Background
Dutch Donor Law |
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In 1998, the Dutch Donor Act was introduced. This law was based on a voluntary opt-in donor registration system in which organ and tissue donation only occurred with explicit consent from the deceased donor. When no decision was registered, the patients’ family members had to decide. Despite various efforts to increase the number of donors to meet the demands for transplantation, 7 million (51%) residents remained unregistered in the Donor Register [57] |
As of July 2020, the opt-in system was replaced by an active donor registration (ADR) system, i.e., an opt-out system. The opt-out system changed the default of donor registration from “family decides in case of nonregistration” to “donation”. This system aims to increase donations and save multiple lives. In addition, it might relieve pressure on patients’ families who must otherwise decide on organ and tissue donation in an often challenging, emotional situation [58]. The new donor law also describes family rights more clearly than in the previous opt-in system |
Four choices for donor registration exist in the opt-out system, which are the same as in the opt-in system: |
1. Consent or opt-in (with or without restrictions to specific organs or tissues), |
2. Refusal or opt-out, |
3. Leave the decision to a designated person, and |
4. Leave the decision to family members (first and second degree) |
The three novel aspects of the law are: |
1. All persons aged 18 years or older who are not yet registered in the Donor Register receive two letters in which they are asked to register their donation wishes. If they do not register, a third letter informs them about being listed in the Donor Register as having “no objection” to organ and tissue donation. In other words, when persons do not actively deregister after these reminders, they are registered with presumed consent, which is legally considered the same as actively registered consent. In the Netherlands, 25 percent (3.3 million people) of people are registered with presumed consent [7, 57] |
2. Registration can still be challenged by families in the case of (presumed) consent to donation if families can convincingly demonstrate a credible case that the donor registrations do not correspond to the patients’ wishes. Families must inform and explain their difficulties, with no requirements with respect to form, to the health care professionals, who can invite them to explain their difficulties |
3. Donation for mentally incompetent persons is also possible. As we did not include cases with mentally incompetent persons, this aspect extends beyond the scope of the present study. We will not elaborate on donation in patients younger than 18 years old either |
More information (in Dutch): https://www.rijksoverheid.nl/onderwerpen/orgaandonatie-en-weefseldonatie/actieve-donorregistratie |
Methods
Design and setting
Case inclusion
Data collection
Data analysis
Results
Case (ID)a | Family donor conversations (n = 15) | Patients (n = 15) | Clinicians (n = 16) | |||||||
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Moment during the dayb | Decoupledc | Duration (min)d | Other attendees | Sex/age | Critical injury | Length of stay (days) | Type of donation discussed (result) | Profession | Sex/age/years of donation experience (years of ICU experience) | |
Consent cases | ||||||||||
14 | D | Yes | 20 | ICU nurse, two daughters, son, two sons-in-law | F 57 | ICH | 7 | DBD, DCD, tissue (DCD) | Donation intensiviste | M 55 27(15) |
16 | B | Yes | 16 | ICU nurse, spouse/partner, friend | M 63 | Not known (PE) | 1 | DBD, DCD, tissue (DBD, tissue) | Donation intensivist | M 55 27(15) |
21 | C | Yes | 19 | ICU nurse, medical intern, son, friend | F 60 | ICH | 4 | DCD, tissue (DCD, tissue) | Fellow | M 31 7.25(3) |
26 | A | Yes | 22 | ICU nurse in training, medical intern, spouse/partner, sister, brother-in-law | M 60 | MI | 14 | DBD, DCD (DCD) | Intensivist | M 40 10(5) |
27 | B | No | 19f | Resident, ICU nurse, spouse/partner, two daughters, two sons, brother-in-law | M 64 | ICH | 1 | DBD, DCD, tissue (DCD) | Intensivist | M 38 6(6) |
29 | D | Yes | 30 | Resident not in training, ICU nurse, spouse/partner, two sons | M 71 | ICH & CA | 0.1 | DBD, DCD (no donationg) | Fellow | M 32 5(1) |
29* | A | No | 32 | ICU nurse, psychiatrist, mother, father | F 25 | CA | 2 | DBD, DCD, tissue (DBD) | Fellow | F 37 6(12) |
Presumed consent cases | ||||||||||
4* | D | Yes | 1:15 2:14 | ICU nurse, two sons, daughter-in-law, sister-in-law | M 62 | TBI, HBI | 1 | DBD, DCD (no donationh) | Donation intensivist | F 48 16(16) |
8* | B | No | 39 | ICU nurse, neurosurgeon, spouse/partner, daughter | M 72 | TBI | 1 | DCD, tissue (no donationg) | Intensivist | F 58 25(25) |
