Ethical conflicts experienced by nurses during the organ donation process

Abstracts

Objective

To determine ethical conflicts experienced by nursing during the organ donation process.

Methods

This qualitative study used the content analysis approach developed by Bardin. We interviewed eleven nurses who had cared for potential donors of organs for transplantation. Four questions were used to guide the interview.

Results

After analysis, five categories emerged: difficulty in accepting brain death; non-acceptance of the multidisciplinary team for withdrawing mechanical ventilation of the non-donor patient after brain death; difficulty of the multidisciplinary team during the organ donation process; and situations that can interfere with the organ donation process and decision making in ethical conflicts.

Conclusion

Ethical conflicts experienced by nurses during the organ donation process were difficulty of health care professionals in accepting brain death as the death of the individual, non-acceptance of withdrawing mechanical ventilation in non-donor patients after brain death, lack of knowledge to perform the brain death protocol, lack of commitment, negligence in care for potential donors, scarcity of human and material resources, religion, and lack of communication.

Ethics, nursing; Transplantation; Direct tissue donation; Conflict (Psychology); Qualitative research

Objetivo

Conhecer os conflitos éticos vivenciados pelos enfermeiros no processo de doação de órgãos.

Métodos

Pesquisa qualitativa utilizando a análise de conteúdo de Bardin. Foram entrevistados onze enfermeiros, com experiência na assistência a potenciais doadores de órgãos para transplante. Foram utilizadas quatro questões norteadoras.

Resultados

Emergiram cinco categorias: dificuldade em aceitar a morte encefálica; não aceitação da equipe multiprofissional de desconectar o ventilador mecânico do paciente em morte encefálica não doador de órgãos; dificuldades da equipe multiprofissional durante o processo de doação de órgãos; situações que podem interferir no processo de doação de órgãos e Tomada de decisão frente a conflitos éticos.

Conclusão

Os conflitos éticos vivenciados pelos enfermeiros no processo de doação de órgãos foram: a dificuldade do profissional em aceitar a morte encefálica como morte do individuo, a não aceitação em desconectar o ventilador mecânico do paciente em morte encefálica e não doador de órgãos, o desconhecimento para a realização do protocolo de morte encefálica, a falta de comprometimento, o descaso no cuidado com o potencial doador a escassez de recursos humanos e materiais a crença religiosa e a falha na comunicação.

Ética em Enfermagem; Transplante; Doção dirigida de tecidos; Conflito (Psicologia); Pesquisa qualitativa

Introduction

Organ transplantation is the last therapeutic alternative for patients with certain severe, acute or chronic disease when there are no other forms of treatment. Transplantation can reverse the clinical picture and aiming to improve the patient’s quality of life.

The process of organ donation involves several agents and actions on the part of nursing professionals for the care of potential donors. The goal is to maintain hemodynamics and the viability of the organ for transplantation. Nurses are also responsible for coordinating the relationship with the donor’s families, who are experiencing the pain of losing a family member yet must also decide whether to donate their loved one’s organs.

The actions of health professionals are guided by codes of professional ethics; however, the decision making can be based on the needs experienced in their day-to-day work.(¹,²)

Given the many advances in biomedical science that occurred in the second half of the 20th century, professional ethical codes are not enough. Organ and tissues transplantation brought extensive discussions about the ethics of decision-making with regard to encouraging organ donation and the process for donating and transplanting organs. (³)

To solve conflicts, ethical analysis of all the related facts is necessary. Knowledge of the theoretical ethics that guide and systematize decision-making is also important. Considering this, knowledge of nurses’ ethical conflicts during the organ and tissues donation process can contribute to reflections and discussions concerning this topic and help the nursing team to understand and advise families as they make their decision.

The objective of this study was to determine nurses’ ethical conflicts on the process for organ and tissue donation for transplantation and, in the face of these conflicts, to understand how decisions are made and what is take into consideration.

Methods

This qualitative study was carried out in a large hospital in São Paulo, Brazil, to determine the experience of nurses facing ethical conflicts during the organ and tissue donation process. We included 11 nurses who delivered care for potential donors, for at least one year, at adult and pediatric critical care units, inpatient units, emergency departments, and surgical centers and nurses on the in-hospital committee for organ and tissues donation for transplantation.

The following questions were used to guide the interviews: “During your professional experience, did any situations pose a conflict of ethics for you?” “Can you report some ethical conflicts that you experienced or observed while providing care of potential organ donors?” “How do you make a decision in a situation of ethical conflict?” “What do you consider when you are making a decision?”

