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Journal of the Academy of Hospital Administration

A Knowledge, Attitude and Practice Study of Organ Donation and its Problems in the Metropolitan City of Delhi

Author(s): P.H. Mishra, Aarti Vij, R.K.Sarma

Vol. 16, No. 1 (2004-01 - 2004-06)

Abstract:

The Transplantation of Human Organ Act was enacted in 1994. The doors were opened for unrelated Cadaver Transplantation, which facilitated the Liver and Heart Transplantation also. But unfortunately till now, only about 1457 kidney, 35 heart and 40 liver transplants have been done. At any point of time there is a huge waiting list for kidney ,heart and liver transplant. This shows the magnitude of problems and potential of curing people of their life threatening diseases, if donors are available.

This is basically due to shortage of organ donors. This may be due to lack of awareness about acute shortage of organs amongst general public and medical professionals, positive attitude and lack of motivation.
A study was conducted in major government and private hospitals of Delhi, where different Organ transplants are being carried out and other hospitals, where it is not, to find out the reason for Organ Transplant program not picking up as well as expected. The study showed that the major reasons for poor performance of Organ Transplant program is lack of awareness amongst public which has generally contributed for poor donor pool, but also lack of awareness, positive attitude and motivation amongst medical professionals. It was also found that major hospitals with more than 1500 to 2000 beds, are not even registered for Organ Transplant program due to lack of infrastructure and other required facilities. Also there are no transplant co-ordinators, brain death registers or brain death committees in these hospitals with more than 4000 beds.

Introduction

Life is a dynamic process. It starts from birth and ends with the death of the individuals. In between come different stages of life with different diseases and its problems. With rapid strides made in surgical fields beginning with Joseph Murrays epoch making kidney allo-transplant on an identical twin at Peter Brent Brigham Hospital, Boston, in 1954,the science and art of Organ Transplantation has indeed come a long way. There is always an ever-increasing demand for the organs, which are always in, short supply all over the world.

Kidney Transplantation:

In India 90,000 End Stage Renal Disease patients are waiting for kidney donors for transplantation at any given point of time. Mean age of these patients is 42 years. This shows the number of productive lives that can be saved by encouraging cadaver donors. From 1991-93, 7250 kidney transplants were carried out of which 32.4% were live related, 62.1% unrelated and 5.2% by spouse donors (Shyama et al 67)

It is estimated that 50-60% of the patients of End Stage Renal Disease can benefit from Renal transplant but due to paucity of donors only 10% of patients get it. It is well known fact that a transplanted patient's quality of life is much better than a patient on dialysis. However, only 3000 kidneys are available for transplant to over 80000 people suffering from kidney failure every year.

According to Chugh et al 64 rough estimates based on individual experience, it is reported that in India at any point of time there are approximately 90000 ESRD patients awaiting transplant.

Liver Transplantation

In India, about 2,00,000 people die of liver disease every year out of which many would have survived and lived a normal life if they had received liver transplantation (Devicum V.A. et al 68)

In India 2,00,000 people die of liver disease every year. An Orthotopic (replacing a diseased organ with a healthy one) Liver transplant mean survival is 5 years in children is 80-90% and 55-85% in adults. Moreover no donor recipient matching is required. It shows the potential of saving lives by promoting organ donation.

Cardiac Transplantation

Cardiac transplant has evolved from a highly experimental procedure to an accepted mode of treatment of many End Stages Cardiac Diseases. The obvious success of cardiac transplantation can be attributed to substantial advances in variety of areas including surgical intervention techniques, donor management, organ preservation, prevention and treatment of rejection and management of complication after transplantation.

There are about 50,000 patients dying of heart ailment every year. They are waiting for a heart transplant in absence of a suitable donor. Heart transplant can only be done after brain death. At AIIMS at any point of time there are 30-40 patients waiting for heart transplant. In USA there are 20,000 potential donors, 40,000 people die of heart failure every year and 2,100 heart transplants are carried every year.

Need for the Study

As per a general survey report carried out by some social service organization, there are roughly about 600 brain deaths annually in Delhi but unfortunately there have been very few (about 12 only) Brain dead cadaver donors in last 2 years, where all vital organs were donated. There are about 50,000 heart cases, 60,000 liver cases and 90,000 End Stage Renal Disease cases requiring transplantation (Indian Transplant 66).

