Organ donation rates vary across comparable intensive care units (ICUs),1 suggesting that donation processes differ between ICUs, despite the existence of clinical guidelines for donor care,2,3 and the coordination efforts of organ donation organizations (ODOs). Aiming to improve donation rates, many studies have examined donor family4,5,6,7,8,9 and ICU staff 10,11,12 experiences with donation decision-making. Comparatively fewer studies have examined the wider process of donor care in the ICU.13,14,15 While a high donation rate is the most obvious measure of success in donor care, even the best donor management may not result in organs suitable for transplant (e.g., a substitute decision-maker (SDM) decides organ donation is not consistent with the patient’s wishes). Research into the process of care for organ donors therefore requires a “program approach” that considers donation as a series of inter-related steps, in which “success” consists of the best possible outcome for an individual case at each step.16 The objective of this study was to describe the process of organ donation in the ICU, identify important drivers of successful donation, and to identify actionable practices that improve organ donation in the ICU.

Methods

We used a sequential mixed-methods design including: i) a qualitative document analysis of hospital policies and protocols,15 ii) a quantitative cross-sectional survey of ICU staff about facilitators and barriers to organ donation,16 and iii) qualitative interviews to investigate results from the document analysis and survey. Detailed reports of the document analysis and survey are published elsewhere.17,18 The culmination of this work is a mixed-methods analysis integrating data from all three studies reported herein (Fig. 1).19,20 This study was approved by the Hamilton Integrated Research Ethics Board.

Fig. 1
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Study design

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Setting

Hamilton General Hospital is a tertiary care, university-affiliated hospital in Canada with a 32-bed neuro-trauma ICU that sees a high volume of deceased organ donation (> 25 completed donations/year). Patient care is provided by approx. 5 physicians (MDs), approx. 170 nurses (RNs), and approx. 50 respiratory therapists (RTs), and smaller numbers of allied health professionals. The regional ODO coordinates 24-hr on-call nurse specialists, generally stationed within the hospital, who solicit consent for organ donation and facilitate deceased donor care in partnership with ICU staff.

Qualitative interview data collection and analysis

Using purposive sampling over a 14 month period, we identified MDs, RNs, and RTs within one month of caring for a potential donor in the ICU. We classified “potential donors” as ICU patients for whom an SDM had been approached to consent for organ donation, either following cardiocirculatory death (DCD) or in a case of donation after brain death (DBD). Through email, a qualitative researcher invited eligible clinicians to participate. To maximize recall, we interviewed participants as soon as possible after they cared for the potential donor. We used a semi-structured interview guide to explore the facilitators and barriers to donation identified in the document analysis and survey17,18 (eTable 1, available as Electronic Supplementary Material [ESM]). Two investigators (E.A., S.O.) conducted 45 min one-on-one interviews in person or by phone, with audio recording. No follow-up was made with participants after the interviews. Interviews continued for each of the three groups until data saturation.21

De-identified transcripts were uploaded into NVivo for analysis.22 We used a qualitative descriptive methodology, coding each interview with conventional qualitative content analysis.23,24,25 Two investigators (S.O., E.A.) coded the first four interviews in duplicate and drafted an initial codebook, which was reviewed and revised with the complete investigative team. All subsequent interviews were coded by a single analyst according to the revised codebook. The two analysts met regularly to review newly coded interviews and to identify themes and relationships in the data.25 All analyses were documented as an audit trail within NVivo.22,26

Integrated mixed methods data analysis

After analyzing the qualitative interviews, we performed an integrative mixed-methods analysis, linking data from the document analysis, survey, and interviews. We used a joint display table, organized according to the interview themes, to contrast and compare findings across the studies.27 We identified practices that improved organ donation in the ICU in three ways: firstly, from existing practices that survey and interview participants described as helpful; secondly, by direct suggestions from interview participants; and thirdly, by inferring solutions to problems identified in the three studies.

Results

Qualitative interview results

We completed 32 interviews between February 2017 and March 2018 (Table 1). We invited 43 participants (of these, nine did not respond and two declined). Five major themes emerged from the interview data, each containing four sub-themes (Fig. 2). Below, we present the themes and sub-themes with illustrative quotes.

Table 1 Interview participant characteristics (n = 32)
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Fig. 2
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Qualitative themes and sub-themes

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Theme 1: Relationships between ICU staff and ODO coordinators

ICU unit staff described the availability of ODO coordinators as a facilitator in all steps of organ donation, This was a highly prominent sub-theme in many interviews (Table 2). Facilitation is enhanced when there is a personal relationship between ICU staff and the coordinator, allowing informal discussion of potential donors:

Table 2 Joint display of subtheme 1: availability of ODO coordinators facilitates donor care
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Some of the [ODO coordinators] are previous ICU nurses… So as soon as we see the signs we call because we know that one of our previous coworkers is going to answer the phone. (RN)

These personal relationships between ICU staff and ODO coordinators are identified as one of the drivers of a positive culture of donation:

I’ll have a coffee with [the ODO coordinator]. I think that helps the culture as opposed to it being a very sterile, formal process. (MD)

