Introduction

Organ donation is an increasingly prevalent process in the United States today, with around 110,000 individuals currently on the organ transplantation waiting list. A significant portion of these individuals will pass away before ever receiving an organ donation due to a shortage of viable organs transplantation. [1] The need for organs is why OPOs place such great importance on obtaining organ donations as efficiently as possible to save the lives of persons on this organ transplantation list. Upon the death of an individual, hospitals are mandated by federal law to contact an OPO to conduct a medical evaluation of the deceased donor to determine if any of their organs are viable for donation. [3] OPOs are also responsible for acquiring and verifying consent for a donation from the deceased's family, medically maintaining the deceased potential donor, planning the transplantation surgery logistics, and supervising the placement and transportation of the donated organ. [3,4] Organ procurement processes are a three-way process: the family of the deceased donor must express consent for donation, the donor's physician must uphold support for facilitating the organ donation, and a third party, the organ procurement organization, must act as the liaison for many different intricacies within the process.

There are currently 58 federally approved OPOs in the United States. The non-profit OPO known as Gift of Life operates within the tri-state area of Pennsylvania, New Jersey, and Delaware. In 2020, Gift of Life successfully transplanted 1,619 organs from 619 donors, giving the recipients of these donations the gifts of sight, healing, and most of all, life. [2] Gift of Life has been the leader for coordinating the most organ donations in the country for the past 13 years, working with 15 transplant centers and 130 hospitals in the region.

With OPOs acting as liaisons between medical professionals and the family of a potential donor and given how emotionally challenging and intense an organ donation process may be, occasionally tensions will arise between OPOs and hospital employees. Current research has surveyed healthcare professionals regarding their opinions and feelings on organ donation as a whole. [5] One study gleaned data that suggested that among the 1,500 medical professionals surveyed, 91% expressed outright support of organ donation, and over 90% would consider or have considered being an organ donor themselves. [5] Some obstacles of organ procurement expressed by healthcare professionals were: confusion over the criteria needed to make a brain-death declaration, reluctance to contact a grieving family, concern for how time-consuming the process is, fear of holding legal responsibility for matters, and apprehension at becoming emotionally involved in the procurement process. [5]

Currently, there are limited literature and research that address the specific topic of tensions arising between hospital clinicians and OPOs. It is underestimated how tensions can jeopardize the success of an organ donation. It is common for the public to think that the main issue with organ donation is family refusal. However, another major factor is a disconnect between medical professionals and OPOs, making organ donation much less efficient. The lack of past research and literature on this topic underscores the need for this study. The purpose of this study was to investigate the relationship between both sides of an organ donation case: the organ procurement organization (in this case, Gift of Life) and various hospitals in the tri-state area. A survey was sent to each of these organizations about the challenges and difficulties in the organ donation process. This research intends to employ a qualitative approach to explore the best ways to mitigate this tension to increase organ donations.

Methodology

Participant Recruitment

The participants in this study were selected through convenience sampling. We contacted a representative from Gift of Life with an introductory email to explain the purpose and goals of our research, and they administered the OPO-specific survey to their team of hospital service coordinators. A similar introductory email was also sent to a few hospital clinicians working in the ICU in various hospitals in the tri-state area, who then sent the hospital-specific survey to their team of ICU professionals.

Survey Development

The OPO-specific survey consisted of six questions, whereas the hospital-specific survey had a total of eight questions. The surveys were created and utilized on the online survey platform called SurveyMonkey, where participants accessed it from a link sent via email. Participants could skip any of the questions provided, and all of their identities were kept anonymous to the researchers. The questions as to their attitudes and opinions about working with the other respective group on an organ donation case were thematically analyzed.

Statistical Analysis

10 individuals responded to the survey sent to Gift of Life, and another 10 respondents participated in the hospital survey. Due to the anonymity of the respondents, the survey's response rate cannot be calculated because it is unknown how many people the email containing the survey reached. The survey responses were coded for thematic analysis using the NVivo qualitative software analysis. Each survey response was analyzed, highlighting key themes throughout, and each theme was noted as a "code" in the data.

