Primary care physicians' attitudes and practices regarding discussing organ donation with their patients.

Abstract

Among the general population, discussing organ donation with a primary care provider may be associated with increased willingness to donate. However, the frequency with which primary care providers hold these discussions with their patients has not been reported.
Cross-sectional mail and an Internet survey of validated questions regarding organ donation were done.
A national sample of 831 primary care physicians. black, and Hispanic physicians were oversampled.
Few physicians reported receiving formal training in donation (17%). Only 5% of physicians have donor cards available in their practice, and only 11% have donation information available in their practice. While 30% of physicians reported discussing end-of-life care with their patients, fewer than 4% reported discussing donation with their patients. However, only 36% felt that discussing donation was outside of their scope of practice. In a multivariate regression model, predictors of discussing donation with patients included having received formal education about organ donation (odds ratio [OR], 2.6; p < .05) and discussing end-of-life care with patients (OR, 12.8; p < .001).
Very few primary care physicians reported discussing organ donation with their patients despite the majority agreeing that it was within their scope of practice. Primary care physicians who had received education on the subject or who regularly discuss end-of-life care with their patients were more likely to discuss donation. Efforts to improve donation in the general population should include a focus on understanding and improving communication about organ donation between providers and their patients.

Full text

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52 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 102, NO. 1, JANUARY 2010
original

communication
BACKGROUND
A
ing. This issue disproportionately affects people of color
who make up more than 50% of those waiting on the
national list for an organ transplant. Blacks, for exam-
ple, continue to represent more than 25% of those wait-
ing despite comprising less than 15% of the population.1
Due to their higher burden of chronic illness and lower
likelihood of receiving a transplant compared to whites,2
many will die without receiving a lifesaving transplant.
Increasing organ donation among people of all ethnici-
ties is a national priority in order to increase the avail-
ability of donated organs and extend the duration and
quality of life for all those waiting.3
Obtaining consent for organ donation from families and
surrogates at the time of death is fraught with difficulties
and is a major factor limiting organ donation and the subse-
quent availability of donated organs for transplantation.4
Only half of the persons who have decided to become a
donor make their family aware of their decision. Without
that essential information, many family members and sur-
rogates express a general reluctance to make end-of-life
decisions regarding their loved ones.5 Understandably, fam-
ilies are often completely occupied with the loss of their
family member and see donation as being of lesser impor-
tance.6 Compounding this problem, many critical care phy-
sicians find obtaining donation consent from families to be
beyond their scope of practice and lack appropriate training
to counsel the family.7 Not surprisingly, professional organ
procurement personnel have been found to be more suc-
cessful in obtaining consent than inpatient physicians.8
Shifting the focus of organ donation consent from fam-
ily members in the acute inpatient setting to the patient in
the ambulatory setting, prior to development of a cata-
s the number of persons waiting for an organ
transplant surpasses 100 000,1 finding new ways
to increase organ donation becomes more press-
Author Affiliations: Center for Reducing Health Disparities, Division of Pul-
monary and Critical Care, MetroHealth Campus of Case Western Reserve
University, Cleveland, Ohio (Dr Thornton); Division of Pulmonary and Critical
Care, University of Washington, Seattle, Washington (Dr Curtis); Benaroya
Research Institute, Seattle, Washington (Dr Allen).
Corresponding Author: J. Daryl Thornton, MD, MPH, Center for Reducing
Health Disparities, MetroHealth Medical Center, 2500 MetroHealth Dr, Ram-
melkamp R209A, Cleveland, OH 44109 (daryl.thornton@case.edu).
Primary Care Physicians’ Attitudes and
Practices Regarding Discussing Organ
Donation With Their Patients
J. Daryl Thornton, MD, MPH; J. Randall Curtis, MD, MPH; Margaret D. Allen, MD, DrSC(Hon)
Funding/Support: This study was funded by the Robert Wood
Johnson Harold Amos Medical Faculty Development Program.
Purpose: Among the general population, discussing organ
donation with a primary care provider may be associated
with increased willingness to donate. However, the frequen-
cy with which primary care providers hold these discussions
with their patients has not been reported.
Setting: Cross-sectional mail and an Internet survey of vali-
dated questions regarding organ donation were done.
Subjects: A national sample of 831 primary care physicians.
black, and Hispanic physicians were oversampled.
Results: Few physicians reported receiving formal train-
ing in donation (17%). Only 5% of physicians have donor
cards available in their practice, and only 11% have dona-
tion information available in their practice. While 30% of
physicians reported discussing end-of-life care with their
patients, fewer than 4% reported discussing donation with
their patients. However, only 36% felt that discussing dona-
tion was outside of their scope of practice. In a multivariate
regression model, predictors of discussing donation with
patients included having received formal education about
organ donation (odds ratio [OR], 2.6; p < .05) and discussing
end-of-life care with patients (OR, 12.8; p < .001).
Conclusions: Very few primary care physicians reported dis-
cussing organ donation with their patients despite the major-
ity agreeing that it was within their scope of practice. Primary
care physicians who had received education on the subject
or who regularly discuss end-of-life care with their patients
were more likely to discuss donation. Efforts to improve dona-
tion in the general population should include a focus on
understanding and improving communication about organ
donation between providers and their patients.
Keywords: organ donation n transplantation n patient-
physician relationship n communication n end-of-life care
J Natl Med Assoc. 2010;102:52-58

