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Donor Action: an international initiative to alleviate organ shortage
Abstract
Donor Action, an international initiative to alleviate organ shortage, provides a comprehensive state-of-the-art methodology that helps critical care units develop a tailor-made approach to optimize donation practices and performance.
To report the impact of the Donor Action methodology on organ donation rates in 8 countries (70 critical care units) in North America and Europe.
Baseline data on the clinical potential for donation, staff attitudes, knowledge toward donation, self-reported confidence in performing a range of donation roles, and educational requirements were gathered. These data were analyzed using the Donor Action database and improvement measures were introduced to address identified weaknesses.
Following introduction of the program's improvement measures, which addressed identified weaknesses, donations increased on average by 53% (P = .0017) per country at 1 year. Sustained improvements settled at 70% to 160% increases at 3 years. Although Donor Action is at various stages of implementation in different countries, the number of centers and countries demonstrating an immediate awareness effect is increasing and sustained effects in centers with the longest follow-up promise a significant impact on donation rates as more countries implement this methodology.
... Whilst DA is at various stages of implementation in different countries in Asia, Europe, North and South America, the number of centers and countries demonstrating immediate and significant effects of awareness is increasing and amounts to an overall increase of approximately 60% at 1 year following implementation. Sustained effects in centers with the longest follow-up promise a similarly encouraging long-term impact on donation rates as more countries implement this meth- odology [30]. Successful organ-donation programs such as DA require a substantial initial financial investment. ...
... Whilst DA is at various stages of implementation in different countries in Asia, Europe, North and South America, the number of centers and countries demonstrating immediate and significant effects of awareness is increasing and amounts to an overall increase of approximately 60% at 1 year following implementation. Sustained effects in centers with the longest follow-up promise a similarly encouraging long-term impact on donation rates as more countries implement this methodology[30]. Successful organ-donation programs such as DA require a substantial initial financial investment. ...
Donor Action (DA) is an international initiative to help critical care units (CCUs) increase their own donation rates through improved-quality donation practices. Following a validated diagnostic review (DR), areas of weakness can be identified, and the appropriate changes introduced. Data gathered from a number of centers in nine European countries (including Germany) 1 year after the introduction of targeted improvement measures demonstrated a 59.2% (P=0.0015) increase in donation rates. This analysis computes the cost-benefit thresholds of implementing the DA methodology from a German health-economic point of view, taking into account the treatment alternatives for end-stage renal disease (dialysis and transplantation) and comparing the DA program with current organ-donation practice. Lifetime direct medical costs and quality-adjusted life years (QALYs) were calculated for both arms, considering only changes in cadaveric renal transplantation rates. If DA leads to a 59% overall increase in organ donation in Germany, the program will result in 33 QALYs and 1.8-million euro cost savings per million population (PMP). Therefore, DA would be cost-effective below 2.66-million euro implementation cost PMP (or 218-million euro for the whole country). As the partial implementation cost of the program was far below the threshold, DA is more cost-effective than other publicly reimbursed medical intervention.
... Много работ посвящено вопросам профессионального образования трансплантационных координаторов [1,40,52]. Трансплантационная координация является, по сути, синтетической профессией и требует специального образования [13]. В большинстве европейских стран (52%) выбрана для обучения испанская программа Transplant Procurement Management (TPM), через которую прошло 11 000 специалистов за время ее существования. ...
This review highlights the main problem in organ donation practice. There was done the analysis of main orga- nizational solutions and best organ donation policy practices with accent on Spain Model of organ donation, and the comparing U.S. organ donation system. Last «break through» international initiatives for improving organ donation practice were brought from WHA and WHO resolutions.
... But the Collaborative holds out the promise that there is additional room to increase donation rates. Quality improvement programs similar to the Breakthrough Collaborative have been used to increase donation rates in Europe and Canada (Roels and Wight, 2001). Another approach to increasing the supply of organs within the current system is to expand the use of organs from " marginal " donors. ...
Organ transplantation is one of the greatest technological achievements of modern medicine, but the ability of patients to benefit from transplantation is limited by shortages of transplantable organs. The median waiting time for patients placed on the kidney transplant waiting list is over three years. Median waiting times for hearts and livers are seven months and two years, respectively. From 1995 to 2005, the number of patients placed on the waiting list for organ transplants grew at an annualized rate of 4 percent per year. As a result of the growth in the demand for organs, many observers have questioned whether the current system is capable of providing enough transplantable organs. Transplant physicians and policymakers are seriously debating proposals to pay donors and their families and to change the legal regime governing the process of obtaining consent to donation. This paper provides an overview of the rules and practices that govern the organ procurement system and reviews proposals to increase donation rates, with a focus on deceased donors.
... Other policy measures are directed at optimizing the process of donor procurement. Examples of such measures are hospital programs like Donor Action [8,9]. and EDHEP [10], or informing the public about the relevant aspects of organ donation [11,12]. ...
