Public awareness and acceptance of tissue and organ donation

Organ donation is a worldwide problem especially in developing countries due to lack of knowledge about brain death and organ transplantation as well as traditional values and beliefs. Limited data are available concerning public knowledge and awareness of organ donation and transplantation in Turkey. A prospective study was carried out and data (n=774) were gathered from a structured questionnaire. The results indicated that 96.6% of participants had heard of organ donation and transplantation, 91.8% approved donation, and 59.2% would consider donating organs of their own. 62.6% were unaware of the donation law. As 81.7% of participants were interested in having more information on the issue, information booklets covering brain death, donation law and the organ donation process may increase donation of organs.     

Perspectives on organ and tissue donation among Chinese Canadians

Organ and tissue transplantation offers great potential for improving quality of life and reducing health care costs associated with end-stage organ failure. However, substantial and persistent shortages of organs and tissues for transplantation exist in Canada and there is a growing gap between those on transplant waiting lists and the organs available for transplantation. Every Canadian should have the opportunity to consider organ and tissue donation and transplantation in a culturally sensitive and respectful manner. During consultation with the Chinese Canadian community in Toronto, it was found that a clear understanding of the attitudes and values of Chinese Canadians regarding organ and tissue donation could assist health professionals in making ethnoculturally sensitive requests for donation to members of this community.     

Understanding organ donation in the collaborative era: a qualitative study of staff and family experiences

Background:  Despite the success of the Breakthrough Collaborative Methodology (BCM) in increasing organ donation rates there has been little published evidence on the effect of the BCM on the wider attitudes and experiences of those involved in organ donation. This study sought to identify whether the National Organ Donation Collaborative in Australia had any additional influence on improving the experiences of staff and family members in the organ donation process.
Methods:  In-depth qualitative interviews with 17 family members from 13 families who had agreed to the organ donation of a deceased relative and 25 nurses and intensive care specialists at the Alfred Hospital, Melbourne, Victoria were carried out.
Results:  The key factor in family members' decision to donate was prior knowledge of the deceased's donation wish. Although most family members did not regret their decision to donate, many were deeply dissatistified and, at times, confused by the technical and administrative nature of the donation process. Most staff members commented that the key community message about donation should be to encourage people to discuss donation rather than urging people to sign donor registers.
Conclusion:  This study identified valuable insights into the processes by which family members and intensive care unit staff deal with the actual processes of donation. Findings suggest that the process for families is far more complex than a simple agreement or refusal to donate. This study suggests that we should not assume that 'rates' of donation in Australia would increase merely through administrative programmes or marketing campaigns.     

A pilot programme of organ donation after cardiac death in China

China's aims are to develop an ethical and sustainable organ transplantation system for the Chinese people and to be accepted as a responsible member of the international transplantation community. In 2007, China implemented the Regulation on Human Organ Transplantation, which was the first step towards the establishment of a voluntary organ donation system. Although progress has been made, several ethical and legal issues associated with transplantation in China remain, including the use of organs from executed prisoners, organ scarcity, the illegal organ trade, and transplantation tourism. In this Health Policy article we outline the standards used to define cardiac death in China and a legal and procedural framework for an organ donation system based on voluntary donation after cardiac death that adheres to both China's social and cultural principles and international transplantation standards.     

The allocation of organs donated by altruistic strangers

In many transplant centers, organ retrieval from altruistic strangers is accepted practice; patients use Internet Web sites and other public media to locate strangers willing to give them an organ. It is argued that altruistic strangers should be permitted to select the recipients of their organs because 1) personal relationships are morally important; 2) it increases the number of available organs; and 3) no one is hurt by the process. Nonetheless, using public media to obtain organs may undermine equity in organ allocation. Organs donated by altruistic strangers do not go necessarily to patients who have the best immunologic match or the most urgent need or who have waited the longest. A publicly chartered organization should be established to coordinate live organ donation, including donation by altruistic strangers. Altruistic strangers should be educated to allocate their donated organs according to a prudent balance of equity and utility rather than their emotional response to a particular patient's plight, identity, or circumstances.     