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL. 102, NO. 1, JANUARY 2010 53
PRIMARY CARE PHYSICIAN DONATION DISCUSSIONS
strophic illness, may have a greater impact on donation.
Primary care physicians might contribute substantially by
directly discussing donation with their patients during rou-
tine patient visits and by serving as a source of donation
information.9,10 However, little is known about how fre-
quently this occurs or what factors might facilitate such
discussions. We surveyed a random national sample of pri-
mary care physicians and over-sampled Hispanic and
black primary care physicians to determine how frequently
they discuss donation with their patients and what factors
encourage and inhibit these discussions from occurring.
METHODS
Contact information was obtained for a random sam-
ple of 1500 general internists and 1500 family physi-
cians from the American Medical Association’s Master-
file. One-third of the names were obtained from the
general Masterfile, one-third from a subset of Masterfile
physicians who designated themselves as black and one-
third from a subset of Masterfile physicians who desig-
nated themselves as Hispanic. A preletter was sent 1
week prior to the survey alerting the physicians to the
study, allowing them to return the enclosed postcard if
they chose not to participate, and providing a unique
password and Web site address to complete the survey
online. A paper copy of the survey was sent to partici-
pants 3 times from August to December of 2004 unless
they withdrew from or completed the study. Each survey
had a unique identification number to ensure the partici-
pants completed the survey only once. A $2 bill was pro-
vided as incentive. The University of Washington
Human Subjects Division approved the study.
Table 1. Physician Characteristics
Characteristics
Physician Sociodemographics
Age, mean ± SD
Women
Born in United States
Physician specialty
Family practice
Internal medicine
Years since medical school, mean ± SD
Religious preference
None
Christian
Jewish
Muslim
Other
Region of United States
Midwest
Northeast
Northwest
Southeast
Southwest
Practice Characteristics
Urban (ref = rural)
Private practice (ref = academic)
Outpatient practice only
Percent of time spent in direct patient care
Donation Characteristics
Support donation
Willingness to donate own organs
Unwilling to donate
Considering donation
Would like to but have not signed a donor card
Signed a donor card
Non-Hispanic
Blacks
N = 233
n (%)

43.6 ± 11.4
124 (53%)
143 (61%)
Hispanics
(All Races)
N = 194
n (%)
Non-Hispanic
Whites
N = 277
n (%)
P Value

<.001a
<.001a
<.001a
<.001a

44.8 ± 10.2
53 (27%)
87 (45%)
47.3 ± 11.3
95 (34%)
243 (88%)
98 (45%)
122 (55%)
18.1 ± 10.3
76 (43%)
102 (57%)
20.1 ± 10.6
161 (61%)
102 (39%)
21.7 ± 11.8<.001a
<.001a
19 (8%)
192 (86%)
2 (1%)
4 (2%)
7 (3%)
18 (9.5%)
160 (86%)
2 (1%)
1 (0.5%)
5 (3%)
47 (17%)
196 (72%)
21 (7%)
5 (2%)
5 (2%)
<.001a
41 (18%)
70 (30%)
5 (2%)
96 (41%)
21 (9%)
17 (9%)
38 (20%)
8 (4%)
82 (42%)
48 (25%)
83 (30%)
67 (24%)
29 (11%)
58 (21%)
40 (14%)

127 (76%)
68 (61%)
117 (52%)
95%
107 (80%)
79 (72%)
84 (44%)
95%
123 (59%)
111 (85%)
154 (57%)
95%
<.001a
<.001a
.07
.29

222 (96%)186 (96%) 272 (99%) .09
<.001a
39 (17%)
38 (16%)
47 (20%)
108 (47%)
21 (11%)
17 (9%)
36 (19%)
114 (61%)
18 (7%)
20 (7%)
20 (7%)
215 (79%)
a p < .001.