Transplantable organs are scarce everywhere. Therefore, countries have developed policies to support the efficient use of potential donors. Nevertheless, the shortage of organs remains. Were these policies in vain? The aim of this study is to assess the impact of donor policies on donor procurement in 10 Western European countries from 1995 to 2005.
To assess the impact of the donor policies we studied the conversion of potential donors into effectuated donors. 80% of the donors died from CVAs or a (traffic) accident. We considered these mortality rates to be a good proxy for potential donors. Here we call the conversion of potential donors into actual donors 'the donor efficiency rate by proxy'.
The mortality rates for CVA and (traffic) accidents have decreased in the countries under study. At the same time, in most countries the donor efficiency rates have steadily increased. The variance in donor efficiency rates between countries has also increased from 1995 to 2005. Four countries introduced a new consent system or changed their existing system, without (visible) long-term effects.
The overall increase in donor efficiency means that the efforts to improve donor policies have paid off. However, substantial differences between countries were found. The success of donor policies in terms of the number of absolute donors is blurred by the success of policies on traffic safety and CVA treatment. It remains unclear which specific policy measures are responsible for the increase in donor efficiency rates. This increase is not related to having a presumed consent system. Furthermore, an analysis of countries that introduced a new consent system or changed their system showed no effect on donor efficiency.
... In Boston and Baltimore it was obvious that each transplant coordinator had a specific role. Roels and Wight (2001) identify role definition and the management structure of specifically trained staff in collaboration with hospital multidisciplinary teams as important in the donation process. At present transplant coordinators are responsible for every aspect of the donation process. ...
• The aim of this qualitative case study was to investigate how organ donation is promoted and managed in North America aimed specifically at patients and relatives. A 4-week study to Boston and Baltimore in America was undertaken to observe and learn how organ donation is promoted and managed within a critical care environment
• The study tour was undertaken specifically to examine the policy and procedures that enhance the procurement of organ donation in specific centres in the USA
• The study tour wanted to examine and gain a better understanding of the issues, policies and procedures used by these centres when seeking permission for organ donation
• Data were collected by a variety of methods involving observation, unstructured informal interviews, examinations of policies and procedures and a daily diary was maintained. A thematic analysis method was used to analyse the qualitative data collected. Four areas were identified as potential areas for learning
• Approaching relatives of potential donors for consent, at a time of intense emotional crisis, is a challenge that involves all nurses working in critical areas
• Nurses are identified as a key component in the process of organ donation; research highlights that approaching relatives can be problematic and stressful for nursing staff
• The British government should consider required request legislation that ensures all hospitals refer potential donors to the Regional Transplant Center
• In-house coordinators could be appointed and protocols developed for referrals of potential donors. It is also suggested that the approach for consent is decoupled and designated requesters approach relatives
... Donor Action (DA) is an international program designed to increase organ donation through education and structured feedback of health professionals, allowing hospitals to improve donation rates through improved donation practices. In localities where it has been implemented organ donation has increased substantially, stabilizing at an average increase of 53% (1,2). The program is composed of a fivestep process: 1) Consolidation of support for organ donation among senior medical personnel; 2) a two-part diagnostic review consisting of a retrospective medical record review and a survey of hospital staff attitudes towards donation. ...
Initiatives aimed at increasing organ donation can be considered health care interventions, and will compete with other health care interventions for limited resources. We have developed a model capable of calculating the cost-utility of organ donor initiatives and applied it to Donor Action, a successful international program designed to optimize donor practices.
The perspective of the payer in the Canadian health care system was chosen. A Markov model was developed to estimate the net present value incremental lifetime direct medical costs and quality adjusted life years (QALYs) as a consequence of increased kidney transplantation rates. Cost-saving and cost-effectiveness thresholds were calculated. The effects of changing the success rate and time frame of the intervention was examined as a sensitivity analysis.
Transplantation results in a gain of 1.99 QALYs and a cost savings of Can 1.0 million per million population.
The cost-effectiveness of Donor Action and other organ donor initiatives compare favorably to other health care interventions. Organ donation may be underfunded in North America.
Introduction:
The Organ Procurement Organization (OPO) was established in August 2018. The organization's workload, work efficiency, and quality control of organ donation and procurement have continuously improved, making it one of the most successful OPOs in Fujian Province. This study explores the factors that influence the success and failure of organ donation in Fujian Province, China.
Methods:
Data from 236 potential organ donors registered at an OPO in Fujian Province between January 2020 and May 2022 were retrospectively analyzed.
Results:
Among the 236 potential organ donors, 71 cases of organ donation were successful (30.08% conversion rate). Univariate analysis showed that demographic factors, such as differences in sex, age, marital status, and domicile location, were significantly associated with successful organ donation (P < 0.05). Among hospital-related factors, differences in hospital departments were significant (P < 0.05). Considering disease-related factors, spontaneous respiration was significant (P < 0.05). For factors related to organ donation, differences in coordinators were significant (P < 0.05). Multivariate analysis showed that age, domicile location, spontaneous respiration, and coordinators influenced organ donation success (P < 0.05). Multifactor analysis revealed that factors, such as age ≤ 50 years, domicile location in other provinces, no spontaneous respiration, and highly skilled coordinators, could promote successful organ donation.