Mandated choice. The preferred solution to the organ shortage?

BACKGROUND--A critical shortage of organs is perhaps the major barrier facing transplantation today. Adopting a system of presumed consent or mandated choice are among the solutions proposed. Under presumed consent, organs may be removed after death without explicit consent, unless the deceased had previously objected or the family objects at the time of death. Under mandated choice, all adults would be required to decide for themselves whether they wish to donate on their deaths and their decisions would be controlling. METHODS--To see if educated young people would support these proposals, I carried out two surveys at the University of Maryland, College Park, Md, of a total of 418 students who were at least 18 years of age. RESULTS--An overwhelming 90% would support mandated choice while a smaller percentage, just over 60%, would support presumed consent. The vast majority believe that the family should not be able to override the previously expressed wishes of their recently deceased loved one. Unfortunately, only a minority of respondents had discussed organ donation with their families and even fewer had signed donor cards. CONCLUSIONS--Even young, educated people frequently fail to consider organ donation prospectively and this is a major barrier to organ retrieval. While presumed consent and mandated choice are designed to deal with this serious problem, mandated choice seems preferable and would likely receive widespread support. Therefore, I suggest that a small scale trial of mandated choice be undertaken as soon as possible in the hope of finding an acceptable system that will quickly and efficiently increase the supply of desperately needed organs.     

Staging of non-small cell bronchogenic carcinoma. Relationship of the clinical evaluation to organ scans

Organ scans are generally performed on patients with bronchogenic carcinoma only when clinical evaluation is suspicious for metastases. However, it is not clear whether the clinical abnormalities will direct attention to the single organ which should be scanned, or if all three organs (bone, brain, liver) should be evaluated if any clinical abnormality is present. We investigated the use of triple organ radionuclide scanning and computerized tomography (CT) of the brain in the initial staging of patients with non-small cell bronchogenic carcinoma with no obvious metastases. Of 122 patients with newly diagnosed lung cancer, 53 met our criteria for further study. Thirty-three (62 percent) of these had at least one clinical abnormality suggestive of metastasis. Bone scanning detected metastases in seven (21 percent) and head CT in two additional patients (6 percent). Brain and liver scanning had no yield. In only five of these nine patients did the clinical abnormality direct attention to the organ with detectable metastases. Twenty of the 53 (38 percent) patients had a negative routine clinical evaluation, yet bone scanning showed metastases in three (15 percent). We concluded that clinical abnormalities are not specific for the organ in which metastases may be detected, so three scans (bone, liver, CT of the brain) should be obtained if there is any suspicion of metastasis based on history, physical examination, and laboratory tests. The value of bone scanning in clinically normal patients deserves further study.     

The Evolution of Living Kidney Donation and Transplantation in Older Adults

Kidney transplantation is a good option for adults aged 65 and older with end‐stage renal disease because it has been shown to reduce morbidity and mortality, improve quality of life, and is more cost‐effective than other renal replacement options. However, older age has been a deterrent to access to the deceased donor waiting list, and individuals aged 65 and older have a lower probability of being referred to and listed for transplantation compared to younger adults. Because the deceased organ supply is limited, living donor kidney transplantation offers an effective alternative for older adults facing long waiting times for cadaveric organs. This article describes the evolution of living kidney donation and transplantation in older adults over 15 years using the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients database. Between 1997 and 2011, 28,034 kidney transplantations were performed in adults aged 65 and older. Living‐donor and cadaveric kidney transplantation increased in older adults over the 15‐year period. Offspring are the most common living donors in this age group, followed by unrelated donors (e.g., friends), whereas the most common donors in younger transplant recipients are spouses, siblings, and parents. The number of living kidney donors aged 65 and older is slowly increasing, although the total number of transplants in this age group remains low. The expansion of living‐donor kidney transplantation in the aging population may offer a solution for organ shortage and thereby improve the quality of life of older adults. More research is needed to understand the older donor–recipient relationship and barriers to transplantation in this population.     