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54 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 102, NO. 1, JANUARY 2010
PRIMARY CARE PHYSICIAN DONATION DISCUSSIONS
Questionnaire Content
The anonymous 15-minute, 41-item questionnaire
was designed to gather information in 5 categories,
including knowledge and personal experience regarding
donation and transplantation as well as physician demo-
graphics and practice patterns (questionnaire available
upon request). Physicians were asked about their own
willingness to become deceased and/or living organ
donors. The questionnaire was developed using focus
groups of physicians, available literature, and prior work
by our group.11,12 After development, the questionnaire
was pilot tested with 25 physicians and modified based
on their recommendations and responses.
Donation and Transplantation
Training, Education, and
Personal Experience
Physicians were asked whether they had received
formal donation training regarding during or following
medical school and whether they had cared for patients
who had received a transplant. Physicians were also
asked if they had participated in the care or medical
decision making of a deceased family member or loved
one. Finally, they were asked if they knew where to
obtain answers to patient questions about donation and
transplantation.
Assessment of Willingness
to Donate Organs
To examine physicians’ level of willingness to donate
organs, respondents were asked whether they agreed
with 3 statements. These statements allowed 4 possible
ordinal responses selected to measure the respondents’
current stage in the decision-making process using the
Transtheoretical Model of Health Behavior Change:13,14
• “I have signed an organ donor card.”
• “ I would like to become an organ donor but have
not signed an organ donor card.”
• “ I am considering becoming a donor but need more
time to think about it.”
Discussing Donation With Patients
Primary care physicians were asked if they had talked
with more than 50% of their patients about organ dona-
tion as well as whether they had talked with more than
50% of their patients about end-of-life issues. They were
also asked if they had organ donor cards or information
regarding donation available in their practice.
Barriers to Discussing Donation
With Patients
Physicians were asked to rate their agreement regard-
ing 9 different potential barriers to discussing donation
with their patients. They were given choices ranging
from 1, strongly disagree, to 4, strongly agree. Respon-
dents were also given the opportunity to write in addi-
tional barriers that they might have encountered.
Characterization of Ethnicity,
Gender, and Other
Demographic Factors
Physician age, gender, and religious affiliation were
collected. Physicians were asked about their race and
ethnicity and were encouraged to choose as many options
as they felt reflected their ethnic background. Statistical
Table 2. Primary Care Physician Donation Training, Education, and Knowledge
Characteristics
Participated in formal training about
organ donation during medical school
Participated in formal training about
organ donation after medical school
Read articles about donation or
transplantation
Cared for patients who have received
transplants
Cared for a loved one at the end of
their life
Percent correct on knowledge
assessment, mean ± SD
Self reported donation knowledge,
mean ± SD
Non-Hispanic
Blacks
N = 233
n (%)
Hispanics
(All Races)
N = 194
n (%)
Non-Hispanic
Whites
N = 277
n (%)
P Value
39 (17%)21 (11%)53 (19%) .05
51 (22%) 35 (19%) 39 (14%).08
83 (36%)75 (40%)102 (38%) .7
155 (67%)135 (72%) 200 (73%).3
151 (65%)130 (69%) 201 (74%).1
68 ± 18%64 ± 18% 61 ± 19%.02a
53 ± 20%50 ± 19% 51 ± 21% .4
a p < .05.