Conclusions:
Programs should clarify the screening criteria for key potential organ donors, enhance the promotion and popularization of organ donation, and boost the number and professional skills of organ donation coordinators to improve the organ donation conversion rate. This article is protected by copyright. All rights reserved.
Background: Organ shortage is still a world-wide problem, resulting in long waiting lists for kidney, liver, and heart transplant candidates across many transplant centers globally. This has resulted in the move toward presumed consent to increase deceased organ donation rates. However, there remains a paucity of literature on public attitude and barriers regarding the opt-out system, with existing studies limited to Western nations. Therefore, this study aimed to understand public sentiment and different barriers toward organ donation from the perspective of Singapore, a highly diverse and multiethnic Asian society.
Methods: A cross-sectional community semi-structured interview was conducted in a public housing estate in Singapore. Pilot test was undertaken before participants were interviewed face-to-face by trained personnel. All statistical evaluations were conducted using Stata. The χ²-test compared subgroups based on patient characteristics while multivariable logistic regression identified predictors of willingness to donate/ assent. Effect estimates were quantified using odds ratio (OR).
Findings: Out of 799 individuals, 85% were agreeable to organ donation after death and 81% were willing to assent to donations of family members' organs, which declined by 16% (p < 0.001) after a clinical scenario was presented. Demographic factors including ethnicity, education, marital, and employment status affected willingness to donate and assent. Knowledge correlated significantly with willingness to donate and assent. In particular, knowledge regarding brain death irreversibility had the strongest correlation (AOR 2.15; 95% CI 1.60–2.89).
Conclusions: Organ donation rates remain low albeit presumed consent legislation, due to patient-level barriers, including but not limited to knowledge gaps, cultural values, religious backgrounds, and emotional impact at relatives' death. To effectively boost donor rates, it is crucial for policy makers to invest in public education and improve transplant provisions and family protocols.
Background/objective:
This study aims to investigate the effects of phased education on attitudes toward organ donation and willingness to donate after brain death.
Methods:
A survey was conducted using a questionnaire to examine attitudes toward organ donation of the families of patients admitted to a surgical intensive care unit (SICU) between March 1, 2014 and September 30, 2016.
Results:
Ninety-two people voluntarily participated in this survey. Before reviewing the educational material, 75.0% had a positive attitude toward organ donation, 60.9% were willing to donate their own organs, and 38.0% were willing to donate a family member's organs. After reviewing the educational material, these figures increased to 92.4%, 80.4%, and 56.5%, respectively. Before receiving an education, there was a significant difference in consistency between people's attitudes and willingness to donate their own organs, versus donating a family member's organs (79.3% vs 54.3%, p < 0.001). With phased education, these percentages increased from 79.3% to 85.9% with regard to donating one's own organs, and from 54.3% to 64.1% with regard to donating a family member's organs.
Conclusion:
Phased education was effective overall, but it had a limited effect on changing the willingness to donate a family member's organs. It increased the consistency between people's attitudes toward organ donation and willingness to donate their own, or a family member's organs.
Before 2010, donor detection rate and donor conversion rate at our tertiary level care institution were low. To assess the effectiveness of the implemented organizational changes, an analysis of organizational indicators with the use of the DOPKI (Improving the Knowledge and Practices in Organ Donation) project was conducted.
Three groups of DOPKI indicators were used: indicators of the potential for deceased organ donation, indicators on areas for improvement in the deceased donation process, and indicators of program effectiveness. We compared the 3-year period before instituting organizational measures with the 3-year period after the changes.
Significant differences in almost all DOPKI indicators were found. Most importantly, the number of actual donors has increased significantly, pointing to the effectiveness of the organizational measures that we put in place in 2010. In addition, the study highlights the value of the use of DOPKI indicators in one intensive care unit to improve the transplant program on a hospital level.
We conclude by arguing that despite the lack of a uniform national database, DOPKI indicators could still be useful for improving the quality of donor programs.
Copyright © 2015 Elsevier Inc. All rights reserved.
Organ transplantation has become the standard of care for treatment of end stage organ failure patients medically suitable for transplantation. Unfortunately, the availability of transplantable organs has not been able to meet the high demand. The organ shortage of transplantation has become worldwide and a national crisis. Despite various attempts to expand the donor pool, the difference between organ supply and organ demand continues. This article reviews methods to increase the number of potential deceased organ donor and the number of organs per donor by aggressive donor management protocol.