Survey Questions

The survey questions administered to Gift of Life representatives are as follows:

1. What is one aspect of donation you wish your hospital partners knew about, but based on your experience, there is more to teach them about it?
2. What, if any, challenges have you faced in your relationship with hospital employees during the organ donation process?
3. What have you done to resolve these challenges with hospital partners?
4. What makes a hospital partner "difficult" to work with?
5. What is the most challenging aspect of the donation process for your hospital partners to understand?

The survey questions administered to ICU representatives are as follows:

1. What, if any, challenges have you faced in your relationship with organ procurement organizations (OPOs) during the donation process?
2. What have you done to resolve these challenges?
3. What makes a partner from an OPO "difficult" to work with?
4. What is the most challenging aspect of your job concerning OPOs?
5. What is one aspect of your job that you wish OPOs knew about but based on your experience, there is more to teach them about it?

Qualitative Data Analysis

Five steps were taken to analyze each of the survey responses and to summarize the findings into coherent and cohesive data adequately:

1. Data Transfer
2. Code Creation
3. Theme Identification
4. Visual Representation
5. Thematic Finalization

Each of the 20 survey responses (10 respondents from Gift of Life representatives and 10 respondents from the ICU) was gathered into 20 separate PDF documents, one for each respondent. These documents were then chronologically uploaded into the NVivo software program. Each document was read thoroughly, and every identified theme was highlighted and labeled as a "code." At the end of the first analysis of all the documents, around 30 coded themes were identified. These codes were combined and condensed into six overarching themes.

Figure 1

A hierarchy map of codes compared by the number of items coded. Each square represents a primary code, and the size of the square is dependent on how many responses were coded and attributed to that specific primary code throughout the 20 responses.

The themes and their respective coded responses were then collated into visual representations such as graphs, word maps, and word trees to represent the data results better. Participant quotes for each of the six major themes were chosen to provide direct insight into the experiences recorded from the surveys. Codes labeled "secondary codes" were also identified and discussed, which are more specific sub-themes that support the ideas of the six major themes labeled as the "primary codes" (Figure 1).

Results

The Business of the ICU

The first theme identified to be a factor in tensions between OPOs and ICU professionals during an organ donation case is the business of the ICU as a whole. The busy environment of the ICU was referenced 24 times as an obstacle to organ donation. Out of the 20 respondents, 11 individuals included the business of the ICU in their responses.

Timing

The secondary code of timing was the most prominent theme that arose throughout this theme's responses (Figure 2). One respondent from Gift of Life disclosed that "Hospital staff are so busy they can't always find a way to give us time/resources to support donation." Another respondent from an ICU shared that "Tests needed by the OPO to optimize 'donating' patient (are) especially difficult if the ICU is very busy, or overnight when specialists/tests needed are not readily available."

Figure 2

A word tree representation of the secondary code of "timing" throughout the 20 survey responses.

Education

10 of the survey responses mentioned education, referencing the theme a total of 20 times. One hospital respondent expressed that "Some staff members (from Gift of Life) need to understand that we do not do this every day and that we need them to educate to us what they would want done." Another respondent from Gift of Life said, "I educate them on our process. They are left having a better understanding of what to expect from the process and are much more comfortable working with us in the future."

Case Follow-Up

A significant secondary code referenced in various responses was the idea of conducting follow-up interviews and meetings about organ donation cases once they are completed (Figure 3). These meetings exist to allow both the Gift of Life representatives and the hospital professionals to debrief the case "to address all issues and resolve them, answer questions," as one respondent put it.

Figure 3

A word map representation of the key theme of "education" and various related quotes from the survey responses. "HCT" means healthcare team. "O.D." means organ donation.

The Family's Interest

The third overarching theme referenced 19 times by 8 respondents was one of the donor family's interests. Respondents expressed that tensions often arise during an organ donation case because the process is a highly sensitive and emotional time for families. It is sometimes challenging to be prompt with the timing while also sympathetic to the family grief (Figure 4). One ICU professional expressed that "Some officials (from an OPO) are not very friendly to staff and family members. I have had some very pushy staff members that were aggressive towards staff and family members. Some staff members lack empathy, and it shows towards the family." On the other hand, a professional from Gift of Life shared that some hospital clinicians are not versed in their view of how OPOs communicate to families, in that "They just don't understand what we really say to families, and they assume we will simply ask, 'Do you want to donate?' They don't realize that we NEVER say those words."

