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Although overall donation and transplantation activity is higher in Europe than on other continents, differences between European countries in almost every aspect of transplantation activity (for example, in the number of transplantations, the number of people with a functioning graft, in rates of living versus deceased donation, and in the use of expanded criteria donors) suggest that there is ample room for improvement. Herein we review the policy and clinical measures that should be considered to increase access to transplantation and improve post-transplantation outcomes. This Roadmap, generated by a group of major European stakeholders collaborating within a Thematic Network, presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation. This framework can be adopted by countries and institutions that are interested in advancing transplantation, both within and outside the European Union. Within this framework, a priority ranking of initiatives is suggested that could serve as the basis for a new European Union Action Plan on Organ Donation and Transplantation.Organ transplantation improves patient survival and quality of life and has a major beneficial impact on public health and the socio-economic burden of organ failure. This Roadmap presents an outline of the challenges to increasing transplantation rates and proposes 12 key areas along with specific measures that should be considered to promote transplantation.

Dynamic consent (DC) was originally developed in response to challenges to the informed consent process presented by participants agreeing to ‘future research’ in biobanking. In the past 12 years, it has been trialled in a number of different projects, and examined as a new approach for consent and to support patient engagement over time. There have been significant societal shifts during this time, namely in our reliance on digital tools and the use of social media, as well as a greater appreciation of the integral role of patients in biomedical research. This paper reflects on the development of DC to understand its importance in an age where digital health is becoming the norm and patients require greater oversight and control of how their data may be used in a range of settings. As well as looking back, it looks forwards to consider how DC could be further utilised to enhance the patient experience and address some of the inequalities caused by the digital divide in society.

Background There is a worldwide shortage of organs available for transplant, leading to preventable mortality associated with end-stage organ disease. While most citizens in many countries with an intent-to-donate “opt-in” system support organ donation, registration rates remain low. In Canada, most Canadians support organ donation but less than 25% in most provinces have registered their desire to donate their organs when they die. The family physician office is a promising yet underused setting in which to promote organ donor registration and address known barriers and enablers to registering for deceased organ and tissue donation. We developed a protocol to evaluate an intervention to promote registration for organ and tissue donation in family physician waiting rooms. Methods/design This protocol describes a planned, stepped-wedge, cluster randomized registry trial in six family physician offices in Ontario, Canada to evaluate the effectiveness of reception staff providing patients with a pamphlet that addresses barriers and enablers to registration including a description of how to register for organ donation. An Internet-enabled tablet will also be provided in waiting rooms so that interested patients can register while waiting for their appointments. Family physicians and reception staff will be provided with training and/or materials to support any conversations about organ donation with their patients. Following a 2-week control period, the six offices will cross sequentially into the intervention arm in randomized sequence at 2-week intervals until all offices deliver the intervention. The primary outcome will be the proportion of patients visiting the office who are registered organ donors 7 days following their office visit. We will evaluate this outcome using routinely collected registry data from provincial administrative databases. A post-trial qualitative evaluation process will assess the experiences of reception staff and family physicians with the intervention and the stepped-wedge trial design. Discussion Promoting registration for organ donation in family physician offices is a potentially useful strategy for increasing registration for organ donation. Increased registration may ultimately help to increase the number of organs available for transplant. The results of this trial will provide important preliminary data on the effectiveness of using family physician offices to promote registration for organ donation. Trial registration ClinicalTrials.gov, ID: NCT03213171 . Registered on 11 July 2017.

