Brain death and tissue and organ transplantation: the understanding of medical students

Abstracts

Objective:

To evaluate the level of knowledge of medical students about transplantation and brain death.

Methods:

An anonymous self-administered questionnaire answered by medical students from the first through the sixth year that was based on information from the Associação Brasileira de Transplante de Órgãos e Tecidos, the Registro Brasileiro de Transplantes and the resolution that defines the criteria for brain death.

Results:

Of the 677 medical students asked, 310 (45.8%) agreed to answer the questionnaire. In total, 22 (7.0%) subjects were excluded. Of the students who participated, 41.3% reported having already attended a class on organ transplantation and 33% on brain death; 9.7% felt able to diagnose brain death (p<0.01); only 66.8% indicated the kidney as the most transplanted solid organ in Brazil.

Conclusion:

The level of knowledge of medical students at this institution regarding brain death and transplantation is limited, which may be the result of an inadequate approach during medical school.

Students, medical; Organ transplantation; Tissue and organ procurement; Brain death; Questionnaire; Education, medical

Objetivo:

Avaliar o nível de conhecimento dos acadêmicos de Medicina sobre transplante e morte encefálica.

Métodos:

Questionário autoaplicado não identificado respondido pelos alunos do curso de Medicina do primeiro ao sexto ano, com base em informações da Associação Brasileira de Transplante de Órgãos e Tecidos, Registro Brasileiro de Transplantes e pela resolução que define os critérios para morte encefálica.

Resultados:

Dos 677 alunos do curso de Medicina, 310 (45,8%) concordaram em responder. Foram excluídos 22 (7,0%) pacientes. Dos que participaram, 41,3% informaram que já assistiram à aula sobre transplante de órgãos e 33% sobre morte encefálica; 9,7% se sentiram aptos a diagnosticar morte encefálica (p<0,01); apenas 66,8% responderam o rim como o órgão sólido mais transplantado no Brasil.

Conclusão:

O nível de conhecimento sobre morte encefálica e transplantes dos alunos de Medicina da instituição é limitado, o que pode ser resultado de uma abordagem inadequada durante o curso de Medicina.

Estudantes de Medicina; Transplante de órgãos; Obtenção de tecidos e órgãos; Morte encefálica; Questionários; Educação médica

INTRODUCTION

Organ transplantation is an alternative for the treatment of certain diseases that are otherwise considered terminal.⁽¹⁾ Kidney and liver transplants have increased in the last few years.^(1,2) In contrast, the rates of lung, heart and pancreas transplants have remained stable in the last 10 years.⁽²⁾ Nonetheless, the waiting lists are still long and, many times, patients die before they are called, mainly because of the low number of effective donors.⁽³⁾

According to Amaral et al.⁽⁴⁾ the effectiveness of the transplant process depends on the knowledge of the population on the subject. The main individual responsible for transmitting this knowledge is the doctor, who often does not participate in the donation process. Thus, the poor knowledge of the physician (being unaware of a brain death (BD) diagnosis and maintaining a potential donor) regarding transplantation may negatively influence every step of the donation process.

To overcome this situation, it is important that more cases of BD be properly identified and that doctors know the transplantation process flowchart, in addition to training competent professionals in this area, to increase transplant numbers.⁽⁴⁾ Therefore, one effective strategy is to act early in the medical education system, focusing medical studies on transplant, including the BD diagnosis, identification of potential donors, and forming procurement teams and specific organ transplant teams in all areas.⁽⁵⁾

The Sistema Único de Saúde (SUS) in the State of São Paulo has the largest chain of high-complexity services in Brazil, a fact that is reflected in the characteristics of its production, which is, proportionately, more specialized in its procedures than the rest of the country. Thus, while the State of São Paulo has 22% of the population of Brazil, SUS/SP oversaw 29% of the high-complexity hospitalizations and 42% of the transplant hospitalizations in 2009 compared to the country as a whole.⁽⁶⁾ The majority (58.5%) of the people in the State of São Paulo are concentrated in three metropolitan areas: Greater São Paulo, Campinas and Santos.⁽⁷⁾ The first two have transplant services available that are mostly affiliated with training centers.

