Investigating Geographic Variation in Mortality in the Context of Organ Donation

Organ procurement organizations (OPOs) report a nearly fourfold difference in donor availability as measured by eligible deaths per million population (PMP) based on hospital referrals. We analyzed whether mortality data help explain geographic variation in organ supply as measured by the number of eligible deaths for organ donation. Using the 2007 National Center for Health Statistics’ mortality data, we analyzed deaths occurring in acute care hospitals, aged ≤ 70 years from cerebrovascular accidents and trauma. These deaths were mapped at the county level and compared to eligible deaths reported by OPOs. In 2007, there were 2 428 343 deaths reported in the United States with 42 339 in‐hospital deaths ≤ 70 years from cerebrovascular accidents (CVA) or trauma that were correlated with eligible deaths PMP (r²= 0.79.) Analysis revealed a broad range in the death rate across OPOs: trauma deaths: 44–118 PMP; deaths from CVA: 34–118 PMP; and combined CVA and trauma: 91–229 PMP. Mortality data demonstrate that deaths by neurologic criteria of people who are likely to be suitable deceased donors are not evenly distributed across the nation. These deaths are correlated with eligible deaths for organ donation. Regional availability of organs is affected by deaths which should be accounted for in the organ allocation system.     

Increasing Organ Donations After Cardiac Death by Increasing DCD Support Among Health Care Professionals: A Case Report

This case report focuses on the University of Wisconsin Hospital and Clinics Organ Procurement Organization (UWHC-OPO) efforts to produce a verifiable and demonstrable increase in organ donations by developing a replicable, transferable and feasible model intervention for increasing health care professionals' support for donation after cardiac death (DCD). A grant from the US Department of Health and Human Services funded a 3-year study allowing the UWHC-OPO to (i) identify barriers to and opportunities for increasing DCD support among those involved in the donation request process, (ii) implement this better understanding of these support factors in the creation of intervention materials designed to increase knowledge of and support for DCD and finally (iii) to track and document the progress made in increasing knowledge, support, number of hospitals with DCD protocols, actual requests made and number of DCD donors. The results of the model intervention were extremely positive, showing lasting increases in DCD knowledge and support, adoption of DCD protocols and referrals in the two tracking survey stages following the intervention. Perhaps most notably, DCD donor numbers within the UWHC-OPO region increased 93% in the year following the intervention and 179% to date.     

An Empirical Examination of the Antecedents of the Acceptance of Donation After Cardiac Death by Health Care Professionals

Findings are reported from a US Department of Health and Human Services (DHHS) funded study to identify barriers to increasing support for donations after cardiac death by health professionals. A donations after cardiac death (DCD) acceptance model is conceptualized and tested via 806 survey responses from certified requestors, all of whom had their identities protected through Institutional Review Board (IRB) protocol. The overall model was significant and explained 35% of the variation in DCD support. Greater knowledge about DCD, greater trust in the organ procurement organization (OPO) and a belief that futility has been reached were all positively associated with DCD acceptance. Negative perceptions of DCD versus brain death, transitioning from caregiving to donation advocate, concerns about the DCD process and the idea that DCD leads to active participation in the death reduced its support. The three greatest impediments to support of DCD exist when health professionals feel they are playing an active role in killing the patient, that a state of death has not yet been reached, and that DCD has more psychological barriers than does the brain death donation process. Opportunities and strategic initiatives are discussed to overcome these barriers, including the value of communication and education initiatives and the need for well-trained requestors. The implementation of these strategic guidelines helped to increase the number of DCD donors by 225%.     

Report of a National Conference on Donation after Cardiac Death

A national conference on organ donation after cardiac death (DCD) was convened to expand the practice of DCD in the continuum of quality end-of-life care. This national conference affirmed the ethical propriety of DCD as not violating the dead donor rule. Further, by new developments not previously reported, the conference resolved controversy regarding the period of circulatory cessation that determines death and allows administration of pre-recovery pharmacologic agents, it established conditions of DCD eligibility, it presented current data regarding the successful transplantation of organs from DCD, it proposed a new framework of data reporting regarding ischemic events, it made specific recommendations to agencies and organizations to remove barriers to DCD, it brought guidance regarding organ allocation and the process of informed consent and it set an action plan to address media issues. When a consensual decision is made to withdraw life support by the attending physician and patient or by the attending physician and a family member or surrogate (particularly in an intensive care unit), a routine opportunity for DCD should be available to honor the deceased donor's wishes in every donor service area (DSA) of the United States.     