Since beginning with the first organ transplantation from brain-dead donor in 1979, organ transplantation has been developing continuously in Korea. However, organ shortage still is a serious problem in the field of solid organ transplantation. For this reason, it is necessary to promote deceased donor organ transplantation and achieve self sufficiency. There are two system requirements managing deceased donor organ transplantation; operational and regulatory systems. In operational system, mutual and balanced cooperation between transplantation centers, organ procurement organism (OPO), registration/allocation system and NGOs is one of most important determinants to maximize brain dead donor. Especially, transplantation center and OPO need to improve in their organ donation process through evaluating donation practices and developing critical pathway for each step. In addition, public education program focusing on the hospital staff, the family of deceased donors and students should be enhanced to increase public awareness for organ donation. In regulatory system, national transplantation authority for the transplant coordination among various structures and policy-making on the issue of organ donation is necessary. For this purpose, Korean Network for Organ Sharing (KONOS) has to be improved into professional and authoritative body and establish more expanded national database network system. Further improvement in operational and regulatory systems to activate organ donation could enable to achieve the Asian leadership in the field of transplantation as well as self sufficiency for organ transplantation.
Background:
The Swiss Monitoring of Potential Organ Donors (SwissPOD) was initiated to investigate the causes of the overall low organ donation rate in Switzerland. The objective of our study was an assessment of the donation after brain death (DBD) process in Swiss adult intensive care units (ICUs), and to provide an overview of the donation efficiency as well as of the reasons for non-donation.
Methods:
SwissPOD is a prospective cohort study of all deaths in Swiss ICUs and accident and emergency departments. This study is an analysis of SwissPOD data of all patients who deceased in an adult ICU between 1 September 2011 and 31 August 2012.
Results:
Out of 3,667 patients who died in one of the 79 adult ICUs participating in SwissPOD, 1,204 were possible, 198 potential, 133 eligible, and 94 utilised DBD donors. The consent rate was 48.0% and the conversion rate 47.5%. In 80.0% of cases, the requests for donation took place before brain death was diagnosed, resulting in a similar proportion of consents and objections as when requests were made after brain death diagnosis.
Conclusions:
Despite the low donation rate, Swiss adult ICUs are performing well in terms of the conversion rate, similar to major European countries. The refusal rate is among the highest in Europe, which clearly has a negative impact on the donation rate. Optimising the request process seems to be the most effective means of increasing the donation rate.
A szerzők a költség-haszon elemzés egy gyakorlati alkalmazását mutatják be, egy szervdonációs eljárás gazdasági elemzésén keresztül. Az ismertetett gazdasági elemzés azt számolja ki, hogy egy szervdonációs minőségbiztosítási program mekkora donorszám növekedés esetén lesz költség-hatékony, és mekkora donorszám növekmény szükséges ahhoz, hogy a program költség-megtakarító legyen. A Donor Action-nek nevezett programot a világ számos országában bevezették, és a cadaver szervdonáció folyamatát elemzi egy standard módszertan segítségével egy adott kórházi centrumban, megállapítva a potenciális donáció folyamatában jelentkező akadályokat. A szerzők összefoglalás-ként megállapítják, hogy a költség-haszon elemzések itt tárgyalt módszertanát különböző egészségügyi programok befektetési küszöbértékeinek számítására jól lehet alkalmazni.
The international project Donor Action (DA) started in Emilia-Romagna (ER) in July 1998, involving 24 main regional intensive care units (ICUs) of which 6 have neurosurgery units. Using a data-analysis computer system, we sought to measure the efficiency and quality of the donation process.
Our study analyzed all data collected by the DA system from July 1998 to December 2008. In particular, we evaluated the following markers: patients with brain damage (BD)/total ICU deaths (Index I); brain death assessments/potential donors (PD, patients in the ICU for more than 6 hours; Index II); refusals/consent requests (Index III); effective donors/total encephalic deaths (PROC 1); and brain death assessments/total encephalic deaths (PROC 2). After collection, data were analyzed by the Regional Transplant Reference Center (CRT)-ER and sent to the National Transplant Centre (CNT) using Q-pido software for comparison with other Italian regions.
During the study period, despite a significant decrease in Index I, we observed a considerable increase in Index II, and, consequently, in donation efficacy. Additionally, we reported a slight increase in Index III. Finally, both PROC 1 and PROC 2 increased through the years, suggesting an improved efficacy of the donation/transplantation system.
Based on our experience, the DA project to increase the level of attention of ICU medical staff about organ donation and to increase interactions between transplantation coordinators and CRT-ER seemed to ameliorate both procurement and transplantation activities.
The rate of organ donation reflects the level of the respective society and country development. In Croatia, attempts have been made to increase this rate. As a consequence, the number of potential donors with confirmed brain death was observed to have steadily increased during the 2004-2008 period. Data on all potential donors where the confirmation procedure for brain death was completed were retrieved and analyzed. The percentage of donors out of all persons diagnosed with brain death and all deaths recorded at the Central Intensive Care Unit and at all Hospital departments was calculated. The mean number or organs per donor was also calculated. During the 2004-2008 period, the number of donors perbrain death persons was 5/unknown, 6/10, 8/13, 11/13 and 18/20; mean age 51, 50, 39, 48 and 44; donor rate per Central Intensive Care Unit deaths 5.9%, 5.6%, 5.8%, 10.4% and 12.1%; donor rate per all hospital deaths 0.4%, 0.5%, 0.5%, 1.5% and 1.9%; and number of organs per donor 1.6, 2.4, 2.6, 3.0 and 2.7, respectively. Study results showed a steady increase in the number of donors and organs per donor at Sestre milosrdnice University Hospital during the 2004-2008 period. More intensive education should be organized at medical schools and for medical professionals to identify brain death persons and potential donors. In addition, mass media campaigns should improve public awareness and perception of the issue.