The present study aimed to assess the understanding of medical students at a private university with respect to BD and transplantation.

METHODS

Study design and population studied

This study was a cross-sectional descriptive study conducted with students from the first through the sixth year of medical school in a private college in the city of Santos (State of São Paulo - SP) that was affiliated with a reference public hospital. This hospital serves a population of over 1.6 million people living in nine counties of the Baixada Santista,⁽⁷⁾ but it does not have a transplant service, despite having two educational centers and 1,600 medical beds, 737⁽⁸⁾ of which are from the SUS.

The participants were asked to answer a voluntary anonymous questionnaire, to assess their degree of understanding about the organ donation process, BD diagnostic criteria and knowledge about the national scope of the transplant program. The study was initiated after it was approved by the Human Research Ethics Committee of the Centro Universitário Lusíada - UNILUS (protocol number 114/2011), and informed consent was obtained from all of the participants.

Research instrument

Because there have been few studies with the same purpose as the present study, no validated tools were found, which required the application of a questionnaire developed by the authors that considered basic information on transplants provided by the Associação Brasileira de Transplante de Órgãos - ABTO),⁽⁹⁾ the Registro Brasileiro de Transplantes - RBT⁽²⁾ and Resolution No. 1,480/97 of the Federal Council of Medicine (Conselho Federal de Medicina - CFM),⁽¹⁰⁾ which defines the criteria for a BD diagnosis.

The questions were divided into three parts: (1) characterization of the population; (2) assessment of knowledge about the national scope of organ transplantation; and (3) assessment of knowledge about the diagnostic criteria for BD.

Population selection

The invitation was extended to all of the students of the institution, and the study was presented in class with the teachers' permission. The students were invited to participate after their learning activities, and those who signed the Informed Consent Form (ICF) were included. Students in boarding regimens were contacted at their respective wards. Anonymous self-administered questionnaires were used, and the participants were requested to return the questionnaire within 20 minutes. The completed forms were deposited at a specific location out of sight of the researchers. The approach in the classroom and in the wards was conducted in a standardized way over only one month to ensure that the collection was concurrent between students. Those participants who exceeded the 20-minute time limit to return the questionnaire were excluded.

Statistical analysis

Students from the first through the sixth year were divided into three subgroups: (1) first and second year; (2) third and fourth year; and (3) fifth and sixth year. There was no sample size calculation because we intended for all of the students to participate in the study. The statistical analysis was performed using the JMP 5.1 software. After a general description of the population, the differences were analyzed by the chi-squared test with a significance level of 5% (p=0.05).

RESULTS

Characterization of the students and their opinions on the subject

Of the 677 medical students, 310 (45.8%) agreed to answer the questionnaire. Of these students, 22 (7%) returned the questionnaire without answering it or answered it in more than 20 minutes and were excluded from the study. The remaining students were not present at the time of the initial approach (Table 1). Of the participants, 41.3% reported having already attended a class on organ transplantation, including 14% in group 1, 43.6% in group 2 and 78.9% in group 3 (p<0.01). In total, 33% reported having attended a class on BD: 2.8% in group 1, 41.8% in group 2 and 62.8% in group 3 (p<0.01). In the self-assessment, 25.5% considered their knowledge level about organ transplantation as excellent or good, and 9.7% felt able to diagnose BD (p<0.01).

Table 1

Characteristics of the students

	1st year	2nd year	3rd year	4th year	5th year	6th year	Total	p value
Enrolled students	80	85	147	169	91	105	677
Number of participants	67	40	42	68	53	18	288
Number of refusals/other losses	3/10	8/37	0 / 85	8/93	3/35	0 / 87	22 / 367
Adherence	83.7	47	28.6	40.2	58.2	17.1	42.5
Mean age (years)	19.80±2.03	20.67±1.73	22.02±2.28	22.83±1.78	22.86±1.80	25.16±2.57	21.86±2.47
Gender								0.31
Female	46 (68.7)	26 (65.0)	27 (64.3)	48 (70.6)	39 (73.6)	8 (44.4)	194 (67.4)
Male	21 (31.3)	14 (35.0)	15 (35.7)	20 (29.4)	14 (26.4)	10 (55.6)	94 (32.6)

• Results expressed in number or percentage (%); mean age±standard deviation. Chi-square test

Assessment of knowledge about the national scope of organ transplantation

Regarding living donor transplantation, 98.9% thought that this type of procedure could be performed (Table 2) with the kidneys (96.2%), bone marrow (90.3%), liver (63.2%), lungs (27.8%) and heart (2.8%).