Figure 4

A word tree representation of the keyword of "family" throughout the 20 survey responses.

Logistics

The logistics of an organ donation case seemed to be a significant factor in matters between hospital clinicians and the OPOs, with the majority of respondents (17) mentioning logistical aspects 37 times throughout the coded data. Figure 5 shows various quotes regarding the logistical issues of organ donation.

Figure 5

A word map representation of the key theme of "logistics" and various related quotes from the survey responses.

Job Responsibilities

One prominent sub-theme that arose throughout the responses was job responsibilities; some nurses responded that many tasks that the physicians can only perform are assigned to them first, creating confusion and unnecessary steps (Figure 5).

Personal Beliefs

According to the surveys administered, ICU professionals' religious and ethical views are also factors in organ donation cases, as 9 respondents referenced the theme 17 times (Figure 6). A Gift of Life respondent shared that "Not everyone on the HCT (health care team) is pro Organ Donation," and many other responses were similar to this quote in terms of the matter of clinicians' personal and ethical beliefs getting in the way of an organ donation.

Figure 6

A word map representation of the key theme of "personal beliefs" and various related quotes from the survey responses. "GLDP" means Gift of Life Donor Program.

Relationship Building

The last major theme that presented itself within the survey responses was the idea of relationship building as a solution to ease tensions between OPOs and ICU professionals. This theme was referenced 14 times by 8 different survey participants. From the data, participants feel that relationship building is vital to build trust between the hospital and the OPO and foster a safe and open environment of conversation and support between an OPO/healthcare professional and the donor's family (Figure 7). One participant shared that "The donation conversation is designed to help the family outside their tragedy, and to be empowered with the only decision about this hospitalization that is theirs to make." Another participant from Gift of Life also said that they "Met with C suite folks to gain support from the top down," the "C suite" being the chief executive officers (CEOs), chief medical officers (CMOs), and chief nursing officers (CNOs) of a hospital.

The last major theme that presented itself within the survey responses was the idea of relationship building as a solution to ease tensions between OPOs and ICU professionals. This theme was referenced 14 times by 8 different survey participants. From the data, participants feel that relationship building is vital to build trust between the hospital and the OPO and foster a safe and open environment of conversation and support between an OPO/healthcare professional and the donor's family (Figure 7). One participant shared that "The donation conversation is designed to help the family outside their tragedy, and to be empowered with the only decision about this hospitalization that is theirs to make." Another participant from Gift of Life also said that they "Met with C suite folks to gain support from the top down," the "C suite" being the chief executive officers (CEOs), chief medical officers (CMOs), and chief nursing officers (CNOs) of a hospital.

Figure 7

A word map representation of the key theme of "relationship building" and various related quotes from the survey responses.

Discussion

The experiences and insights from the survey participants provide a plethora of suggestions that can be utilized to mitigate tension in organ donation cases. The environment of the ICU is fast-paced, intense, and complicated, making it difficult for ICU professionals to adopt the responsibilities of an organ donation case in addition to the duties that their job already holds. On the other hand, individuals from Gift of Life stress that the timing of an organ donation is critical to its success. Delays occur when hospital clinicians do not promptly fulfill specific steps. Hospital clinicians feel utterly protective of the donors' families, and some have expressed that OPO employees are too aggressive in dealing with families. Yet, respondents from Gift of Life contrast their feelings on this matter, as they are adamant about approaching the family with sensitivity and respect. Another issue that accompanies organ donations is the personal beliefs of the physician working with an OPO on organ donation. Tensions arise if the physician does not personally agree with organ donation and its related ethical matters. Among the anecdotes provided by the survey respondents, a few suggestions stand out as the most viable solutions for support of tension-free organ donation. They include an increase in organ donation education and relationship building between the OPO, hospital clinicians, and the donor's family.

Gaps in education on the organ donation process create an environment of confusion and misunderstanding between hospital clinicians. Thus, it would be highly beneficial to increase education on the process, such as implementing courses in medical and nursing schools that train aspiring medical professionals on the specific details of the process from the point of view of an OPO. The same can be done for OPO professionals, in which they are also taught more about the intricate logistics that the ICU has to handle in an organ donation.

