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The impact of health professionals' attitudes about being registered donors on the availability of organs

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VOL: 98, ISSUE: 45, PAGE NO: 36

Matthew Davies, BSc, medical student, Guy's, King's and St Thomas' Medical School

Alison Corney, BSc;Susan Conlon;Richard Freeman;Stephan Claridge;Rebecca Crawford are medical students, Guy's, King's and St Thomas' Medical School;Abdu Mohiddin, MSc, MBChB, MFPHM, is honorary lecturer/specialist registrar in public health, Department of Public Health Science, Guy's, King's and St Thomas' School of Medicine, King's College London

Organ transplantation has emerged from being an experimental procedure undertaken by patients brave enough to seek a cure for their illnesses to a discipline to which patients with end-stage organ failure are now routinely referred.

Organ transplantation has emerged from being an experimental procedure undertaken by patients brave enough to seek a cure for their illnesses to a discipline to which patients with end-stage organ failure are now routinely referred.

Despite implementing many strategies to increase the number of organ donors, such as the introduction of the donor card in 1971 and the establishment of the national organ donor register in 1994, demand for organs continues to outstrip supply.

This year, in the UK, there were 460 cadaveric organ donors by the end of August but there are still 5,692 patients on the waiting list (UK Transplant, 2002).

Although there are many reasons for this mismatch between patients needing a transplant and the availability of donors, the failure of health professionals to identify potential donors or to gain consent from bereaved relatives is considered to be significant. Such failures may be due, at least in some part, to the attitudes of health professionals towards becoming organ donors themselves.

There are a number of reasons for the shortage of organs. Fig 1 shows the rising number of people waiting for transplants set against the decline in numbers of organ donors.

This decline is due largely to successes in other public health policy areas, such as the 37 per cent decrease in the number of deaths from road traffic accidents in people aged 16-60 years old between 1990 and 2000 (Department of the Environment, Transport and the Regions, 2001).

Although many factors may account for the shortage of available organs, the failure of health professionals to identify possible donors is generally considered one of the most significant (Boey, 2002). The shortage of organs may also be the result of the failure of health professionals to gain consent from bereaved relatives to donate the deceased's organs.

It seems reasonable that if health professionals have yet to come to terms with their own feelings about organ donation, they are unlikely be effective in actively educating the general public or obtaining approval for organ donation from grieving families.

A comprehensive study with a large sample of nurses confirmed that nurses' attitudes and commitment to organ donation were related to the number of requests made for tissue and organ donation and the number of consents obtained (Matten et al, 1991).

Kent and Owens (1995) measured the attitudes and commitment to organ donation of nurses in the UK. They adapted a questionnaire originally devised by Parisi and Katz (1986) to measure the attitudes and commitment to organ donation of a sample of 112 nurses from three hospitals. Fifty-seven per cent of the nurses were willing to donate their own organs, and had signed donor cards.

However, the authors concluded that nurses' attitudes to donation were mixed. They noted that some nurses have doubts about donating organs and that these doubts may be contributing to the imbalance in the supply and demand of organs.

The authors suggested that further work needed to be done in relation to the attitudes of qualified health care professionals towards organ donation. Additional work is also needed to explore the attitudes of trainee health care professionals towards organ donation.

Cantwell and Clifford (2000) compared the attitudes of medical and nursing students in the UK and found that all but one of the respondents to the survey had a generally positive attitude towards organ donation.

There was a significant relationship between the extent of this positive attitude held by each student and their personal willingness to donate organs. Among the student nurses, 74 per cent had already signed a donor card, compared with only 43 per cent of the medical students. The difference in the two groups' personal commitment was found to be statistically significant.

Previous studies have shortcomings as they concentrate solely on one measure of a person's commitment to organ donation - the carrying of a donor card. However, there are other ways in which people can show their commitment to being an organ donor such as being on the NHS Organ Donor Register and telling their next of kin of their wishes.

Ultimately it is the next of kin who legally has the final say in whether or not a relative's organs are donated. Therefore it can be argued that the next of kin is the most important factor and will have the most profound effect on the availability of donor organs.

This study attempts to address the level of commitment that nurses, other health care professionals and their student equivalents have to becoming organ donors themselves.

Method
Sample and setting

We sampled 290 staff and students within London teaching hospitals. The staff consisted of doctors and nurses directly involved in the transplant process (they were part of the transplant team) and third-year medical and diploma nursing students.

These four groups were chosen for the study as it was felt that doctors and nurses who were involved in the transplant process had greater personal experience of the organ donation process compared with medical and nursing students.

Questionnaire

We used a 12-item interview-based questionnaire, which had three distinct components. The first section addressed demographics and the second looked at any positive steps taken by the sample group towards donating their organs. Positive steps taken by members of the sample group were identified as:

- Having a donor card;

- Being on the NHS Organ Donor Register;

- Having discussed their wishes regarding organ donation with their next of kin.

The final section of the questionnaire asked whether personal experience of organ transplantation had influenced or would influence the attitude of the sample group towards organ donation.

Statistical analysis

All data were entered into a Microsoft Excel spreadsheet and analysed using STATA and the t-test where appropriate to determine whether there were any statistically significant differences between the variables.

Results
The response rate from the 290 people questioned was 100 per cent. The median age of the sample was 27.5 years with a range of 18-50 years.

In keeping with the national profile of nursing being predominately female there was a sample bias because 66 per cent of respondents were female (Table 1).