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 102, NO. 1, JANUARY 2010 55
PRIMARY CARE PHYSICIAN DONATION DISCUSSIONS
analysis was limited to the 3 most highly represented
racial and ethnic groups (black, Hispanic, and white).
Statistical Analysis
Mean values of continuous variables were compared
across the three predominant racial and ethnic groups
using analysis of variance. The Bonferroni multiple
comparison test was used for pairwise comparisons
among the 3 groups. Kruskal-Wallis equality of propor-
tions rank test was used to compute medians across the
3 groups. Proportions of categorical variables were com-
pared using c2 tests. Ordinal variables were compared
using c2 test for trend. Logistic regression was used to
assess the independent associations of physician race
and ethnicity on discussing donation with more than
50% of their patients. Similarly, an ordinal logistic
regression model incorporated increasing willingness to
donate as the ordinal outcome variable and physician
race and ethnicity as the predictors of interest. The
approximate test of proportional odds assumption was
used to ensure that the ratio of cumulative odds for
increasing willingness to donate was constant.15 Poten-
tial confounding variables were determined a priori and
included in the multivariate regression models. Statisti-
cal significance was defined as a 2-tailed test with p <
.05. All analyses were performed with Stata 9.2 statisti-
cal software (Stata, College Station, Texas).
RESULTS
The survey was mailed to 3000 primary care physi-
cians. Of these, 236 (8%) were returned undelivered
because of invalid mail and e-mail addresses. The survey
was completed by 831 people, representing a response
rate of 30% (831/2764). Physicians self-identified as
35% white, 29% black or African American, 24% His-
panic, 8% Asian, 1% Native American, 1% Pacific
Islander, and 1% other. They were also well-distributed
with regard to age, gender, religion, and primary care
specialty (Table 1).
The average age of all physicians in the cohort was
45 ± 11 years. Black physicians were younger than white
physicians (44 ± 11 vs 47 ± 11 years, p = .001), but not
younger than Hispanic physicians (45 ± 10 years, p =
.8). Other demographic factors also varied by race and
ethnicity.
Donation Support and Willingness
The majority of physicians supported organ donation
(97%). More white physicians reported having signed a
donor card (79%, vs 61% for Hispanics and 47% for
blacks, p < .001). Overall, 60% of all physicians in the
cohort had signed a donor card.
Donation Training and Knowledge
Few primary care physicians in this cohort had
received training on organ donation during (16%) or fol-
lowing (17%) medical school. This did not vary by race
or ethnicity (Table 2). A larger proportion of physicians
(37%) reported regularly reading donation or transplan-
tation articles, and the majority reported having cared
for patients who had received a transplant (71%). A sig-
nificant number of physicians also reported knowing
someone who had donated or received an organ (79%).
Despite these experiences, physician knowledge of
donation and transplantation was relatively low. Black
physicians had higher knowledge scores than white and
Hispanic physicians (68%, vs 64% white and 64% His-
panic, p = .05 and .04, respectively). Most physicians
gauged their knowledge of organ donation and trans-
plantation to be poor, with no statistically significant dif-
ferences across the 3 groups.
Discussing Donation With Patients
Only 5% of physicians reported having donor cards
available, and only 11% reported having donation infor-
mation available in their practice. Exactly half of the
physicians reported knowing where to get donor infor-
mation should a patient raise questions about it. How-
Table 3. Informing Patients About Donation
Characteristics
Talked with >50% of patients about donation
Talked with >50% of patients about end-of-life (DNR,
living will, etc)
Have donation cards available in the physician’s office
Have information on donation available in the
physician’s office
Know where to get donation information if patient asks
Non-Hispanic
Blacks
N = 233
n (%)
12 (5%)
Hispanic
(All Races)
N = 194
n (%)
10 (5%)
Non-Hispanic
Whites
N = 277
n (%)
6 (2%)
P Value
.14
66 (29%)
12 (5%)
68 (36%)
10 (5%)
63 (23%)
19 (7%)
.01a
.65
23 (10%)
115 (51%)
20 (10%)
101 (53%)
35 (13%)
137 (50%)
.58
.83
a p < .05.

