Next of kin decisive on organ donation

Changing the donor registration systems is not expected to result in more donor organs. We better try to solve the bottlenecks in the donation process within hospitals and to reduce the number of refusals by next of kin, as NIVEL research shows, based on which study Remco Coppen took his doctor’s degree on 3 September at Tranzo, Tilburg University in the Netherlands.

In the Netherlands, about 1300 people are on the waiting list for a donor organ, but there are no more than about 200 to 220 donors each year. Consequently, there is a serious shortage of donor organs. Amendments to the Dutch Organ Donation Act or changes in the Dutch consent system, which is based on explicit consent, to a presumed consent system does not solve this shortage according to the PhD-thesis of Remco Coppen. "Indeed, countries with a presumed consent system have more donors, but those countries also have for example more traffic deaths. After adjusting the national donation rates for differences in mortality rates which are relevant for organ donation (e.g. traffic-deaths and CVA), the differences in donation rates between presumed and explicit consent countries disappear. The absence of differences in organ donor procurement between presumed and explicit consent countries can be explained by a similar practice around organ donation. In each country the medical staff consults the next of kin about the donation of organs: in practice, next of kin give their final approval, regardless of the consent system.”

Close contact with relatives
Taking into account the differences in mortality rates for CVA and traffic-accidents between 10 Western European countries, only Spain and Austria have more donors than the Netherlands. In these countries, next of kin seem to be more willing to consent to organ donation. In Austria, this can probably be explained by its autopsy custom which makes the decision to donate organs easier. Spain is well-known for its intensive system and organisation of organ donation. An important element of the Spanish system is a very intensive contact between the medical staff and the relatives.

Decision under pressure
"It is remarkable that despite the positive attitude towards organ donation of the Dutch population, relatives often refuse a donation procedure," says Coppen. "The consultation of next of kin always takes place under very emotional and stressful circumstances. On the one hand, it is, therefore, required to educate people and to make sure they reflect about their view on organ donation, which may lead to consent registration or a family discussion on this topic. On the other hand, it is also important for the medical staff to be prepared for a consultation with next of kin regarding organ donation and to train them how to conduct such a consultation. However, there is still little known on communication styles which work in Dutch practice. We also hardly know why next of kin refuse the donation of organs."

No magic bullet
"That a system change will not solve the organ shortage is a very disappointing message for people on the waiting list," says Coppen. "Although a system in which everyone is a donor (presumed consent) does not lead to more donor organs, such a system may show, for example, more solidarity with the people on the waiting list than our current system based on explicit consent. This may explain why there is still much debate about the Dutch consent system."

Currently NIVEL studies the process of organ donation in hospitals, in collaboration with the Erasmus Medical Centre and iBMG of the Erasmus University. "There are disparities in the number of donations between similar hospitals. This suggests that there are still opportunities to increase the number of successful organ donation procedures," argues Coppen. "We now search for bottlenecks in the donation process in hospitals. These bottlenecks should be solved in order to prevent procedures being more difficult than necessary, and to prevent that for this reason organ donation procedures do not proceed.”