Increasing organ donation by increasing consent to donate

When seeking consent for organ donations, in-person requests made to substitute decision-makers, with physician involvement, are more likely to result in a positive response, according to a study of organ donation in Ontario, Canada, published in CMAJ (Canadian Medical Association Journal).

“Optimization of the approach of potential organ donors to support consent decisions is critical to ensure patient wishes are respected and to remove any barriers to organ donation,” writes Dr. Jeffrey Singh, a critical care physician at the University of Toronto and the Trillium Gift of Life Network, Toronto, Ontario, with coauthors.

Organ donation rates are still low in Canada, ranging from 8.8 to 21.2 donors per million population, with almost 4500 people on organ transplant waiting lists. Many people die while on transplant waiting lists, as the demand for donated organs is greater than the supply.

In many parts of the country, substitute decision-makers are asked to give consent for organ donation, even if the potential donor has registered consent to donate.

“Substitute decision-makers faced with consent decisions often do so in emotionally charged circumstances, and many do not know the explicit wishes of the patient,” write the authors. “Given this context, the process of obtaining consent and the supports provided may have a substantial impact on the decision.”

Researchers looked at factors associated with positive consent for organ donation in Ontario with an aim to identify those that could be modified to increase rates of consent. The study included 34 837 people aged 18 years and older referred for organ donation between 2013 and 2019. The average number of referrals received by Trillium Gift of Life Network, Ontario’s sole organ donation network, doubled from 300 per month in 2013 to 600 per month in 2019, and the number of consents increased from 36 to 64 per month in the same time frame.

Demographic characteristics, such as older age of the patient and a request by telephone rather than in person, were associated with declined donations. In addition, religion and faith had an effect, as substitute decision-makers who identified with Aboriginal spirituality or Buddhist, Christian Orthodox, Hindu, Jewish or Muslim faiths were much less likely to consent than people who said they were atheist, agnostic, Christian or had no religion. Patients from small centres were more likely to consent than those in large urban centres, and people living in high-income neighbourhoods were less likely to consent than people in middle-income neighbourhoods.

The authors found that timely referrals to donation, in-person requests and those involving physicians along with a trained donation coordinator increased the likelihood of a positive response.

“Specific interventions to ensure timely referrals to organ donation organizations, toincrease in-person approaches to substitute decision-makers for consent and to encourage physician participation in the approach process may increase rates of organ donation consent,” the authors conclude.

In related commentary, Dr. Sam Shemie, Montreal Children’s Hospital, McGill University Research Institute and Deceased Organ Donation, Canadian Blood Services, writes, “Once a donation system has optimized foundational practices, the final challenge to improving organ donation and transplant rates is boosting consent.”

Substitute decision-making represents a particular challenge that needs to be addressed.

“Family override of a registered decedent’s wishes remains a challenge, and this highlights a disconnect between legislation and practice. Under Canadian law, families have no legal authority to withhold consent if the deceased person provided valid consent, yet family override of legally valid registered consent may be important and modifiable.”

The author suggests that Nova Scotia’s recent legislation, which moves the province to presumed consent unless a patient opts out, will be an interesting social experiment for organ donation in Canada.

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