As per a study by Asian Development Bank on Vulnerable Road users in Asia pacific (1998), Asia pacific has 44% of road deaths, although only 16% of vehicles in the world. In India about 300,000 accidents and 59,927 (1995) fatalities occurred on roads and 20.3 deaths /10,000 motor vehicles. It is estimated that by 2020, RTA will occupy sixth position in the list of cause of death. These are the huge number of potential donors, who if motivated properly, can fulfill the big gap between the requirement of organs for transplant and the number of donors available

In National Capital Territory of Delhi about 9,000 accidents occur every year resulting in 2,000 fatalities and 8,000 injuries for about 13,000 vehicles. In India 1 accidental death occur every 2 minutes on roads. In 1998 2,58,408 Accidents occurred out of which 36% were road traffic accidents (Indian Express report). People affected are in the age group of 15-45 years. Most of them are healthy. If public awareness is spread and people are motivated; this can be a source of organ donation .

Human Organ Transplantation Act was passed in Indian Parliament in 1994 and notified on Feb 4, 1995, yet India lags far behind the rest of the world, in Organ donation and transplantation. The law restricts the unlawful removal and transplantation of human organs as well as regulates hospitals conducting the removal, storage or transplantation of human organs. The act aims to stop commercial dealings in human organs. It stipulates that no organ can be removed from a donor unless the person is a close relative or is someone certified as brain dead.

Despite Human Organ Transplantation Act being passed in 1994 and declaring brain death as real death, cadaver Organ donation has not really taken off as well as expected. As is evident from data given below, cadaver Organ donation that could have saved thousands of lives, is really very poor.

INDIAN CADAVER Organ Transplantation FIGURES (1995-2003)

Place Kidney Liver Heart Lungs Pancreas
Chennai 178 7 15 1  
Vellore 37 3      
Coimbator 28        
Madurai 8        
Mumbai 55 1      
New Delhi 55 20 20    
Hyderabad 12 3      
Pune 40        
Ahemedabad 52       1
Indore 6        
Kochi 8   1    
Lucknow 5        
Ludhiana 4        
Bangalore 24 1 1    
Chandigarh 6        
Total 518 35 37    

Source-Indian Transplant Journal (Feb-June 2003, Page-VIII)

Aim and Objectives

Present study was carried out with the aim of studying the cause of shortage of cadaver organ donors, be it lack of infrastructure and facilities, lack of communication, lack of knowledge and attitude.

Objectives

To evaluate the present knowledge and attitude about organ donation amongst public to identify the factors influencing their attitude towards Organ Donation.

Matierials and Methodology

Study of current national and international literature available on the subject was done. Questionnaire based study was done about the Knowledge, Attitude and Practice by Doctors, Nurses, Students and Public.

Study tools

1. Structured questionnaires
2. Study of previous studies and literature available on the subject.

Data Analysis

The data so collected was systematically arranged. Statistical package (Epi info and SPSS) applicable to sociological studies was applied for the analysis of the data.

Limitations of the Study

1. Since Organ Transplantation is done in many hospitals (especially Kidney) all over India, all the areas could not be studied.
2. Sample size was limited to 200 due to limitation of time and practical feasibility.
3. Study was limited to mainly urban population. Hence views of rural population could not be elicited.
4. As the questionnaires were in English, only English literate people could be questioned.
5. The study was done only amongst hospital going people and not amongst general public. Hence their views may be influenced by personal experience

Observation & Discussion

The study was done to find out the Knowledge, Attitude and Practice about organ donation and transplantation, amongst 55 doctors, 45 nurses, 39 medical students and 42 general public (total 200 structured questionnaire were distributed, 181 people replied & returned it).

Demographic profile of the respondents:

1. There were 83 females (46.63%) and 95 males (53.37%). 5 people preferred not to mention their sex.
2. Profession-wise distribution of respondents was Doctors 22.47%, Nurses 24.70%, Medical students 26.40%, General public 26.40%.
3. Religion-wise distribution of respondents. As the questionnaire was distributed randomly and no effort was made to select people from different religion, 75.72% of respondents were found to be Hindus, 15.60% Christians and 7.60% from other religions. 5 people preferred not to mention their religion
4. Age-wise distribution of respondents 0-20 yrs 11.49%,20-40 yrs 53.45%,40-60 yrs 32.18%,60-82 yrs(1 person 82 yrs) 2.87%.