Ethical aspects of living-donor kidney transplantation

Living donor kidney transplantation is considered an established treatment for end-stage renal failure and is accepted in different transplant forums, nationally and internationally, while ensuring the safety of the donation, the information, the motivation and caring, the free consent and the absence profit. Safety: the living donor nephrectomy is not extent of risks so a good assessment of the donor's health status and psychosocial situation must be performed to evaluate if the benefits to donor and recipient outweigh the risks assumed. Information and Consent: to be considered ethically acceptable, the donor must be able to give his free consent to the donation after understanding the information provided, accepting the risks and benefits of organ donation, knowing the treatment alternatives for the recipient and the long-term consequences of his decision The absence of profit: offering or receiving money for an organ or other human tissue violates the principles of justice and equity and it is considered ethically and legally unacceptable Motivation: it is important to make a good psychosocial assessment to identify whether the motivation is altruistic or not and, in other terms, to detect any kind of coercion (ex, in the family). Living donation must not be offered in desperate family situations so it is important to assess family relationships to rule out the absence of freedom in donor's choice.The Role of Health Care Ethics Committees: there exists a normative in our country that regulates living donation and establishes that the hospital ethics committees should participate in the process of living donation in all cases. Their job is to assess the process and develop a report on the donor free consent to donation. The responsible person of the living transplant program should provide the documentation necessary to the committee. An interview with the potential donor can be required in some cases.     

Transplantationsmanagement: Angebot und Vermittlung von Spenderorganen

The German Organ Transplantation Foundation (Deutsche Stiftung Organtransplantation, DSO) is responsible for all steps in the organ donation process – allocation of the donated organs is the task of the Eurotransplant International Foundation. The German transplantation law stipulates urgency and prospects of success as allocation parameters. At the same time, all patients have the same chance to receive an organ for transplantation. The standing committee on organ transplantation of the German Medical Association (Bundesärztekammer) has developed guidelines for organ allocation and updates these according to the latest findings in science and research. The European Parliament has recently issued security and quality standards, which are designed to reduce patient waiting times. Only an increase in the number of organ donations will relieve the pressure on the allocation situation.     

Caring for organs or for patients? Ethical concerns about the Uniform Anatomical Gift Act (2006)

In 2006, the National Conference of Commissioners on Uniform State Laws rewrote the Uniform Anatomical Gift Act. To overcome the problem of family members prohibiting organ donation from their deceased loved ones even when a donor card existed, the commissioners modified the act to prevent end-of-life care from precluding organ donation. An unintended consequence of the new wording creates the potential for end-of-life care that prioritizes care of the potential donor organs over care and comfort of the dying person. The commissioners have now revised the act, but the original version has already been legislated in many states, with others poised to follow. To protect dying patients' wishes about their end-of-life care, states that have legislated or are considering the original act must replace it with the revised version. A long-term and important ethical precept must stand: Care of dying patients takes precedence over organs. Another laudable goal must be promoted as well: Organ donation is an important part of end-of-life care.     

Regulatory bases of living-donor kidney transplantation

Living donor kidney transplantation is regulated in Spain by the transplantation law 30/1979 and developed by Royal Decree 2070/1999. These policies permit the living donation of an organ while its function is compensated by the rest of the body. It further specifies that the destination of the organ must be the transplantation in a specific person (this specification allows for the donation, not only among emotionally related, but between people that do not know each other, provided it is done altruistically, without any purpose of profit and without coercion). The donor must be competent, healthy and had reached 18 years old (which is evidenced by a medical certificate) and should be well informed of the consequences of their decision. The donor must give their consent to donation, free from inducement and consciously in the courts of civil registration. In order to guarantee the quality and safety of the procedure, the centers that performed this therapeutic must be authorized both for the nephrectomy and the transplantation.     