Table 2

Assessment of the knowledge about the national scenario of organ transplantation

Questions	Curricular year
	1st/2nd	3rd/4th	5th/6th	Total	p value
Organ transplantation is a:					0.41
Treatment	71 (67.0)	64 (59.2)	47 (67.0)	182 (64.0)
Cure	35 (33.0)	44 (40.8)	23 (32.0)	102 (36.0)
Total	106 (100)	108 (100)	70 (100)	284 (100)
Which one is the most transplanted organ in Brazil?					<0.01*
Kidney	53 (50.5)	83 (75.4)	55 (77.4)	191 (66.8)
Liver	37 (35.2)	11 (10.0)	16 (22.6)	64 (22.4)
Lung	4 (3.8)	7 (6.4)	0 (0.0)	11 (3.8)
Heart	11 (10.5)	9 (8.2)	0 (0.0)	20 (7.0)
Total	105 (100)	110 (100)	71 (100)	286 (100)
Can people under 18 years old be donors?					0.7
Yes	82 (77.4)	86 (78.9)	57 (82.6)	225 (79.2)
No	24 (24.6)	23 (21.1)	12 (17.4)	59 (20.8)
Total	106 (100)	109 (100)	69 (100)	284 (100)
Is it possible to perform living donor transplantations?					0.07
Yes	104 (97.2)	110 (100)	71 (100)	285 (98.9)
No	3 (2.8)	0 (0.0)	0 (0.0)	3 (1.1)
Total	107 (100)	110 (100)	71 (100)	288 (100)

• Results expressed in numbers (%). Chi-square test.* The p value refers to the comparison between the kidney and the other organs.

Regarding exclusion from the waiting list as a recipient, the students thought that the following patients should be excluded: drug users (33.7%), alcoholics (24.6%), non-donors (7.3%), foreigners (4.2%) and criminals (2.8%), and 57.6% thought that no one should be excluded. Regarding exclusion of donors, students reported that HIV+ patients (89.6%), cancer patients with metastases (83%), patients with brain tumors without metastasis (6.6%) and patients with sepsis or multi-organ system failure (MOSF) (75%) should be excluded. Among all the students, 77% thought that SUS pays for living donor transplantation and deceased donor transplantation, 16.3% thought that SUS only pays for deceased donor transplantation, and 4.9% thought that SUS only pays for living donor transplantation.

Evaluation of knowledge about brain death

Regarding BD diagnosis, 66.0% of the students thought that two doctors not members of the transplantation team would be necessary, which was a more frequent belief in the group of 5^th and 6^th year students (p<0.01); 43.7% of the students thought that two clinical evaluations with a time interval determined by the age of the patient would be necessary (p=0.09). As a complementary test, 35.4% of the students indicated the need for a transcranial Doppler (p<0.01). Regarding an indication to perform resuscitation in the event of cardiorespiratory arrest, 78.1% thought that the patient should be resuscitated (p=0.46) (Table 3).