Organ donation organization coordinators also create a culture of donation through education sessions for ICU clinicians, highlighting the importance of donation in the hospital culture:

…as soon as a new group [of ICU staff] is coming through, the [ODO coordinators] talk to them, to get them on the ball. This is one of the expectations in the ICU. (RN)

Collaboration with the ODO coordinators is reciprocal. ICU staff describe assisting ODO coordinators to navigate family dynamics as one of their major responsibilities in donation:

I always take the discussion just as far as I need to understand where the family is at… So that I can prepare [the ODO coordinator] for their discussions and coach on an approach with their family. (MD)

Theme 2: Standardized processes

ICU staff describe the positive impact of standardization on almost every aspect of donor care. Standardized referral criteria empower staff to take the lead in identifying potential donors:

I make the call. I don’t wait for the family to tell me their loved one was a donor. (RN)

Procedural order sets and checklists are also described as beneficial, providing staff with clarity on current practices for donor management:

Things get checked off as [completed]…blood work, consent, the talk with the family, a debriefing with the physician and the [ODO] coordinator… It’s better because now you actually have an on-paper document to follow through. (RN)

Other effective standardized processes include worksheets for donor care; worksheets to document bronchoscopy findings; a life support withdrawal order set; and a process for re-intubating patients after DCD for lung recovery. Staff describe the need for a standardized communication “huddle” to ensure all team members are on the same page before approaching an SDM for discussions about donation:

[So] we have this huddle and we all discuss what we know about the family and the patient and make sure that we get all our facts together before we approach the family. (MD)

Theme 3: Staff beliefs

ICU staff describe informal “chatter” as a mechanism to work through contentious issues in donation. This allows individuals to acknowledge the existence of multiple viewpoints, and to determine their personal willingness to participate in specific donation-related activities. One strategy to support the diversity of staff beliefs is having charge nurses “check-in” to ensure individuals were comfortable with the treatment plans for donation, such as administering pre-mortem heparin in DCD:

It’s different for every nurse. Everyone comes at organ donation from a different moral standpoint, which is why…. there needs to be a sort of huddle prior to assigning the nurse a DCD patient. Are they comfortable with it? (RN)

While caring for donors is an expectation of staff in the ICU, informal arrangements are made to match staff assignments to donor types they are comfortable with—DBD, DCD, or both. Transferring care of patients is described as a way to maintain the comfort level of individual staff, while still providing care consistent with the patient’s wishes:

From a practical point of view, I actually have an ethical objection to [giving heparin in DCD]. So, based on that, I don’t get involved with the mechanics of DCD when the time comes and I would transfer the patient to one of my colleagues…. I’m very supportive of DCD and I think you have to choose a patient rightly. (MD)

While ICU staff are satisfied in knowing that donation will benefit organ recipients, their primary motivation in offering donation is that it can help families:

Organ donation is important to me because I see it as helping families deal with the tragedy of an incredible loss… the family was extremely appreciative and involved. And that reinforced my motivation to support organ donation. (MD)

Theme 4: Integration of donation and high quality end-of-life care

The donation process can positively impact the end of life experience for families. ICU staff described it as beneficial because it adds meaning or purpose to the death of a loved one; that their death could have a positive impact on someone’s life:

I think it helped [the family] with their grief, because they knew their mother’s death was not in vain… she said “If we can save one life or help one person, my mom would not have died in vain.” She specifically said that to me. So when I heard we got three [organs] I was so happy because I knew the kids would feel better. In dealing with their grief, this would help them. (RN)

Donation procedures add external time pressures to end-of-life care, increasing stress for families and staff at several time points in the donation process: assessing the patient for suitability of donation, including cardiac angiography and bronchoscopy (DBD, DCD); waiting until the operating room is ready before withdrawal of life support (DCD); time from withdrawal of life support to cardiocirculatory death; and shortened time for families to be with the donor after the declaration of death (DCD):

…the heart stops and the family has no time to say goodbye.. you get those two minutes to say goodbye and the body is rushed out and taken to the OR… (RN)

The ICU staff report most deviations from “usual” end of life care in negative terms. For instance, in DCD, withdrawal of life support is often done in the postoperative recovery room rather than ICU, a situation described by one nurse as “awful”. Staff identified strategies to minimize the negative impacts of donation activity upon end of life care, such as having consistent ICU staffing and a private room for families to use.

While staff viewed organ donation as contributing to quality end of life care, many described the eventual inability to donate, especially in the context of DCD, as devastating:

…if you [miss] that two hour window… not only did the patient die, but their organs weren’t allowed to be donated as well, and that’s a double negative for the families and difficult for them to swallow. (MD)

Theme 5: Feedback and staff support

While the ODO provides feedback on unit-level indicators, such as the routine notification rate, staff identified individual performance feedback as an opportunity to enhance donor care:

Right now, I can’t be told that I’m doing something incorrect. So it’s very, very difficult to modify behaviour unless I know exactly what the behaviour is… (MD)

Intensive care unit staff identified feedback on the outcomes of donation as motivation for continued engagement in organ donation:

…we get personal letters back from [the ODO] letting us know that we were involved in a specific case and this resulted in x, y, and z… if you’re having a bad day, you just pull up the [donation] files and look at all you’ve done to help. (MD)

While MDs often received letters, other ICU staff (RNs and RTs) had to actively seek information on the outcomes of the organ donors they had cared for.

