Acceptance Level of Living Liver Donation Among Primary Care Nursing Personnel C. Conesa, A. Rı´os, P. Ramı´rez, J. Sánchez, E. Sánchez, M.M. Rodrı´guez, L. Martı´nez, F. Ramos, and P. Parrilla ABSTRACT Introduction. Living liver donation is not exempt from risks to the donor, although it is currently ethically accepted. It is important to examine the level of acceptance among the different health levels toward this therapeutic option, in order to design promotion and awareness-raising activities. The objective herein was to analyze the attitudes and the factors that condition them among nursing personnel in Primary Care (PC) toward living liver donation. Materials and Methods. This random survey was stratified by geographical location (6 health areas in our community) among PC nurses, obtaining a total of 139 nurses from 34 health centers. Attitudes toward living liver donation were evaluated using a questionnaire on donation which included different psychosocial variables. For the distribution of the questionnaire, the nursing coordinator of each centers was contacted to distribute questionnaires which were completed anonymously. The chi-square test and Student t test were applied. Results. Attitudes toward living liver donation were favorable in 89% of those questioned (n ⫽ 124) if it is related donation; 3% (n ⫽ 4) were against donating a living hemiliver and 8% (n ⫽ 11) had doubts. It is important that up to 76% (n ⫽ 106) have cared for transplant patients or patients awaiting transplant, however, no relationship was observed with attitude to this type of donation (P ⫽ .489). Of all the analyzed variables, there was only a significant relationship between attitudes and concern about possible body mutilation (P ⬍ .0005), and partners attitudes toward this matter (P ⬍ .0005). It is noteworthy that no relationship was found with attitudes toward cadaveric donation (P ⫽ .062). Conclusion. Despite the risk of morbidity and mortality in the donor, the attitude of the PC nursing personnel toward living liver donation was favorable, especially if the donation is related.
D
ESPITE SPAIN having the highest level of cadaveric donation in the world, the deficit in livers available for transplant is increasing, given that the indications for transplant are increasing at a greater rate.1 This means that presently in the 21st century mortality on the liver transplant waiting list is higher than ever, namely between 8% and 10%.1 To deal with this deficit split transplants are being performed in adults,2 domino transplants in certain metabolic hepatopathies,3 and “suboptimal” donors are being used, and living donation is being encouraged. However, while transplant of the right hepatic lobule from a living donor to an adult is increasing in Japan, the United States, and other European countries,4 –7 in Spain it is anecdotal.1
Primary Care (PC) is the first point of contact of society with the health care system in Spain. This means it is a key piece in any program for promoting health at the popula-
From the Coordinación Regional de Trasplantes de la Comunidad Autónoma de Murcia, Consejerı´a de Sanidad (C.C., A.R., P.R., M.M.R.); Gerencia de Atención Primaria I de Murcia, Centro de Salud de Fortuna (C.C.); the Departamento de Cirugı´a, Hospital Universitario Virgen de la Arrixaca (A.R., P.R., L.M., P.P.); and the Asociación de Ayuda al Enfermo Renal (ADAER) (J.S., E.S., F.R.), Murcia, Spain. Address reprint requests to Dr Antonio Rı´os Zambudio, Avenida de la Libertad no 208, Casillas 30007, Murcia, España. E-mail:
[email protected]
© 2005 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/05/$–see front matter doi:10.1016/j.transproceed.2005.10.036
Transplantation Proceedings, 37, 3631–3635 (2005)
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tion level. In this respect, many studies have shown that PC personnel are fundamental to promote organ donation.8 –11 Therefore, if we want to encourage living donor liver donation, it is important that PC professionals are-in favor it as they are the ones who will be consulted by our patients and their opinions are usually quite influential. The objective herein was to analyze attitudes toward living liver donation among
nursing personnel in PC centers, and to analyze the psychosocial variables that influence such opinions. MATERIALS AND METHODS Study Population The sample was stratified for geographical location (6 health areas) among he 75 PC health centers in our autonomous community,
