Dying With Assistance and Organ and Tissue Donation: The Link

Owing to the wide gap between the number of patients who would benefit from transplantation and the availability of organs and tissues, there is a pressing need to explore the intentions of healthcare providers to enable a novel organ and tissue donation paradigm. Organ and tissue donation and transplantation is a well-established practice that: (a) greatly improves quality of life and survival of recipients with end-stage organ system failure (Hong et al., 2006; Lien et al., 2010; Rabbat, Thorpe, Russell, & Churchill, 2000; Sela et al., 2013); (b) alleviates pressure facing healthcare systems to increase the number of organ donors that provide a substantial cost-saving advantage (Barnieh et al., 2011; CBS, 2012); (c) provides psychological and emotional benefits for families (Dicks, Ranse, Northam, Boer, & van Haren, 2017); and (d) promotes quality end-of-life care that respects patient autonomy (Cerutti, 2012).

Deceased organ donation routinely occurs following neurological determination of death or cardiocirculatory death in the intensive care unit. Controlled donation after cardiocirculatory death (cDCD), the more complex practice model that is available in the palliative care setting, is contingent on medical assistance in dying (MAiD). MAiD is an end-of-life care option that deliberately helps end the life of a terminal patient for compassionate reasons at their explicit request (Government of Canada, 2016). cDCD in the context of MAiD further escalates the level of complexity posing significant ethical and procedural challenges for clinical decision-making in end-of-life care. While sanctioned by Canadian society and legislation, it remains under deliberation in hospice and palliative care communities in prominent jurisdictions (Parliament of Canada, 2016). Neverthless, according to the World Health Organization, "every country must strive for self-sufficiency in meeting its peoples’ healthcare needs and opportunities for donation should be provided in as many circumstances of death as possible [that] begin with resources obtained locally" (2011, p. S31).

Literature shows that it may be helpful to understand healthcare providers’ beliefs around their intentions to enable organ and tissue donation, recognizing the importance of attitudes, subjective norms, and perceived behavioural controls that influence intentions. Therefore, the Theory of Planned Behavior (TPB) seems to be a useful and relevant conceptual model to examine the issue of this, where the importance of these independent constructs can be studied together within a single framework. According to Ajzen (1991), “at the most basic level of explanation, the TPB postulates that behavior is a function of salient information, or beliefs, relevant to the behavior [and] it is these salient beliefs that are considered to be the prevailing determinants of a person’s intentions and actions” (Ajzen, 1991, p. 189). Each construct (i.e., attitude, subjective norm, behaioral control) is related to a specific set of beliefs which are the opinions or ideas that we believe to be true – and we can hold a great many subjective beliefs about any given behavior (Ajzen, 1991). Likewise important are the external factors such as socio-demographic variables (e.g., age, gender, profession) that can also influence the intention to adopt a behavior through the other constructs (Ajzen, 1991). The theory can be applied to any behavior under an individual’s volition, including enabling organ and tissue donation (Kent, 2002).

When the traditional deceased organ donation model shifts from intensive care to palliative care with the confluence of MAiD and cDCD, conflicting determinants of intention (i.e., attitude, norm and control) are posited for end-of-life care decision-making for palliative care providers. In jurisdictions where this practice has been made available, the body of research that conveys palliative care providers’ intentions to engage in, and take up, cDCD is nonexistent. Framed by the TPB, the overarching aim of this study is to examine healthcare providers’ attitudes, subjective norms, perceived behavioral controls, and intentions surrounding cDCD in the context of MAiD, and to determine what constructs are the key correlates of intention. Therefore, the purpose of the study is to: (1) measure the value of the behavioural, normative and control belief sets held by palliative care providers; (2) evaluate the relationship among attitudes, subjective norms and perceived behavioral controls of palliative care providers in relation to their intentions to engage in, and take up, the cDCD practice model; and (3) determine what the key statistical predictor(s) of intention is to enable this practice model.

Following ethics and operational approval, a cross-sectional electronic survey design will be used to provide a one-time assessment of palliative care providers’ attitudes, subjective norms, perceived behavioral controls, and intentions to engage in, and take up, the cDCD practice model for patients that have been approved for MAiD. Inclusion criteria will comprise the selection of participants using an all-inclusive convenience sampling of physicians and registered nurses working in the areas of hospice and palliative care within Alberta Health Services – Calgary Zone. Measures in this study will include a questionnaire that consists of two defined sections: (1) demographics; and (2) measures of the TPB constructs. In order to examine the relationship among attitude, norm, control and intention, zero order correlations will be calculated. Hierarchical regression analyses will be used with attitude, norm and control determinants established to predict intentions to engage in, and take up, cDCD in MAiD. Because of the importance of optimizing organ and tissue donation potential, enhanced understanding of what may be influencing intentions, may help inform points of intervention and future research among healthcare providers to link cDCD to the MAiD patients who choose donation.