Besides improving organ donation education, tensions can be dissipated by promoting relationship-building efforts in organ donation. From all sides of the process, it is highly beneficial for the OPO, hospital clinicians, and donor families to get to know each other in a caring, amicable manner. Building relationships foster a safe environment for grieving families and makes organ donation easier and smoother. By creating trust between individuals in this process, tensions are lessened, and organ donation can be viewed positively.

Organ donation is a process that has saved thousands of lives. Both organ procurement organizations and hospitals share the goal of saving as many lives as possible and improving the quality of life for as many individuals as possible through organ donation. Thus, easing the tensions between the two entities will result in easier, more seamless organ donation cases and bring hope to those who desperately depend on the availability of organs to have another chance at life. We hope that through this research, we can provide background, experiences, and anecdotes that can educate individuals and create some context for improving future organ donations so that organ donation is a better experience for all.

Ethical Imperatives

Statistics show that about 110,000 individuals are currently on the organ transplantation waiting list. Many will pass away before ever receiving an organ due to a shortage of viable organs for transplantation. Sadly, recent research indicates that up to 28,000 organs (including 17,000 kidneys) are not recovered every year due to poor performance and lack of accountability from hospital staff and OPOs. In some cases, hospital staff lacks the incentives to refer in-hospital deaths to OPOs, and OPOs staff are unavailable to respond to hospital referrals. [6] The potential of saving about 25,000 lives annually and billions in taxpayer funds highlights the need to ease the tensions between hospital clinicians and OPOs. The ethical principles of Beneficence and Common Good place obligations on the stakeholders to resolve their differences and increase organ donations. Both principles are significant in healthcare when deciding what is best for the patients and society.

The principle of Beneficence entails the moral obligations to confer benefits and prevent, remove, or minimize harm and risk to others. It also incorporates weighing an action's possible goods against its costs and possible harms. [7] This principle traces its roots to the Hippocratic Oath that stipulates, "Above all, do no harm" (primum non nocere). In healthcare, this principle places a moral responsibility on clinicians to treat their patients in ways that will maximize benefits and minimize harm. Contextually, patients are the potential organ donors whose dignity ought to be respected throughout the donation process and the hundreds of thousands of individuals waiting for a life-saving organ. Tensions between hospital clinicians and OPOs undermine the selfless act of organ donations and harm patients who would die without receiving an organ. Therefore, Beneficence demands that these stakeholders work together to increase the much-needed life-saving gifts.

Also, tensions between hospital clinicians and OPOs imperil the Common Good. The Common Good is defined as that for the sake of which civil society exists. [8] It assures beneficial necessities to everyone in society. The cooperative efforts of many people are required for establishing and maintaining the Common Good. [9] Sickness affects the level of an individual's productivity and contribution to society. The unaddressed tensions that affect organ supply for the patients negatively impact society due to lost wages (or skills). The principle of the Common Good demands a resolution of issues that jeopardize individual and communal flourishing. The medical costs from dialysis, suffering, sorrow and loss of productivity due to illness endanger how people benefit and contribute to the Common Good. Consequently, there is a moral imperative to work together to increase organ donation to help patients live longer and fulfill their societal obligations.

Limitations to the Study

The COVID-19 pandemic substantially affected the responsiveness of ICU professionals to our project's survey because they were inundated with a surplus of patients and had less time to participate in our project. Thus, only 20 participants provided input for the surveys, a number which could be limiting in terms of the scope of answers and experiences provided. Therefore, the anecdotes we received from the surveys may not be inclusive of the experiences of other healthcare professionals in the ICU.

Limiting the study's survey responses strictly to the tri-state area may not be generalizable to all areas of the United States. OPOs may have different relationships and experiences with hospitals (and vice versa) depending on the geographic area.

Funding

The John P. McNulty Scholars Program provided funding for the data analysis software programming package at Saint Joseph's University.

Acknowledgments

Special thanks to  Dr. Bege Dauda of Saint Joseph's University served as an advisor on the best practices of the NVivo program for data analysis. Joseph Paparo, Hospital Services Coordinator at Gift of Life, provided background on organ procurement organizations and educated us on the specific logistics and overarching mission of Gift of Life.