The psychological examination and evaluation of unrelated kidney donors in Israel: a suggested model.

Altruistic organ donors represent a special population when compared to related living donors, requiring appropriate protection and attention regarding informed consent and psychological aspects related to the donation. Following the introduction of the Israeli Transplant Law of 2008, a retrospective study of altruistic donor files revealed that important psycho-diagnostic aspects were not emphasized in the existing guidelines. Thus, a new tool was formulated which incorporated those elements, including assessment of emotional maturity, ego strength, degree of interest in others, reality testing, degree of pressure to donate, anxiety, dysphoric and depressive factors and the ability to function under stress. The study examined 598 cases reviewed by the Central Evaluation Board over the period May 2008 - June 2016. Overall, 23.4% candidates were disqualified of whom 41% were declined on grounds related to mental health. Most of the donors were rejected based on 3-5 elements. Of these, a deficient assessment of reality in ambiguous situations, lack of emotional maturity, and lacking or partial ability to function effectively under stress, were most commonly cited as reasons for rejection. This model allowed the detection of important conditions previously not incorporated into existing guidelines and may serve as a model for other transplantation programs worldwide.

Outcome of Kidney Transplantation in Israel Following Uncontrolled Donation after Cardiocirculatory Determination of Death.

BACKGROUND: A limited program for kidney donation from uncontrolled donation after cardiocirculatory determination of death (uDCDD) was implemented at four hospitals in Israel in close cooperation with Magen David Adom (MDA), the national emergency medical service. OBJECTIVES: To assess the outcome of transplantations performed between January 2017 and June 2022. METHODS: Donor data included age, sex, and cause of death. Recipient data included age, sex, and yearly serum creatinine levels. A retrospective study of out-of-hospital cardiac arrest cases treated by MDA during 2021 were analyzed to assess their compatibility as potential uDCDD donors. RESULTS: In total, 49 potential donors were referred to hospitals by MDA. Consent was obtained in 40 cases (83%), organ retrieval was performed in 28 cases, and 40 kidneys were transplanted from 21 donors (75% retrieval rate). At 1-year follow-up, 36 recipients had a functioning graft (4 returned to dialysis) and mean serum creatinine 1.59 ± 0.92 mg% (90% graft survival). Outcome after transplantation showed serum creatinine levels (mg%) at 2 years 1.41 ± 0.83, n=26; 3 years 1.48 ± 0.99, n=16; 4 years 1.07 ± 1.06, n=7; and 5 years 1.12 ± 0.31, n=5. One patient died of multiple myeloma at 3 years. The MDA audit revealed an unutilized pool of 125 potential cases, 90 of whom were transported to hospitals and 35 were declared dead at the scene. CONCLUSIONS: Transplant outcomes were encouraging, suggesting that more intensive implementation of the program may increase the number of kidneys transplanted, thus shortening recipient waiting lists.

Posttraumatic growth among participating and non-participating organ donor families in grief support groups.

This article aimed to assess posttraumatic growth among participating and nonparticipating families of organ donors in grief support groups. The program, in the form of both face-to-face and WhatsApp groups, is unique in that it extends over many years without limitation for a predefined period, is open to both immediate and extended family members, and is conducted according to predetermined topics. A questionnaire was completed by 84 participants and 115 non-participant family members. Most participants had attended for between 1 and 5 years (57.2%), although 33.3% had participated for >5 years, including 16.7% who participated for >10 years. All measures of posttraumatic growth were significantly higher in group participants (3.40 [0.75] vs. 3.15 [0.75], p = .010) than non-participants. The often-prolonged participation in the groups suggests there may be an important need for ongoing contact with and support for these families even many years after the loss.

Brain Death Determination in Israel: The First 9 Years of Experience Following Changes Made by the Brain and Respiratory Death Determination Law.