11* | A | No | 1:35 2:21 | ICU nurse in training, fellow, spouse/partner, son, daughter | M 68 | ICH | 0.5 | DBD, DCD (DCD) | Intensivist | M 44 11(11) |
15 | B | No | 19 | ICU nurse, daughter with her boyfriend, mother | F 60 | ICH | 1 | DBD (DBD) | Fellow | M 31 7(2.75) |
18 | C | Yes | 12 | ICU nurse, ICU nurse in training, spouse/partner, son, daughter, daughter-in-law, son-in-law, brother, sister-in-law | M 53 | ICH | 0.3 | DBD, tissue (no donationg) | Intensivist | M 62 31(31) |
19 | B | Yes | 10 | ICU nurse, ICU nurse in training, ODC, spouse/partner, mother, mother-in-law | F 41 | CVA | 1.5 | ** (no donationh) | Fellow Intensivist | F 30 2.5(2.5) M 47 22(16) |
20 | B | Yes | 14 | ICU nurse, fellow, two sisters, daughter, niece | M 61 | CVA | 2 | DBD, DCD, tissue (DCD) | ICU resident not in training | F 32 1.75(1.75) |
23 | B | Yes | 18 | ICU nurse, medical intern, spouse/partner, daughter, son-in-law | M 63 | TBI | 4 | DCD (DCD) | Donation intensivist | M 43 17(10) |
Q. no. | ID number | Quote |
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Results | ||
1 | I11Case011 | I, and with me probably many other clinicians, pay far too little attention to it [tissue donation] and have limited knowledge about it. It is an addition [to organ donation]: you don’t want to overload the family either. You’re satisfied with what you may have achieved [organ donation] and at some moment it is enough for yourself or the family |
Clinicians’ points of departure for a donor conversation | ||
2 | I30Case029 | I’m positive about it [donation]. (..) Yes, I think it does [influencing professional conduct]. I do think that it
[donation] is easier to convey or to get people motivated for when you can show the usefulness of it |
3 | I20Case019 | Maybe also because you have a bit of internal resistance to impose it [donation in the case of presumed consent] on them [the family]. I want to be compliant with the law, which is of course one of the arguments why the conversation is going the way it is. So, you can’t avoid it. However, it’s a bit uncomfortable. That you go from something so emotional, from someone’s grief to something very formal, namely, a legal framework on which we base our argumentation structure |
4 | I15Case014 | It was no surprise what was registered in the Donor Register [in this case: consent]. They immediately said: ‘yes, yes, yes’, they understood. So, in that sense, it was relatively easy. We had a common base on which you can continue to build on. (..) No [There were no disagreements with the family] and not within the family either |
5 | I15Case014 | It’s what I said about finding a ‘landing site’ [for donation with the family], that’s the most crucial thing: that you [clinician] find an entry point. In addition, as long as the entry point isn’t there, there is no acceptance that things are truly radically different from now on and that someone is being ripped out of their [families] lives. Of course, this applies to a greater extent to younger patients and more unexpected deaths. If that acceptance isn’t there, you can’t truly have a conversation about donation. (..) So people must be convinced [about the imminent death] |
6 | I17Case015 | However, if you can already estimate for yourself, okay (..) this truly is not going to be a donation, but you still have to check that with the family, that you do notice that you are going to look for arguments within yourself on which you actually hold back the donation. So that you actually no longer have to ask the question or that you can just keep it [the conversation] very short (..) When prior communication with the family has been difficult, then you think: poah, it’s going to be very complicated if I must ask the donation question in a very open manner. (..) Sometimes, it can help to check for yourself: are there any other reasons…? (..) that you (..) look even stricter at arguments whether it [donation] is possible at all or whether there are simply already contra-indications not to do it [pursue the donation]. (..) It perhaps tends faster toward those contra-indications than you would normally do |
7 | I21Case019 | You must think a lot about the legislation, what the consent… or how patient is registered and what it then means, right? As a doctor you must be almost half a lawyer to tell it all apart. That makes it a bit difficult. That [presumed consent] is now clear, now that I’ve done it once [the donor conversation], but I must think every time which 5 or 4 forms of registration exist |
