Addressing the unintended adverse consequences of first-person consent and donor registries

One of the most common reasons given for the refusal to donate in both the United States and the United Kingdom is that the potential donor, in his lifetime, said he did not want to be a donor. This objection has not always been given by families refusing to donate and appears to be an unintended consequence of donation strategies based on public education, donor registries, and first-person consents. A history of the objection is given, possible meanings are explored, and strategies for dealing with it are suggested.     

Family override of valid donor consent to postmortem donation: issues in law and practice

In 2005, 3974 Canadians were on waiting lists for organ transplants and 275 patients died while waiting. Canada's organ shortage has led to calls for changes to Canada's organ donation system and its legal framework. Herein we examine an issue in which law reform could both increase the number of available organs and better align practice with respect for autonomy, a core value underpinning the Canadian legal system: the issue of family overrides of a valid donor consent to postmortem donation. That is, we examine what should happen when an individual consented to postmortem donation but the family would like to override that consent. First, we examine the requirements for valid donor consent. Second, we consider the legal status of family overrides of valid donor consent in relation to postmortem donation. Third, we describe the available data with regard to the practice of permitting families to override valid donor consent and discuss the possible reasons for this practice. Finally, we describe and defend the desired results with respect to law reform and describe the actions needed to realize these results.     

The morbidity of split-skin graft donor sites in the elderly: the case for mesh-grafting the donor site

An impression that the healing of split-skin donor sites in the elderly is significantly prolonged compared with that in younger patients was confirmed by retrospective and prospective clinical studies. Possible explanations are discussed. In a prospective clinical trial of 20 consecutive patients over the age of 60 part of the donor site was covered with a meshed skin graft leaving the remaining unmeshed area as a control. In all patients the mesh-grafted area was healed in 10 days while the control "unmeshed" area demonstrated the same morbidity we had noted in patients over 60 in our retrospective study. It is suggested that the mesh grafting of small split-skin donor sites in the elderly can accelerate the rate of healing and significantly reduce the demands on hospital and community resources.     

Informed consent: a case for more education of the surgical team.

A questionnaire was given to 37 members of staff of the Department of Surgery, Addenbrooke's Hospital, Cambridge, in order to determine whether their knowledge was adequate to give accurate information to patients regarding operations and thus to obtain properly informed consent for that operation. Each participant was asked to estimate the 24-h and 30-day mortality for five common elective operations. A wide range of answers was given for operations by all groups. Estimates of 24-h mortality after unilateral inguinal herniorrhaphy differed between staff grades by a factor of 3, but estimates of 24-h mortality after thyroidectomy differed by a factor of 100 between consultant surgeons and staff nurses. Our findings suggest that some members of the surgical team have insufficient knowledge about common operations to obtain properly informed consent from patients.     

Tumor implantation at the flap donor site: a case report

The genesis of cancer and its variable patterns of spread have been theorized and debated upon for decades. Recurrences, both local and metastatic, are dreaded by both the patient as well as the surgeon. An interesting case of tumor implantation at the flap donor site was noted in a patient who underwent a primary flap reconstruction for cancer of the cheek. The details of the case and theories regarding tumor implantation have been enumerated in this report.     

Informed consent and decision-making about adult-to-adult living donor liver transplantation: a systematic review of empirical research

Adult-to-adult living donor liver transplantation (LDLT) is a complex procedure that poses serious health risks to and provides no direct health benefit for the donor. Because of this uneven risk-benefit ratio, ensuring donor autonomy through informed consent is critical. To assess the current knowledge pertaining to informed consent for LDLT, we conducted a systematic review of the empirical literature on donors' decision-making process, comprehension about risks and outcomes, and information needs for LDLT. Of the 1423 identified articles, 24 met final review criteria, representing the perspective of approximately 2789 potential and actual donors. As donors' decisions to donate often occur before evaluation, they often make uninformed decisions. The review found that 88% to 95% of donors reported understanding information clinicians disclosed about risks and benefits. However, donors reported unmet information needs, knowledge gaps regarding risks, and unanticipated complications. Few donors reported feeling pressure to donate. Most studies were limited by cultural differences, small sample sizes, inconsistent measures, and poor methodological approaches. This systematic review suggests that informed consent for LDLT is sub-optimal as donors do not adequately appreciate disclosed information during the informed consent process, despite United Network for Organ Sharing/CMS regulations requiring formal psychological evaluation of donor candidates. Interventions are needed to improve donor-clinician communication during the LDLT informed consent process such as through the use of comprehension assessment tools and e-health educational tools that leverage adult learning theory to effectively convey LDLT outcome data.     

Minimally invasive optimization of organ donor resuscitation: case reports

Increased use of expanded donors requires optimal organ perfusion to prevent graft damage. In this regard, pulmonary artery catheters have been advocated to monitor hemodynamic status. Cost, catheter placement, and inconsistent management preclude broad use of pulmonary artery catheters. Esophageal Doppler monitoring also monitors hemodynamic status and can be instituted in minutes by an organ procurement coordinator, Concomitant assessment of acid-base balance using base excess and/or anion gap can help determine resuscitation efficacy. Esophageal Doppler monitoring is described to help salvage 2 hemodynamically deteriorating donors. Anion gap and corrected base excess identified poor resuscitation status in both donors and normalized after improvement in hemodynamic status. Compared to pulmonary artery catheters, esophageal Doppler monitoring may provide a more accessible means to assess and improve hemodynamic status. Base deficit and/or anion gap may determine resuscitation efficacy by exposing acid-base imbalance resulting from poor tissue perfusion. The full efficacy of this approach remains to be determined.