Comparison of communication and personal characteristics of living kidney donors and a matched quota sample

Deceased organ donation does not meet the need for kidney transplants. Thus, it is important to examine topics relevant to kidney donors such as communication leading to the donation decision and donor characteristics. This study reports personal characteristics and communication leading to the decision to donate among living kidney donors and a demographically matched quota sample. Donors had higher scores for compassion, while non‐donors reported more volunteerism. Donors and non‐donors did not differ in conversation or conformity orientations of family communication styles. Only 4.7% of donors reported being asked to donate directly. Matched respondents reported feeling more comfortable than unsettled with the idea of being asked directly and indicated a preference to learn of the need directly or indirectly, giving them the option to volunteer. The majority of donors were giving to family members and friends, and the matched sample indicated greater willingness to donate to immediate family members, followed by friends. Practical implications of the findings are offered.     

Family initiated discussions about organ donation at the time of death

Rodrigue JR, Cornell DL, Krouse J, Howard RJ. Family initiated discussions about organ donation at the time of death.
Clin Transplant 2010: 24: 493–499.
© 2009 John Wiley & Sons A/S. Abstract: Some family members initiate organ donation discussions before being approached by donor coordinators or healthcare providers. We examined differences between families that did vs. did not initiate organ donation discussions and factors predicting donation consent among those families that self‐initiated the discussion. Next‐of‐kin of donor‐eligible individuals (147 donors, 138 non‐donors) from one organ procurement organization completed a telephone interview. Seventy‐three families (25.6%) first mentioned organ donation, and 54 (74%) of them consented to donation. Several characteristics of the deceased and next‐of‐kin were associated with whether family members initiated the donation discussion with donation coordinators or healthcare providers. Moreover, family mention of donation was more likely to yield consent when the deceased was younger (OR = 0.95, CI = 0.92–0.99), next‐of‐kin was a registered donor (OR = 3.86, CI = 2.84–6.76), and when family was more satisfied with the healthcare team (OR = 1.20, CI = 1.04–1.39). Knowing the deceased’s donation intentions and being exposed to positive organ donation messages are more likely to trigger families to raise donation with providers. Organ procurement organizations (OPOs) and healthcare providers should work collaboratively to develop strategies for how best to respond to families who initiate this conversation.     

Organ Donation Decision: Comparison of Donor and Nondonor Families

Family members continue to play a prominent role in donation decisions at time of death. This study examined the relative influence of donor and next-of-kin factors, requestor characteristics, communication processes and satisfaction with the health care team on the donation decision. Data were gathered via structured telephone interview with 285 next-of-kin of donor-eligible deceased individuals who had been approached by coordinators from one organ procurement organization (OPO) in the southeastern USA from July 2001 to February 2004. Univariate and multivariate analyses showed that several variables were associated with the donation decision. Subsequent logistic regression analyses revealed that donation was more likely when the deceased was younger, white (OR = 3.20, CI = 1.3, 5.7) and had made his/her donation intentions known (OR = 4.35, CI = 2.6, 7.3), and when the next-of-kin had more favorable organ donation beliefs (OR = 8.72, CI = 5.2, 14.7), was approached about donation by an OPO coordinator (OR = 3.74, CI = 2.2, 6.4), viewed the requestor as sensitive to their needs (OR = 2.70, CI = 1.6, 4.5) and perceived the timing of the request as optimal (OR = 6.63, CI = 3.6, 12.1) (total regression model, chi square = 133.2, p < 0.001, 92.7% of cases correctly predicted). Findings highlight the need for continued public education efforts to maximize positive beliefs about organ donation, to share and document donation decisions and to improve communication processes among the OPO personnel, hospital staff and prospective donor families.     