Table 1. Variables That Affect Opinions Toward Living Liver Donation Among Primary Care Nursing Personnel in Health Centers Variable
Mean age (40 ⫾ 10 y) Sex Male (n ⫽ 47) Female (n ⫽ 92) Marital status Single (n ⫽ 39) Married (n ⫽ 90) Divorced (n ⫽ 8) Widower (n ⫽ 2) Location of the center Urban (n ⫽ 91) Rural (n ⫽ 48) Work situation Permanent position (n ⫽ 84) Temporary (n ⫽ 16) Contracted (n ⫽ 38) DK (n ⫽ 1) Care to transplant patients Yes (n ⫽ 106) No (n ⫽ 29) DK (n ⫽ 4) Experience of ODT Yes (n ⫽ 61) No (n ⫽ 78) Prosocial activities Yes (n ⫽ 37) No (n ⫽ 96) DK (n ⫽ 6) Attitude to cadaveric donation Yes (n ⫽ 107) No (n ⫽ 32) Concern about mutilation Yes (n ⫽ 14) No (n ⫽ 125) Partner’s opinion Yes in favor (n ⫽ 89) Doesn’t know (n ⫽ 28) Yes against (n ⫽ 3) Doesn’t have partner (n ⫽ 12) DK (n ⫽ 7) Needs a transplant Yes (n ⫽ 70) No (n ⫽ 69) Living kidney donation Yes (n ⫽ 20) Yes, family (n ⫽ 109) Never (n ⫽ 1) Undecided (n ⫽ 9)
Yes (n ⫽ 15; 11%)
Yes, related (n ⫽ 109; 78%)
Never (n ⫽ 4; 3%)
Undecided (n ⫽ 11; 8%)
P
36 ⫾ 10
40 ⫾ 9
39 ⫾ 12
44 ⫾ 9
.351
5 (33%) 10 (67%)
37 (34%) 72 (66%)
2 (50%) 2 (50%)
3 (27%) 8 (73%)
.878
5 (33%) 9 (60%) 1 (7%) 0 (0%)
30 (27%) 72 (66%) 5 (5%) 2 (2%)
2 (50%) 1 (25%) 1 (25%) 0 (0%)
2 (18%) 8 (73%) 1 (9%) 0 (0%)
.247
9 (60%) 6 (40%)
73 (67%) 36 (33%)
3 (75%) 1 (25%)
6 (54%) 5 (46%)
.789
7 (47%) 2 (13%) 6 (40%) 0
69 (63%) 11 (10%) 28 (26%) 1
3 (75%) 0 (0%) 1 (25%) 0
5 (46%) 3 (27%) 3 (27%) 0
.788
11 (73%) 3 (20%) 1
86 (79%) 21 (19%) 2
2 (50%) 2 (50%) 0
7 (64%) 3 (27%) 1
.489
4 (27%) 11 (73%)
53 (49%) 56 (51%)
1 (25%) 3 (75%)
3 (27%) 8 (73%)
.203
4 (27%) 10 (67%) 1
29 (27%) 77 (70%) 3
2 (50%) 2 (50%) 0
2 (18%) 7 (64%) 2
.082
12 (80%) 3 (20%)
85 (78%) 24 (22%)
3 (75%) 1 (25%)
7 (64%) 4 (36%)
.062
2 (14%) 13 (86%)
5 (5%) 104 (95%)
1 (25%) 3 (75%)
6 (55%) 5 (45%)
.000
11 (73%) 3 (20%) 0 (0%) 1 (7%) 0
73 (67%) 20 (18%) 0 (0%) 11 (10%) 5
2 (50%) 2 (50%) 0 (0%) 0 (0%) 0
3 (27%) 3 (27%) 3 (27%) 0 (0%) 2
.000
8 (53%) 7 (47%)
57 (52%) 52 (48%)
3 (75%) 1 (25%)
2 (18%) 9 (82%)
.125
13 (87%) 2 (13%) 0 (0%) 0 (0%)
6 (5%) 103 (95%) 0 (0%) 0 (0%)
1 (25%) 2 (50%) 1 (25%) 0 (0%)
0 (0%) 2 (27%) 0 (0%) 9 (83%)
.000
DK, don’t know; ODT, organ donor transplantation.
PC NURSES ACCEPT LIVING LIVER DONATION
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selecting 34 centers. In these centers a random sample among the nursing personnel was carried out. Two centers were excluded for not wanting to participate, resulting in a total of 32 valid health centers and a total number of 139 selected professionals.
Opinion Survey and Study Variables The study was performed between October 2002 and October 2003. Opinions toward organ donation were evaluated using a questionnaire validated in our geographical area.12 For distribution of the questionnaire, contact was made in each selected center with the nursing coordinator to whom the study was explained. This person was made responsible for the distribution of the survey. The self-administered questionnaire was completed anonymously. The process was coordinated by two collaborating health workers from the Regional Transplant Co-ordination Centre and two members of the Kidney Patient Association (ADAER). Sociopersonal variables were analyzed (age, sex, marital status, location of the center, work situation); variables on knowledge about donation (prior experience with the subject); social interaction variables (partner’s opinion, care to transplant patients); variables on attitudes toward the body (cadaveric manipulation); prosocial behavior; attitudes toward cadaveric donation, living kidney donation, and living liver donation with the study being about living donation in two situations (unrelated and related living donation); and on the possibility of needing an organ transplant oneself in the future.
Statistics Descriptive statistics were performed on each of the variables. Student t test and the chi-square test were applied together with an analysis of remainders. The differences were considered significant for values of P ⬍ .05.
RESULTS
With respect to living liver donation, 89% (n ⫽ 124) were in favor, but 78% were in favor only if it was related (n ⫽ 109), 3% (n ⫽ 4) were against donation of a living hemiliver, and the remaining 8% (n ⫽ 11) had doubts about this kind of donation. Only 11% would be in favor of non-related living donation (Table 1).
Fig 1.
