Alone in the USA over an estimated 120.000 people are waiting for a donor organ with 21 patients dying per day due to the deficit [
Despite the flagrant need for donor organs, resistance remains among the general public and even among health professionals to ODT. This should not come as a surprise. ODT constitutes a complex ethical and value laden field of interdisciplinary interventions. It is a surgical and medical field that requires the highest scientific standards, but likewise one, where ethics, values, and personal beliefs play an immense role. Not surprisingly, then, extensive research has been done on attitudes to ODT in the general public, in medical students, and in health professionals (HPs) [
Studying the attitudes of HPs has been found to be of particular relevance. Publications addressing psychosocial and ethical issues have shown that despite the obvious need for organ donation, the most important factor hindering ODT is, despite the will of the deceased, the attitude of intensive care unit members to organ donation [
On the basis of existing research literature and an expert focus group study (see the following), it became clear that the barriers and facilitators in ODT medicine are multiple and intricate as they relate to ODT knowledge, ethics, stressors, individual beliefs, and religiosity. Hence, the purpose of this study was to investigate to what extent HPs (physicians and nurses) experience such facilitators and barriers in ODT and to what extent they are intercorrelated. We thus intended to combine single causes to circumscribed factors of respective barriers and facilitators to analyze them for differences regarding profession, gender, spiritual/religious self-categorization, and self-estimated knowledge of ODT and to gauge their interaction.
We developed a survey in close collaboration with leading staff of the Bavarian branch of the German Organ Transplantation Foundation (DSO) to map personal values and beliefs with attitudes toward ODT. After an extensive literature review, we conducted a multiprofessional focus group discussion with 15 experts in the field of ODT (Mayr et al., in preparation) to identify various facilitators and barriers in ODT. The focus group discussion was recorded and transcribed verbatim and analyzed using Thematic Content Analysis [
This review and qualitative development process led to the identification of five relevant themes for the experience of barriers and facilitators in ODT: (1) knowledge of ODT, (2) ethical appraisal of ODT, (3) ethical arguments favoring ODT in dialogue with relatives, (4) stressors, and (5) belief barriers.
The above-stated categories were the primary source for the items used in the current survey. The postulated questions were carefully discussed in the preliminary expert rounds and then tested among medical students and professionals. The optimized version was tested among further healthcare professionals by using the think-aloud protocols [
Items were scored on a 4-point scale ranging from strong agreement
During the next step of the validation process, we exploratively tested the factorial structure of the rather heterogeneous item topics and finally the internal reliability (Cronbach’s coefficient
Data were entered by scanning the completed paper surveys in the scanning software
The study obtained ethics approval (#383-12/2014) was gotten from the Ethics Committee of Ludwig Maximilian University of Munich.
A total of 293 paper questionnaires were distributed in around ten wards at University Hospital in Munich to both physicians and nurses working in various ways and to different degrees with ODT in medical and surgical departments. The survey was introduced to the team members of every participating ward by members of the research team. The response rate was 64% (
Characterization of enrolled persons (
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33.9 ± 11.1 |
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Women | 71 |
Men | 29 |
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With partner | 55 |
Single | 42 |
Divorced/widowed | 3 |
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Catholic | 45 |
Protestant | 21 |
Other | 4 |
None | 30 |
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R+S+ | 28 |
R+S− | 12 |
R−S+ | 7 |
R−S− | 53 |
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Physicians | 27 |
Nurses | 73 |
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Full time | 86 |
Part time | 14 |
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With TX unit | 92.5 |
Without Tx unit/other | 7.5 |
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Donors | 26 |
Donees | 46 |
Both | 20 |
Neither nor | 8 |
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Physical | 4.0 ± 2.8 |
Mental | 3.8 ± 2.7 |
In total, 45% were Catholics, 21% Protestants, 4% had other affiliations, and 30% were not affiliated. With respect to their religious and/or spiritual self-categorization, 28% regard themselves as both religious
Within the sample, 41% believed in life after death and 34% did not, whereas 25% were undecided. In trend, more women (47%) than men (27%) were convinced (
Within the sample, 92% stated to be adequately informed about the legal regulatory aspects of ODT and 96% about brain death signs. The few who did not consider themselves satisfactorily informed about the regulatory aspects were mainly found in the group of nurses (9.5% of nurses and 2.2% of physicians;
When asked about their own consent to become an organ donor after death, a vast majority of the HPs agreed to donate their organs (77%) and tissue (such as the cornea or heart valves (71%)). There were no significant differences for gender, profession, and spiritual/religious self-categorization (data not shown).