BACKGROUND: Changes accommodating requirements of religious authorities in Israel resulted in the Brain and Respiratory Death Determination Law (BRDDL), which came into effect in 2009. These included considering patient wishes regarding the brain respiratory death determination (BRDD), mandatory performance of apnea and ancillary testing, establishment of an accreditation committee, and accreditation required for physicians performing BRDD. OBJECTIVES: To assess the impact of the legislation from 2010-2019. METHODS: Data collected included the number of formal BRDDs and accredited physicians. Obstacles to declaring brain death and interventions applied were identified. RESULTS: Obstacles included lack of trained physicians to perform BRDD and interpret ancillary test results, inability to perform apnea or ancillary testing, and non-approach to next-of-kin objecting to BRDD. Interventions included physician training courses, additional ancillary test options, and legal interpretation of patient wishes for non-determination of BRD. As a result, the number of non-determinations related to next-of-kin objecting decreased (26 in 2010 to 5 in 2019), inability to perform apnea or ancillary testing decreased (33 in 2010 to 2 in 2019), and number of physicians receiving accreditation increased (210 in 2010 to 456 in 2019). Last, the consent rate for organ donation increased from 49% to 60% in 2019. CONCLUSIONS: The initial decrease in BRDDs has reversed, thus enabling more approaches for organ donation. The increased consent rate may reflect in part the support of the rabbinate and confidence of the general public that BRDD is performed and monitored according to strict criteria.

Changes in consent rate, expressed deceased donation decision-making, and family interactions in Israel-a national retrospective cohort study.

This study aimed to compare the consent rate for deceased organ donation in Israel over two time periods, namely 2004-2009 (2004/9) and 2016-July 2020 (2016/20). Donor and family data were collected from the Israel National Transplantation Center Registry and included donor characteristics, reasons for family consent and refusal, and a subjective assessment of donor coordinator-family interactions. The consent rate increased from 41.6% over the period 2004/9 to 61.8% for the period 2016/20 (P < 0.0001). A significant increase in the proportion of Jewish donors was noted (49.8% in 2004/9 vs. 67.5% in 2016/20, P < 0.0001), while no increase in the consent rate for the Muslim population was noted. Religious objections as a reason for refusal decreased significantly (37.6% vs. 27.3%; P = 0.02), while the proportion of families citing donating as the "right thing to do" increased significantly (7% vs. 26.6%; P < 0.0001). Finally, a significant increase in the proportion of very positive DC-family interactions (59% to 78.3%, P < 0.0001) was noted. In conclusion, the increased consent rate in 2016/20 was associated with changes in expressed decision-making and donor coordinator-donor family interactions. Additional interventions tailored to all different populations groups need to be developed and further investigated.

Access of non-residents to transplantation of deceased donor organs: practices and strategies in the European setting.

The access of non-resident patients to the deceased donor waiting list (DDWL) poses different challenges. The European Committee on Organ Transplantation of the Council of Europe (CD-P-TO) has studied this phenomenon in the European setting. A questionnaire was circulated among the Council of Europe member states to inquire about the criteria applied for non-residents to access their DDWL. Information was compiled from 28 countries. Less than 1% of recipients of deceased donor organs were non-residents. Two countries never allow non-residents to access the DDWL, four allow access without restrictions and 22 only under specific conditions. Of those, most give access to non-resident patients already in their jurisdictions who are in a situation of vulnerability (urgent life-threatening conditions). In addition, patients may be given access: (i) after assessment by a specific committee (four countries); (ii) within the framework of official cooperation agreements (15 countries); and (iii) after patients have officially lived in the country for a minimum length of time (eight countries). The ethical and legal implications of these policies are discussed. Countries should collect accurate information about residency status of waitlisted patients. Transparent criteria for the access of non-residents to DDWL should be clearly defined at national level.

Donation after circulatory death today: an updated overview of the European landscape.

Donation after circulatory death (DCD) has become an accepted practice in many countries and remains a focus of intense interest in the transplant community. The present study is aimed at providing a description of the current situation of DCD in European countries. Specific questionnaires were developed to compile information on DCD practices, activities and post-transplant outcomes. Thirty-five countries completed the survey. DCD is practiced in 18 countries: eight have both controlled DCD (cDCD) and uncontrolled DCD (uDCD) programs, 4 only cDCD and 6 only uDCD. All these countries have legally binding and/or nonbinding texts to regulate the practice of DCD. The no-touch period ranges from 5 to 30 min. There are variations in ante and post mortem interventions used for the practice of cDCD. During 2008-2016, the highest DCD activity was described in the United Kingdom, Spain, Russia, the Netherlands, Belgium and France. Data on post-transplant outcomes of patients who receive DCD donor kidneys show better results with grafts obtained from cDCD versus uDCD donors. In conclusion, DCD is becoming increasingly accepted and performed in Europe, importantly contributing to the number of organs available and providing acceptable post-transplantation outcomes.

