donated for research or use as 3rd party donations for other patients. Donors were cleared for donation by an independent physician. Thirty three donors (14 mothers, 18 fathers, 1 brother) of 34 relatives asked, agreed to donate bone marrow for MSC expansion and all additional uses. One parent whose child died before receiving MSC's requested they be used for 3rd party donations. Fourty five patients (included 6 adults) were treated with MSC's (see table 1 for details). Thirty one patients (68%) received MSC's from a parent, the remaining treatments being 3rd party for acute GvHD. All donors were considered suitable for PBSC or BM donation, although excess weight, mild hypertension and depression were documented in a minority of donors. No adverse events were documented after bone marrow donation, but one parent suffered severe bone pain, requiring opiate analgesia, during G-CSF administration. At 6 weeks follow up no adverse effects were reported. MSC donation either alone or in combination with stem cell mobilization can be achieved without major problems. Parental donor commitment is definitely related to the needs of the child. However, donor altruism to include other unknown patients including adult recipients was uniformly evident in our studies. Donation of stem cells for parents is a stressful situation and requests for multiple donations of various types of cell products can raise questions about medical and ethical considerations. Our protocols show that well informed parents have a propensity to commit to others needs as well as their offspring's. It is therefore essential when introducing experimental treatments to establish a balance between donors commitment and patient needs.Table 1Patient and donor characteristicsPATIENTS n=45OUTCOMEDONORS n=33Male2921 alive19Female1612 alive14Age (range years)7.0 (0.6–16.4)38 (26–53.3)Hematological malignancy35Immune deficiency3Others7Haplo+ MSC2115 aliveOwn child donationsCord + MSC91 rejection 1 deathOwn child donationaGvHD15CR in 11 patients14/15 3rd party donationsComplications2 a GvHD (grade I)Severe pain 1 donorInfections 14 patientsPlatelet tx in 4 haplo-donors

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

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

Traumatic Memories of Relatives Regarding Brain Death, Request for Organ Donation and Interactions with Professionals in the ICU

Little is known about the memories of relatives after they have been confronted with the brain death of a loved one and the request for organ donation. We conducted this study, guided by Grounded Theory, to explore relatives' experiences, their interactions with health care providers and what influenced their memories. We interviewed 40 relatives (31 consenting to and 9 refusing organ donation) of 33 brain-dead individuals. Relatives described their experiences as a difficult process composed of several stages spanning from the initial encounter to the final decision about donation. Long-term memories of bereaved relatives were influenced by the characteristics of their decision-making style (clear vs. ambivalent) and the perceived quality of the interaction with professionals on the intensive care unit. Organ-focused behavior of professionals and an ambivalent decision-making style of relatives appear to be risk factors for traumatic memories.

Efficiency of HLA-A, -B, -C, -DRB1 High-Resolution Typings of Newly Recruited Potential Stem Cell Donors.