Various responses to different attributes of Knowledge, Attitude & Practice were analysed. Frequency distribution was studied, important variables were analysed to find co-relation between different variables.

The study was conducted by using pre-structured questionnaire having 10 questions each regarding knowledge, attitude and practice about Organ Donation and Transplantation.

Knowledge:

Adequacy of Knowledge:

It was found that 25% had adequate and 53.04% of respondents had only partial knowledge about Organ donation, despite 75% of respondents being medical professionals.
According to Ahmed 47 et al also, the main reason given for low organ donation amongst people of Asian origin was lack of knowledge.Wamser says there is a 50% reduction in Organ donation due to lack of knowledge & awareness.

Knowledge of Act

51% of people knew about Transplantation of Human Organs Act, which is poor response seeing that 75% of the respondents were related to medical field. The legal aspect of the Act was not very clear in the mind of public.

Attitude

53.30% of respondents had a positive Attitude towards organ donation whereas 46.70% has negative attitude.
Kiberd-c 20 says that discussion sessions with lectures were helpful in changing the attitude of people.

Attitude in different Qualification category

Qualification Positive
Attitude
Negative
Attitude
Graduate 60.07 37.93
Matriculate 58 42
Post-Graduate 42.47 57.53

Although the attitude of Matrics and Graduates is similar. Surprisingly postgraduates had more negative attitude than other two categories. It means that the higher education does not necessarily improves attitude towards organ donation. Kiberd-c 20 also says that discussion sessions with lectures were helpful in changing the attitude of people.

Positive Attitude in different Professional category

Doctors 40%, Public 57.14%, Nurse 57.78%, Student, 61.54%, Pearson chi2 (3)=11.4883, Pr=0.009 significant
"Profession and Attitude graphics here"

More of Public, Students and Nurses had positive attitude but surprisingly 60% of Doctors had Negative attitude. This needs improvement through more positive education and training. Cantwell 15 says that education program helps in improving the attitude of Nurses about Organ donation. Pearson chi2 (3)=5.5750, Pr=0.134 Insignificant.

PRACTICE

Practice - It was found that 78.02% were aware of the Correct Practice, whereas 21.98% were not aware of the Correct Practice of organ donation. Hence there is lots of scope of improvement in Correct Practice.

1. Knowledge - Knowledge of Correct practice in different Religion category. Christians 96.43%, Hindus 75.16%,

It showed that Christians are more aware about the correct practice of Organ donation.Pearson chi2 (1)=6.3316 (more than 3.84, for 1 freedom), Pr=0.012 (less than .05). Significant

2. Knowledgeof correct practice in different Sex category-
Female 89.16%, Male 70.53%.Females were more aware of the correct practice of Organ donation. Pearson chi2 (1)=9.3377, Pr=0.002.Significant

3. Willingness to donate organs:

61.59% people are ready to donate their organs after death; only 4.9% said no, while 27.32% are undecided. 81.08% of those who have heard/seen Organ Transplantation, are ready to donate. According to Kigawa13 also publicity of first organ transplantation increased organ donation

4. Awareness about shortage of Organs

It showed that most of the people know about the acute shortage of Organs. Surprisingly 2% people think that there is excess of organs, which needs improvement in the knowledge.There is a contrast in what people of 0-20 yrs age group think about availability of organs in that 5.56% of them think that there is excess of organs. This means that there is a need to increase the awareness of younger age group about Organ donation. Wamser et al, that there is a 50% reduction in Organ donation due to lack of knowledge & awareness.

5. Telling the Family

Most of the people are very jittery about telling it to their family about their wish for Organ Donation. But those who would like to tell would like to tell it to every body (53.01%).

Buckley49 et al says that greater efforts should be directed through public education at importance of telling one's family about their wishes about Organ Donation

6. Ability to ask for Organ Donation

63.64% of the people will be able to ask relatives of a dying patient to donate organs for a needy patient whereas 5.45% say's they cannot. 16.97% are undecided whereas 13.94% people will think over. This can be improved by training and education.

As per Wilk-L, Mickell et al,25 medical Examiner refusal of organ procurement from potential donors impact on pediatric organ donation as family refusal. Increased organ procurement in Medical Examiner refusal related cases will require improved communications between MES, physicians, and organ procurement organizations.

