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The rule of 3s - three factors that triple the likelihood of families overriding first person consent for organ donation in the UK


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The Rule of Threes:


Registration on the organ donor register is recognised at law as first person consent in the UK

There is no legal provision for next of kin to override an individuals wishes unless there is evidence that their

views had changed or that they acted in error

Despite this, an override rate of 11.7% was observed between April 2012 - May 2015

Taking the average conversion and organ utilisation rates during this period, over 500 additional

transplants could have been carried out had the individuals wishes been honoured

We sought to identify potentially modifiable factors associated with next of kin choosing to override their

loves ones wish to donate their organs for transplantation in the event of their death


Retrospective observational study using NHSBT national potential donor audit 1 April 2012 - 31 March 2015

Univariable and multivariable logistic regression used to model the probability of the family overriding their

relative’s wish to donate as recorded on the organ donor register

Analysis performed using commercially available software (SAS enterprise guide 6.4, SAS)

Results - 3 strong associations


Three factors showed a three-fold odds ratio of overrides:

Non-involvement of the SNOD in the family approach

National guidance recommends involvement of the SNOD in donation approaches

This demonstrates that even when the patient is known to be on the donor register,

their autonomy is more likely to be overruled if the SNOD is not present

This adds to the existing evidence that involvement of the SNOD is associated with

higher consent rates

Donation after circulatory death (rather than after brainstem death)

Families more frequently cited the length of the donation process in DCD overrides

The duration from consent to treatment withdrawal has increased over the past 5


NHSBT have introduced measures to shorten the duration of this process

Black, Asian or Minority Ethnicity

BAME communities are at increased risk of diseases (e.g. renal) requiring


Lower BAME donation rates perpetuates a situation of increasingly unmet need for

organs from BAME donors

Further exploration of donation as an end of life choice for BAME communities is

essential to address this health inequality

DCD perceived differently

Do we need the SNOD present given the

patient is known to be on the organ

donor register?

James Morgan1, Cathy Hopkinson2, Cara Hudson2 Paul Murphy1,3, Dale Gardiner4,5, Olive MacGowan2, Cathy Miller2

Three factors that triple the likelihood of families overriding first person consent for organ donation in the UK

Author affiliations:

1. Leeds General Infirmary, Department of Critical Care, Leeds Teaching Hospitals NHS Trust

2.NHS Blood & Transplant, Department of Statistics & Education

3.NHS Blood & Transplant, National Clinical Lead

4.Department of Adult Critical Care, Nottingham University Hospitals NHS Trust

5.NHS Blood & Transplant, Deputy National Clinical Lead

References: See corresponding online publication in Journal of the Intensive Care Society.

Tables reproduced with permission.

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