Understanding Factors Influencing Decision Making during Assessment of Potential Organ Donors: A Qualitative Study of Clinicians Assessing the Medical Suitability of Potential Donors

Abstract

Background. Potential organ donors are carefully assessed by expert clinicians (donation specialists) who evaluate a variety of factors, including balancing potential transplant benefits and biovigilance risks, under time constraints. We aimed to identify and understand the factors that donation specialists consider when appraising a potential organ donor and how they balance the risk and benefits when determining the medical suitability to proceed to donation. Methods. Exploratory qualitative study involving semi-structured interviews with 12 donation specialists in NSW, Australia. Interviews included 1) open-ended questions focused on the general potential organ donation pathway and 2) hypothetical potential donor scenarios, with participants invited to voice their decision-making process. Interviews were audio-recorded, transcribed verbatim, and analyzed using the framework method. Results. We identified 3 themes: 1) from automatic exclusions to more collaborative decision making; (2) "risk appetite," uncertainty, and information gaps; and 3) the role of recipients and their families in decision making. Deceased donor medical suitability was determined by a complex interplay of clinical practice guidelines, guidance from colleagues, and personal risk propensity, with variability in decision making irrespective of standardized information provision. Decisions that a potential donor was unsuitable were often driven by compounding risks, accentuated in the context of missing information and incomplete medical histories. Considering both potential donor and potential recipient profiles in tandem and including potential recipients and/or their families in decision making was considered important. However, narratives were marked by frustration with patients' risk propensity and challenges with communication under time pressure. Conclusion. Clinicians assessing the medical suitability of potential deceased organ donors face challenges such as incomplete medical histories and communication barriers. Decision-support tools and early engagement with potential recipients and their families to elicit their preferences and risk tolerance could aid clinicians in making more informed decisions under time pressure.

Highlights: In this qualitative study with Australian donation specialists, we found that potential deceased donor medical suitability was determined by a complex interplay of clinical practice guidelines, guidance from colleagues, and personal risk propensity, with variability in decision making irrespective of standardized information provision.Decisions to forego a potential donor were often driven by compounding risks and worsened by missing information and incomplete medical histories.Considering both potential donor and recipient profiles in tandem and including the recipient and/or their families in decision making were considered important but challenging under time pressure.

Keywords: medical decision making; organ donation; risk; transplant.

Figure 1

Organ referral process in NSW, showing biovigilance decision points.