The implementation and utilization of an organ donation dedicated medical advisory service: A descriptive study.

BACKGROUND: Obstacles encountered during the organ donation process may result in the loss of organs. A centralized medical advisory service (MAS), providing a 24/7/365 service, was established in 2007 to respond to queries from healthcare professionals regarding organ safety, brain death (BD) determination, and donor management. METHODS: Data collected from 2007 to 2017 included the number and context of the queries and the mean number of organs transplanted/donor. Since 2012, the number of six donor management goals (DMGs) met at the time of consent has been monitored. RESULTS: The number of queries relative to the number of potential donors increased from 12.4% (n = 78 queries) in 2007 to 48.2% (304 queries) in 2009 and has remained widely utilized, with most queries consistently related to organ safety. The context of the queries informed the formulation of protocols relating to donor infections and malignancy and identified difficulties regarding BD determination and subsequent implementation of solutions. A mean of 5.0 ± 0.7 DMGs was achieved, while the number of organs transplanted/donor increased from 3.4 in 2007 to 4.0 in 2017. CONCLUSION: We suggest that this model may provide a valuable resource to improve the safety, standardization, and quality of the donation process.

Incentivizing Organ Donor Registrations with Organ Allocation Priority.

How donor organs are allocated for transplant can affect their scarcity. In 2008, Israel's Parliament passed an Organ Transplantation Law granting priority on organ donor waiting lists to individuals who had previously registered as organ donors. Beginning in November 2010, public awareness campaigns advertised the priority policy to the public. Since April 2012, priority has been added to the routine medical criteria in organ allocation decisions. We evaluate the introduction of priority for registered organ donors using Israeli data on organ donor registration from 1992 to 2013. We find that registrations increased when information about the priority law was made widely available. We find an even larger increase in registration rates in the 2 months leading up to a program deadline, after which priority would only be granted with a 3-year delay. We also find that the registration rate responds positively to public awareness campaigns, to the ease of registration (i.e. allowing for registering online and by phone) and to an election drive that included placing registration opportunities in central voting locations. Copyright © 2016 John Wiley & Sons, Ltd.

Age limitation for organ transplantation: the Israeli example.

In 2013 the Israeli Ministry of Health appointed a public committee to examine the policy of placing an age limitation on candidates listed for organ transplantation. The committee rejected the use of an age limit criterion for listing candidates for transplantation and recommended to abolish it. However, opinions differed regarding the use of recipients' age in shaping a fair organ allocation policy. The committee's recommendations were adopted and put into force as of April 2014. This article unfolds the committee deliberations on accommodating values of formal equality for optimising the use of organ transplantation.

Transcendental Spirituality and Acquaintance With the Activities of the Domestic National Transplant Center as Factors Shaping Attitudes Toward Organ Donation.

CONTEXT: Organ donation has been shown to be perceived as inappropriate by religiously observant individuals. The impact of spirituality level on attitudes toward organ donation has not been broadly explored. OBJECTIVE: To explore the contribution of ethnicity, spirituality, level of religious observance, and acquaintance with the activities of the Israel National Transplant Center (INTC) to forming attitudes toward organ donation among Jews and Muslim Arabs in Israel. DESIGN: A descriptive cross-sectional survey. PARTICIPANTS: Three hundred five (65.2%) Jewish and 163 (34.8%) Muslim Arab respondents living in Israel. RESULTS: Jewish respondents had more positive attitudes toward organ donation than Muslim Arabs. Muslim Arabs had a higher mean spirituality score than Jews. Gender, age, ethnicity, level of religious observance, education, 4 spirituality dimensions, and acquaintance with the activities of the INTC explained 41.5% of the variance in attitudes to organ donation. Transcendental spirituality, acquaintance with the activities of the INTC, and level of religious observance had the highest contribution to explaining attitudes to organ donation, while gender and age had a low contribution. Ethnicity, education, and the 3 other spirituality dimensions were not found to have a significant contribution. CONCLUSION: A multifaceted approach to improving attitudes toward organ donation among Jews and Muslim Arabs in Israel is important.