Table 3

Assessment of the knowledge about brain death

Questions	Curricular year
	1st/2nd	3rd/4th	5th/6th	Total	p value
Regarding the diagnosis
Two doctors not affiliated with transplant	53 (49.5)	77 (70.0)	60 (84.5)	190 (66.0)	<0.01
Two clinical assessments with a time interval that varies according to the age	38 (35.5)	53 (48.2)	35 (49.3)	126 (43.7)	0.09
Regarding complementary exams used for diagnosis
Cerebral angiography	36 (33.6)	31 (28.2)	36 (50.7)	103 (35.8)	<0.01
Transcranial Doppler	14 (13.0)	44 (40.0)	44 (62.0)	102 (35.4)	<0.01
Skull x-ray	7 (6.5)	4 (3.6)	1 (1.4)	12 (4.8)	0.22
Electroencephalogram	88 (82.2)	92 (83.6)	56 (78.9)	236 (81.9)	0.71
Regarding the indication to perform resuscitation maneuver in case of CRA	71 (80.7)	62 (79.5)	42 (72.4)	175 (78.1)	0.46

• CRA - cardiorespiratory arrest. Results expressed in numbers (%). Chi-square test.

DISCUSSION

The present study showed that medical students have a low level of knowledge about organ and tissue transplantation and BD. The subject of organ transplantation is not addressed uniformly in the curriculum of medical schools.⁽¹¹⁾ In addition, the low level of knowledge about BD is due, in part, to the limited contact that students have with this subject prior to graduation.⁽¹²⁾ Regarding the medical education at the institution studied, there is only one specific class about kidney transplantation in the nephrology division and one class about BD in the clinical neurology division. However, students have shown a proactive posture in seeking out this specific information given that 41% of the respondents had encountered the subject of transplantation in activities outside the regular curriculum (academic leagues, transplant modules at academic conferences and others).

In the present study, the mean response rate was 42.5% of the students, which was higher than the study of Galvão et al.,⁽¹³⁾ (32%), which analyzed students from a public medical school in São Paulo, and higher than a South African study⁽¹⁴⁾ (30%) with a similar objective.

To increase the number of transplants, doctors should be able to diagnose BD.^(15,16) In the studied school, in total, 90.3% of the students did not feel able to diagnose BD, though there was a significant difference between the overall rate and the rate for students from group 3. Ten years ago, Amaral et al. conducted a similar study with teachers and found that 44% of them could not diagnose BD.⁽⁴⁾ In Belo Horizonte (State of Minas Gerais - MG), a study found that 83.5% of the students performing self-assessments had only "a little" knowledge about BD.⁽⁵⁾

In summarizing the results, we would emphasize that only three findings were significant (p<0.05) in a way that was consonant with the increasing knowledge of the students throughout the graduation: the kidney as the most commonly transplanted organ in Brazil; two physicians not affiliated with the transplantation are required to diagnose BD; and the transcranial Doppler as a complementary test to diagnose BD.

The present study had limitations because it used a single center, there was no sample size calculation, the questionnaire was not validated, and there was some difficulty in finding students in grade sixth because the board regimen stages do not always take place in the hospital (basic health units and secondary hospitals).

Brazil hit the mark of 12.6 donors per million inhabitants in 2012,⁽²⁾ and this is an insufficient number compared with developed countries. Spain, which is a reference nation for its organ procurement model, had a rate of 35.3 donors per million in the same period.⁽¹⁷⁾ This difference exists, at least in part, because doctors are alert to potential donors, diagnose BD early and contact the central procurement agency. Organ transplantation is a reality of everyday medical practice for which the recognition of potential donors is extremely important. Thus, medical education is essential for the adequate functioning of the national transplant program.⁽¹⁸⁾

CONCLUSION

The level of knowledge of medical students at our institution regarding brain death and transplantation is limited, which could be the result of inadequate education during medical school.