We next intended to combine specific topics (either facilitators or barriers) addressed with different single items to specific factors and tested first their internal reliability before we would address differences between HPs with respect to these topics.
To address ethical barriers HPs perceived in ODT, the respective items were condensed to specific factors. However, the internal reliability of these six items was rather weak (Table
Mean values, reliability, and factor analysis of item addressing the perception of ethical issues.
Factors and items | Mean value (score 1–4) |
SD | Corrected item-total correlation | Alpha if item is deleted ( |
Loading factor 1 | Loading factor 2 |
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Handling of the personal convictions of colleagues | 2.40 | 0.83 | .395 | .648 | .781 | |
Respect for the individual problems of patients/relatives | 2.16 | 0.76 | .426 | .638 | .726 | |
Transparency of the system | 2.01 | 0.89 | .548 | .591 | .634 | .406 |
Justice in the distribution of organs | 1.87 | 0.83 | .445 | .631 | .533 | .403 |
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Scandals in transplantation medicine | 1.71 | 0.77 | .335 | .667 | .773 | |
Lack of organs | 1.70 | 0.76 | .326 | .669 | .737 |
Extraction of the main components (eigenvalue > 1); varimax rotation with Kaiser’s normalization.
Rotation is converged in 3 iterations. Both factors explain 55% of variance.
In the developmental phase we found that beliefs and values favoring ODT were most clearly formulated as arguments for ODT when HPs conversed respectfully with people who reflected whether they should release the body of their brain dead relative for ODT. Hence, HPs were asked whether they believed it was acceptable to propose arguments to relatives in favor of ODT and what would be viable arguments proposed in such conversations.
The facilitating arguments were tested for their reliability. As shown in Table
Mean values, reliability, and factor analysis of item addressing the agreement to consider facilitating ODT arguments with relatives.
Factors and items | Mean value (score 1–4) |
SD | Corrected item-total correlation | Alpha if item is deleted ( |
Loading factor 1 | Loading factor 2 |
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Your consent could be a source of meaning in your own life | 2.78 | 0.94 | .603 | .723 |
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Your consent would be an act of charity | 2.75 | 0.99 | .569 | .730 |
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Your consent is an ethical duty | 3.50 | 0.77 | .355 | .771 |
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The death of the diseased would have a purpose | 2.70 | 1.03 | .491 | .749 |
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.323 |
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Your consent can save the life of another person | 1.47 | 0.74 | .462 | .754 |
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Your consent can do good | 1.69 | 0.85 | .509 | .744 |
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You might come to a point where you yourself could be in need of a transplantation | 1.98 | 0.99 | .498 | .746 | .333 |
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Extraction of the main components (eigenvalue > 1); varimax rotation with Kaiser’s normalization.
Rotation is converged in 3 iterations. Both factors explain 61% of variance.
Next we asked for the stress barriers of HPs which were addressed with six items (Table
Mean values, reliability, and factor analysis of item addressing stress barriers in the care of potential donors with brain death.
Factors and items | Mean value (score 1–4) |
SD | Corrected item-total correlation | Alpha if item is deleted ( |
Loading factor 1 | Loading factor 2 |
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Spinal or vegetative reflexes, such as lazarus signs | 2.56 | 0.87 | .473 | .640 | .801 | |
Continuation of intensive care, despite established brain death | 2.29 | 0.92 | .559 | .607 | .709 | .326 |
Acceptance of brain death as death of a human being | 2.02 | 0.83 | .607 | .595 | .686 | .427 |
Care for relatives | 3.03 | 0.81 | .376 | .671 | .654 | |
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Overwork/having to take the position of a colleague who does not take part in ODT | 2.12 | 0.82 | 2.74 | .703 | .867 | |
Overwork/having to take the position of a colleague who does not take part in ODT | 2.42 | 0.86 | .285 | .699 | .565 |
Extraction of the main components (eigenvalue > 1); varimax rotation with Kaiser’s normalization.
