Barriers and Enablers to Organ Donation After Circulatory Determination of Death: A Qualitative Study Exploring the Beliefs of Frontline Intensive Care Unit Professionals and Organ Donor Coordinators

Abstract

BackgroundA shortage of transplantable organs is a global problem. The purpose of this study was to explore frontline intensive care unit professionals' and organ donor coordinators' perceptions and beliefs around the process of, and the barriers and enablers to, donation after circulatory determination death (DCDD).MethodsThis qualitative descriptive study used a semistructured interview guide informed by the Theoretical Domains Framework to interview 55 key informants (physicians, nurses, and organ donation coordinators) in intensive care units (hospitals) and organ donation organizations across Canada.ResultsInterviews were analyzed using a 6-step systematic approach: coding, generation of specific beliefs, identification of themes, aggregation of themes into categories, assignment of barrier or enabler and analysis for shared and unique discipline barriers and enablers. Seven broad categories encompassing 29 themes of barriers (n = 21) and enablers (n = 4) to DCDD use were identified; n = 4 (14%) themes were conflicting, acting as barriers and enablers. Most themes (n = 26) were shared across the 3 key informant groups while n = 3 themes were unique to physicians. The top 3 shared barriers were: (1) DCDD education is needed for healthcare professionals, (2) a standardized and systematic screening process to identify potential DCDD donors is needed, and (3) practice variation across regions with respect to communication about DCDD with families. A limited number of differences were found by region.ConclusionsMultiple barriers and enablers to DCDD use were identified. These beliefs identify potential individual, team, organization, and system targets for behavior change interventions to increase DCDD rates which, in turn, should lead to more transplantation, reducing patient morbidity and mortality at a population level.

Potential organ donor identification and system accountability: expert guidance from a Canadian consensus conference

“…The conference Steering Committee met over nine months to prepare the agenda, consensus building process, and develop key documents including terms of reference, environmental scan with ODOs, 5 , 6 systematic literature review of criteria to define and identify potential deceased organ donors, 6 national assessment of the barriers and enablers to increasing DCD in Canada, 5 , 6 and a terminology guide provided to conference participants. The conference’s 47 participants (Appendix) included pan-Canadian representation from critical care, neurocritical care, emergency medicine, donation, transplantation, research, healthcare administration, health professional education, knowledge translation, ethics, law, patient safety and quality organizations, and family partners.…”

“…Multiple overlapping criteria are used to define and identify potential donors in Canada and worldwide. 5 , 6 The most common elements include mechanical ventilation, low Glascow Coma Scale, EOL discussions, devastating brain injury, and brain/brainstem death. The acronym GIVE (Glascow Coma Score less than five, Intubated, Ventilated, EOL care) 16 has been used as a memory aid for key clinical triggers.…”

“…Identifying and referring a potential donor is challenged by several issues, including inconsistent definition of a potential donor, variability in required referral legislation (Table) that is often not respected and difficult to enforce, and the natural discomfort surrounding the juncture of EOL care and donation. Multiple overlapping criteria are used to define and identify potential donors in Canada and worldwide 5,6. The most common elements include mechanical ventilation, low Glascow Coma Scale, EOL discussions, devastating brain injury, and brain/brainstem death.…”

“…The Canadian National Transplant Research Program (CNTRP) identified challenges with defining, identifying, and referring potential donors in their study exploring barriers to donation after circulatory death (DCD). 5 , 6 Although virtually all HCPs surveyed by Canadian Blood Services in 2011 believed it was important that patients and families be offered the opportunity to donate organs and/or tissues, only 35% reported that this opportunity was routinely offered at their hospital. 7 There are also inconsistencies across the country, as the likelihood of becoming a donor is dependent on the city, hospital, and even department within which a patient dies.…”

“…Given that donation opportunities occur in low numbers, deceased organ donation may not be a high-priority concern for many hospitals and healthcare professionals (HCPs). The Canadian National Transplant Research Program (CNTRP) identified challenges with defining, identifying, and referring potential donors in their study exploring barriers to donation after circulatory death (DCD) 5,6. Although virtually all HCPs surveyed by Canadian Blood Services in 2011 believed it was important that patients and families be offered the opportunity to donate organs and/or tissues, only 35% reported that this opportunity was routinely offered at their hospital 7.…”