The increasing demand for organs for transplantation entails a consensual need for enhancement of organ procurement activity. As organ donors reside mainly in hospital intensive care units (ICUs), the Donor Action programme is aimed at identifying critical areas in ICUs, in order to improve the first step of organ donation. The purpose of this paper is to analyse the problem of identification of potential donors by means of a chart revision of patients who died in 14 ICUs in the Emilia-Romagna region between 1 July 1998 and 31 December 2000. All deaths and patients with severe brain insult (score on Glasgow Coma Scale (GCS) = 3/15) were assessed by the local transplant coordinators together with a professional at the Transplant Reference Centre. Brain death diagnoses and potential donor referrals were therefore assessed in the study period, which was subdivided into five semesters. Of the 3,056 deaths reported in 30 months, 1,248 were due to severe brain damage (GCS score = 3). Brain death diagnosis (BD) was performed in 509 patients (40.8%). Although we applied the same parameters over the whole length of the study, we observed a significant increase in BDs (from 87 in the first semester to 125 in the last, 30.5% to 53.0% of the patients with GCS 3 ( P=0.003, chi(2) for trend=16.072), in spite of a slight decrease in the total number of deaths and in the total number of patients with GCS score = 3 (from 649 to 587, and from 44% to 41%, respectively). Study population characteristics could have contrasted with rather than facilitated our results: age and gender did not change significantly, whilst cause of death showed a significant reduction in trauma and an increase in cerebrovascular incidents over the whole length of the study. We can conclude that the more careful assessment of patients dying in ICUs, by the Donor Action programme, significantly contributed to the improvement of BDs observed in the study period. Therefore, Donor Action seems to be an efficient quality control programme to improve identification of potential donors, the first stage of organ procurement.
Few studies on presumed consent and environmental predictors of cadaveric organ donation in Europe have been published.
To determine if a presumed consent policy and other variables can be used to predict the cadaveric organ donation rate per million population.
Secondary analysis of published data.
Europe.
The unit of analysis for this study is the individual country.
Cadaveric organ donation rate per million population.
Original and transformed data were subjected to ordinary least-squares regression. All 4 independent variables were significant predictors of cadaveric donation rate, including (1) having a presumed consent (opting-out) policy in practice, (2) number of transplant centers per million population, (3) percentage of the population enrolled in third-tier education, and (4) percentage of population that is Roman Catholic.
Findings may be useful to academics and professionals responsible for organ procurement. Additional research is necessary for practical application of findings. Generalizing these findings beyond Europe may be problematic because of external validity constraints.
To identify factors to improve the identification of brain dead patients in intensive care units (ICUs).
Prospective study conducted in 79 ICUs in 54 hospitals.
All hospitalized patients with a Glasgow Coma Scale (GCS) score less than 8.
During the study period hospital staff completed a form for each patient with a GCS less than 8. Hospital information units provided us with statistics from the discharge forms. The characteristics of the hospitals were also recorded. We included a total of 792 patients with a GCS less than 8; 120 of these patients were diagnosed as being clinically brain dead (15.1%). These patients accounted for 11.8% of the comatose patients in ICUs, 11.7% of the deaths occurring in ICUs, and 3.3% of the deaths that occurred in the hospital during the study period. Two multivariate linear regressions were performed to predict the number of clinically brain dead patients in the ICUs. The regression analyses included causes of death or causes of coma, and hospital characteristics. The presence of a coordination team and the number of transplant coordinators were positively associated with the number of brain dead patients in both models. The number of patients carried to the ICU by a mobile emergency unit was also positively associated in the model with causes of coma.
Increasing the number of hospital coordinators and collaboration with mobile emergency units should lead to the identification of more brain dead patients among comatose patients in ICUs.
To quantify the potential for organ donation in Victoria and identify missed opportunities for organ donation.
Prospective medical record audit of all deaths in 12 Victorian hospitals.
Data on deaths, total potential donors, organ donors and outcome of requests for organ donation were collected. Patients in whom brain death was confirmed or likely to occur and in whom organ donation was not requested (unrealised potential donors) were classified by an independent panel. Rates of organ donation and unrealised donors were determined as a proportion of total potential donors and hospital deaths and the maximal potential organ donor rate was estimated.