Background Limited data are available on organ donation practices and recipient outcomes, particularly when comparing donors who experienced cardiac arrest and received extracorporeal cardiopulmonary resuscitation (ECPR) followed by veno-arterial extracorporeal membrane oxygenation (ECMO) decannulation, versus those who experienced cardiac arrest without receiving ECPR. This study aims to explore organ donation practices and outcomes post-ECPR to enhance our understanding of the donation potential after cardiac arrest. Methods We conducted a nationwide retrospective cohort study using data from the Japan Organ Transplant Network database, covering all deceased organ donors between July 17, 2010, and August 31, 2022. We included donors who experienced at least one episode of cardiac arrest. During the study period, patients undergoing ECMO treatment were not eligible for a legal diagnosis of brain death. We compared the timeframes associated with each donor’s management and the long-term graft outcomes of recipients between ECPR and non-ECPR groups. Results Among 370 brain death donors with an episode of cardiac arrest, 26 (7.0%) received ECPR and 344 (93.0%) did not; the majority were due to out-of-hospital cardiac arrests. The median duration of veno-arterial ECMO support after ECPR was 3 days. Patients in the ECPR group had significantly longer intervals from admission to organ procurement compared to those not receiving ECPR (13 vs. 9 days, P  = 0.005). Lung graft survival rates were significantly lower in the ECPR group (log-rank test P  = 0.009), with no significant differences in other organ graft survival rates. Of 160 circulatory death donors with an episode of cardiac arrest, 27 (16.9%) received ECPR and 133 (83.1%) did not. Time intervals from admission to organ procurement following circulatory death and graft survival showed no significant differences between ECPR and non-ECPR groups. The number of organs donated was similar between the ECPR and non-ECPR groups, regardless of brain or circulatory death. Conclusions This nationwide study reveals that lung graft survival was lower in recipients from ECPR-treated donors, highlighting the need for targeted research and protocol adjustments in post-ECPR organ donation.

Context— Since nearly all registered organ donors in the United States signed up via a driver's license transaction, motor vehicle (MV) offices represent an important venue for organ donation education. Objective— To evaluate the impact of organ donation video messaging in MV offices. Design— A 2-group (usual care vs usual care + video messaging) randomized trial with baseline, intervention, and follow-up assessment phases. Setting— Twenty-eight MV offices in Massachusetts. Intervention— Usual care comprised education of MV clerks, display of organ donation print materials (ie, posters, brochures, signing mats), and a volunteer ambassador program. The intervention included video messaging with silent (subtitled) segments highlighting individuals affected by donation, playing on a recursive loop on monitors in MV waiting rooms. Main Outcome Measures— Aggregate monthly donor designation rates at MV offices (primary) and percentage of MV customers who registered as donors after viewing the video (secondary). Results— Controlling for baseline donor designation rate, analysis of covariance showed a significant group effect for intervention phase (F= 7.3, P= .01). The usual-care group had a significantly higher aggregate monthly donor designation rate than the intervention group had. In the logistic regression model of customer surveys (n = 912), prior donor designation (β = −1.29, odds ratio [OR] = 0.27 [95% CI = 0.20–0.37], P < .001), white race (β = 0.57 OR = 1.77 [95% CI = 1.23–2.54], P = .002), and viewing the intervention video (β = 0.73, OR = 1.54 [95% CI = 1.24–2.60], P= .01) were statistically significant predictors of donor registration on the day of the survey. Conclusion— The relatively low uptake of the video intervention by customers most likely contributed to the negative trial finding.

Background Policy decisions about opt-in and opt-out consent for organ donation are based on limited evidence. To fill this gap we investigated the difference between deceased and living organ donation rates in opt-in and opt-out consent systems across a 13 year period. We controlled for extensive covariates and estimated the causal effect of consent with instrumental variables analysis. Method This panel study used secondary data analysis to compare organ donor and transplant rates in 48 countries that had either opt-in or opt-out consent. Organ donation data were obtained over a 13-year period between 2000 and 2012. The main outcome measures were the number of donors, number of transplants per organ and total number (deceased plus living) of kidneys and livers transplanted. The role of consent on donor and transplant rates was assessed using multilevel modeling and the causal effect estimated with instrumental variables analysis. Results Deceased donor rates (per-million population) were higher in opt-out ( M  = 14.24) than opt-in consent countries ( M  = 9.98; χ  = -4.27, 95% confidence interval (CI) = -8.08, -0.45, P  = .029). However, the number of living donors was higher in opt-in ( M  = 9.36) than opt-out countries ( M  = 5.49; B  = 3.86, 95% CI = 1.16, 6.56, P  = .006). Importantly, the total number of kidneys transplanted (deceased plus living) was higher in opt-out ( M  = 28.32) than opt-in countries ( M  = 22.43; B  = -5.89, 95% CI = -11.60, -0.17, P  = .044). Similarly, the total number of livers transplanted was higher in opt-out ( M  = 11.26) than opt-in countries ( M  = 7.53; B  = -3.73, 95% CI = -7.47, 0.01, P  = .051). Instrumental variables analysis suggested that the effect of opt-in versus opt-out consent on the difference between deceased and living donor rates is causal. Conclusions While the number of deceased donors is higher than the number of living donors, opt-out consent leads to a relative increase in the total number of livers and kidneys transplanted.