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56 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 102, NO. 1, JANUARY 2010
PRIMARY CARE PHYSICIAN DONATION DISCUSSIONS
ever, less than 4% of all primary care physicians in this
study reported that they had talked with the majority of
their patients regarding organ donation. This did not
vary by race or ethnicity (Table 3). In contrast, 30% of
physicians reported discussing end-of-life care with
more than half their patients. Hispanic physicians dis-
cussed end-of-life care more frequently than white phy-
sicians (36%, vs 23%, p = .01) but not more frequently
than black physicians (29%, p = .39).
In a multivariate logistic regression model identifying
independent predictors of physicians discussing donation
with their patients, 2 significant predictors emerged: (1)
discussing end-of-life care with the majority of their
patients (odds ratio [OR], 12.8; p < .001) and (2) having
received formal donation education (OR, 2.6; p < .05).
Other variables included in the model but not found to be
statistically significant were physician race, ethnicity, gen-
der, age, knowledge level about donation and transplanta-
tion, personal willingness to donate, and having donor
cards or information available in the office (Table 4).
Barriers to Discussing Donation
With Patients
Physicians concurred with several of the available
impediments to discussing organ donation with their
patients. However, of note, the barriers identified varied
by physician race and ethnicity (Table 5). White physi-
cians were more likely to agree with statements that
reflected being too busy or having too high of a patient
load (p = .01 for both). A greater proportion of black
physicians indicated that language difficulties prevented
them from communicating about donation with their
patients (p = .003). A higher proportion of black physi-
cians were also more likely to agree with having moral
objections to organ donation (p = .009). Overall, 64% of
physicians expressed not having enough staff to ade-
quately address the issue of donation. While the major-
ity (63%) felt that organ donation was not a high priority
in the care of their patients, only 36% felt discussion of
donation was outside of their scope of practice.
DISCUSSION
In this nationally representative study, primary care
physicians reported receiving little formal education on
organ donation and transplantation, having a low level
of knowledge about donation and transplantation, and
rarely having donor information or donation cards avail-
able in their office for patients. Only a small percentage
of these physicians reported regularly discussing organ
donation with their patients. This study is the first to
report on the paucity of donation discussions among a
nationwide sample of primary care physicians and their
patients. To our knowledge, it is also the first to report
the barriers physicians experience in conducting dona-
tion discussions within their practices.
The question then arises regarding the appropriate-
ness of focusing on the primary care physician as a facili-
tator for these discussions if the physician has little train-
ing or knowledge on the subject. First, the gap between
the number of persons in need of organs and the number
of donated organs has failed to close despite substantial
efforts. Additional methods are needed to successfully
reduce this gap. Second, in the United States, direct
patient consent for organ donation continues to be
addressed most commonly at departments of motor vehi-
cles by workers who also are not fully trained to address
the topic. It is not surprising that donation conversion
rates are so low. The most compelling reason/rationale is
that primary care physicians are currently and success-
fully impacting end-of-life care by addressing the issue
directly with patients at an earlier stage in their illness.16-18
Adding the topic of organ donation to these end-of-life
discussions may have a similarly positive effect on
patient attitudes toward donation.10 However, it is well
recognized that primary care physicians are already bur-
dened with the need to address too many issues in an
increasingly compressed clinical encounter. Adding the
topic of organ donation may be another hurdle many
physicians may choose not to cross. Indeed, many physi-
cians in this study felt they had too little time, too much
work, and too few ancillary staff to appropriately address
Table 4. Predictors of Physicians Discussing Donation With >50% of Their Patients
Predictor
Physician race/ethnicity (white = referent)
Women
Age
Physician willingness to donate own organs
Received donation education during or following medical school
Physician knowledge of donation and transplantation
Have information about donation available in the physician’s office
Have donation cards available in the physician’s office
Discuss end-of-life care with >50% of patients
OR (95% CI)P Value
1.0 (0.4-2.7)
1.0 (1.0-1.0)
1.6 (0.9-2.8)
2.6 (1.0-6.5)
0.9 (0.8-1.1)
2.5 (0.8-7.6)
2.0 (0.5-8.1)
12.8 (4.2-39)
.96
.28
.11
<.05a
.29
.11
.32
<.001b
Abbreviations: CI, confidence interval; OR, odds ratio.
a p < .05.
b p < .001.

