Organization of Organ Donation

#### **Chapter 1**

## Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions

*Dilar Costa and Joana Silva*

#### **Abstract**

Kidney transplantation is considered the best therapeutic option and survival is dependent on adherence to the drug regimen. Adherence to the therapeutic regime thus becomes the key to success. However, the literature shows that not all patients are adherent, and readmission due to graft dysfunction is a reality. Although a direct relationship between adherence to the therapeutic regimen and graft dysfunction cannot be attributed, the issue of adherence is far from not deserving the attention of health professionals. This text aims to identify the importance of nursing interventions in promoting adherence to the therapeutic regimen. In an exploratory approach to the process of adherence, and reflecting on concordance and its relevance to adherence, given the heterogeneity of both definitions, we aimed to study the nurses' role and the type of interventions to promote adherence to the therapeutic regimen in transplanted renal patients. We conclude that education and counselling are the predominant interventions and that concordance is part of this practice, where the expected outcome is kidney graft survival as a consequence of adherence to the therapeutic regimen.

**Keywords:** adherence to the therapeutic regimen, patient compliance, adherence, concordance, nurse interventions, nurse care, renal allograft, renal transplantation, renal recipients

#### **1. Introduction**

Kidney transplantation is recognised in the medical literature as the best therapeutic option in end-stage chronic kidney disease [1, 2].

There are both clinical and non-clinical reasons to believe that kidney transplantation is beneficial for the person with end-stage renal disease because it reduces cardiovascular risk from 9.0 to 3.5–5.0% per year for patients who remain on dialysis. Added to this are the numerous benefits associated with better quality of life, more freedom (not being dependent on dialysis), more time for daily activities (time gained from not being dependent on dialysis), reduced symptoms such as fatigue, sleep disturbances and, as hypothesised, more work activity [3, 4].

Adherence to the therapeutic regimen of transplanted kidney patients is fundamental in preventing kidney graft rejection, complications, and re-hospitalisations with increased costs for the person and the health system [5].

There is much evidence of the importance of adherence to the therapeutic regimen for kidney transplant patients, highlighting the consequences of non-adherence and giving depth to the benefits that adherence evokes, linking it to processes of wellbeing and good health.

The direct relationship between adherence and satisfactory health outcomes is perceived, and there are numerous references that report changing behaviours, modifying diet, managing medication, changing routines, and adopting healthy lifestyles, as a bridge to a long life with the kidney graft and better quality of life [6–8].

An indispensable component of kidney graft survival is adherence to the therapeutic regimen, which, although it extends beyond medication adherence to include dietary compliance and lifestyle changes, has mainly been studied on the pharmacological side [9–12].

In one study the authors state that the probability of losing the kidney graft is seven times higher in the group of people not adherent to immunosuppressive medication, a reason in itself sufficient to capture the attention of the scientific community [3].

Some studies have tried to provide an empirical response to this problem, focusing on other aspects that are part of the therapeutic regimen. The results of the study by Gheih and colleagues reveal a clear preference of participants for the adherence to immunosuppressive medication (97.0%), but also show high values of adherence to low-fat diet (73.0%), infection prevention (89.0%), mouth care (brushing of teeth after meals) (37.0%), and physical exercise (walking) (23.0%). Lower adherence values were found in the activities related to monitoring water intake (12.0%), blood pressure (10.0%), temperature (6.0%), and urine output monitoring (2.0%) [7].

Adhikari and colleagues consider that lifestyle modifications have a high weighting in the success of kidney transplantation, however, the levels of adherence achieved by participants for all lifestyle dimensions assessed were low (64.1%), although with strong expression in some dimensions, particularly with regard to self-monitoring (89.54%), medical appointments (88.23%), infection prevention (93.46%), and dietary compliance (83.66%) [8].

These results seem to be in line with what we have previously said about the possible relationship between kidney graft survival and adherence to the therapeutic regimen in its broadest sense.

In this field of intervention, the multiplicity of factors associated with therapeutic adherence moves different actors and approaches. Innovative and pioneering, some projects evoke the individual and collective dimension of action [13–16].