In strategic stem cell donor registry planning, it is of special importance to decide how to type newly registered donors. This question refers to both the selection of HLA loci and the resolution (low, intermediate, or high) of HLA typings. In principle, high-resolution typings of all transplant-relevant loci are preferable. However, cost considerations generally lead to incomplete typings (only selected HLA loci with low or intermediate typing resolution) in practice.Here, we present results of a project in which newly recruited donors are typed for the HLA-A, -B, -C, and -DRB1 loci with high resolution by sequencing. Efficiency of these typings is measured by subsequent requests for confirmatory typings (CTs) and stem cell donations. Results for donors who were included in the project (Donor Group A) are compared to requests for donors with other, less complete typing levels: HLA-A and HLA-B at intermediate resolution, HLA-DRB1 at high resolution (Group B); HLA-A, -B, -C, and -DRB1 at intermediate resolution (Group C); HLA-A, -B, and -DRB1 at intermediate resolution (Group D). All data are taken from the donor file of DKMS German Bone Marrow Donor Center. Since the four groups differ considerably regarding their age and sex distributions, calculations are also carried through for restricted data sets that include only male donors up to age 25.Results are shown in Table 1. Donors of Groups A and B have similar CT request frequencies of 5.90 and 5.92 requests per 100 donors per year in the resctricted data sets, respectively. These frequencies significantly exceed the corresponding frequencies of the other groups with less complete typing levels. For donation requests, the frequency is signifcantly higher for Group A than for Group B (restricted data sets): 1.45 vs 1.02 requests per donor per year (p<0.05). Obviously, the additional HLA information for Group A donors leads to a higher ratio between donations and CT requests. Again, figures are much lower for Groups C and D. These results are based on a high number of requests even for the restricted data sets, namely between 44 and 90 donation requests and between 227 and 619 CT requests per group.Our results show that full (HLA-A, -B, -C, and -DRB1) high-resolution typings at donor recruitment lead to significantly higher probabilities for donation requests. Donor centers and registries should carefully take into account these higher probabilities when they consider full high-resolution typings for newly recruited donors. However, the final decision regarding the typing strategy at recruitment must also depend on the individual cost structure of a donor center or registry. The presented results are based on a donor file that consists mainly (≈99%) of Caucasian donors. It should be subject to further analyses if these results also apply to other, more heterogeneous donor pools.Table 1:Requests per 100 donors per year by donor groupCT requestsDonation requestsDonor GroupFull data setOnly male donors≤ 25Full data setOnly male donors≤ 25A5.145.901.451.45B4.605.920.841.02C2.503.030.580.67D2.362.800.380.48

Second Stem Cell Harvest from Unrelated Donors for Patients with Relapse or Graft Failure after First Transplantation: Patient Age >50 Years and Relapse of Malignant Disease Are Associated with Poor Outcome.

Introduction: Hematopoietic progenitor cells from unrelated donors are increasingly used for allogeneic stem cell transplantation (SCT). A second donation of peripheral blood stem cells (PBSC) or bone marrow is widely accepted in case of graft failure of relapse.Patients and methods: We retrospectively investigated the outcome of seventy (n=70) patients with hematological malignancies (AML/MDS n=29, CML n=19, ALL n=17, other n=5) receiving a second SCT using PBSC (n=67) or bone marrow (n=3) from the same unrelated donors. Patients had a median age of 30 years (range 1–59) and the reason for a second donation of stem cells consisted of either relapse (n=37) or graft failure (n=33). Whereas in 21 patients no conditioning was used in the remaining patients it was busulfan or TBI-based in the majority of cases.Results: After a median follow-up of 33 months (range 7.9–76.2) after 2nd SCT a total of 55 patients died due to treatment-related mortality (63%) or relapse (16%) resulting in a median overall survival (OS) for all patients of 3 months. The OS was significantly better in patients < 50 years (38 vs. 8 %, p=0.01) and in case of graft failure (37% vs. 7%, p=0.02). Time interval between SCT, HLA-disparity, disease type (AML/MDS vs. CML vs. ALL), infused CD34+ cells/kg or graft source at first transplant had no impact.Conclusion: These data show the lack of efficacy of a second infusion of HSC from the same donor especially in older patients and in cases in which relapse of malignancy is the reason for second transplant. Given the currently unknown long-term effects of a repeated exposure to G-CSF, the factors mentioned above should be kept in mind whenever a request for a second HSC donation is considered.