Potential of organ donation from deceased donors: study from a public sector hospital in India

Deceased donor organ programme is still in infancy in India. Assessing deceased donation potential and identifying barriers to its utilization are required to meet needs of patients with organ failure. Over a 6‐month period, we identified and followed all presumed brainstem dead patients secondary to brain damage. All patients requiring mechanical ventilation with no signs of respiratory activity and dilated, fixed and nonreacting pupils were presumed to be brainstem dead. All events from suspicion of brainstem death (BSD) to declaration of BSD, approach for organ donation, recovery and transplants were recorded. Subjects were classified as possible, potential and effective donors, and barriers to donation were identified at each step. We identified 80 presumed brainstem dead patients over the study period. The mean age of this population was 35.9 years, and 67.5% were males. When formally asked for consent for organ donation (n = 49), 41 patients’ relatives refused. The conversion rate was only 8.2%. The number of possible, potential and effective donors per million population per year were 127, 115.7 and 9.5, respectively. The poor conversion rate of 8.2% suggests a huge potential for improvement. Family refusal in majority of cases reflects poor knowledge and thus warrants interventions at community level.     

Factors associated with positive attitudes toward organ donation in Arab Americans

Padela AI, Rasheed S, Warren GJW, Choi H, Mathur AK. Factors associated with positive attitudes toward organ donation in Arab Americans.
Clin Transplant 2011: 25: 800–808. © 2010 John Wiley & Sons A/S. Abstract: Background: The demand for transplantable organ continues to exceed supply, particularly in minority patient populations. We explored the factors influencing organ donation attitude within the Arab American community. Methods: Secondary data analysis from a face‐to‐face survey administered in late 2003 to 1016 adults from a representative population‐based sample on Greater Detroit Arab Americans. Results: Christian Arab Americans were more likely than Muslim Arab Americans, and women more than men, to believe organ donation after death was justifiable. Higher educational attainment and income, as well as greater acculturation into American society, were associated with greater odds of believing organ donation to be justified. Self‐reported health status and level of psychological distress and health insurance status were not associated with beliefs about organ donation. Conclusions: A multifaceted approach toward increasing organ donation rates in this growing population requires targeted community‐health care system collaborations involving religious and civic leaders using Arabic language and culturally sensitive media. Summary: Arab Americans represent a growing population about which little is known in regard to organ donation and transplantation. This population is not specifically captured within national and local transplantation databases, and little empiric work has assessed attitudes and barriers toward organ donation and transplantation within this community. Our work represents the first to use a representative population‐based sample to explore the modifiable and non‐modifiable characteristics of those who believe cadaveric organ donation to be justified.     

We Have an Obligation to Provide Organs for Transplantation After We Die

The rhetoric of providing organs for transplantation is similar to that of a charity with terms such as 'donate life' and 'gift of life' frequently being used. It is argued that providing organs from deceased individuals should be and is a moral obligation or moral duty. We place high value on the lives of others, even if we do not know them (such as people on the transplant waiting list). And because permitting organ removal after death poses no risks, discomfort, costs or inconvenience, it is an obligation of easy rescue. The transplant community should begin to frame the discussion in these terms.     

Examining the association between media coverage of organ donation and organ transplantation rates

Research addressing the organ shortage in the USA has examined multiple factors influencing one's decision to become an organ donor. One of these research lines addresses media coverage of organ donation. The present investigation seeks to advance this research line by examining the association between organ donation media coverage and organ transplantation rates. A content analysis spanning January 1990 to December 2005 of three television networks reveals an overall positive association between coverage and transplantation rates. The implications of our findings are discussed along with recommendations for practitioners and advocates alike.     