46.34% of the people are not sure if they will donate if asked for, 26.83% are afraid to ask, whereas 19.52% think that it is unethical. 13.94% people will think over. This shows that there is lots of need to improve the attitude of people by training and education.

As per a study by Powener-DJ et al 26. Brain death is an anatomically and physiologically complex process., neurosurgeons are in a unique position to positively influence the supply of transplantable organs. Neurosurgeons can also play a leading role in the multidisciplinary approach required to support the families of potential organ donors during the translation form neuro intervention therapy to somatic support.

People who know about who know about Human Organ Transplantation Act will be able to ask the relative about Organs Donation more easily.

Recommendations

It is recommended that there should be major initiative to spread the awareness amongst general public by including a chapter about Organ Transplant program and acute shortage of organs in the secondary school text books. It is also recommended that there should be regular training of medical professionals to improve their attitude and motivation to talk to family of brain dead patients for organ donation. There should be transplant co-ordinators, brain death registers in all the hospitals and de linking of registration procedure for organ harvesting and transplantation to avoid unnecessary harassment to the family of donors.

1. Education:

Most of the people (72.13%) think that education is the most important tool to improve Organ Donation. Callender14 also says that culturally appropriate health education programs help improving Organ donation.

2. Publicity:

Much more publicity and education is needed to improve the Knowledge, Attitude and Practice among the public as well as medical professionals. Newspaper was the widely used medium, although the use of T.V. and magazines were almost equal. This proves that media can play a very important role. Media: Plays a very vital role in spreading knowledge in general public. It can make or break a public program. Hence they should do more positive publicity generously for this noble cause. They should always be involved in full confidence. According to Kigawa13 publicity of first organ transplantation increased organ donation. Matesanz-R 42 says that negative publicity from media decreases organ donation.

1. Widespread dissemination of information about brain death, Cadaver donation & the success of transplantation both in lay public and health care staff are required. This is also proved by a study done by Ahmed 47 et all, the main reason given for low organ donation amongst people of Asian origin was lack of knowledge about donor card and how to get it.

2. Most of the people are very jittery about telling it to their family about their wish for Organ Donation. This is very important, as it is the family that decides about Organ Donation after the donor is dead. Education is the most important tool to improve it. Buckley49 et all says that greater efforts should be directed through public education at importance of telling one's family about their wishes about Organ Donation.

3. The staff of ICU, Emergency services, Neurosurgery department and treating doctor should be trained how to talk to the family about Organ Donation when the Patient is brain dead. This should be done in a very seductive and tactful manner as consent for Organ Donation depends on the quality of hospital care and specific aspects of donation request process (DeJong-W 21).

4. Resident doctors and staff of Emergency department and ICUs should be trained to improve their behavior towards relatives of prospective donors.

5. There are still a large number (majority) of populations in Doctors, Nurses, Students and General Public, which cannot ask relative of a dying patient about Organ donation because they are not sure if they will donate. Surprisingly 40% Doctors and 33.33% of Nurses do not know how to ask about Organ donation. 28.57% General Public, 16.67% of Nurses & Students think, it is unethical to ask relative of a dying patient about Organ donation. Hence a sea change in practice is needed through training and publicity. Callender 14 says that it requires multiple educational interventions.

6. The ability to ask for Organ donation is directly proportional to level of education, which should be increased.

7. The main stress of education should be at Graduate and Matric (Nursing) level, which should be increased

8. The willingness for Organ donation is directly proportional to level of education, which should be increased.

9. The knowledge about Human Organ Transplantation Act directly increases with level of education. People who know about the Act are more willing for Organ donation. Hence awareness about the Act should be increased.

As per McBride-M; Chapman-JR 36 in Australia: the programs are supported by an infrastructure of donor coordinators, matching and allocation procedures and national co-operative requesters which record and publish the outcome of each form of transplant. Four national origination's work to promote transplantation: the transplantation the Australian kidney foundation; and the Australian co-ordaining committee for organ Registries and donation have been very helpful.

3. Improvement in Attitude:

1. More males than females are not sure whether the relatives will donate organs if asked for. More males than females are aware that there is acute shortage of Organs. This requires a sea change in attitude of male medical professionals DeJong 31 says that the satisfaction with the hospital care received and the way Organ donation is asked for , effects decision to donate organs.