The Declaration of Istanbul on Organ Trafficking and Transplant Tourism

Organ commercialism, which targets vulnerable populations (such as illiterate and impoverished persons, undocumented immigrants, prisoners, and political or economic refugees) in resource-poor countries, has been condemned by international bodies such as the World Health Organization for decades. Yet in recent years, as a consequence of the increasing ease of Internet communication and the willingness of patients in rich countries to travel and purchase organs, organ trafficking and transplant tourism have grown into global problems. For example, as of 2006, foreigners received two-thirds of the 2000 kidney transplants performed annually in Pakistan.The Istanbul Declaration proclaims that the poor who sell their organs are being exploited, whether by richer people within their own countries or by transplant tourists from abroad. Moreover, transplant tourists risk physical harm by unregulated and illegal transplantation. Participants in the Istanbul Summit concluded that transplant commercialism, which targets the vulnerable, transplant tourism, and organ trafficking should be prohibited. And they also urged their fellow transplant professionals, individually and through their organizations, to put an end to these unethical activities and foster safe, accountable practices that meet the needs of transplant recipients while protecting donors.Countries from which transplant tourists originate, as well as those to which they travel to obtain transplants, are just beginning to address their respective responsibilities to protect their people from exploitation and to develop national self-sufficiency in organ donation. The Declaration should reinforce the resolve of governments and international organizations to develop laws and guidelines to bring an end to wrongful practices. “The legacy of transplantation is threatened by organ trafficking and transplant tourism. The Declaration of Istanbul aims to combat these activities and to preserve the nobility of organ donation. The success of transplantation as a life-saving treatment does not require—nor justify—victimizing the world''s poor as the source of organs for the rich” (Steering Committee of the Istanbul Summit).Organ transplantation, one of the medical miracles of the 20th century, has prolonged and improved the lives of hundreds of thousands of patients worldwide. The many great scientific and clinical advances of dedicated health professionals, as well as countless acts of generosity by organ donors and their families, have made transplantation not only a life-saving therapy but a shining symbol of human solidarity. Yet these accomplishments have been tarnished by numerous reports of trafficking in human beings who are used as sources of organs and of patient-tourists from rich countries who travel abroad to purchase organs from poor people. In 2004, the World Health Organization called on member states “to take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs” (1).To address the urgent and growing problems of organ sales, transplant tourism, and trafficking in organ donors in the context of the global shortage of organs, a Summit Meeting of more than 150 representatives of scientific and medical bodies from around the world, government officials, social scientists, and ethicists, was held in Istanbul, Turkey, from April 30 to May 2, 2008. Preparatory work for the meeting was undertaken by a Steering Committee convened by the Transplantation Society and the International Society of Nephrology in Dubai in December 2007. That committee''s draft declaration was widely circulated and then revised in light of the comments received. At the Summit, the revised draft was reviewed by working groups and finalized in plenary deliberations.This Declaration represents the consensus of the Summit participants. All countries need a legal and professional framework to govern organ donation and transplantation activities, as well as a transparent regulatory oversight system that ensures donor and recipient safety and the enforcement of standards and prohibitions on unethical practices.Unethical practices are, in part, an undesirable consequence of the global shortage of organs for transplantation. Thus, each country should strive both to ensure that programs to prevent organ failure are implemented and to provide organs to meet the transplant needs of its residents from donors within its own population or through regional cooperation. The therapeutic potential of deceased organ donation should be maximized not only for kidneys but also for other organs, appropriate to the transplantation needs of each country. Efforts to initiate or enhance deceased donor transplantation are essential to minimize the burden on living donors. Educational programs are useful in addressing the barriers, misconceptions, and mistrust that currently impede the development of sufficient deceased donor transplantation; a successful transplant programs also depend on the existence of the relevant health system infrastructure.Access to health care is a human right but often not a reality. The provision of care for living donors before, during, and after surgery, as described in the reports of the international forums organized by the Transplantation Society in Amsterdam and Vancouver (2–4), is no less essential than taking care of the transplant recipient. A positive outcome for a recipient can never justify harm to a live donor; on the contrary, for a transplant with a live donor to be regarded as a success means that both the recipient and the donor have done well.This Declaration builds on the principles of the Universal Declaration of Human Rights (5). The broad representation at the Istanbul Summit reflects the importance of international collaboration and global consensus to improve donation and transplantation practices. The Declaration will be submitted to relevant professional organizations and to the health authorities of all countries for consideration. The legacy of transplantation must not be the impoverished victims of organ trafficking and transplant tourism but rather a celebration of the gift of health by one individual to another.     