8 | I11Case011 | I talked to [name donation intensivist*] about it, because it was a person who was registered with ‘no objection’ [presumed consent] and [name donation intensivist] (..), of course, considers it important how we use and apply that. (..) [name donation intensivist] emphasised the approach of the new donor law [laughs]: that ‘no objection’ is not ‘we ask family consent’, but that there is consent, that in particular actually. That you take that into account. So don’t pretend that there was no [donor] registration, but that we consider it as consent |
9 | I20Case019 | We already felt it coming [resistance], because the ICU nurse indicated that she truly sensed resistance to donation. In addition, yes, our approach since the new donor law is that (..) we would like to start the donation after all. (..) Therefore, we thought, we need slightly more context and some sort of subtitles for the donation from the organ donor coordinator. Therefore, we asked her to join us. (..) I think she certainly added value in getting them [the family] to think a bit [about donation] |
10 | I4Case004 | With such a complicated case in the middle of the night, (..) it takes an awful lot of time, and we have *number* other patients too of course. Therefore, you can’t just take infinite time for it [discussing donation]. (..). Look, you take the time, and you make time for it, but of course you can’t go on endlessly about it, of course you also have other patients who you must give your attention to, those who actually still have a chance of survival. (..) During one of the conversations, I had to leave for CPR [cardiopulmonary resuscitation], and then you must [remind] yourself all over again: oh yes, where was I? Oh yes, where were we? |
Routes of discussing patients’ donor registrations in donor conversations | ||
11 | I26Case026 | It is a constant search for a balance between, say, the donation process and the grieving process, so you also must plead for both. (..) You always must make sure it doesn’t go off the rails on one of those fronts. Therefore, I think that going along too easily with the wishes of the family, while something else is registered, I would call that 'derailing'. However, on the other hand, it is also … If continuing the donation, yes, is hurtful toward the family, if there is a breach of trust, that is also derailed. You must prevent that. (..) And to say what is more important: donation or a good contact with a good grieving process. (..) I think that also differs a bit from moment to moment. (..) It is a very crazy comparison if you must draw up a balance of motives and arguments between the interests of one individual [the patient]—possibly with the family around—on the one hand, and the social interest of the organ donation on the other |
12 | I15Case014 | Then [in consent cases], you often notice that the interests of organ donation take precedence, because that path is already being taken [due to the positive donor registration]. In addition, then you must make sure that you keep the family on track. Intensive guidance and… However, also giving direction—That is what we also do. When someone [health care professional] says ‘but we can wait maybe another 6 h [for diagnosing brain death]’, that you [clinician] then say ‘no’. Our job then is to protect the family from being too utilitarian—which just no longer suits their emotional capacity. (..) You must coach the family. So also during the course [of donation], you constantly have to keep in touch with the family, the guidance of ‘where are you [in the process]?’ To check again: is it [the procedure] bearable for you? Or what can we do differently to make it better for you? |
Consent cases Route A: Consent | ||
13 | Case014 | Clinician: We would like to follow up on her wish, the wish [consent] she indicated herself in the donor register. (…) And she made her wish very clear, and therefore, we [the health care professionals] want to fulfil that wish as best as possible |
14 | Case014 | Clinician: (..) For this, we always consult the Donor Register, and she’s in it. She was registered in it [with consent]. Maybe you know that too? Daughter 1: Yes (..) Clinician: (..) We would like to follow-up on her wish, what she herself has indicated in the Register Daughter 2: Please Clinician: Do you agree with that? Daughter 1: Definitely Son: Yes, good |
15 | I26Case026 | There are some comments that indicate that they [the family] are okay with it [the donation]. Sometimes they say, ‘we know that it is his own choice’ or (…) ‘nevertheless, his death can lead to something positive’. (…) When amongst the people present no discussion about donation rises, and they simultaneously nod as a response to donation, then I assume a somewhat alleged permission… or alleged agreement of the family to at least further initiate the donation process. (…) I don’t remember exactly what they said in this case, but I think it was after one or two sentences, that I got the impression: well, donation is all right |