Expanding the liver donor pool includes reconsidering geographic characteristics. We evaluated demographics, trends, and outcomes of transplants from donors outside the contiguous US. Adult liver-only transplants from 2010 to 2022 were categorized by donor location (mainland US vs. non-mainland) using national registry data. Post-transplant survival was evaluated using time-to-event analysis, univariate and multivariable Cox regression. 1531 (1.5 ​%) liver transplants utilized non-mainland organs (991 performed in mainland US). Non-mainland to mainland donors were older, smoked less, had a lower BMI, and less steatosis (all p ​< ​0.05). Non-mainland organs traveled further (1241 vs. 84 miles,p ​< ​0.01) with longer ischemic times (8.6 vs. 5.9 ​h,p ​< ​0.01). Length of stay (p ​= ​0.80) and acute rejection (p ​= ​0.14) did not differ. Non-mainland recipients had similar survival at 1-(aHR 1.02, p ​= ​0.85), 5-(aHR 0.93, p ​= ​0.38), and 10-years (aHR 0.96, p ​= ​0.56). Non-mainland recipients had similar LOS and survival despite longer distance and cold ischemic time, emphasizing further consideration for non-mainland transplantation. •From 2010 to 2022, 1531 transplants utilized non-mainland donor organs, with 991 performed at centers in the mainland US.•Non-mainland donors had lower BMI, rates of cigarette smoking, and hepatic steatosis.•Outcomes were similar for non-mainland liver transplants despite longer ischemic time and travel distance.•Selected non-mainland liver donors may be increasingly considered for mainland transplantation.

In May 2020, England implemented soft 'opt-out' or 'deemed consent' for deceased donation with the intention of raising consent rates. However, this coincided with the COVID-19 pandemic, making it difficult to assess the early impact of the law change. Wales and Scotland changed their organ donation legislation to implement soft opt-out systems in 2015 and 2021 respectively. This study provides a descriptive analysis of changes in consent and transplant rates for deceased organ donation in England, Scotland and Wales. Logistic regression and descriptive trend analysis were employed to assess the probability of a patient who died in critical care becoming a donor, and to report consent rates using data, respectively, from the Intensive Care National Audit and Research Centre (ICNARC) in England from 1 April 2014 to 30 September 2021, and from the Potential Donor Audit for England, Scotland and Wales from April 2010 to June 2023. The number of eligible donors in April-June 2020 were 56.5%, 59.3% and 57.6% lower in England, Scotland and Wales relative to April-June 2019 (pre-pandemic). By April-June 2023, the number of eligible donors had recovered to 87.4%, 64.2% and 110.3%, respectively, of their levels in 2019. The consent rate in England, Scotland and Wales reduced from 68.3%, 63.0% and 63.6% in April-June 2019 to 63.2%, 60.5% and 56.3% in April-June 2023. While the UK organ donation system shows signs of recovery from the COVID-19 pandemic, the number of eligible potential donors and consent rates remain below their pre-pandemic levels.

Background Listening and responding to family concerns in organ and tissue donation is generally considered important, but has never been researched in real time. We aimed to explore in real time, (a) which family concerns emerge in the donation process, (b) how these concerns manifest during and after the donor conversation, and (c) how clinicians respond to the concerns during the donor conversation. Methods A qualitative embedded multiple-case study in eight Dutch hospitals was conducted. Thematic analysis was performed based on audio recordings and direct observations of 29 donor conversations and interviews with the family members involved (n = 24). Results Concerns clustered around six topics: 1) Life-event of a relative’s death, 2) Dying well, 3) Tensions and fears about donation, 4) Experiences of time, 5) Procedural clarity, and 6) Involving (non-)present family. Most concerns occurred in topics 1 and 2. Clinicians mostly responded to concerns by providing information or immediate solutions, while sometimes acknowledgement sufficed. When concerns were highly charged with emotion, the clinicians’ responses were less frequently attuned to families’ needs. Cues of less clearly articulated concerns gained less follow-up. Then, concerns often remained or reappeared. Conclusion The identified concerns and the distinction between clearly and less clearly articulated concerns may prove valuable for clinicians to improve family support. We advise clinicians to engage with a curious, probing attitude to enhance the dialogue around concerns, elaborate on less clearly articulated concerns and identify the informational needs of the family.