On analysis of the variables related to this attitude, the only factors of significance were concern about possible manipulation of the body (P ⬍ .0005), attitude toward living kidney donation (P ⫽ .0005), and partner’s opinion toward this subject (P ⬍ .0005). Thus, among those who were concerned about body mutilation, attitudes were favorable to living liver donation in 50% as opposed to 94% among patients who do not present this concern (Fig 1). With respect to attitudes toward living kidney donation, a clear relationship between both attitudes has been found as can be seen in Fig 2, such that 100% of those who have doubts about kidney donation have doubts about liver donation, etc. As for partner’s attitude, as can be seen in Fig 3, partner’s opinion against is a factor that causes many doubts in attitude toward living liver donation. We must highlight that no relationship has been found with cadaveric donation (P ⫽ .062). However, 76% (n ⫽ 106) had cared for transplant patients or patients awaiting transplant. No relationship was found between this and attitude toward this type of donation (P ⫽ .489). DISCUSSION
In Spain, in spite of the great development in cadaveric organ donation, in recent years there has been a clear tendency to stabilize with respect to capacity for obtaining organs. In this situation, living transplantation is an alternative. However, when the time comes to talk about living donation, evaluation of kidney donation is very different from that of liver donation. Thus, living kidney donation is a clear alternative,13 as it is ethically acceptable due to the low risk of surgery in healthy donors14 and due to the fact that results are better in comparison to cadaveric donation.15 On the other hand, the potential risks for the living liver donor are high.4 –7,16,17 Thus, the rapid increase in donation of a living liver segment that has occurred in Spain in recent years seems to point toward a greater interest among liver surgeons in a predisposed general population,
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CONESA, RÍOS, RAMÍREZ ET AL
Fig 2.
especially in related donation, where emotional factors are decisive. Until the present, studies that analyze attitudes toward living donation were scarce. They generally concentrated on the family unit as a potential donor and recipient,18 and more recently on population attitude.12,19 Two aspects are clear among these studies. The first is that the population is quite in favor of living donation, but only as long as it is related. The second is that the living donation also has positive effects on the donor, such as improved self-esteem and closer affective relationships.20 Despite the implicit risk that comes with this type of liver donation, in our study we have seen that PC nursing personnel present an attitude which is clearly in favor of living liver donation only so long as it is related (not necessarily for family members; it can be for people with no family relationship). This fact is important, as it has to be taken into account that for the development of living donation it is fundamental that health professionals encourage it, especially at the PC level. It must be remembered that PC is the point of contact between society and the
Fig 3.
health system. It is where most people can find the answers to their fears and doubts about a certain type of treatment.9 In this respect, it is important to highlight that attitudes toward related living liver donation were more favorable among nursing personnel than among the population in our geographical area12 (89% vs 74%). This means that there is a strong potential for more living organs than cadaveric organs, a possibility that has yet to be developed in Spain. However, if we only analyze when the donation is considered to be unrelated the opposite occurs; the attitude was more favorable among the population than among the nursing personnel (21% vs 11%). However, this aspect is less important as living donation among strangers is a minor activity, and it is not the objective of our Transplant Coordination Centres nor of the National Transplant Organisation to encourage this activity. On analyzing the factors that might determine attitudes toward living liver donation, we observed no influence of classic psychosocial factors that influence cadaveric donation, not even the attitude toward cadaveric donation, a finding that coincides with population data in our geograph-
PC NURSES ACCEPT LIVING LIVER DONATION
ical area,12 where no relationship has been seen with psychosocial factors. However, in our population, there is a clear relationship with psychosocial factors, but in our population we see a clear relationship with attitude toward cadaveric donation.12 A surprising aspect about our health personnel that should be highlighted given their close relationship with surgical activity, body manipulation, and so on, is the clear relationship seen between concern about possible mutilation of the body due to donation and negative attitudes toward donation. However, we should mention that only 10% of those questioned reported such a concern, so this effect is minimal. One factor that is related to this attitude and also occurs in cadaveric donation21,22 is the partner’s opinion toward donation. Thus, Fig 3 shows that when a partner is against, there is a significant decrease in attitudes toward living donation. The third factor that we have observed is the strong relationship between attitudes toward living kidney and liver donation, which may be related or unrelated. Probably the main problem in living donation is accepting it, in other words, accepting that the extirpation of an organ from a healthy person is justifiable to improve the quality of life of another person or in some cases to save another’s life. Once this premise is accepted, the attitude is more favorable toward any kind of donation considered for such an end. Such a favorable predisposition of PC professionals may be used as a source to promote living donation, especially among reluctant populations as we have seen that there is a great lack of knowledge about this subject.12 However, it should be taken into account that the attitude of a Spanish patient or family member is not the same as that of patients from other countries where the cadaveric organ donation rate is low. A Spanish patient knows that in a relatively short time a cadaveric organ may be obtained, thus avoiding the loss of a living organ from a family member. However, its development should be examined with caution, as it is a type of surgery that relatively frequently causes morbidity in the donor population.17 Therefore, it should only be carried out in centers with a large volume of cases and experience.17 What is more, it should be remembered that a series of invasive procedures have to be performed on all the potential liver donors for one recipient. These procedures include biopsy and arteriography, which can produce morbidity in people who do not even become donors.17,23 We conclude that despite the risk of donor morbidity and mortality, the attitudes of PC nursing personnel toward living liver donation were favorable, especially if it is a related donation.
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