16 | I28Case027 | To give the family the feeling that they had some control, so to speak. (..) This sense of control of the family is especially that you [as clinician] emphasise that everything is possible. (..) And you give a few examples of that [ “everything”]. That if they want to be with their loved one all the time through the donation procedure, that’s fine. That if they want to leave [the hospital] and just want to be called [by telephone], that’s fine. That if the partner would like to lay in bed with the patient, that’s fine. However, that it [the donation procedure] should be bearable, it must be bearable [for the family] |
17 | Case028 | Clinician: The most important message I want to give you is that a lot [regarding donation] is possible. There’s – I think almost anything is possible, but just try to keep in touch with us [health care professionals], and then we’ll see what’s feasible and how we can support you. (..) It’s a tough time |
Presumed consent cases | ||
18 | I7Case008 | I would say that apparently it is not their last will [in case of presumed consent], but it is not so clear, is it? Last will is: ‘yes or no’. However, not reacting and being obliged to it [donation], I don’t know if that is truly a last will |
19 | I20Case019 | And I find that second part [that presumed consent equals ‘donation’] very difficult. In this donor conversation, there was clearly immediate resistance [to donation, after introducing the topic] and to bring a counterbalance then… to truly slow people down in their reflections that they must choose a course at that moment. I find that very difficult, because you have the feeling that you have to bypass the family a bit in their wishes. Therefore, in that sense it is not always a very pleasant announcement |
20 | Case011 | Clinician: Tell me a little bit, what did he say, what did you talk about [regarding donation]? (..) C: However, he said, if I understand correctly, if there is anything I can help someone with… than he would like that (..) C: I especially want to hear a little bit more from you… that’s what you tell ma’am, that he basically supported that [donation] (..) C: Therefore, what I’m taking from you now is that what actually is registered now [presumed consent], even though he didn’t actively do that, but just by doing nothing- (..) C: That [presumed consent] suits him? (..) C: Okay, but still you guys talked about it and does that fit with what- (..) C: What he thinks, and for you, it suits him and it’s not a problem for you either |
21 | Case011 | Clinician: The rules that are now formulated for him, will be literally: it [donation] is his last will that he wants in principle, because he has not opposed to it (..) (..) Clinician: If you as a family do not make it clear that he or you have important disagreements to this for certain reasons, then we will of course just want to follow his last will. That is how the legislator wants it (..) |
Route B: Presumed consent | ||
22 | Case023 | Clinician: (..) He is registered with ‘presumed consent’ Partner: That’s right C: Yes, did you know that? P: Yes C: Did he consciously bring that about? P: Yes C: Yes, knowing that that actually means that you give consent to organ donation P: YES C: Yes, that is also the meaning it [presumed consent] has. In addition, you talked about that together at that time, of what you thought about his point of view or…? P: Yes, we talked about that too C: Yes, and what do you think of his point of view? P: Well, he had to know that himself. It’s his decision |
23 | I20Case019 | It’s not some kind of shared decision-making, such as offering a treatment in the outpatient clinic (..) There’s just a law, that we’re supposed to abide or try to abide. (..) It’s a decision that we [made] from a legal point of view in consultation with the [medical] team (..). Then, it will be a conversation with the family where you want to announce what we are planning to do [donation] (..) |
24 | Case015 | In principle, the approach of the hospital is (..) to cooperate with it, organ donation. (..) So that we are going to initiate everything to be able to donate organs to other people |
25 | Casus019 | Clinician (intensivist): If you are convinced [that donation was not their known wish of the patient] and it does sound that way, it is clear to me that that [donation] would be against her will if she could still have a say on this (spouse: yes well…), then we just shouldn’t do it, I think Spouse: I think that’s the wisest thing to do Clinician (fellow): I think we agree on that too, right? |