Derivation and Implementation of a Protocol in Israel for Organ Donation after Cardio-Circulatory Death.

BACKGROUND: Strategies aimed at expanding the organ donor pool have been sought, which has resulted in renewed interest in donation after cardio-circulatory death (DCCD), also known as non-heart beating donors (NHBDs). OBJECTIVES: To describe the derivation and implementation of a protocol for DCCD in Israel and report on the results with the first six cases. METHODS: After receiving approval from an extraordinary ethics committee, Ministry of Health, the steering committee of the National Transplant Center defined and reached consensus on the unique challenges presented by a DCCD program. These protocol included medical aspects (construction of a clinical pathway), social and ethical aspects (presentation of the protocol at a public gathering(, legal/ethical aspects (consent for organ preservation procedures being either implied if the donor had signed an organ donor card or received directly from a surrogate decision maker), and logistical aspects (pilot study confined to kidney retrieval and to four medical centers). Data regarding organ donors and recipients were recorded. RESULTS: The protocol was implemented at four medical centers. Consent for organ donation was received from four of the six potential donors meeting criteria for inclusion, in all cases, from a surrogate decision maker. Of the eight kidneys retrieved, only four were suitable for transplantation, which was carried out successfully for four recipients. Graft function remained normal in all cases in 6-12 months follow-up. CONCLUSIONS: The DCCD program was successfully implemented and initial results are encouraging, suggesting that expansion of the program might further aid in decreasing the gap between needs and availability of organs.

Spirituality as a predictive factor for signing an organ donor card.

PURPOSE: To examine differences in spirituality, purpose in life, and attitudes toward organ donation between people who signed and those who did not sign an organ donor card. DESIGN: A descriptive cross-sectional survey conducted in Israel with a sample of 312 respondents from the general population, of whom 220 (70.5%) signed an organ donor card. Data were collected during April-June 2013. METHODS: Participants completed a paper questionnaire and a Web-based questionnaire consisting of four sections: spiritual health, purpose in life, attitudes toward organ donation, and social-demographic questions. Descriptive statistics, t test, chi-square test, and a logistic regression analysis were performed. FINDINGS: Differences in mean scores between respondents who signed an organ donor card and those who did not were indicated in transcendental spirituality (p < .01), purpose in life (p < .05), and attitudes toward organ donation (p < .01). No statistically significant difference was found between the groups in the overall spirituality mean score. The spiritual transcendental dimension, individual's purpose in life, and attitudes toward organ donation explained 34.3% of the variance of signing an organ donor card. CONCLUSIONS: Signing an organ donor card was found to be correlated with high purpose in life, positive attitudes toward organ donation, and low level of transcendental spirituality. CLINICAL RELEVANCE: Nurses should assess the patient's spiritual needs in order to construct appropriate programs for promoting signing an organ donor card. Nurses who signed an organ donor card should be encouraged to share this information with their patients.

Interactions between health care personnel and parents approached for organ and/or tissue donation: influences on parents' adjustment to loss.

CONTEXT: The effect of loss on those approached for organ and/or tissue donation, particularly in the years thereafter, has received little attention. OBJECTIVE: To assess whether adjustment of a parent to loss of a child is influenced by interactions with health care personnel. METHODS: A self-administered questionnaire was completed by the parents of 216 decedents. Interactions in the hospital were assessed by examining the experience in the hospital, physical separation from the child, and the relationship with health care professionals. Adjustment to loss was defined by 4 components: grief, personal growth after loss, meaning of life after loss, and the meaning of organ donation. RESULTS: A positive experience in the hospital was significantly associated with the meaning of donation. Increased satisfaction with the separation process was associated with better adjustment on all components. Finally, a better relationship with health care professionals was associated with less grief and with greater personal growth. These results were characterized after adjustment for time since loss, which was from 6 months to 27 years. CONCLUSIONS: Interactions in the hospital appear to influence adjustment to loss significantly. Appropriate interventions may aid parents in their adjustment to life.