Results of a survey on organ donation and transplantation in the metropolitan area of Guadalajara,Mexico

OBJECTIVE: To evaluate knowledge of and disposition towards organ and tissue donation for transplantation among the adult population of metropolitan Guadalajara, Jalisco, Mexico. MATERIAL AND METHODS: A survey was conducted by personal interview with street-recruited persons over 18 years of age using a 29-item questionnaire. Metropolitan Guadalajara was divided into four municipalities and a proportional number of interviews was assigned to each one based on number of inhabitants, socio-economic stratum, age and gender. RESULTS: Four hundred individuals were interviewed. Approximately 80% knew about organ donation and 65% knew that it was legal; however, only 24% had discussed the topic with their relatives. Seventy-one percent did not know how to donate organs and only 25% knew about organ donor cards. On the other hand, 66% were willing to donate, 16.5% would not donate and 17% were undecided. Bodily mutilation was the main reason (40%) given to not donate. 89% would authorize organ donation from a deceased relative, assuming the relative had previously expressed the desire to donate; on the contrary, only 29% would give such an authorization without their relative's prior consent. Finally, 65% considered the driver's license an adequate mean to express their desire to donate and 50% considered the information the mass media disseminated on the subject to be insufficient. CONCLUSIONS: The majority of the metropolitan Guadalajara population knew about organ donation and would be willing to donate their organs. However, a high percentage did not know how to donate and considered the information disseminated on the subject insufficient. An on-going mass media campaign could resolve this matter and hopefully increase organ donation among this population.     

Health insurance and cardiac transplantation: a call for reform

Cardiac transplantation is an accepted therapy for patients with end-stage heart failure (ESHF). Presently in the U.S., patients with ESHF need to have health insurance or another funding source to be considered eligible for cardiac transplantation. Whether it is appropriate to exclude potential recipients solely due to lack of finances has received considerable interest including being the subject of a recent major motion picture (John Q, New Line Cinema, 2002). However, one important aspect of this debate has been underappreciated and insufficiently addressed. Specifically, organ donation does not require the donor to have health insurance. Thus, individuals donate their hearts although they themselves would not have been eligible to receive a transplant had they needed one. By querying Siminoff's National Study of Family Consent to Organ Donation database, we find that this situation is not uncommon as approximately 23% of organ donors are uninsured. Herein we also discuss how the funding requirement for cardiac transplantation has been addressed by the federal government in the past, its implications on the organ donor consent process, and its potential impact on organ donation rates. We call for a government-sponsored, multidisciplinary task force to address this situation in hopes of remedying the inequities in the present system of organ allocation.     

Selection of donor and organ viability criteria: expanding donation criteria

Donation criteria have been becoming more flexible over the years. Currently, the only absolute exclusion criteria are human immunodeficiency virus infection (HIV), uncontrolled tumor disease and bacterial or viral infections. ClinicaL. conditions dictate organ viability criteria: biochemical, morphological and functional, that must be fulfilled by the donors and their organs in order to focus the decision on which donor organs can be used. These criteria attempt to assure that the transplanted organs function after the extraction, transformation, implantation and reperfusion process without transmitting any infectious or tumour disease. In recent years, the gross and microscopic appearance has become one of the fundamental criteria for selection of potentially viable organs. At present, there is no age limit for hepatic and renal donation; the principal contra-indication is chronic organ damage. The use of each organ must be decided individually after a profound analysis of all the viability criteria, weighing the advantages and disadvantages of the implant of a certain organ for the recipient.     

Missed opportunities: saving lives through organ donation following voluntary assisted dying

Organ donation after voluntary assisted dying (VAD) in Australia may potentially increase organ transplant rates. Despite significant international experience with donation after VAD, there has been little discussion of this in Australia. We review potential ethical and practical concerns relating to donation after VAD and advocate action to establish programmes in Australia that ensure safe, ethical and effective donation after VAD.     