2. Most of the religious groups are still not sure whether people will donate organs or not, if they ask for it. This needs change in attitude through religious teaching as no religion stops organ donation. As per Giliman 19 majority of religious faith take positive response about organ donation.

3. There is wide difference between Christians and Hindus in the ability to ask about Organ donation. Hindus are more clear and confident about asking for Organ donation. Hence organ donation should be encouraged in other religions also through involvement of religious leaders and teachers.

4. Willingness to donate Organs increase with age. Hence younger generation should be more educated & encouraged about it.

4. Social Improvement

1. The cadaver donation should be encouraged by all possible means. Despite the Transplantation of Human Organs Act, the Cadaver donors are still as low as 20.35%. According to Bidigare-SA 29, family physicians can increase the commitment to organ donation through a relatively simple intervention.

2. 46.34% of the people are not sure if the relatives will donate organs, if asked for, 26.83% are afraid to ask, whereas 19.51% think that it is unethical. 13.94% people will think over. Doctors and staff should be regularly trained for how to ask for. Organ donation. According to DeJong 31 ,organ donation rate could be increased by enhancing the quality of hospital care and ensuring that the request for organ donation is handled in a way that meets the families informational and emotional needs

3. More the people are aware about acute shortage of organs; more of them are ready to donate. Hence awareness improves organ donation.

4. 72.62% of those who know about the Act are ready to donate. This clearly shows that the knowledge about the Act improves the Organ donation. 81.08% of those who have heard/seen Organ Transplantation, are ready to donate, This clearly shows that the seeing/ hearing about Organ Transplantation improves the Organ Donation. Hence more publicity is required for successful Organ Transplantation. A study by Roark D 27 also says that visit by a recipient encouraged even skeptics for organ donation.

5. There is a contrast in what people of 0-20 yrs age group think about Organ donation, than others in that 55% of them are not yet decided about their willingness for Organ donation. This means that there is urgent need to increase the awareness of younger age group by including a chapter on Organ donation in their textbooks.

6. There is still a wide belief that Organs can be procured form Market. This may be due to various reports of Organ trading in the media. There is need for improvement in awareness.

7. There are still a large number of people, which is undecided about organ donation. Majority of them are Medical students. It is similar between Doctors & General Public (25%) is not yet decided about organ donation. This implies that there is need for improvement in the attitude towards organ donation. Cantwell-m 15 study also says that doubts existed in the minds of medical students about organ donation.

5. Improvement in Technical Expertise

1. Patients should be referred early for transplantation to improve survival after transplantation. This is also supported by a study by Eckhoff-DE 50 , that black patients who were referred late for Liver transplantation, in a more critical condition, had a poor survival

All the hospitals with possibility of cadaver donors should make their ICU staff more sensitive about handling cases of cadaver organ donation & a standard protocol must be developed. They should be frequently trained how to deal with relatives of a prospective organ donor. As per a study by Wamsev et al41, key to a successful organ donation program is (1) Active care for ICU staff. (2) Annual lectures about new development (3) Visiting donor in ICUs accompanied by successfully transplanted recipients (4) Hard work by ICU staff to maintain standard of knowledge and patient care (5) Steady flow of information and coordination between ICU staff and Transplant team.

3. More doctors should get trained in transplantation surgeries and more aseptic techniques should be followed to improve post transplant survival of patients. It is clear from the evaluation of infrastructure available that major hospitals of Delhi do not have trained transplant surgeons and infrastructure to carry out transplant program.

4. Post transplant infection is the most common cause of postoperative death. Hence rationale use of antibiotic and strict adherence to antiseptic techniques should be followed.

5. Like Japan, South Korea and Taiwan, living donor transplantation should be encouraged to improve postoperative survival.

6. Concentrated National effort should be made to promote more brain dead cadaver donation, so that more number of transplants are carried to improve teething problems. Randhawa G48 studied Organ donation social and cultured issues. He found that health care professionals should be more aware of such issues when discussing transplantation with potential donors or their family and high light need for a national information campaign

6. Coordination

1. It is very essential to appoint dedicated transplant coordinators in all the hospitals where there is possibility of brain dead patients and possible organ donors. They have helped all over the world. Parter LM et al,33 studied donor families experience of organ donation, in New Zealand 23/49 would have liked further help form transplant coordinator.