Of 5551 deaths, there were 112 potential donors, with 66 requests for organ donation resulting in 39 consents (consent rate of 59%) and 37 organ donors (33% of total potential donors; 0.7% of hospital deaths). Two consented potential donors did not donate due to failed physiological support (5%). There were 46 medically suitable unrealised potential donors; 3 with confirmed brain death. Approximately half of these patients had treatment withdrawn in the intensive care unit and half in the Emergency Department. The estimated maximal potential donor rate was 30 per million population.
The potential for organ donation in Victoria is relatively low compared with previous estimates in Australia and overseas. An increase in the organ donation rate may be possible through increasing consent and the identification and support of potential donors. This would require substantial changes in clinical practice that have resource and ethical implications.
The aim of this study was to assess knowledge, attitudes, and proficiency in relation to organ donation among staff members of intensive care units (ICUs) in donor hospitals, and possibly identify areas for improvement. The investigation was carried out as a collaboration between the transplant center and appointed key persons in all 17 ICUs in 15 hospitals in northern Denmark. A total of 1168 structured questionnaires were distributed to the health care professionals in the ICUs in the region; 689 were returned, giving a response rate of 59%. In general, there is a positive attitude among health care professionals toward organ donation. However, a considerable fraction of 11% declares to be against organ donation. Only 49% of the ICU health care professionals are willing to donate their own organs after death. By comparison, 74% of the general Danish population are willing to donate organs after death. Doctors are more positive toward organ donation than the nursing staff. Thus, 95% of the doctors are positive to organ donation compared to 81% of the nurses; 70% of the doctors will donate own organs after death compared to 45% of the nurses. Further, the survey demonstrates as expected a significant lack of experience in organ donation. Our data show a considerable need for more education and training, especially on how to inform and support the donor relatives and how to identify potential donors. The survey also discloses a substantial need for information regarding the results of transplantation.
The results of solid organ transplantation have improved during the last decade. Five-year patient survivals over 80% and graft survivals over 70% are common in many transplant centers. Also, quality-of-life assessments show that not only adults but even small children have a good quality of life after successful organ transplantation. Furthermore, transplantation programs have proved to be cost-effective. However, the organ shortage is a worldwide problem, which has in many countries led to prolonged waiting times, deaths on the waiting list, increased living related donations, acceptance of lower-quality organs, and in some instances even commercialization of the organ supply. Thus, it is extremely important to find strategies that increase the number of cadaveric organs for donation. In Finland organ transplantation is concentrated in one center with about 250 transplantations of different organs performed annually. The number of patients needing a new cadaveric organ is steadily increasing, but the number of donors has remained the same during the last decade. To improve cadaveric organ procurement the Donor Action (DA) program, which consists of a Hospital Attitude Survey and a medical records review performed by the donor hospital, has proved to increase the number of cadaveric donors. We introduced the DA program in Finland in 2000. Here in we report the results of this program in terms of its impact on the availability of cadaveric donors.
Elective ventilation describes the procedure of transferring selected patients dying from rapidly progressive intracranial haemorrhage from general medical wards to intensive care units for a brief period of ventilation before confirmation of brain stem death and harvesting of organs. This approach in Exeter has led to a rate of kidney retrieval and transplant higher than has been achieved elsewhere in the United Kingdom, with a stabilisation of numbers on patients on dialysis. Recently doubt has been cast on the legality of our practice of elective ventilation on the grounds that relatives are not permitted to consent to treatment of an incompetent person when that treatment is not in the patient's best interests. We are thus faced with the dilemma of a protocol that is ethical, practical, and operates for the greater good but which may be illegal. This article explores various objections to the protocol and calls for public, medical, and legal debate on the issues.It is four years since the Exeter protocol for elective ventilation of potential organ donors was published.1 Briefly, patients admitted to general medical wards with rapidly deepening coma from irremediable intracranial haemorrhage are considered for organ donation. After assessment by a senior doctor suitability as a donor is established with the transplant team, and the intensive care unit is approached about bed availability. The relatives are informed of the poor prognosis and near inevitability of death, and organ donation is then discussed, focusing on the wishes of the dying …
The organ procurement community has always considered public education a primary challenge. According to conventional wisdom, greater awareness generated by public education will lead to more donated organs. This notion may be based on faulty assumptions about public education and about the relationship between awareness and behavior. Public education, as the primary focus for the organ procurement community, should be abandoned. Increased efforts in professional education and basic research are more appropriate endeavors for organ procurement organizations.
The growing shortage of suitable organs, associated with an increased acceptance of elderly patients on the waiting lists for kidney transplantation, has prompted many centers to expand their donor pool with kidneys from 'marginal', e.g. older donors. This survey first deals with the physiology and concomitant anatomo-pathological findings of the normal aging kidney and the aging remnant kidney, and how these age-related processes may further negatively influence the outcome of transplanted kidneys. Subsequently, we review the sometimes conflicting data published on the short- and long-term outcome of kidneys grafted from elderly donors, and complete this survey with our own experience on the outcome of 838 cyclosporin treated adult recipients, of which 170 (20%) received a cadaveric kidney from a donor aged ≥50 years old, with 1 and 3 year graft survival rates of more than 80%.