Rotation is converged in 3 iterations. Both factors explain 57% of variance.
We asked respondents which representations in dying and death could constitute a barrier for ODT from their personal perspective and from the assumed perspective of relatives. Four questions related to the immanent, earthly life, whereas four items related to the transcendent and to the afterlife. We differentiated perceived own ODT barriers (Table
(a) Mean values, reliability, and factor analysis of item addressing own perception of ODT barriers. (b) Mean values, reliability, and factor analysis of item addressing assumed ODT barriers of relatives.
Factors and items | Mean value (score 1–4) |
SD | Corrected item-total correlation | Alpha if item is deleted ( |
Loading factor 1 | Loading factor 2 |
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The wish that the body should resurrect integrally | 3.07 | 0.99 | .686 | .858 |
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Belief in reincarnation, rebirth, karma, or similar | 2.96 | 0.99 | .635 | .863 |
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The wish to arrive intact in the afterlife | 2.67 | 1.06 | .705 | .855 |
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.310 |
That the soul prevails in the body beyond established death | 2.92 | 1.00 | .694 | .857 |
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The wish to be buried whole |
2.21 | 1.02 | .666 | .859 | .527 | .512 |
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That ODT violates the body | 2.75 | 1.02 | .556 | .871 |
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That the corpse would be blemished | 2.30 | 0.99 | .663 | .860 |
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That the process of death is not complete with brain death | 2.21 | 1.13 | .521 | .867 |
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Extraction of the main components (eigenvalue > 1); varimax rotation with Kaiser’s normalization.
Rotation is converged in 3 iterations. Both factors explain 68% of variance.
Factors and items | Mean value (score 1–4) |
SD | Corrected item-total correlation | Alpha if item is deleted ( |
Loading factor 1 | Loading factor 2 |
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The wish that the body should resurrect integrally | 2.34 | 0.89 | .796 | .840 |
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Belief in reincarnation, rebirth, karma, or similar | 2.38 | 0.90 | .731 | .848 |
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The wish to arrive intact in the afterlife | 2.22 | 0.83 | .776 | .843 |
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That the soul prevails in the body beyond established death | 2.35 | 0.90 | .758 | .844 |
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That the corpse would be blemished | 1.71 | 0.67 | .585 | .865 |
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That the process of death is not complete with brain death | 1.49 | 0.66 | .321 | .886 |
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That ODT violates the body | 2.11 | 0.91 | .535 | .871 |
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The wish to be buried whole |
1.87 | 0.75 | .563 | .866 | .466 | .516 |
Extraction of the main components (eigenvalue > 1); varimax rotation with Kaiser’s normalization.
Rotation is converged in 3 iterations. Both factors explain 71% of variance.
As shown in Table
With these factors we analyzed whether or not the addressed facilitators and barriers were associated in any way. As shown in Table
Correlations between the tested factors.
ODT arguments to be communicated to relatives | Own perception of ODT barriers | Putative ODT barriers of relatives | Stress barriers: medical reasons | Ethical barriers to ODT | ||||
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Personal ethical facilitators | Concrete altruistic effects | Transcendent barriers | Immanent barriers | Transcendent barriers | Immanent barriers | |||
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Personal ethical facilitators | 1,000 | ,463 |
−,029 | ,142 | ,054 | ,223 | −,003 | .012 |
Concrete altruistic effects | 1,000 | −,131 | ,059 | ,003 | ,219 | ,015 | −,013 | |
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Transcendent barriers: protection of the soul | 1,000 | ,512 |
,376 |
,151 | −,091 | −,025 | ||
Immanent barriers: affection of the physical body | 1,000 | ,193 | ,487 |
−,148 | −,004 | |||
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Transcendent barriers: protection of the soul | 1,000 | ,381 |
−,023 | ,117 | ||||
Immanent barriers: affection of the physical body | 1,000 | −,110 | ,166 | |||||
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.010 |
Generally, we can show that, with respect to ODT arguments communicated to relatives,
Mean values.