Personnel in cadaveric organ transplant-related hospital units faced with living liver donation: an attitudinal study in a Spanish hospital with a cadaveric and living liver transplant programme.

INTRODUCTION: The attitude of health-care personnel is fundamental for the procurement of transplant organs, especially in those services that are related to transplantation. The objective of this study is to find out the attitude towards living liver donation among personnel who work in transplant-related services in a hospital with a cadaveric and living organ transplant programme. MATERIALS AND METHODS: A random sample was taken and stratified by type of service and job category (N=330), in services related to transplantation (procurement units, transplant units and follow-up units). Attitude was evaluated using a validated psychosocial questionnaire. Control group: a random sample of personnel in clinical services that do not have any direct contact with solid organ transplantation. Student's t-test and the chi(2) test complemented by a logistical regression analysis were applied in the statistical analysis. RESULTS: The questionnaire completion rate was 94% (N=309). Only 10% (N=31) of respondents are in favour of living liver donation if it is unrelated, but another 67% (N=207) are in favour if donation were for a relative. Of the rest, 11% (N=33) do not agree with living liver donation and the remaining 12% (N=38) are undecided. In the control group, attitude towards living liver donation is favourable in 82% (N=344) (P=0.0908). An analysis of the variables that influence attitude shows that the following factors are significantly related: (1) age (P=0.037); (2) a respondent's belief that he or she may need a transplant in the future (P=0.013); and (3) if it were necessary, a willingness to receive a donated living liver organ (P=0.000). Of the variables that have the most influence on attitude towards living liver donation in the bivariate analysis, there are two variables that are statistically significant in the multivariate analysis: (1) age and (2) willingness to accept a donated living liver organ from a relative if it were needed (OR=14.19). There is also a close relationship between attitude towards living liver donation and attitude towards living kidney donation (P=0.000) CONCLUSIONS: There is a favourable attitude towards living liver donation among personnel in units related to the transplantation and donation process, although it is less favourable than expected. Therefore, it will be necessary to increase this level of acceptance and to improve information about the matter if we want to encourage living liver donation. The youngest workers in these units are those who are most in favour, which leads us to believe that there is a hopeful future for this type of liver donation that is so necessary given the cadaveric organ deficit.     

Registering wishes about organ and tissue donation: personal discussion during licence renewal may be superior to online registration

Consent to organ and tissue donation is higher when the deceased has indicated a wish to donate. The Australian Organ Donor Register (AODR) is the national register of preferences regarding donation. The AODR has a number of limitations; it has no mechanism for requiring individuals to register their wishes, while the online format both raises concerns about the validity of the consent obtained and precludes personal discussion of fears and concerns about donation. A solution to these limitations is to utilize state‐based agencies that administer driving licences. This strategy ties the donation decision to an existing task (renewal of driving licences), and provides an opportunity for a personalized intervention at the time the decision is being made.     

Effect of race upon organ donation and recipient survival in liver transplantation

The effect of the race of the donor on organ donation and on the outcome of clinical liver transplantation has not been addressed previously. The aims of this study were to determine: (1) the number of organs donated by each of the major racial groups of the United States, (2) the outcome of transplantation of these organs across racial groups, and (3) the pattern of liver disease that required transplantation in each of these racial groups. A significantly higher proportion of organs were donated by white non-Hispanic Americans than either black or Hispanic Americans. There was no significant difference in survival when an organ was transplanted between black and white Americans and vice versa. Postnecrotic cirrhosis from a variety of causes was the most common indicator affecting black and white recipients, while primary biliary cirrhosis and primary sclerosing cholangitis were uncommon in the black population. While the number of organs donated by blacks was low, it was, however, proportional to the number of black recipients in this study. Reasons for the low rate of donation by the black and white Hispanic population are discussed. It is concluded that race is not a criteria to be used in selection of donors for liver transplantation. Educational programs addressing issues of organ donation and transplantation directed towards the black and Hispanic populations are recommended.Supported by research grants from the Veterans Administration, Project Grant DK 29961 from the National Institutes of Health, Bethesda, Maryland, and from the NIDDK 32556.