2.Increase coordination between treating physician and transplant team is required. As per Wilk-L, Mickell et al, 25 medical Examiner refusal of organ procurement from potential donors impact on pediatric organ donation as family refusal. Increased organ procurement in Medical Examiner refusal related cases will require improved communications between MES, physicians, and organ procurement organizations.

3. Donor Organs are a national health resource and they should never be wasted for the want of suitable recipients. Hence organ sharing between transplant centers must be promoted. ORBO is an initiative in this direction. Hence all the centers receiving organs from donors must inform ORBO about availability of organs. McBride-M; Chapman-JR 36An overview of transplantation in Australia: The programs are supported by an infrastructure of donor coordinators, matching and allocation procedures and national co-operative requesters which record and publish the outcome of each form of transplant. Four national origination's work to promote transplantation: the transplantation the Australian kidney foundation; and the Australian co-ordaining committee for organ Registries and donation have been very helpful.

4. Initial approach to the family of organ donors should be for eye donation. If they agree for it, then they should be asked about other organs. This is very successfully done in Chennai.

5. The address of donors & recipients should be regularly updated so that it is not missing at the time of need. A study by Wamsev 41et al, on Reasons for 50% reduction in the number of organ donors within 2 yrs. Austria says that Key to a successful transplantation program is-. Repeated mailing of updated information brochures and Letter of thanks after each reported donor

6. Neuro surgeons should cooperate more and promote organ donation. As per a study by Powener-D.et al,26 on Current considerations in the issue of brain death. Brain death is an anatomically and physiologically complex process., neurosurgeons are in a unique position to positively influence the supply of transplantable organs. Neurosurgeons can also play a leading role in the multidisciplinary approach required to support the families of potential organ donors during the translation from neuro intervention therapy to somatic support.

7. Authorization committee for non-related donors should meet more frequently to clear donors who are waiting for their clearance

Legal Improvement

To promote more brain death cadaver donation some changes are needed in Human Organ Transplantation Act such as:

1. Intimation of Brain death to relatives- Treating physician should announce brain death once it is decided by laid down criteria.

2. Required request Law- in the event of brain death, it should be compulsory for the ICU staff to suggest for organ donation and request their permission for the same.

3. Inclusion of clause of Organ donation in driving license.

4. Delinking of hospitals- where ' Organs can be retrieved' from the hospitals where they can ' actually be transplanted'. Moving brain dead persons from one hospital that, that is not ' approved' limits the scope of the number of brain dead patients who can be available for donation.

5. In medico-legal cases-it should be made possible to under take 'post mortem' at the same time as the ' Organ retrieval' surgery. Shifting patient from one hospital for Organ donation to another for post mortem makes relatives very emotionally traumatized and delays the process of handing over the body.

6. It should be made compulsory for all the hospitals with ICU facilities, to have dedicated transplant coordinators in their ICUs, both to identify brain dead patients and inform appropriate authorities for necessary action and to counsel patient's family for Organ donation.

7. The Act should be brought into the concurrent list of constitution so that all the states implement it.

8. Grand parent should be included in the near related category as the age of end stage renal disease in India is less than that in the west hence grand parent should not need to prove altruism to the authorization committee.

9. Parameters for the authorization committee work on should be clearly laid upon.

10. Presumed consent - Every person dying of brain death should be presumed to have wished for organ donation until a written refusal is made by the family.

11. There are a large number of populations, which do not know about the Act. Surprisingly, Nurses and Medical students also do not know about the Act. That means that they need to be educated more about the Act by introducing it in their textbooks.

12. Donor card - should be introduced, which can be made in the form of National Identity card.

Financial Impact

1. Publicity in media is very costly; it needs lots of money and charity. Hence corporate houses should come forward to donate for this noble cause.

2. There is large number of people who are ready to advocate financial compensation and exchange of transplant (like blood donation) to improve organ donation. It needs to be debated. As per an article in BMJ also, AMA considers whether to pay for donation of organs.

Improvement in Infrastructure

As is very clear from the study that major hospitals of Delhi are lacking in infrastructure to get licensed for Organ transplant. The necessary infrastructures should be improved. Doctors should be trained about brain death, Brain death committees should be formed, and dedicated transplant coordinators should be employed to help in making decision about organ donation. More ever they should improve their patient care, as it is an important factor for family while making decision. The better they have been cared for, the more readily they agree for organ donation.

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