26 | I7Case008 | There will always be parts [families] that say ‘yes’ and some that say ‘no’ [to donation]. Then, you should still try to explain how the registration arose, that it is the law. (..) Just [emphasise] that we can also do a lot of good for other people [with donation]. To try to persuade them anyway |
Route C: Consensus with the family and family involvement | ||
27 | I17Case015 | Therefore, it’s not my intention to truly ask consent, but I do think that it also feels much better for uhm… everyone, if they [the family] have had the feeling that there is still some kind of participation or whether it is a joint decision. Even if it is not a joint decision [by law] |
28 | I20Case019 | I think in that moment [when introducing donation], you just have to provide a stage for their [family’s] feelings so that they don’t feel completely unheard or that you have a huge battle with the family, but after that, you also have to slow them down a bit in the sense that yeah ‘it may feel like a question [for consent], but in fact it isn’t. However, completely disconnection them [the family] from that decision is not truly possible either |
29 | I20Case019 | In case of presumed consent, (..) you don’t know it for sure [whether the patient gives consent for donation], so that’s why I also let the opinion of the family weigh more strongly, I guess |
30 | I26Case026 | Then, I think in clinical practice – even though I don’t think the law is meant in that way – it [donation] will often fail because we want to keep a somewhat good contact with the family; at least not a total break of contact. (..) However, if, despite my efforts in which we show that we are serious about it [the donation] the situation remains that they [the family] continue to oppose to the donation, then yeah, they will eventually get what they want, so to speak |
31 | I15Case014 | The family keeps a vote in it [whether donation is pursued] and is still leading in what happens in the end. Otherwise, you distort the relationships you’ve built. For such a delicate subject. (..) Well, if it truly turns into a very severe conflict then I’m not going to persist. Then, it may be that the one who has difficulties with the donation gets the heaviest vote. However, that must be discussed intensively with them: why do you come to that decision? What’s holding you back? |
32 | I22Case020 | If they [the family] then say ‘he truly didn’t want that [donation]’ or for whatever reasons, then I’d be quicker to accept that if someone is registered with presumed consent [compared to an actively registered consent]. Instead of… because with consent I can say ‘yes, but he explicitly indicated that [consent] himself’. If there is presumed consent, yes, I think that the opinion of the family weighs more heavily for me |
33 | I29Case028 | The goal of every donor conversation is to effectuate donation, but yeah, somewhere in your head, (..) there is a kind of dual advocate. Who on the one hand wants to create as much health as possible and therefore harvest as many organs as possible and give them to other people, but on the other hand, there is also someone who must tell the family that a family member is dying, and you also want to offer those people some form of support. I do find it more difficult to convince people that [donation] is what the patient would have wanted if people [the family], who know the patient much better, certainly claim the opposite |
34 | Case011 | Clinician: (..) I think what’s important is that we align it [the donation procedures] with ma’ams [spouse] needs and your [daughter and son] needs. Taking that together with what he [the patient] had wanted [donation] and that we try to bring those things together as best we can, and sometimes it can’t be perfect and somewhere it’s too much at some point and then you have to stop it [donation] too |
Route D: Family consent | ||
35 | Case004 | Clinician: If you do not respond to the letters [with the request to register donation wishes], then you actually agree with donation, but even then, we always want to ask it to you, as a family, because we think that’s important Sister-in-law: So, they [the adult children of the patient] can still say ‘we don’t want to pursue the donation’ or ‘we do want to pursue the donation’? Can they decide that as relatives? Clinician: yes, that’s indeed possible |
36 | I4Case004 | Look, those people were totally shaken and confused too, and young too, there’s a lot coming at them. (..) Therefore, yeah, I didn’t think you had to go on about that [that it should be a donation based on the presumed consent registration] for a very long time. We gave those people a lot of time to think about it [donation], I thought that was more important than putting forwards the arguments why they thought that he shouldn’t be a donor after all. Because we just asked the donation question [for consent] |