ODT arguments to be communicated to relatives | Own perception of ODT barriers | Assumed ODT barriers of relatives | Stress barriers: medical reasons | Ethical barriers to ODT | |||||
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Personal ethical facilitators | Concrete altruistic effects | Transcendent barriers | Immanent barriers | Transcendent barriers | Immanent barriers | ||||
All | Mean | 2.92 | 1.72 | 2.89 | 2.41 | 2.33 | 1.76 | 2.46 | 2.10 |
SD | 0.69 | 0.72 | 0.87 | 0.89 | 0.80 | 0.62 | 0.67 | 0.59 | |
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Yes (92%) | Mean | 2.87 | 1.68 | 2.91 | 2.41 | 2.32 | 1.76 | 2.43 | 2.12 |
SD | 0.68 | 0.67 | 0.86 | 0.89 | 0.79 | 0.59 | 0.66 | 0.56 | |
No (8%) | Mean | 3.40 | 2.21 | 2.63 | 2.46 | 2.46 | 1.74 | 2.79 | 1.90 |
SD | 0.65 | 0.98 | 0.97 | 0.98 | 0.97 | 0.94 | 0.73 | 0.92 | |
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6,6 | 1,2 | 0,0 | 0,3 | 0,0 | 3,5 | 1,6 | |
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.0112 | n.s. | n.s. | n.s. | n.s. | .064 | n.s. | |
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Yes (78%) | Mean | 2.86 | 1.64 | 2.91 | 2.44 | 2.29 | 1.73 | 2.44 | 2.15 |
SD | 0.71 | 0.67 | 0.89 | 0.93 | 0.82 | 0.60 | 0.65 | 0.57 | |
No (22%) | Mean | 3.16 | 2.03 | 2.86 | 2.34 | 2.43 | 1.80 | 2.53 | 1.94 |
SD | 0.59 | 0.82 | 0.80 | 0.81 | 0.77 | 0.68 | 0.73 | 0.66 | |
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4.6 |
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0.1 | 0.3 | 0.7 | 0.4 | 0.5 | 3.5 | |
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.0343 |
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n.s. | n.s. | n.s. | n.s. | n.s. | .062 | |
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R−S− (53%) | Mean | 3.07 | 1.79 | 2.91 | 2.44 | 2.21 | 1.75 | 2.47 | 2.15 |
SD | 0.68 | 0.71 | 0.96 | 0.94 | 0.83 | 0.67 | 0.63 | 0.62 | |
R+S+ (47%) | Mean | 2.74 | 1.63 | 2.90 | 2.39 | 2.48 | 1.78 | 2.45 | 2.05 |
SD | 0.68 | 0.68 | 0.74 | 0.84 | 0.73 | 0.56 | 0.70 | 0.55 | |
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1.9 | 0.0 | 0.1 | 4.4 | 0.1 | 0.0 | 1.3 | |
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n.s. | n.s. | n.s. | .0376 | n.s. | n.s. | n.s. | |
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Women (71%) | Mean | 2.89 | 1.71 | 2.87 | 2.41 | 2.29 | 1.72 | 2.58 | 2.07 |
SD | 0.69 | 0.72 | 0.87 | 0.89 | 0.78 | 0.60 | 0.63 | 0.56 | |
Men (29%) | Mean | 2.98 | 1.76 | 2.95 | 2.43 | 2.43 | 1.84 | 2.20 | 2.20 |
SD | 0.70 | 0.72 | 0.88 | 0.92 | 0.86 | 0.66 | 0.68 | 0.66 | |
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0.5 | 0.2 | 0.3 | 0.0 | 1.0 | 1.1 |
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1.7 | |
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n.s. | n.s. | n.s. | n.s. | n.s. | n.s. |
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n.s. | |
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Physicians (26%) | Mean | 2.73 | 1.50 | 2.93 | 2.36 | 2.33 | 1.64 | 2.13 | 2.22 |
SD | 0.66 | 0.62 | 0.85 | 0.91 | 0.85 | 0.55 | 0.65 | 0.65 | |
Nurses (73%) | Mean | 3.00 | 1.81 | 2.88 | 2.43 | 2.33 | 1.80 | 2.59 | 2.06 |
0.60 | SD | 0.69 | 0.73 | 0.88 | 0.89 | 0.78 | 0.64 | 0.64 | 0.57 |
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4.6 | 5.9 | 1.6 | 2.0 | 0.0 | 2.0 |
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2.3 | |
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.0348 | .0169 | n.s. | n.s. | n.s. | n.s. |
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n.s. |
1
2
3Cohen’s
4
5Cohen’s
6Cohen’s
7
8Cohen’s
9Cohen’s
10
Medical reasons as stress barriers are of lower relevance in the sample, particularly for women (
There were no significant differences in the perception of ethical barriers to ODT for gender, profession, or SpR self-categorization.
When the HPs were categorized for their willingness to serve as an organ donor, we saw significant differences: those who do not wish to donate their own organs showed stronger disagreement to communicate
