How clinicians discuss patients' donor registrations of consent and presumed consent in donor conversations in an opt-out system: a qualitative embedded multiple-case study.

BACKGROUND: The Netherlands introduced an opt-out donor system in 2020. While the default in (presumed) consent cases is donation, family involvement adds a crucial layer of influence when applying this default in clinical practice. We explored how clinicians discuss patients' donor registrations of (presumed) consent in donor conversations in the first years of the opt-out system. METHODS: A qualitative embedded multiple-case study in eight Dutch hospitals. We performed a thematic analysis based on audio recordings and direct observations of donor conversations (n = 15, 7 consent and 8 presumed consent) and interviews with the clinicians involved (n = 16). RESULTS: Clinicians' personal considerations, their prior experiences with the family and contextual factors in the clinicians' profession defined their points of departure for the conversations. Four routes to discuss patients' donor registrations were constructed. In the Consent route (A), clinicians followed patients' explicit donation wishes. With presumed consent, increased uncertainty in interpreting the donation wish appeared and prompted clinicians to refer to "the law" as a conversation starter and verify patients' wishes multiple times with the family. In the Presumed consent route (B), clinicians followed the law intending to effectuate donation, which was more easily achieved when families recognised and agreed with the registration. In the Consensus route (C), clinicians provided families some participation in decision-making, while in the Family consent route (D), families were given full decisional capacity to pursue optimal grief processing. CONCLUSION: Donor conversations in an opt-out system are a complex interplay between seemingly straightforward donor registrations and clinician-family interactions. When clinicians are left with concerns regarding patients' consent or families' coping, families are given a larger role in the decision. A strict uniform application of the opt-out system is unfeasible. We suggest incorporating the four previously described routes in clinical training, stimulating discussions across cases, and encouraging public conversations about donation.

Organ donation after euthanasia starting with anesthesia at home is legal in The Netherlands, Belgium, Canada and Spain.

We would like to respond to the article "Organ donation after euthanasia starting at home in a patient with multiple system atrophy Tajaâte et al., [2021] 22:120" on organ donation after euthanasia from home [ODEH]. Although we welcome the performance of ODEH, we would like to make some critical comments regarding the article, both in relation to factual inaccuracies and in terms of the vision expressed on this subject. In this letter we stress the protection of autonomy of vulnerable euthanasia patients, we contradict the assumption of illegality, we question if the anesthesia method utilized is optimal and correct a mistake in regard to an article to which is referred of ourselves.

Practice and challenges for organ donation after medical assistance in dying: A scoping review including the results of the first international roundtable in 2021.

The procedure combining medical assistance in dying (MAiD) with donations after circulatory determination of death (DCDD) is known as organ donation after euthanasia (ODE). The first international roundtable on ODE was held during the 2021 WONCA family medicine conference as part of a scoping review. It aimed to document practice and related issues to advise patients, professionals, and policymakers, aiding the development of responsible guidelines and helping to navigate the issues. This was achieved through literature searches and national and international stakeholder meetings. Up to 2021, ODE was performed 286 times in Canada, the Netherlands, Spain, and Belgium, including eight cases of ODE from home (ODEH). MAiD was provided 17,217 times (2020) in the eight countries where ODE is permitted. As of 2021, 837 patients (up to 14% of recipients of DCDD donors) had received organs from ODE. ODE raises some important ethical concerns involving patient autonomy, the link between the request for MAiD and the request to donate organs and the increased burden placed on seriously ill MAiD patients.

Prospective Multicenter Observational Cohort Study on Time to Death in Potential Controlled Donation After Circulatory Death Donors-Development and External Validation of Prediction Models: The DCD III Study.

