Objective To identify modifiable factors that influence relatives' decision to allow organ donation. Design Systematic review. Data sources Medline, Embase, and CINAHL, without language restriction, searched to April 2008. Review methods Three authors independently assessed the eligibility of the identified studies. We excluded studies that examined only factors affecting consent that could not be altered, such as donor ethnicity. We extracted quantitative results to an electronic database. For data synthesis, we summarised the results of studies comparing similar themes. Results We included 20 observational studies and audits. There were no randomised controlled trials. The main factors associated with reduced rates of refusal were the provision of adequate information on the process of organ donation and its benefits; high quality of care of potential organ donors; ensuring relatives had a clear understanding of brain stem death; separating the request for organ donation from notification that the patient had died; making the request in a private setting; and using trained and experienced individuals to make the request. Conclusions Limited evidence suggests that there are modifiable factors in the process of requests for organ donation, in particular the skills of the individual making the request and the timing of this conversation, that might have a significant impact on rates of consent. Targeting these factors might have a greater and more immediate effect on the number of organs for donation than legislative or other long term strategies.

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Organisation of critical care services affects patient outcomes, as does the quality of care preceding intensive care unit (ICU) admission. Opportunities for improvement in both these spheres were identified in a district hospital high dependency unit (HDU). Changes were made to the medical and nursing leadership and staffing in HDU including enhanced ICU clinician and nursing responsibility for patient care, admission and discharge, development of a common critical care nursing pool, dedicated daytime supervised trainee medical staff and the option for ward staff to refer patients for an HDU evaluation. Data evaluating the number of patients admitted to ICU, requiring invasive ventilatory support and requiring renal replacement therapy were collected in real time on the existing Scottish Intensive Care Society database and retrospectively analysed using statistical process control (SPC) chart methodology. Organisational changes in HDU care were associated with SPC evidence of statistically significant reductions in patients receiving invasive ventilation, number of patient ventilation days, level 3 care days and renal replacement therapy days. Changing the organisation of HDU care in our setting was associated with marked changes in the pattern of intensive care use. It reduced the number of people receiving invasive ventilation and reduced number of ventilation, level 3 and renal replacement therapy days.

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