Training for Doctors and Nurses to Deal With Bereaved Relatives After a Sudden Death: Evaluation of the European Donor Hospital Education Programme (EDHEP) in Germany

The sudden death of a person is one of the most extreme and painful experiences for the relatives, and doctors require special communication skills to deal adequately with the bereaved. The Dutch European Donor Hospital Education Programme was developed to train doctors and nurses in talking to the bereaved relatives and to make the donation request. In Germany, the one-day workshop has been adapted to the German language, law, and clinical practice. The evaluation data of 75 workshops and experiences of 760 participants (doctors, nurses, and psychologists) are reported. The framework of, methods used, and issues dealt with in the workshop were clearly appreciated by the great majority of the participants. Criticisms and suggestions were directed mainly at the duration of the workshop. One third of the participants pleaded for a 2-day workshop, two thirds for a refresher course half a year later. The main effects reported were that two thirds of the participants rated that relatives could be helped, talked with, and cared for in a better way. The workshop participants also reported that they themselves were better able to cope with the situation and were more inclined to take on the task following the workshop. Finally, the necessities and limits of psychosocial training for doctors and their staff are discussed.

The decision-making process of parents regarding organ donation of their brain dead child: A Greek study

The purpose of this qualitative study, which was part of a larger study on parental bereavement, was to explore the decision-making process of parents who were invited to donate the organs and tissues of their brain dead child. Research objectives were to investigate how parents reach a decision and which factors affect consent or refusal regarding organ donation. The experiences of 22 parents of 14 brain dead children, hospitalized in two pediatric intensive care units (PICU) in Athens, were studied through semi-structured interviews. Data collection and analysis of the overall study were performed according to grounded theory methodology. Factors that influenced parents’ decisions were identified and classified into (a) personal factors, (b) conditions of organ request, (c) parents’ prior knowledge and experience with organ donation or serious illness, and (d) interpersonal factors. Findings can help care providers to facilitate the decision-making process and respond to parental needs while taking into account the socio-cultural context within which decisions are made. The donation request is meaningful and effective when it is integrated into an approach that offers ongoing support to parents who are faced with the unexpected death of their child.

Potential for organ donation in Victoria: an audit of hospital deaths

To determine the potential for organ donation in 12 Victorian hospitals. Prospective audit of all deaths in 12 major public hospitals in the state of Victoria between January 2002 and October 2004. Number of organ donors and potential organ donors (patients with brain death or likely to progress to brain death within 24 hours if supportive treatment continued), requests for organ donation and consents. Unrealised potential donors (organ donation not requested) were categorised by an independent panel of intensivists as category A (brain death formally diagnosed); B (brain death not formally diagnosed but criteria likely to be fulfilled); and C (potential to progress to brain death within 24 hours). There were 17,230 deaths, 280 potential organ donors and 220 requests for organ donation. The 60 unrealised potential organ donors were classified as category A (3), B (17) and C (40). Consent rate was 53% to 65%, depending on the definition of potential donor (categories A, B and C or category A only). Consent rate was lower when discussions about organ donation were held by trainees or registrars (21%) than when specialists were present (57%) (P = 0.004). A maximum practically achievable organ donation rate for Victoria was estimated to be 15 to 17 donors per million population (current rate, 9 per million population). The potential for organ donation in Victoria is limited by a small organ donor pool. There is potential to increase the number of organ donors by increasing the consent rate (lower than expected from public surveys), the identification of potential organ donors (particularly those likely to progress to brain death if supportive treatment is continued), and requests for organ donation.