BACKGROUND: Acceptance of organs from controlled donation after circulatory death (cDCD) donors depends on the time to circulatory death. Here we aimed to develop and externally validate prediction models for circulatory death within 1 or 2 h after withdrawal of life-sustaining treatment. METHODS: In a multicenter, observational, prospective cohort study, we enrolled 409 potential cDCD donors. For model development, we applied the least absolute shrinkage and selection operator (LASSO) regression and machine learning-artificial intelligence analyses. Our LASSO models were validated using a previously published cDCD cohort. Additionally, we validated 3 existing prediction models using our data set. RESULTS: For death within 1 and 2 h, the area under the curves (AUCs) of the LASSO models were 0.77 and 0.79, respectively, whereas for the artificial intelligence models, these were 0.79 and 0.81, respectively. We were able to identify 4% to 16% of the patients who would not die within these time frames with 100% accuracy. External validation showed that the discrimination of our models was good (AUCs 0.80 and 0.82, respectively), but they were not able to identify a subgroup with certain death after 1 to 2 h. Using our cohort to validate 3 previously published models showed AUCs ranging between 0.63 and 0.74. Calibration demonstrated that the models over- and underestimated the predicted probability of death. CONCLUSIONS: Our models showed a reasonable ability to predict circulatory death. External validation of our and 3 existing models illustrated that their predictive ability remained relatively stable. We accurately predicted a subset of patients who died after 1 to 2 h, preventing starting unnecessary donation preparations, which, however, need external validation in a prospective cohort.

Determining the impact of timing and of clinical factors during end-of-life decision-making in potential controlled donation after circulatory death donors.

Controlled donation after circulatory death (cDCD) occurs after a decision to withdraw life-sustaining treatment and subsequent family approach and approval for donation. We currently lack data on factors that impact the decision-making process on withdraw life-sustaining treatment and whether time from admission to family approach, influences family consent rates. Such insights could be important in improving the clinical practice of potential cDCD donors. In a prospective multicenter observational study, we evaluated the impact of timing and of the clinical factors during the end-of-life decision-making process in potential cDCD donors. Characteristics and medication use of 409 potential cDCD donors admitted to the intensive care units (ICUs) were assessed. End-of-life decision-making was made after a mean time of 97 hours after ICU admission and mostly during the day. Intracranial hemorrhage or ischemic stroke and a high APACHE IV score were associated with a short decision-making process. Preserved brainstem reflexes, high Glasgow Coma Scale scores, or cerebral infections were associated with longer time to decision-making. Our data also suggest that the organ donation request could be made shortly after the decision to stop active treatment and consent rates were not influenced by daytime or nighttime or by the duration of the ICU stay.

The Role of Gender in the Employment, Career Perception and Research Performance of Recent PhD Graduates from Dutch Universities.

Recent decades have seen a sharp increase in the number of female PhD graduates in the Netherlands. Currently, the share of females among newly graduated PhDs is almost on par with that of males. A considerable body of scientific studies has investigated the role of gender in the academic workplace. However, the role of gender in the careers of all PhD graduates, including those outside academia, has been studied less. In this study, we investigate gender differences in type of job, occupation, career perception and research performance of recent PhDs. The study is based on a survey of persons who obtained a PhD from one of five Dutch universities between 2008 and early 2012. We show that gender differences in post-PhD careers are non-existent in some aspects studied, but there are small differences in other aspects, such as sector of employment, type of contract, involvement in teaching and management, and career perception. In contrast, male and female PhDs differ sharply on two factors. The first is field of PhD, females being heavily underrepresented in engineering and the natural sciences. The second is part-time employment, females being much more likely to work part-time than males, especially if they work in the Netherlands. In later career stages, the combination of the small and large differences can be presumed to affect the career progression of female PhDs through cumulative disadvantage.

What took them so long? Explaining PhD delays among doctoral candidates.

A delay in PhD completion, while likely undesirable for PhD candidates, can also be detrimental to universities if and when PhD delay leads to attrition/termination. Termination of the PhD trajectory can lead to individual stress, a loss of valuable time and resources invested in the candidate and can also mean a loss of competitive advantage. Using data from two studies of doctoral candidates in The Netherlands, we take a closer look at PhD duration and delay in doctoral completion. Specifically, we address the question: Is it possible to predict which PhD candidates will experience delays in the completion of their doctorate degree? If so, it might be possible to take steps to shorten or even prevent delay, thereby helping to enhance university competitiveness. Moreover, we discuss practical do's and don'ts for universities and graduate schools to minimize delays.