The process of organ donation and its effect on consent

OBJECTIVE: To identify those factors that enhance or inhibit organ donation in order to provide data to help policy makers, hospital administrators and transplantation professionals make informed choices about how to modify the donor system and to structure 'best practice' interventions. SUMMARY OF BACKGROUND DATA: Legislative efforts to increase donation rates have not been successful. An emphasis on process is needed to help explain this. METHODS: The study was conducted using a stratified random sample of 23 hospitals in the Pittsburgh and Minneapolis/St Paul standard statistical metropolitan areas. Each week, the medical charts of all in-patient and emergency room patient deaths at each hospital were reviewed using a standardized review protocol to determine eligibility for organ, tissue, and cornea donation. A total of 10,681 patient charts were reviewed over a 4-yr period. Eight hundred and twenty-eight cases out of 1,723 eligible cases were selected for inclusion in the study. Data were collected on 827 of these cases. All health care providers (HCPs) who spoke with the family after the patient's death or discussed donation with the family were interviewed. RESULTS: Of the 10,681 patient charts reviewed, 16.5% were eligible to donate either organs, tissues, or corneas, and 87.0% of donor-eligible patients' families were approached and asked to donate. Consent rates were 23.5% for corneas, 34.5% for tissues, and 46.5% for organ donation. Multiple logistic regression demonstrated that the best and strongest predictor of donation decisions was the family's initial response to the donation request, as reported by the HCP. Three initial response groups are examined and compared. Those families who expressed an initially favorable reaction were most likely to agree to donation. Furthermore, discussion patterns differed by initial reaction group, with families who expressed initial indecision about donation sharing more characteristics with families who were not favorable than those who were favorable. More detailed information was provided to the favorable families, as compared to the other two groups, concerning the effect of donation on funeral arrangements and costs. Families who were favorable were also more likely to meet with an organ procurement organization representative than were other families. The strongest predictor of a family's unfavorable response to a donation request was the belief that the patient would have been against donation. A number of other variables, including HCP attitudes, also had an impact on the family's decision to donate. CONCLUSIONS: A number of discussion and HCP characteristics are associated with a family's willingness to consent to organ donation. Further study is needed to determine if interventions based on the characteristics identified in this study will increase consent to donation.     

Altruistic Living Donors: Evaluation for Nondirected Kidney or Liver Donation

A program was established within our regional procurement organization to permit evaluation of altruistic living donors (LD) interested in nondirected kidney or liver segment donation prior to transplant center referral. During the initial 30 months of program operations, 731 donor inquiries were received of which 131 individuals called back after review of mailed information materials. Forty-seven candidates initiated and 19 completed the evaluation process. Seven underwent donation to include six kidneys and one liver segment, five are actively pending donation, five were excluded from donation following transplant center evaluation and two took no further action after their intended liver recipients received deceased donor (DD) transplants. Psychological evaluation of these 19 candidates found them to be free of psychopathology, highly cooperative and self-directed. They did not exhibit attention-seeking or religious motivations for their actions. All seven donors and recipients continue to do well postoperatively. This evaluation program has made possible large-scale screening and education of prospective altruistic LD within the general population and also provides a unique opportunity to further our understanding of those individuals interested in living-nondirected donation.     

Organ donation video messaging: differential appeal,emotional valence,and behavioral intention

Video narratives increasingly are used to draw the public's attention to the need for more registered organ donors. We assessed the differential impact of donation messaging videos on appeal, emotional valence, and organ donation intentions in 781 non‐registered adults. Participants watched six videos (four personal narratives, one informational video without personal narrative, and one unrelated to donation) with or without sound (subtitled), randomly sequenced to minimize order effects. We assessed appeal, emotional valence, readiness to register as organ donors, and donation information‐seeking behavior. Compared to other video types, one featuring a pediatric transplant recipient (with or without sound) showed more favorable appeal (p < 0.001), generated more positive emotional valence (p < 0.01), and had the most favorable impact on organ donor willingness (p < 0.001). Ninety‐five (12%) participants clicked through to a donation website after viewing all six videos. Minority race (OR = 1.94, 95% CI = 1.20, 3.13, p = 0.006), positive change in organ donor readiness (OR = 0.26, 95% CI = 0.14, 0.48, p < 0.001), and total positive emotion (OR = 1.05, 95% CI = 1.03, 1.07, p < 0.001) were significant multivariable predictors of clicking through to the donation website. Brief, one‐min videos can have a very dramatic and positive impact on willingness to consider donation and behavioral intentions to register as an organ donor.     

Incentives for organ donation: proposed standards for an internationally acceptable system

Incentives for organ donation, currently prohibited in most countries, may increase donation and save lives. Discussion of incentives has focused on two areas: (1) whether or not there are ethical principles that justify the current prohibition and (2) whether incentives would do more good than harm. We herein address the second concern and propose for discussion standards and guidelines for an acceptable system of incentives for donation. We believe that if systems based on these guidelines were developed, harms would be no greater than those to today's conventional donors. Ultimately, until there are trials of incentives, the question of benefits and harms cannot be satisfactorily answered.     