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JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 102, NO. 1, JANUARY 2010 57
PRIMARY CARE PHYSICIAN DONATION DISCUSSIONS
the issue of organ donation with their patients. However,
the majority of physicians in this study also felt that they
lacked suitable training in organ donation and that the
subject was difficult to discuss. It may be that with
proper training, physicians would feel more comfortable
in initiating these discussions and therefore be able to
hold them without adding significantly more time to
their existing schedules. For example, a randomized
controlled trial piloting brief verbal discussions and dis-
tributing written materials on organ donation in family
medicine office visits was shown to have a significant
impact on patient willingness to donate.19 In addition, if
organ donation were to be incorporated into existing dis-
cussions of end-of-life care, the discussions might
remain brief and effective.
Prior studies that have examined the willingness of
physicians to donate their organs have uncovered a simi-
lar lack of willingness to donate.9,20,21 However, even if so,
in this study, personal decisions by physicians on dona-
tion were not significantly associated with whether physi-
cians discussed donation with their patients. This suggests
that physicians may be able to separate their personal feel-
ings regarding donation from what they recommend to
their patients. This finding needs greater exploration, and,
if true, further supports the concept of utilizing the ambu-
latory setting to increase willingness to donate.
Race and ethnicity of primary care physicians may
play an important role in improving organ donation, par-
ticularly among minorities. Black and Hispanic physi-
cians are more likely to care for patients of similar race
and ethnicity. Black patients rate their visits with physi-
cians of their own race as more participatory than with
physicians of other races.22 As a result, understanding
the practices of minority and white physicians will be
important in understanding communication regarding
advanced care planning. In this study, the race and eth-
nicity of the primary care physicians was not shown to
impact the frequency of discussions on organ donation,
even though a higher proportion of black physicians
expressed moral objections to donation. The relation-
ship between physician and patient race and ethnicity on
donation discussions could not be examined here but
remains an area that needs further in depth exploration.
Physicians reported having received little donation
and transplantation training during or after medical
school, and had low perceived and actual donation
knowledge. Organ donation education appears not to
have significantly increased in medical schools judging
by recent studies of Ohio medical students.12,23 Several
organizations, including the United Network of Organ
Sharing, have developed training curricula for medical
schools, but it is unclear how often they are implemented.
It may be helpful for medical school educators to recog-
nize that training their students may positively impact
organ donation among the general population by improv-
ing physician competence in discussing donation.24
The findings here should be interpreted in the context
of the study limitations. One limitation is that the study
relied on physician self-report. Since physicians were not
directly observed in their practice to record how often
they actually spoke to patients about donation, it is pos-
sible that recall bias may have been present, leading phy-
sicians to underreport the frequency of their donation
discussions. Response bias may also have eliminated
participants who infrequently discuss donation with their
patients. In spite of this potential, the response rate here
is higher than in other studies about end-of-life care con-
ducted using the American Medical Association’s Mas-
Table 5. Barriers to Physicians Discussing Donation With Their Patients
Characteristics
Not enough staff
Too heavy a patient load
Too busy or too little time
Organ donation is a difficult subject to discuss.
I lack suitable training in organ donation.
Language difficulties prevent adequate communication
about organ donation with my patients.
Organ donation is outside my scope of practice.
I have moral objections to donation.
Organ donation is not a high priority in the care of my
patients.
Non-Hispanic
Blacks
N = 233
n (%)
134 (58%)
144 (63%)
153 (67%)
182 (55%)
126 (56%)
Hispanic
(All Races)
N = 194
n (%)
118 (61%)
118 (62%)
121 (65%)
110 (57%)
117 (62%)
Non-Hispanic
Whites
N = 277
n (%)
188 (70%)
201 (75%)
208 (78%)
135 (50%)
148 (55%)
P
Value
.06
.01a
.01a
.22
.28
46 (20%)
80 (35%)
18 (8%)
25 (13%)
65 (34%)
12 (6%)
41 (15%)
95 (36%)
14 (5%)
.003b
.9
.009b
182 (68%)113 (60%) 182 (69%).3
a p < .05.
b p < .001.

