A scoping review of the perceptions of death in the context of organ donation and transplantation

Abstract

Background Socio-cultural perceptions surrounding death have profoundly changed since the 1950s with development of modern intensive care and progress in solid organ transplantation. Despite broad support for organ transplantation, many fundamental concepts and practices including brain death, organ donation after circulatory death, and some antemortem interventions to prepare for transplantation continue to be challenged. Attitudes toward the ethical issues surrounding death and organ donation may influence support for and participation in organ donation but differences between and among diverse populations have not been studied. Objectives In order to clarify attitudes toward brain death, organ donation after circulatory death and antemortem interventions in the context of organ donation, we conducted a scoping review of international English-language quantitative surveys in various populations. Study appraisal A search of literature up to October 2020 was performed, using multiple databases. After screening, 45 studies were found to meet pre-specified inclusion criteria. Results 32 studies examined attitudes to brain death, predominantly in healthcare professionals. In most, around 75% of respondents accepted brain death as equivalent to death of the person. Less common perspectives included equating death with irreversible coma and willingness to undertake organ donation even if it caused death. 14 studies examined attitudes to organ donation following circulatory death. Around half of respondents in most studies accepted that death could be confidently diagnosed after only 5 min of cardiorespiratory arrest. The predominant reason was lack of confidence in doctors or diagnostic procedures. Only 6 studies examined attitudes towards antemortem interventions in prospective organ donors. Most respondents supported minimally invasive procedures and only where specific consent was obtained. Conclusions Our review suggests a considerable proportion of people, including healthcare professionals, have doubts about the medical and ethical validity of modern determinations of death. The prognosis of brain injury was a more common concern in the context of organ donation decision-making than certainty of death.

Decision-making About Premortem Interventions for Donation: Navigating Legal and Ethical Complexities

“…Although there may be a concern that discussion of such minor interventions may unnecessarily burden families, information that would be routinely provided in the context of therapeutic patient care should also be provided when instituted for the purpose of facilitating donation. The greater the risk of harm to donors, the greater the likely concern regarding the use of a PMI, 23 and hence expectations that decision-making about use of PMIs will involve explicit and informed consent by legally authorized decision-makers. In practice, ethical guidance regarding such decision-making is often limited or unclear 5,21,24,25 and may be poorly aligned with relevant legal frameworks for decision-making as we discuss later.…”

“…34 This has been interpreted by the State Health department and professional bodies as preventing a substitute decision-maker from consenting to PMIs because of the nontherapeutic nature of the intervention. 23,35 Legislative definitions in the Australian Capital Territory and South Australia may present similar issues. 36,37 A consequence in New South Wales and possibly other jurisdictions with similar legislation is that no one can consent to PMIs on behalf of a person who lacks capacity.…”

“…34 This has been interpreted by the State Health department and professional bodies as preventing a substitute decision-maker from consenting to PMIs because of the nontherapeutic nature of the intervention. 23,35 Legislative definitions in the Australian Capital Territory and South Australia may present similar issues. 36,37…”

A machine-learning approach to estimating public intentions to become a living kidney donor in England: Evidence from repeated cross-sectional survey data

“…While research continues at pace to expand the numbers of deceased organs available for transplant including organ preservation ( 28 ), public attitudes ( 29 ), family behaviors ( 30 , 31 ), professional training ( 32 ), law and policy changes ( 21 , 33 ) and awareness and understanding in and between minority and faith perspectives, ( 21 , 26 , 31 , 34 , 35 ); investigations into (changing) attitudes and motivations to become a living donor have been much more limited. In 2018, NHSBT also published a warning after living donation hit an 8-year low ( 36 ).…”

The ethics of donation after circulatory death organ recovery: an overview of new considerations arising from procurement practice and policy changes

“…After brain death criteria for donors were established in 1968 [2], DCD donation was largely abandoned until the growing need for organs lead to a resurgence of the practice beginning in the early 2000 s [3]. Since then, there has been extensive ethical debate about the definition of cardiopulmonary death, the acceptable management of the donor after withdrawal of life-sustaining treatment, potential conflicts of interest between the declaring physician and the procurement team, and the significance of healthcare professional and public attitudes towards DCD donation [4,5 ▪▪ ,6].…”