Deceased Organ Donor Characteristics and Organ Utilization in Israel, 2004-2013.

BACKGROUND: The number of patients awaiting organ transplantation continues to exceed the number of available organs. OBJECTIVES: To document changes in the demographic characteristics of brain-dead, heart-beating organ donors over the past 10 years which may impact on organ utilization. METHODS: Data were extracted from the Israel Transplant Registry and the Donor Action database for the 10 year period 2004-2013, inclusive. RESULTS: The median age of the donors increased from 44 (range 3-73 years) to 53.5 years (range 1-79 years) (P < 0.001). There was a significant increase in the median age of donors of kidneys (33 to 51 years, P < 0.001), livers (41 to 53 years, P < 0.001) and lungs (40 to 49.5 years, P < 0.001). The number of donors dying from trauma decreased (34.5% to 20%, P < 0.001), while those with anoxic brain damage increased (14.5% to 25%, P < 0.001). The percent of male donors decreased over the study period, from 63% to 53%. An increase was noted in the mean number of organs transplanted per donor, from 3.29 to 3.82 per donor, due mainly to a significant increase in the utilization of lungs (31.5% to 51.3%, P < 0.001) and livers (76.3% to 82.4%, P < 0.001) while heart utilization decreased significantly since 2006 (40.9% to 17.5%, P < 0.001). CONCLUSION: Trends in the heart-beating, brain-dead organ donor pool in Israel over the past 10 years reveal significant changes in demographic characteristics which in the future will impact on the number of organs available for transplantation.

A practical Israeli strategy for appealing for organ donation.

CONTEXT-Most reports on organ donation have been related to the importance of support for families, explanations of brain death, and the appeal for organ donation. In contrast, no reports have addressed organ donation from the perspective of intervention in cases of "sudden mourning" and the practical aspects of how to facilitate donation in such cases. OBJECTIVE-To develop a specific strategy for professional intervention in cases of imminent death to bring the family to a state of cognitive and emotional preparedness that will enable them to accept the tragic news, donate organs, and then take leave of the deceased. METHOD-The strategy presented here was developed on the basis of the records of donor coordinators who documented their interaction with families; consultations with professionals in the fields of marketing, persuasion, and negotiating; research conducted on families who did or did not donate organs; and statements made by family members of donors in focus and support groups in more than 10 years. RESULTS-The strategic approach includes early-stage rules such as staff self-awareness, and then later, critical stages of the process that take place before and at the time of determination of brain death: preparation for and the notification of death itself and the request for organ donation, including persuasion skills, coping with resistance and expressions of anger, and physical leave-taking from the deceased. CONCLUSIONS-The flexible, strategic approach set out here is designed to maximize the chances of procuring organ donation while protecting the family's rights and welfare.

The utilization of solid organs for transplantation in the setting of infection with multidrug-resistant organisms: an expert opinion.

Organ transplantation remains the optimal treatment for many patients suffering from end-stage organ disease. Increasing numbers of patients admitted to intensive care units, among them potential heart-beating, brain-dead organ donors, are exposed to infections with multidrug-resistant organisms, in particular carbapenem-resistant Klebsiella pneumoniae (CR-KP). An extensive literature search failed to reveal any information regarding the eligibility for transplantation of organs from such donors. For this reason, in 2009, the Israel Transplant Center, together with the Israeli Society for Infectious Diseases, established a working group with the intention of developing a national-specific approach to the use of these organs. In this viewpoint article, we present an algorithm based on expert opinion and our clinical experience with a donor who was found to be an asymptomatic carrier of CR-KP.

Predicting willingness to donate organs according to the demographic characteristics of the deceased's family.