Few who do not feel adequately informed about the regulatory aspects of ODT had stronger disagreement for
The vast majority of HPs were in favor of ODT. In fact, most consented to donate their own organs (77%), they agreed that the lack of organs is an ethical problem (88%), and they found it acceptable to propose arguments to relatives in favor of ODT (78%). These findings confirm existing research indicating that HPs working in ODT are generally highly motivated [
However, the HPs in our study also identified various types of interwoven barriers and facilitators in ODT, confirming the fact that ODT is a difficult medical and ethical field in which to navigate. Interestingly, we saw a tendency that HPs tended to disagree with the barriers that they themselves considered significant factors barring ODT. When communicating with relatives, the majority of HPs found it rather acceptable to propose concrete altruistic arguments that have formerly been found associated with high ODT advocacy [
The HPs in our study reported a high degree of being well informed of legislative aspects of ODT (92%) and the signs of brain death (96%). This does, however, not entail that all HPs agree with the legislative aspects of ODT. In fact, only 67% of HPs in our sample agreed (54% physicians and 71% nurses), suggesting a potential conflict encircling the existing legal practices. The few who did not feel adequately informed about regulatory aspects of ODT tended in general to be less willing to propose arguments in favor of ODT in the dialogue with relatives, suggesting low commitment to ODT advocacy
Our findings thus confirm former research indicating lack of knowledge regarding ODT as one of the primary potential barriers to ODT in the public [
As mentioned, most HPs in our sample agreed to donate their own organs, something formerly found to be generally correlated with a high commitment to ODT advocacy [
In our study, HPs saw significant ethical barriers to ODT particularly in the “justice” of the “distribution of organs.” This confirms existing research in the field suggesting that HPs consider legal, ethical, and value laden questions in ODT to constitute significant barriers in HPs to ODT [
With regard to the ethical facilitators in ODT, the majority of HPs in our study agreed that it was acceptable to propose ethical arguments in the dialogue with relatives of potential donors that as mentioned has been found associated with high ODT advocacy. We found two ethical constructs that HPs considered important in the dialogue with relatives:
The HPs in our sample identified differentiated stress barriers to ODT in their daily clinical work. HPs considered “care for the relatives” a lesser stressful barrier than “acceptance of brain death as death of a human being.” The strongest variance was found for nurses (and thus women, too) who disagreed that
This should come as no surprise on the basis of international research. Important barriers and facilitators are found in the perceived stress and coping resources in handling ODT. Such stress and resources have not only been identified by relatives of potential donors and by those waiting for an organ [
In our study, we identified two constructs of barriers: first, “transcendent barriers: protection of the soul,” that is, barriers relating to transcendent, spiritual/religious notions working against ODT advocacy; second, “immanent barriers: affection of the physical body.” In general, the HPs tended to see belief barriers to a lesser degree for themselves than for relatives, particularly immanent beliefs (such as “that ODT violates the body”) as an assumed barrier for relatives. HPs tended to rather disagree that transcendent beliefs (such as “the wish that the body should resurrect integrally”) constituted barriers to ODT.