REFERÊNCIAS

• ¹
  Lima CX, Lima MV, Cerqueira RG, Cerqueira TG, Ramos TS, Nascimento M, et al. Organ donation: cross-sectional survey of knowledge and personal views of Brazilian medical students and physicians. Transplant Proc. 2010;42(5):1466-71.
• ²
  Associação Brasileira de Transplante de Órgãos. Dados numéricos da doação de órgãos e transplantes realizados por estado e instituição no período: janeiro/dezembro - 2012. Registro Brasileiro de Transplantes. 2012;18(4). [internet]. [acesso em 22 fev. 2012]. Disponível em http://www.abto.org.br/abtov03/Upload/file/RBT/2012/rbt2012-parciall.pdf
  » http://www.abto.org.br/abtov03/Upload/file/RBT/2012/rbt2012-parciall.pdf
• ³
  Arbour R. Clinical management of the organ donor. AACN Clin Issues. 2005;16(4):551-80; quiz 600-1. Review.
• ⁴
  Amaral AS, Roza BA, Galvão FH, Jardim KM, Medina-Pestana JO. Knowledge of organ donation among one group of Brazilian professors of medicine. Transplant Proc. 2002;34(2):449-50.
• ⁵
  Oliveira Júnior RE, Saldanha BO, Oliveira AP, Santos EA, Oliveira MP, Pereira WA, et al. Conhecimento sobre morte encefálica e doação de órgão entre estudantes de medicina de Belo Horizonte. J Bras Transpl. 2009;12(3):1149-53.
• ⁶
  Barata LR, Mendes JD, Bittar OJ. Hospitais de ensino e o sistema único de saúde. Rev Adm Saúde. 2010;12(46):7-14.
• ⁷
  Bittar OJ. Inúmeros números do planejamento de saúde. Rev Adm Saúde. 2005;7(28):79-94.
• ⁸
  DATASUS. Ministério da Saúde. Cadastro Nacional de Estabelecimentos de Saúde (CNES). CNES - Recursos Físicos - Hospitalar - Leitos de internação - São Paulo. [internet]. [acesso em 27 fev. 2013]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?cnes/cnv/leiintsp.def
  » http://tabnet.datasus.gov.br/cgi/tabcgi.exe?cnes/cnv/leiintsp.def
• ⁹
  Associação Brasileira de Transplante de Órgãos e Tecidos. Doação de órgãos e tecidos [Internet]. [citado 2011 Out 18]. Disponível em: http://www.abto.org.br/abtov02/portugues/profissionais/doacao/doacao.aspx
  » http://www.abto.org.br/abtov02/portugues/profissionais/doacao/doacao.aspx
• ¹⁰
  Brasil. Lei nº 9434/97 de 04 de fevereiro de 1997. Dispõe sobre a remoção de órgãos, tecidos e partes do corpo humano para fins de transplante e tratamento. Brasil. Resolução CFM nº 1480/97, de 08 de agosto de 1997. Regulamenta o termo de Declaração de Morte Encefálica.
• ¹¹
  Garcia CD, Goldani JC, Neumann J, Chem R, Chem E, Camargo JJ, et al. Importância do programa educacional de doação e transplante em escolas médicas. J Bras Transpl. 2009;12(1):1049-51.
• 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
  Galvao FH, Caires RA, Azevedo-Neto RS, Mory EK, Figueira ER, Otsuzi TS, et al. Conhecimento e opinião de estudantes de medicina sobre doação e tranplante de órgãos. Rev Assoc Med Bras. 2007;53(5):401-6.
• ¹⁴
  Sobnach S, Borkum M, Hoffman R, Muller E, McCurdie F, Millar A, et al. Medical students' knowledge about organ transplantation: a South African perspective. Transplant Proc. 2010;42(9):3368-71.
• ¹⁵
  Maia BO, Amorim JS. Morte encefálica: conhecimento de acadêmicos de enfermagem e medicina. J Bras Transpl. 2009;12(2):1088-91.
• ¹⁶
  Tessmer MG, Mielke GI, Barcellos FC, Moraes BP, Gatto CS. Doação de órgãos: opinião e entendimento sobre morte encefálica de estudantes universitários. J Bras Transpl. 2011;14(1):1466-71.
• ¹⁷
  Organización Nacional de Trasplantes. Memoria de actividad de donación. [internet] 2011. [acesso em 14 out. 2012]. Disponível em: http://www.ont.es/infesp/Memorias/MemDon2011.pdf
  » http://www.ont.es/infesp/Memorias/MemDon2011.pdf
• ¹⁸
  Pêgo-Fernandes PM, Garcia VD. Estado atual do transplante no Brasil. Diagn Tratamento. 2010;15(2):51-2.

Publication Dates

• Publication in this collection
  Oct-Dec 2013

History

• Received
  10 July 2013
• Accepted
  19 Sept 2013