BACKGROUND: Transplant professionals need to gain a better understanding of the factors that facilitate willingness to donate a family member's organs, in order to increase the rate of organ donation. OBJECTIVE: To conduct an integrated analysis of demographic data relating to key family members, so as to help transplant professionals predict the likelihood that family members would be willing to donate organs. METHOD: Demographic variables were collected on 753 brain-dead patients and 995 first-degree relatives in 20 Israeli hospitals from 2004 to 2009. The data were recorded by transplant coordinators who used a uniform format to document meetings with next of kin. The data were analyzed by using the Chaid Statistical Test from the SPSS statistical package. RESULTS: In this total study population, the most significant factor affecting the decision to donate was religion. With increasing religiousness, the likelihood of consent decreased. A large disparity was apparent among Moslems, Christians, and Jews. Within the religious groups, education (Jews), familial proximity to the deceased (Christians and Moslems), and the quality of relationships with the medical staff (Moslems) were the main predictors of consent. SUMMARY: Most countries have Christian, Moslem, and Jewish residents, so the conclusions of this study and its implications for practice should be relevant for transplant coordinators anywhere. The recommendations, which stem from the results of this study, relate to activities of transplant coordinators before and during their interaction with families, before the request for organ donation.

A Comparison of Recalled Pain Memory Following Living Kidney Donation Between Directed and non-Directed, Altruistic Donors.

Introduction: Pain following donor nephrectomy for living kidney donation is common. In Israel, non-directed, altruistic donations account for 45% of all kidney transplants. Design: This cross-sectional, retrospective survey included 2 groups of donors derived from the data of Israel Transplant, namely directed and non-directed, altruistic donors, who donated between 2015 to 2018. The degree of recalled pain memory post-surgery was assessed using the Visual Analog Scale at 5 time points: immediately post-surgery, after 1 week, 1 month and 3 months post-surgery and in the month preceding completion of the questionnaire. In addition, continued requirement for analgesics for more than one-month post-surgery, the degree of interference with daily activities in the month preceding the questionnaire and the recalled time to return to full-time employment were also noted. Results: In total, 246 (131 directed and 115 non-directed, altruistic) donors were included in the study. Non-directed, altruistic donors reported statistically significantly lower degrees of recalled pain memory at all time points, a lower requirement for prolonged analgesic use and less recalled interference with daily activities due to pain. In addition, these donors recalled returning significantly earlier to full-time employment. Finally, no significant differences in the degree of recalled pain memory were noted for directed donors according to their relation to the recipient, apart from donation to a spouse. Conclusion: These unique findings, if validated in a prospective study, could provide important information to potential non-directed, altruistic donors regarding the expected level of post-surgical pain and their return to full-time employment.

The Effect of Priority Given to Donor Card Holders on the Allocation of Livers for Transplant-Evidence From 7 Years of the Israeli Priority Program.

BACKGROUND: The Israeli Transplant Law grants priority in organ allocation to patients signing a donor card. Liver transplant candidates get additional 2 points on their Model for End Stage Liver Disease score for signing a donor card, 0.1 points for a relative holding a card, and 5 points if a relative donated an organ. We studied the effect of the priority program on waiting list mortality and allocation changes due to priority. METHODS: Using Israeli Transplant data of 531 adult liver transplant candidates with chronic liver disease listed between 2012 and 2018 we compared waitlist mortality and transplant rate of candidates with and without priority. Then we analyzed liver allocations resulting from additional priority points and followed outcome of patients who were skipped in line. RESULTS: Of the 519 candidates, 294 did not sign a donor card, 82 signed, 140 had a relative sign, and for 3, a relative donated an organ. The rates of waitlist mortality in these 4 groups were 22.4%, 0%, 21.4%, and 0%, respectively, and the transplant rates were 50%, 59.8%, 49.3%, and 100%, respectively. Of the 30 patients who were skipped because of priority, 24 subsequently underwent transplant, 2 are on the waiting list, and 4 died within 0.75, 1.75, 7, and 17 mo. CONCLUSIONS: The 2 points added to the Model for End Stage Liver Disease score were associated with lower waitlist mortality and higher transplant rate for candidates signing a donor card without significantly affecting access to transplant during allocation. Further research and consideration of optimal policy when granting priority for candidates signing a donor card should continue.