As mentioned, HPs tended to feel discomfort proposing
A large bulk of research has centered on how religion/spirituality can entail both barriers and facilitators to ODT [
Moreover, it has been shown that religious beliefs impact the concrete practice of various fields of medicine such as general practice [
International research indicates strong correlation between the various facilitators and barriers in ODT. Thus, Irving and coworkers point to the intricacy of multiple barriers and facilitators and write that “intractable factors, such as religion and culture, are often tied in with more complex issues such as a distrust of the medical system, misunderstandings about religious stances and ignorance about the donation process” [
Such multiplicity and intricacy have been found important in other studies and are evident in the professional setting, even from a structural, systemic perspective, as ODT entails a complex multiprofessional, ethical interaction: (1) it generally depends on the cooperation of various hospitals, departments, professions, and organ allocation institutions; (2) organ donation depends on HP interaction with patients, potential organ donors, and their relatives. This multidimensional interaction holds many inherent barriers against successful ODT. In such a complex field, there are no singular causes. In line with
The study population is small and HPs were recruited in a few departments of the University Hospital in Munich only and with a response rate of 64%. Although we do not assume the data as representative of ODT HPs in general, we at least can add further important aspects to the general discussion. For future studies larger sample sizes and inclusion of other regions of Germany (with their specific cultural settings) should be included. Due to the cross-sectional design of this exploratory study, causal interpretations are not possible.
This study confirms a general high agreement with the importance of ODT among ODT HPs. Nevertheless, we identified both facilitators and barriers in the following fields that impact each other: (1) knowledge of ODT and willingness to donate own organs, (2) ethical delicacies in ODT, (3) stressors to handle ODT in the hospital, and (4) individual beliefs and self-estimated religion/spirituality. Thus we found that ODT constitutes a medically and ethically complex and intricate field of medical intervention and that continuous optimization of HPs’ knowledge of ODT is of relevance for their own perception of barriers and facilitators through education and continued learning. Continued learning concerning specific knowledge of brain death has decreased the experienced ethical and practical barriers that the notion of brain death constitutes ODT [
Recognition and articulation of personal beliefs and convictions in both relatives and HPs are likewise of high relevance for ODT, although often considered a personal matter and not one of medical discourse. Insights and experiences could be brought to ODT from the palliative field, where the actual handling of such intricate ethical and spiritual values and beliefs is very much part of medical attention, even in a rather secularized European setting. Our study suggests that actively addressing the perceived belief barriers in ODT through interdisciplinary teamwork including both HPs but also psychologists and chaplains may continue to enhance a favourable ODT culture.
Finally, recognizing the intricacy of barriers and facilitators in ODT may contribute to the facilitation of ODT in avoiding blind spots in the continued efforts to help more people survive due to better availability of organs for transplantation.
Organ donation and transplantation
Health professionals.
The authors declare that they have no competing interests.
Niels Christian Hvidt contributed to design of questionnaire on basis of expert focus group and interpretation of data (primary author). Beate Mayr and Eckhard Frick offered design of questionnaire on basis of expert focus group and major contributions to writing of paper. Piret Paal offered design of questionnaire on basis of expert focus group, interpretation of data, and major contributions to writing of paper. Anna Forsberg offered major contributions to writing of paper. Arndt Büssing offered statistical analysis, interpretation of data, and major contributions to writing of paper.
The authors wish to thank for fruitful collaboration Dr. Thomas Breidenbach, Nicole Erbe, and Dorothee Seidel of German Organ Transplantation Foundation (DSO) as well as the experts of their focus group.