End-of-Life Decision Making, Organ Donation, and Critical Care Nurses

End-of-Life Decision Making, Organ Donation, and Critical Care Nurses

Maximizing Organ Donation Opportunities Through Donation After Cardiac Death

John Edwards is the clinical administrator for Gift of Life Donor Program in Philadelphia, Pa, overseeing all clinical aspects of organ and tissue recovery, and a faculty member for the Gift of Life Institute, Philadelphia, providing training and mentoring for healthcare organizations nationally. Patti Mulvania oversees the clinical education program for the Gift of Life Donor Program in Philadelphia and is a faculty member of the Gift of Life Institute, specializing in consent and clinical communication. Virginia Robertson is the associate director of the Gift of Life Institute in Philadelphia. Formerly, she was the director of hospital services for the Gift of Life Donor Program. Gweneth George is the director of hospital services for the Gift of Life Donor Program in Philadelphia. She directs a team of nearly 20 hospital development staff accountable for donation performance in 150 acute care hospitals. Richard Hasz is vice president of clinical services for the Gift of Life Donor Program in Philadelphia. He oversees the day-to-day clinical operations, including transplant coordination, hospital development, organ preservation, and tissue recovery. Howard Nathan is president and chief executive officer of the Gift of Life Donor Program in Philadelphia. The program has been involved in coordinating more than 22 000 organ transplantations and tens of thousands of tissue transplantations since 1974.

Timely Referral of Potential Organ Donors

Timely Referral of Potential Organ Donors

Obstacles to organ donation in Swedish intensive care units

To identify obstacles to organ donation in Swedish intensive care units. A survey exploring attitudes and experiences of organ donation activities was sent to half of all anaesthetists and all neurosurgeons in Sweden (n=644). Total response rate was 67%; 69% from the anaesthetists and 54% from the neurosurgeons. Neurosurgeons had more experiences of caring for potential donors and requesting donation than anaesthetists. Twenty-seven percent of the anaesthetists were not confident with clinical neurological criteria for brain incarceration. Nine per cent found donation activities solely burdensome, and 14% wanted an external team to take over the donation request. A quarter regarded the request definitely as an extra load on the family, and more than half of the respondents had refrained from asking in emotionally strained situations. Forty-nine per cent had a neutral approach to relatives when requesting donation while 38% had a pro-donation approach. Thirty-six per cent terminated ventilator treatment for a potential donor without waiting for total brain infarction. Lack of resources in the ICUs resulted in not identifying a possible donor according to 29% of respondents. Knowing the prior wish of the deceased was regarded as the single most important factor that facilitated the work with organ donation for the intensivists. The identified obstacles (neutral approach of donation request, ethical problems concerning the potential donor and the relatives, varying competence in diagnosing total brain infarction, and lack of intensive care bed resources) require tailored efforts in order to increase organ donation. Checking these factors can be used as a quality control when analysing donation activities at hospitals.

Adding exchange to charity: A reference price explanation

Charities often request donations while offering a near-worthless token, like a key chain, in exchange. Little research has examined whether such ‘exchange’ requests are met with higher compliance rates than simply asking people to donate. Our studies suggest that in simple donation settings people may have difficulties in estimating a socially acceptable donation amount and therefore prefer opportunities that provide them with an anchor price. The value of a material good in a donation setting can play this anchoring role and signal a reference price. To the extent that the suggested reference price is low enough, exchange requests lead to more compliance than simple donation requests. However, our results indicate that, when accompanied by specified amounts, simple donation requests result in even better compliance rates than exchange requests.

The Ingredients of a Successful Donation by Brain Death Program in Greece

The Ingredients of a Successful Donation by Brain Death Program in Greece

Living Donation Decision Making: Recipients' Concerns and Educational Needs

Despite the advantages of living donor transplantation, evidence suggests that some potential recipients with living donors have psychological concerns that prevent them from pursuing living donation. Addressing these concerns through education may increase the rates of living donation. To understand the psychological barriers and educational needs of potential kidney recipients regarding living donation. Qualitative focus group study of kidney transplant recipients, donors, and family members to explore their assessment of the advantages of dialysis and deceased donor transplantation over living donation, their concerns about living donation, and what types of living donation education would be most helpful. Kidney recipients reported that they might not pursue living donation because they felt guilty and indebted to the donor, did not want to harm or inconvenience the donor, did not want to accept a kidney that a family member might need later, and did not want to disappoint the donor if the kidney failed. Recipients were generally unaware that donors could personally benefit from donating and would rather wait for donor volunteers than ask anyone directly. Both donors and recipients thought that training on how to make the donation request and education about living donors' motivations for donation and transplant experience could help more renal patients pursue living donation.