The results (shown in detail in Tables 2-6) were as follows:

- 97 per cent of the sample agreed with organ donation, although only 58 per cent had taken at least one positive step to ensure that their organs could be used upon their death;

- 64 per cent of the professional cohort (qualified doctors and nurses) compared with 53 per cent of the student cohort (nursing and medical students) had taken at least one positive step to ensure their organs would be donated upon their death;

- 60 per cent of the medical cohort (doctors and medical students) compared with 58 per cent of the nursing cohort (nurses and nursing students) had taken at least one positive step to ensure their organs would be donated upon their death;

- It was found that only 40.7 per cent of the sample who agreed with organ donation carried donor cards. Interestingly, of these, 66 per cent claimed the reason they did not carry donor cards was lack of access (see Table 4);

- 22 per cent of those who carried a donor card or who put themselves on the donor register, or those who carried a card and were also on the donor register, had not told their next of kin.

Discussion
It is interesting that of the 97 per cent of the sample who agreed in principle with organ donation, only 47 per cent had taken any positive steps to identify themselves as potential organ donors. This discrepancy between positive attitude and low commitment to donate is consistent with previous studies (Prottas and Batten, 1988).

Given that the sample population is highly educated and already works in or is training for a job in the health care industry, it can only be assumed that if the general public been included in the sample population, the figures would have shown an even larger disparity between people's intentions to donate organs and the actions they had taken to achieve this.

Previous public opinion surveys in the UK have reported that around 70 per cent of the population would be willing to donate organs after their death, but only 20 per cent make their views known by carrying a donor card or being listed on the organ donor register (New et al, 1994).

There was an expectation at the start of this research that it would reveal that members of the transplant teams would show a greater commitment to donating their own organs than their student equivalents, as a result of their perceived level of knowledge regarding organ procurement.

However, our results show that there is no statistically significant difference between those who worked in the transplant team and the third-year medical and diploma nursing students.

One reason for this disparity may be that medical and nursing students are more aware of the benefits of organ donation than was originally thought.

Alternatively, experience of the transplant process may not have a positive influence on a person's commitment towards organ donation.

Although members of transplant teams see the positive aspects of donation, they are also more aware of the negative aspects, such as witnessing organ rejection and bodily mutilation.

Our results also showed no significant difference between the level of commitment to organ donation between the medical cohort and the nursing cohort. It may be the case that in the current climate of multidisciplinary teamwork between doctors and nurses, that the two groups have many of the same experiences in working within the transplant domain and consequently, share similar attitudes.

Cantwell and Clifford (2000) found that nursing students were more committed to donating organs, with more signing donor cards than the medical students. However, our results contradict this study, with 32 per cent of both the nursing students and medical students carrying donor cards. Our findings also showed that of the 168 health professionals who agree with donation but do not carry a donor card, 66 per cent claimed that it was due to lack of access to cards. This is worrying coming from health care professionals.

Of the people who had taken a positive step by carrying a donor card or being on the NHS Organ Donor Register, 22 per cent of these had not informed their next of kin of their wishes.

This may demonstrate a lack of knowledge regarding the legalities of organ donation, or perhaps a lack of desire to discuss the subject with friends and family.

In a similar study into the attitudes of health staff involved in organ donation Gross (2000) found that 25 per cent of respondents did not know whether their next of kin were familiar with their wishes.

Limitations
The sample was not randomly chosen. For example, only those students attending lectures were asked to complete the questionnaire.

There was no account of ethnicity made in the design of the questionnaire. It has been shown that disparities exist between different ethnic groups and their attitude to and support of organ donation. A total of 95 per cent of the organ donor pool is Caucasian while 20 per cent of patients on waiting lists are from ethnic minorities (Dyer, 1997). Consequently, a question about the ethnicity of respondents should have featured on our questionnaire.

Recommendations
There is enormous scope to increase the number of potential organ donors in the population of qualified doctors and nurses as well as their student equivalents.

People who agree with organ donation need to be identified and advised on how to give informed consent to ensure their organs can be used after death. As 66 per cent of our sample of nurses, other health care professionals and students claimed lack of access to be the reason for not carrying a card, it should be made much easier to obtain one.

Boots the Chemist has adopted an interesting scheme, where shoppers can have the donor card stamp placed on their Advantage Card and their details entered onto the donor register.

Alternatively, greater focus could be placed on educating people about other ways of identifying themselves as potential donors - such as being on the NHS Organ Donor Register and informing next of kin - and the legal standing of each of these options.

As carrying cards and being on the donor register have no legal standing in organ donation, more policies should be introduced to inform the next of kin when a person decides to use these ways of identifying themselves as a potential donor.

People applying for a donor card via UK Transplant's website (uktransplant.org.uk) have the option of sending an e-mail to their next of kin to inform them of their decision, while in the USA, donor cards must also be signed by the next of kin to gain legal validity (Fig 3).

It has been suggested that the UK government should change the rules governing organ donation from an 'opt-in' to an 'opt-out' system. In such a system, individuals would be presumed to have consented to their organs being used for transplant unless they had registered their wish not to be considered.

The British Medical Association believes that moving to a system of presumed consent, combined with other reforms to the transplant infrastructure, would play an important part in improving the supply of organs. This would raise issues regarding informed consent and the ability of some people to make an informed decision for example, people who have dementia.

This study suggests that when more health care professionals become potential organ donors themselves and serve as good role models for patients and their relatives, a higher success rate of organ procurement should be achieved.

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