Discourses were analyzed using the content analysis approach proposed by Bardin. Development of this study followed national and international ethical aspects in research on human subjects.

Results

Eleven professionals who experienced ethical conflicts during the organ and tissue donation process participated in this study. Of these, nine were women and two were men; the age range was 26 to 39 years. The mean time since graduation from college was eight years. The participants had worked at the institution for four to 19 years. Most interviewees worked in adult and pediatric critical care units. The following categories were identified during analysis of the interview responses:

Difficulty accepting brain death

Not only physicians and nurses have difficulty accepting brain death; the family members of the potential donors do as well.

The study participants expressed ambiguous feelings when confronted with the care of potential donor: While they recognized that the death of one patient can enable the other to continue living, they also were aware that the potential donor’s heart was still beating despite brain death and that the person should receive care in the same manner as if he or she were alive.

The respondents also resisted starting the brain death protocol because of the difficulty in dealing with death and the acceptance the brain death; this behavior is a barrier to proving the diagnosis of brain death. The same was observed during the interview with family members who showed difficulty accepting brain death.

Non-acceptance of multidisciplinary team of withdrawing mechanical ventilation to non-donor patient after brain death

This category represents a major source of conflict experienced by nurses when physicians, and nurses themselves, are reluctant not withdraw mechanical ventilation for a brain-dead patient who is not an organ donor.

Although nursing professionals are aware of the existence of legislation and institutional protocols to support the removal of mechanical ventilation, they emphasize the non-acceptance of withdrawing this measure. The difficulty concerns not only disconnecting the device but also explaining the situation to the family.

For the nurse, removing mechanical ventilation from someone whose heart is beating, even after the diagnosis of brain death, generates the impression that he/she has given up and is “killing” the patient. Nurses also experience this feeling in situations when physicians are undecided about removing the device, and for them it appears that physicians are deciding whether they will let the patient die or not, although the patient is already dead. When nurses recognize that the institutional guidelines for removing mechanical ventilation in non-donor patients after brain death must be followed, they often find a barrier in the form of non-acceptance by physicians. This situation creates a stalemate between the nurse and physician. It also generates discomfort with regard to keeping a patient who has already died on artificial support, and postpones addressing the wishes of the family to receive their loved one’s body for a funeral.

In addition, nurses report problems with families who do not agree to remove the support from the patient because they believe that a miracle will occur and the person will awaken.

Difficulties of multidisciplinary team during the organ donation process

Difficulties reported by the multidisciplinary team involve nurses’ conflicts during the organ donation process. These are related to the medical team’s lack of knowledge regarding how to carry out the brain death protocol and the lack of commitment on behalf of the health care professionals. This leads to negligence and inadequate assistance in caring for the brain-dead patient.

Nurses reported that the medical team has doubts about how and when to determine brain death. This situation generates conflict for family members because they are informed before the diagnosis and for the nursing team, who, at the conclusion of the brain death protocol, have several questions that create uncertainty and doubt. This situation is even worse when there are divergent opinions among the medical team about the appropriate way to conduct the protocol.

Situations that can interfere in the organ donation process

The nurses identified the following situations as presenting ethical conflicts and as interfering in the organ donation process: religion, lack of communication, difficulties in interpersonal relationships, and scarcity of human and material resources. Nurses reported that such situations cause indifference, lack of commitment, and dissatisfaction, which affect the effective deployment of the process.

Decision-making when facing ethical conflicts

When nurses face ethical conflicts, they often make decisions based on discussion. They reported that communication and team work are important aspects in this process, but it was not clear from what basis the professional assumes a position regarding the conflict. Concerns about legislation and the principle of beneficence were identified when actions performed for the purpose of benefiting another person were mentioned. In the case of organ donation and transplantation, there is greater benefit with an intervention that saves lives.

Discussion

Ethical conflicts experienced by nurses were structured into five categories. Their experience confirmed what has been described in other studies with nurses during the organ donation process.

The analysis of results enables us to reflect on the perceptions of nurses who confront ethical conflicts in practice during the organ donation process. It also can be used to support professionals who seek to improve their actions in resolving ethical conflicts over organ and tissue donation for transplantation.