Participants noted the emotional impact of caring for organ donors, and the need for a planned debriefing or other support post-donation:

I think it would be a good idea to provide some kind of support or counselling to staff members… if you’re a more timid person, it might be better if the support was just provided without you actually having to come forward and ask for it. (RT)

ICU staff noted that support and debriefing are difficult given the nature of shift work. Several staff members suggested that sessions targeted at night-shift staff would be valuable.

Integrated mixed-methods results

Table 3 summarizes the results of the mixed-methods analysis in the form of 22 suggested practices to improve donation, arranged according to the interview themes. The joint display table of mixed-methods analysis is in ESM eTable 2.

Table 3 Results of mixed-methods analysis: 22 suggested practices for improving the organ donation process in the intensive care unit
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Discussion

In this sequential, multiphase, mixed-methods study, we used multiple data sources to describe the process of organ donation in an academic tertiary-care ICU. Important insights from this study include: i) identification of 22 actionable practices to improve the practice of donation; ii) recognition that ICU staff are highly concerned about the impact of donation upon families; and iii) ICU staff desire opportunities to improve team communication and receive feedback and support after caring for potential donors.

Suggested practices align with those reported elsewhere

The five key steps in organ donation in the ICU that were identified in the document analysis are consistent with those of other organizations, supporting the generalizability of our study findings.16,28,29 Similarly, several of the 22 practices we identified have been suggested elsewhere, indicating that they may be widely applicable,28,29,30,31 while others are unique to our study. Results of this study parallel some of the best practices from the US Organ Donation Breakthrough Collaborative (integrating ODO staff, early referral to the ODO, ongoing staff education), which have been associated with measurable increases in organ procurement.29,30 This supports our hypothesis that small practice changes can have a significant cumulative impact on donation outcomes.

Intensive care unit staff are highly concerned about the impact of donation upon families and end of life care

Study participants identified DCD as more challenging than DBD, partly because they perceive families to be distressed when donation does not occur. This perception is consistent with results from interviews with donor families.32,33 Participants in the present study considered care of the patient and family an overriding priority and only saw donation as a positive outcome if it was consistent with patient values and preferences. This is a novel observation, but has been hinted at in existing research.34 The current study supports the use of shared decision-making with ICU staff and families when considering donation,9,10,11,12 and suggests that efforts to motivate and engage ICU staff in donation may be more effective if framed in terms of how it benefits families. Conversely, policies and practices that increase donation activity but negatively impact families (e.g., withdrawal of life support in the operating room to shorten ischemic time) are unlikely to receive support from ICU staff.

Opportunities to improve communication and feedback exist

ICU staff made suggestions to standardize communication with the donation team in a pre-meeting “huddle,” consistent with findings from other studies.15 In the interviews, they noted a need for individual and unit-level feedback to improve practice and motivate ICU staff to participate in donation. This novel finding was limited to information given during interviews; there are no documents or survey items related to performance feedback. Though less robust than other themes that were supported by triangulation, this theme identifies a novel opportunity to improve donation practice by providing staff with feedback and support. Such practices should be implemented cautiously, as feedback in team settings is not always associated with improved performance.35

Strengths and limitations

Strengths of this qualitative study included its setting in a high volume donation center, whereby the ICU staff’s experience contributes to the richness of the data. Our recruitment of ICU staff with recent experience caring for potential donors provided detailed illustrations of participants’ viewpoints. We used multiple forms of triangulation to enhance the trustworthiness of study results19,20,21 (available as ESM eTable 3). Data triangulation was achieved by purposive sampling of ICU staff from multiple specialties across a variety of cases. Investigator triangulation was achieved by including physicians, nurses, and non-ICU personnel on the investigative team, and having two investigators interview and code in parallel: a male ICU clinician who has worked in this ICU (S.O.) and a female non-clinical, qualitative researcher (E.A.). We used methodologic triangulation, comparing results across qualitative and quantitative research methodologies. Lastly, we followed the Consolidated Criteria for Reporting Qualitative Research

(COREQ) guidelines for qualitative research to ensure transparency and completeness of reporting36,37 (available as ESM eTable 4).

This study is limited by its single-centre approach, which may reduce the generalizability of results, particularly to centres where potential donors are rare or to centres with contrasting laws and policies for deceased donation (e.g., “opt-out” consent). Nevertheless, these findings are consistent with other findings, which supports the transferability of these results. Through detailed descriptions included in the document analysis, survey, and interviews, readers can infer the applicability of the study findings and suggested practices to their local context.

Conclusions

Incorporating the perspectives of ICU staff, we were able to identify 22 practice changes to improve the process of organ donation in the ICU. Future research is required to evaluate whether these findings are transferrable across a wider range of ICU settings, and the extent to which they account for the variability of donation rates between otherwise comparable ICUs.