Background. Upon the availability of a cadaveric donor kidney, a delicate allocation process precedes every transplantation. A remodeled Eurotransplant Kidney Allocation System (ETKAS)-derived from simulation studies-was installed in March 1996. The purpose was to adjust long waiting times and international exchange balances, while aiming at an optimal HLA-mismatch distribution. The new ETKAS consisted of a point-score system that was 100% patient oriented. Methods. The impact of the new ETKAS on the composition of the waiting list, and the outcome of the allocation procedures during its first year, were evaluated and compared with the results obtained in 1995. Results. The percentage of long-waiting patients and of patients with poorly matchable HLA phenotype increased significantly, from 9% to 19% and from 19% to 29%, respectively. Zero HLA-A-, HLA-B-, HLA-DR-mismatched patients still comprised 23% of the kidney transplant activity. The kidney exchange of the different Eurotransplant countries became balanced within 4 months; this persisted during the rest of the year. Pediatric patients had a high transplantation rate due to an assignment of extra points. The composition of the waiting list showed, after 1 year, fewer long-waiting patients and fewer patients with rare HLA phenotypes. Conclusions. The new ETKAS was able in its first year to meet the goals set at its introduction. In comparison with the old ETKAS, there was a better tradeoff between HLA matching and waiting time. The value of computer simulation studies has been demonstrated impressively in the context of organ allocation.
Objectives.
—To estimate the potential supply of organ donors and to measure the efficiency of organ procurement efforts in the United States.
The Pennsylvania Statewide Donor Study evaluated deaths under the age of 66 occurring in 149 participating hospitals in 1987. After elimination of 6146 patients from 11,983 based upon ICD-9 code criteria, an on-site medical record review was performed on 5603 patients. Each patient was assessed for organ donor suitability based upon brain death and medical suitability criteria--and, after a series of eliminations, 453 patients were found to have a moderate or higher potential as acceptable organ donors. An estimation of the organ donor rate was placed between 38.3 and 55.2 donors per million population per year, depending upon the stringency of organ donor criteria. Educational efforts targeted at physicians, patient's families and transplant surgeons will be necessary, however, to attain this maximal rate.
The influence of donor age on outcome was studied in the recipients of 12,131 cadaveric renal allografts, 3026 heart allografts, and 2913 liver allografts with followup information in the UNOS data base for transplants performed between 10/1/87 and 12/31/89. For recipients of kidney transplants, donors of ages 6-15 had significantly better 1-year graft survival than donors of ages 56-65, but the difference was only 7.0%. Donors of age greater than 65 actually did better than donors ages 56-65, but donors less than or equal to 5 were less satisfactory. Kidneys from older donors survived as well as kidneys from younger donors in patients with repeat transplants, diabetes, black race, age over 45, O HLA or 5 and 6 HLA matches, delayed graft function, shared kidneys and PRA greater than 50. For kidney recipients, multifactorial analysis by Cox regression showed that donor age was less important than the use of ALG, donor race, diabetes or peak PRA in ages 16-45, delayed function, repeat transplant, and HLA match. Recipients of heart transplants from donors ages 45-55 had 1-year graft survival that was 8.4% less than recipients of hearts from donors age 16-45. However, 32.7% of heart patients died during the first 12 months after listing without benefit of a transplant. Liver transplant recipients of donor ages 16-45 had 10.8% better 1-year graft survival than recipients of donors greater than 45, but a greater percentage of older donors were transplanted to high risk and older recipients. Tragically, 24.3% of patients listed for liver transplantation died within 12 months without a transplant. This analysis shows that satisfactory graft survival can be achieved using older donors and that age in itself should not be a barrier to organ donation, providing that organ function is normal and that specific disease of the organ is absent.
For the past 4 years (1986 to 1989), there has been virtually no change in the number of organ donors, despite significant efforts targeted toward increasing supply. The number of donors has plateaued at about 4,000 annually. Meanwhile, the number of people awaiting transplants continues to increase at a remarkable rate. Between December 1987 and December 1990, the number of people awaiting a kidney, heart, liver, heart-lung or pancreas transplant increased by 65%. This demand/supply disparity has led to much interest in the assessment of the organ procurement system. Such an assessment must endeavor to compare the supply of potential donors with actual donor procurements. Numerous studies have been conducted to estimate potential donor supply. Some relied upon the review of in-hospital death records, whereas others attempted to search and identify potential donors in large mortality databases. Regardless of their source, patient records are examined and databases searched to exclude those deaths where contraindications to organ donation are present. Due to the severe shortage of donors, exclusion criteria have been relaxed to include deaths of marginal potential donors. Six major studies, all conducted between 1975 and 1991, indicate that the number of potential donors per million population is between 28.5 and 104. The most realistic estimates of supply place the number of donors between 43 and 55 per million population. The range of potential donors is, therefore, somewhere between 7,088 and 25,865. The most realistic range is between 10,694 and 13,679. These estimates must be adjusted further based upon public attitudes toward donation. Between 53% and 68% of the public is willing to donate the organs of relatives under appropriate circumstances. Thus, between 5,700 and 9,300 donors may be available annually. Whereas the demand for extrarenal organ transplantation could conceivably be met, the need for kidney donors is likely to continue to exceed supply. The situation could be improved by encouraging both living-related and living-unrelated kidney donation. Also, further consideration might be given to the possible use of nonheart-beating cadaveric donors.