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58 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATIONVOL. 102, NO. 1, JANUARY 2010
PRIMARY CARE PHYSICIAN DONATION DISCUSSIONS
terfile.25 Finally, given the nature of cross-sectional stud-
ies, it is not possible to ascertain whether the barriers
selected by survey participants were perceived impedi-
ments or whether they actually prevented physicians
from discussing donation with their patients.
In conclusion, despite substantial support for organ
donation among physicians, as well as the majority of
physicians feeling that donation education is within
their scope of practice, primary care physicians were
found rarely to discuss donation with their patients.
Efforts to increase organ donation among the general
population should examine ways to educate primary
care providers about donation and to encourage them to
incorporate discussions of donation into the routine and
end-of-life care of their patients.
REFERENCES
1. US Transplantation Data; 2009.
2. Sehgal AR. The net transfer of transplant organs across race, sex, age,
and income. Am J Med. 2004;117:670-675.
3. Simmons RG, Abress L. Quality-of-life issues for end-stage renal disease
patients. Am J Kidney Dis. 1990;15:201-208.
4. Gortmaker SL, Beasley CL, Sheehy E et al. Improving the request process
to increase family consent for organ donation. J Transpl Coord. 1998;8:210-
217.
5. Braun UK, Beyth RJ, Ford ME, McCullough LB. Voices of African American,
Caucasian, and Hispanic surrogates on the burdens of end-of-life decision
making. J Gen Intern Med. 2008;23:267-274.
6. Sanner MA. Two perspectives on organ donation: experiences of poten-
tial donor families and intensive care physicians of the same event. J Crit
Care. 2007;22:296-304.
7. Evanisko MJ, Beasley CL, Brigham LE et al. Readiness of critical care phy-
sicians and nurses to handle requests for organ donation. Am J Crit Care.
1998;7:4-12.
8. Siminoff LA, Gordon N, Hewlett J, Arnold RM. Factors influencing fami-
lies’ consent for donation of solid organs for transplantation. JAMA.
2001;286:71-77.
9. Conesa C, Rios A, Ramirez P et al. Primary care doctors faced with living
organ donation. Transplant Proc. 2006;38:863-865.
10. Thornton JD, Curtis JR, Allen MD. Completion of advanced care
directives is associated with willingness to donate. J Natl Med Assoc.
2006;98:897-904.
11. Thornton JD, Wong KA, Cardenas V, Curtis JR, Spigner C, Allen MD. Eth-
nic and gender differences in willingness among high school students to
donate organs. J Adolesc Health. 2006;39:266-274.
12. Edwards TM, Essman C, Thornton JD. Assessing racial and ethnic differ-
ences in medical student knowledge, attitudes and behaviors regarding
organ donation. J Natl Med Assoc. 2007;99:131-137.
13. Prochaska JO, DiClemente CC. The transtheoretical approach : crossing
traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin; 1984.
14. Prochaska JO, DiClemente CC. Stages and processes of self-change of
smoking: toward an integrative model of change. J Consult Clin Psychol.
1983;51:390-395.
15. Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. New York,
NY: Wiley; 2000.
16. Gordon NP, Shade SB. Advance directives are more likely among
seniors asked about end-of-life care preferences. Arch Intern Med.
1999;159:701-704.
17. Kronman AC, Ash AS, Freund KM, Hanchate A, Emanuel EJ. Can pri-
mary care visits reduce hospital utilization among Medicare beneficiaries
at the end of life? J Gen Intern Med. 2008;23:1330-1335.
18. Wright AA, Zhang B, Ray A et al. Associations between end-of-life dis-
cussions, patient mental health, medical care near death, and caregiver
bereavement adjustment. JAMA. 2008;300:1665-1673.
19. Bidigare SA, Ellis AR. Family physicians’ role in recruitment of organ
donors. Arch Fam Med. 2000;9:601-604, discussion 605.
20. Conesa C, Rios A, Ramirez P et al. The primary care physician faced
with organ donation: attitudinal study in South-Eastern Spain. Ups J Med
Sci. 2006;111:353-359.
21. Schaeffner ES, Windisch W, Freidel K, Breitenfeldt K, Winkelmayer WC.
Knowledge and attitude regarding organ donation among medical stu-
dents and physicians. Transplantation. 2004;77:1714-1718.
22. Cooper-Patrick L, Gallo JJ, Gonzales JJ et al. Race, gender, and part-
nership in the patient-physician relationship. JAMA. 1999;282:583-589.
23. Essman C, Thornton J. Assessing medical student knowledge, attitudes,
and behaviors regarding organ donation. Transplant Proc. 2006;38:2745-
2750.
24. Essman CC, Lebovitz DJ. Donation education for medical students:
enhancing the link between physicians and procurement professionals.
Prog Transplant. 2005;15:124-128.
25. Mebane EW, Oman RF, Kroonen LT, Goldstein MK. The influence of physi-
cian race, age, and gender on physician attitudes toward advance care
directives and preferences for end-of-life decision-making. J Am Geriatr
Soc. 1999;47:579-591. n