Variation in cadaveric organ donor rates in the UK.

BACKGROUND: Considerable variation exists in the organ donation rate between kidney retrieval areas (KRAs) within the UK. The causes for this are unknown. This study examines whether or not observed variations are correlated with various possible explanatory factors. METHODS: A geographical study involving Poisson regression analysis was carried out of all 21 KRAs in the UK in 1999 and 2000, with donor rate as dependent variable, and the following independent variables: road traffic accident, intracerebral haemorrhage and other trauma death rates; intensive care unit (ICU) bed numbers; co-location of transplant and neurosurgical units; population ethnicity; proportion of the population on the organ donor register; transplant coordinator numbers; and transplant unit numbers. Main outcome measures were: donor rate in each KRA; strength of association between independent and dependent variables; and magnitude of changes in the donor rate associated with changes in independent variables. RESULTS: The donor rate varied between eight and 27.4 donors per million population per year. There was an association between donor rate and general ICU bed numbers (more beds associated with a higher donor rate), but this was of borderline statistical significance (P = 0.065). However, the donor rate was negatively associated (P = 0.02) with neurosurgical ICU bed numbers (more beds, fewer donors) and the proportion of the population from minority ethnic communities. There was no statistically significant association with the other independent variables. CONCLUSIONS: There is significant variation in the organ donor rate between different parts of the UK. More research is needed to explore the counter-intuitive association between neurosurgical ICU beds and donations, and to determine the remaining causes of the observed variation.     

Portrayal of organ donation and transplantation on American primetime television

Recently, both living and deceased organ donation rates have hit a plateau, despite increases in need for viable organs. One approach to improve donation rate is public education and policy; thus, it is necessary to understand the information the public is receiving regarding organ donation. We hypothesized that primetime medical dramas portray organ donation and transplantation in a negative manner. We compiled data on all primetime medical drama episodes with transplant themes from November 2008 through June 2010 and assessed depictions of organ donors and transplant candidates. Positive and negative thematic elements surrounding the process and individuals involved were also identified. One hundred and fifty-five million and 145 million households watched episodes containing any negative message and any positive message, respectively. Episodes containing only negative messages had over twice the household viewership per episode compared to episodes containing only positive messages (8.4 million vs. 4.1 million, p = 0.01). Widespread exposure to these representations may reinforce public misconceptions of transplantation. The transplant community should consider the popularity of medical dramas as an opportunity to impact the perception of organ donation and transplantation for millions of Americans.     

The expectancies of living kidney donors: do they differ as a function of relational status and gender?

BACKGROUND: While two-thirds of the living kidney donors continue to be genetically related to the recipient, there has been a 300% increase in unrelated living donors over the last 10 years. Also, women continue to represent more than half of all the living kidney donors. This study examined whether donor expectancies varied as a function of relational status or gender. METHODS: 362 kidney donor candidates (232 related, 130 unrelated) completed the Living Donation Expectancies Questionnaire (LDEQ). A 2 (relational status: related or unrelated) x 2 (gender: male or female) multivariate analysis of variance was conducted to examine main and interaction effects across the six domains of the LDEQ: interpersonal benefit (IB), personal growth (PG), spiritual benefit (SB), quid pro quo (QPQ), health consequences (HC) and miscellaneous consequences (MC). RESULTS: The highest expectancies were for PG (54.1%) and IB (29.8%), followed by expectations of MC (18.2%), SB (16.9%), HC (14.4%), and QPQ (4.4%). Multivariate analyses showed a relational main effect [F = 4.18, P = 0.02] and a gender main effect [F = 5.09, P = 0.01]. Subsequent univariate analyses showed significant effects (P<0.05) for IB (related>unrelated), QPQ (men>women), HC (unrelated>related, men > women) and MC (unrelated > related). CONCLUSION: Overall, donor candidate expectancies appear to be realistic in light of previous findings of donor benefit. However, some living donor expectancies may vary as a function of donor relational status and gender. It may be important to assess and appropriately address both positive and negative expectancies at the time of donor evaluation. The LDEQ may be a useful clinical tool for assessing such expectancies.