Although the concept of death is related not only to cardiorespiratory arrest but also to the absence of cerebral and encephalic trunk activity (i.e., brain death equals death), several uncertainties exist among health professionals because of the belief that life exists while the heart is beating. For both the health care team and families, the maintenance of potential donors with a beating heart in the critical care unit generates the feeling that the patients are still alive.

Currently, medical and nursing practice in the context of continual advances and increased technological resources results in a battle between knowledge and cultural pressures. Often, these situations imply changes in values about life, generating insecurity among professionals and repercussions for the patient.

This reality indicates that society is still changing its perceptions about life and is still trying to understand the definition of death. Changes to culture and human values require time for the creation of new conceptions and experiences. Previous studies agree with these assumptions, having found that most of the studied populations did not accept brain death as death.(⁴-¹⁰) In Brazil, the diagnosis of brain death in patients with clinical signs of brain death is confirmed by two clinical exams and one complementary test, which are part of care delivery for patient and their families. A major conflict reported by the nurses in our study concerns withdrawing therapeutic support for non-donor patients with a diagnosis of brain death. The justification of withdrawal would be to avoid additional costs and avoid prolonging the suffering of families. Despite knowledge of the existence of legislation and institutional protocols that support the disconnection of the ventilator, professionals emphasize non-acceptance for several reasons, such as the respect for personal, cultural, and social values; concern about creating conflicts with families who would not accept organ donation; concern regarding legal problems; lack of societal preparation to understand the procedure; and family members’ belief that the patient’s clinical course could reverse. Other studies agree with this affirmation and show that health care professionals have difficulty accepting the diagnosis of brain death as death and, consequently, do not accept withdrawal of life support after this diagnosis.(¹¹,¹²)

Removing life support might cause discomfort because the individual appears to be alive through artificial maintenance.(¹³) However, criteria for brain death seem to be accepted; there is little resistance to removal of the organs for transplant but rather to the withdrawing of devices. This contradiction leads to beliefs that brain death is usually considered only for transplantation, when, in fact, it means death, independent of whether or not the organs will be used. The beating heart affects the performance of the procedure, and this difficulty increases when there are conflicts between medical team and family members, or when personal values and religion are involved.(¹³,¹⁴)

Difficulties reported by multidisciplinary teams during the organ donation process, such as lack of knowledge, negligence, and lack of commitment and professionalism, confirmed the results of earlier studies.(¹⁵-¹⁷) In general, research reveals that lack of knowledge about the organ donation process has a negative impact on attitudes toward organ donation, even among health professionals, which can lead to not identifying potential donors and not performing the brain death protocol, identified in practice by actions of professionals involved.(⁴-⁶,⁸)

Nurses perceived religion, lack of communication, and scarcity of human and material resources as situations that could interfere in the process of organs donation.

Religion is an important factor in decision-making in many areas. A study on religion and organ and tissue donation highlighted that any religion is absolutely opposed to organ donation; however, the degree of understanding about religions concerning the moment of death is diverse.(¹⁸) Some religions perform rituals with the body after death, which constitutes a negative factor for organ donation authorization.(¹⁸) In practice, some families have refused to donate and justify their decisions on the basis of their religion; the impression is that families invoke religion in an attempt to ameliorate the difficulty of making the decision.(¹⁴)

Other conflicts experienced by nurses, such as the difficulty with interpersonal relationships and scarcity of human resources, can trigger disappointment, disrespect, lack of teamwork, and lack of communication, all of which result in negligence and poor care for the patient. The nurses in this study believe that these conflicts pose difficulties during development of their activities.

To resolve conflicts, an ethical analysis of related facts is necessary, as is knowledge of the types of ethical theories to direct and systematize decision making.(¹⁹) However, in nurses’ decision making we did not identify ethical streams to support their positions. Nonetheless we did find support for the notion of beneficence and concern with legislation regarding brain death, and observed that the nurses emphasize use of discussion in these situations.

Conclusion

Ethical conflicts experienced by nurses during the organ donation process were health care professionals’ difficulty accepting brain death as the death of the individual, non-acceptance of withdrawing mechanical ventilation of the non-donor patient after brain death, lack of knowledge to perform the brain death protocol, lack of commitment, negligent care for the potential donor, scarcity of human and material resources, religion, and lack of communication.

