Timing of Request Key to Families' Consent for Organ Donations

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Timing of Request Key to Families' Consent for Organ Donations

By John Gever, Senior Editor, MedPage Today
Published: April 22, 2009
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

WHEELING, W.Va., April 22 -- How and even where family members of potential organ donors are asked for consent can affect their ultimate decisions, researchers found.
Action Points 

    * Explain to interested patients that organ transplantation requires consent either from the donor, if living, or from surviving family members if the donor is deceased or otherwise unable to provide consent.


    * Explain that the availability of organs for transplant is therefore highly dependent on family members' willingness to provide consent.


    * Explain that this study was a review of earlier analyses that varied substantially in their methods and collected data. It is therefore subject to all the limitations in these underlying analyses.

A review of 20 earlier studies identified seven modifiable factors that influence whether relatives allow or deny organ donations, wrote J. Duncan Young, B.M., D.M., of John Radcliffe Hospital in Oxford, England, and colleagues in a paper published online in BMJ.

"The two factors that had the largest effect on consent rates were the person making the request and the timing of this conversation," Dr. Young and colleagues said.

Consent rates were highest when an organ procurement coordinator was involved in making the request -- not just the potential donor's treating physician or other personnel involved in the donor's care, they said.

In an accompanying commentary, Teresa J. Shafer, chief operating office of LifeGift Organ Donation Center in Fort Worth, Texas, pointed out that consent requests go beyond "simply 'popping the question.' "

The other key considerations:

    * Information discussed during the request
    * Perceived quality of care of the donor
    * Relatives' understanding of brain stem death
    * Setting in which the request is made
    * Sufficient time to make the request and for families to consider it

Dr. Young and colleagues said the reasons behind the granting or refusal of consent were important because donations are refused in a large number of cases -- 41% in a recent British study.

However, no large prospective studies have been reported. Consequently, Dr. Young and colleagues reviewed 20 observational studies and post hoc audits that examined factors underlying the consent decision.

The 20 studies involved a total of nearly 8,000 potential donations. Methods varied widely -- many involved structured telephone interviews with donors' family members, but some were based on chart reviews or surveys of hospital staff. Topics emphasized in the interviews also varied.

The studies used in this systematic review were mainly from the U.S. There were no randomized trials.

As a result, Dr. Young and colleagues did not pool data from the included studies.

Some of the areas where there appeared to be consensus or a preponderance of evidence included:

    * Relatives who believed they were given enough information to make an informed decision were more likely to consent
    * Making the consent request at the same time as the notification of death or tests for brainstem death reduced the likelihood of consent
    * A perception that the donors received good care increased the likelihood of consent
    * Family members with good understanding of the concept of brainstem death were more likely to give consent
    * Requesting consent in a private room, rather than a crowded hallway or waiting room, decreased refusal rates
    * A combined approach to donation requests that includes an organ procurement coordinator along with hospital staff led to the highest consent rates
    * Staff training in donation requests may raise consent rates

All these factors are modifiable, Dr. Young and colleagues noted.

In her commentary Shafer said requests are a dynamic process that start with observation, but may succeed or fail based on careful collaboration and planning.

"Organ procurement organization requesters should approach the family a second time if they are initially disinterested or decide not to donate," she recommended.

Second approaches often succeed, she added, regardless of who made the initial request "because families often alter their original position and consent to donate."

Shafer said early referrals of potential donors to organ procurement organizations are essential because it allows time to make unhurried consent requests.

"Notifying the [organization] shortly before or at the time the patient is being considered for brain death testing is too late," she said.

A plan to withdraw ventilator support or a Glasgow Coma Score of 4 or 5 are more useful clinical triggers for a potential donation referral, Shafer said.

Such early notification allows time for organ procurement and hospital staff to develop a plan for requesting donation consent, she said.

No external funding for the study was reported.

Dr. Young reported that he is chief investigator of an ongoing randomized study of "collaborative requesting" in seeking organ donations. No other potential conflicts of interest were reported by study authors or the editorialist.

Primary source: BMJ
Source reference:
Simpkin A, et al "Modifiable factors influencing relatives' decision to offer organ donation: systematic review" BMJ 2009; DOI: 10.1136/bmj.b991.

http://www.medpagetoday.com/Surgery/Transplantation/13851