"Mandatory" or required request for donation of the organs of patients dying in hospitals has been promulgated as a means of increasing the rate of organ harvest and alleviating the critical shortage of transplantable organs. Although the federal and many state governments have passed legislation to make such requests compulsory, the efficacy of this approach has not been demonstrated. Examination of the experience at our trauma center and in this region, before and after the enactment of a "strong" required request law by the State of New Jersey, did not reveal a statistically significant change in organ procurement. We conclude that such laws are unlikely to achieve the desired result in the absence of fundamental changes in the attitudes of the public and treating physicians.
To estimate the potential for solid organ donation; to identify modifiable reasons for nondonation.
Retrospective medical records review.
Sixty-nine acute care hospitals in four geographic areas of the United States in 1990, and a stratified random sample of 89 hospitals in three of the same areas and 33 of the same hospitals in 1993. Patients: PATIENTS < or = 70 yrs of age who were brain dead and medically suitable for donation.
None.
Standard forms were used to record patient demographic and hospital information. Reasons for nondonation were coded as "not identified," "family not asked," "consent denied," or "other." The main outcome measures were rate of donation and rates of nonidentification, not asking, and nonconsent. Organ donation occurred among 33% (299/916) of medically suitable cases identified in 1990 (95% confidence interval 30% to 36%). Ninety-four potential donors were not identified, 156 were not asked, 326 families denied consent, and 41 potential donors were categorized as "other," including patients who had suffered a cardiac arrest, and medical examiner prohibition of donation. In the 1993 study, organ donation occurred in an estimated 33% of suitable cases. In 1990, rates of donation were highest among patients <50 yrs of age, patients who died of traumatic causes, and non-Hispanic white patients. Logistic regression showed lower odds of donation for African American patients (odds ratio 0.38, 95% confidence interval 0.23 to 0.63) independent of potentially confounding hospital and patient variables (p=.0001). Donation rates did not vary by hospital size or type.
Despite legal and policy initiatives, only one third of potential donors became donors in 1990, with similar results in 1993. Extrapolating the 1990 findings to the United States suggests a pool of 13,700 medically suitable donors per year. Prospective identification and requesting donation in all suitable potential donor cases could lead to 1,800 additional donors per year.
Although transplantation centers directly benefit from organ and tissue donation, they continue to yield low organ and tissue referral and donation rates. Our medical center and organ procurement organization developed a model to increase referral and donation rates. This model, called the Transplant Center Development Model, facilitates the donation process, specializes staff education, and promotes administrative involvement. After it was was implemented at our medical center in 1991, the referral and donation rates from 1988 to 1990 were compared with those from 1991 to 1993. The results showed that after implementation of the model, the organ referral mean increased 47%; the organ donation mean, 50%; and the tissue donation mean, 117%. These findings suggest that this model may be a valuable tool in transplant center development.
Organ procurement efforts are central to the transplant sector of the health care system, yet procurement effectiveness is not routinely assessed. MRRs provide a solid foundation for identifying gaps in organ procurement performance, implementing and tracking the success of QI initiatives, and monitoring ongoing performance.
Attempts have recently been made to expand the number of cadaveric kidneys available for transplantation by using kidneys from donors without heartbeats in addition to those from brain-dead donors with beating hearts. We studied the efficacy of transplanting kidneys from donors without heartbeats on the basis of aggregate results from the Kidney Transplant Registry of the United Network for Organ Sharing.
We compared the early function and survival rates of 229 kidney grafts from donors without heartbeats with those of 8718 grafts from cadaveric donors with heartbeats. All transplantations were performed at 64 U.S. transplantation centers. Cox proportional-hazards analysis was used to evaluate 10 major risk factors for graft failure.
The survival rate at one year was 83 percent for kidney grafts from donors without heartbeats, as compared with 86 percent for grafts from donors with heartbeats (P=0.26). Among the kidneys from donors without heartbeats, the survival rate at one year was 89 percent for grafts from donors who had died of trauma, as compared with 78 percent for grafts from donors who had died of other causes (P=0.04). The survival rates were high for grafts from donors without heartbeats despite the poorer early function of these grafts; 48 percent of the recipients required dialysis within the first week after transplantation, as compared with 22 percent of the recipients of grafts from donors with heartbeats. The primary-failure rate for kidneys from donors without heartbeats was 4 percent, as compared with 1 percent for kidneys from donors with heartbeats.
Transplantation of kidneys from donors whose hearts have stopped beating, especially those who have died of trauma, is often successful, and the use of kidneys from such donors could increase the overall supply of cadaveric kidney transplants.