Referências

• ¹
  Coelho LC, Rodrigues RA, Marcon SS, Lunardi VL. Conflitos éticos na revelação de informações - Parte II. Cienc Cuid Saúde. 2008; 7(1):73-82.
• ²
  Fernandes JD, Rosa DD, Vieira TT, Sadigursky D. Dimensão ética do fazer cotidiano no processo de formação do enfermeiro. Rev Esc Enferm USP. 2008;42(2):396-403.
• ³
  Lima AA, Silva MJ, Pereira LL. Sofrimento e contradição:o significado da morte e do morrer para enfermeiros que trabalham no processo de doação de órgãos para transplante. Enferm Global. 2009;(15):1-16.
• ⁴
  Teixeira RK, Gonçalves TB, Silva JA. A intenção de doar órgãos é influenciada pelo conhecimento populacional sobre morte encefálica? Rev Bras Ter Intensiva. 2012;24(3):258-62.
• ⁵
  Cohen J, Ami SB, Ashkenazi T, Singer P. Attitude of health care professionals to brain death: influence on the organ donation process. Clin Transplant. 2008;22(2):211-5.
• ⁶
  Escobar EM. Importancia de los cuidados intensivos en la donación y el trasplante de órganos. Rev Bras Ter Intensiva. 2012; 24(4):316-7.
• ⁷
  Flóden A, Berg M, Forsberg A. ICY nurses’ perceptions of responsibilities and organization in relation to organ donation – A phenomenographic study. Intensive Crit Care Nurs. 2011;27(6):305-316.
• ⁸
  Everidge CS, Donation After Cardiac Death – Ethical dilemmas and implications for advanced pratice nurses. Dimens Crit Care Nurs. 2012; 31(4):228-34.
• ⁹
  Mathur M, Taylor S, Tiras K, Wilson M, Abd-Allah S. Pediatric critical care nurses’ perceptions, knowledge, and attitudes regarding organ donation after cardiac death. Pediatr Crit Care Med. 2008;9(3):261-9.
• ¹⁰
  Moraes, EL, Carneiro AR, Araújo MN, Santos FS, Massarollo MC. Desconexão do ventilador mecânico de não doadores de órgãos: percepção de médicos intensivistas. Bioethikós (Centro Universitário São Camilo). 2011;5(4):419-26.
• ¹¹
  Shein AE, Carvalho PR, Rocha TS, Guedes RR, Moschetti L, Salvia JC, et al. Avaliação do conhecimento de intensivistas sobre morte encefálica. Rev Bras Ter Intensiva. 2008;20(2):144-148.
• ¹²
  Bitencourt AG, Neves FB, Durães L, Nascimento DT, Neves NM, Torreão LA, et al. Avaliação do conhecimento de estudantes de medicina sobre morte encefálica. Rev Bras Ter Intensiva. 2007;19(2):144-50.
• ¹³
  Lago PM, Piva J, Garcia PC, Troster E, Bousso A, Sarno MO, et al. Morte encefálica: condutas médicas adotadas em sete unidades de tratamento intensivo pediátrico brasileiras. J Pediatria. 2007;83(2):133-40.
• ¹⁴
  Moraes EL, Massarollo MC. Recusa de doação de órgãos para transplante relatados por familiares de potenciais doadores. Acta Paul Enferm. 2009; 22(2):131-5.
• ¹⁵
  Lemes MM, Bastos MA. Os cuidados de manutenção dos potenciais doadores de órgãos: estudo etnográfico sobre a vivência da equipe de enfermagem. Rev Latinoam Enferm. 2007;15(5):986-91.
• ¹⁶
  Monteiro MA, Barbosa RC, Barroso MG, Vieira NF, Pinheiro AK. Dilemas éticos vivenciados por enfermeiros apresentados em publicações de enfermagem Rev Latinoam Enferm. 2008;16(6):1054-9.
• ¹⁷
  Guido LA, Linch GF, Andolhe R, Conegatto CC, Tonini CC. Estressores na assistência de enfermagem ao potencial doador de órgãos Rev Latinoam Enferm. 2009;17(6):1023-9.
• ¹⁸
  Ambrosina M, Regina F. Crença religiosa e doação de órgãos e tecidos: revisão integrativa da literatura. Rev Enferm UFSM. 2011;1(3):44-57.
• ¹⁹
  Mascarenhas NB, Rosa DO. Bioética e formação do enfermeiro: uma interface necessária. Texto & Contexto Enferm. 2010;19(2):366-71.

Publication Dates

• Publication in this collection
  July 2014

History

• Received
  13 Jan 2014
• Accepted
  29 Apr 2014