It is interesting to mention that the individual action of a health professional does not potentiate change, but the articulation between health professionals. Change occurs thanks to the action of the individual and groups, such as health professionals, family, network of friends, amongst others.

From time to time there are also great leaps due to social, economic, and political transformations, but it is necessary to invest at a personal level (of the individual and their families) since individual and collective investments are dimensions that coexist, interact, and complement each other, being essential for the success of adherence to the therapeutic regime.

Thus, we have a clear perception of the need for interdependence between all participants in the process. The awareness of the existence of multiple actors and

#### *Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions DOI: http://dx.doi.org/10.5772/intechopen.110879*

interdependencies in changing behaviours and lifestyles and the respect for each one's field of intervention is a common emphasis amongst nurses.

This professional group often assumes the pivotal position by managing the therapeutic plan with the patient and his/her family, which often involves the orientations of different professionals. All are the reason for success or failure, in a process whose dynamics is made of this interaction [17].

But the most important result with regard to practices promoting adherence to the therapeutic regimen is the empowerment of the patient and compliance with that regimen.

Adherence to the therapeutic regimen involves transitions and adaptations, which brings us to a great challenge if we consider that the trends verified in the literature consecrate a low adherence or non-adherence to the therapeutic regimen.

According to the World Health Organisation (WHO) about 50.0% of chronically ill patients do not adhere to the therapeutic regimen [18].

The literature gives us a clear idea of the prevalence of non-adherence amongst kidney transplant recipients (28.0%) and the implications of non-adherence to immunosuppressive therapy on health outcomes, episodes of graft rejection (20.0%) and organ loss (16.0%) [19].

A second point to be considered is the method used to measure adherence to therapy. The values vary between 2.0 and 67.0%, and the causes of conditioning adherence to the announced values are strongly linked to the operationalisation of the definitions and the measurement methods used. The indicators of adherence used vary between "taking compliance", "dosing compliance", "timing compliance", amongst others.

The methods used include electronic monitoring, which also differ, such as the Medication Event Monitoring System (MEMS), the Short Message Service (SMS) and, more recently, technology based on digestible Integrated Circuits (ICs). Additionally, traditional methods such as patient reports and diaries, direct observation of therapy administration, pill counting, measurement of the concentration of the drug or its metabolite in the blood, and measurement of a biomarker in the blood are also used [20–23].

These two aspects of therapeutic adherence, although distinct, are strongly interconnected. In fact, the traditional method and the more recent methods that employ technology play a primordial role in the context of promoting therapeutic adherence in individuals. Conversely, we could say that the variety of methods does not give us a single standard, the desired gold standard, central to a consensual explanation of therapeutic adherence by the scientific community.

Although international statistics are not very favourable in this area, the therapeutic alliance between the kidney transplant patient and the nurse, marked by their proximity, may intensify the relationship, translating into a greater capacity of the patient to manage his/her therapeutic regimen and annul the interferences and obstacles that contribute to non-adherence.

But what is meant by medication adherence and therapeutic adherence?

The concept has evolved over time, but there is no consensus amongst authors on its definition. The literature offers us different perspectives of therapeutic adherence, as we will see below.

#### **2. Definition of adherence therapeutic**

As previously stated, the definition of adherence to the therapeutic regimen is not consensual amongst authors and has evolved over time [24].

It has captured the interest of the scientific community, but although numerous studies from different disciplines have been developed to explain the phenomenon, it is still a worldwide problem.

For the nursing discipline, and based on the International Council of Nurses (ICN) definition, adherence to the therapeutic regimen is defined as adherence behaviour in a broader perspective, namely: "self-initiated action to promote wellbeing; recovery and rehabilitation; following guidelines without deviations; engaged in a set of actions or behaviours. Complies with treatment regimen; takes medicines as prescribed; changes behaviour for the better, signs of healing, seeks medicines on indicated date, internalises the value of a health behaviour, and obeys instructions regarding treatment. (Often associated with support from family and people who are important to the client, knowledge about medicines and disease process, client motivation, relationship between health professional and client)" ([25], p. 2).

However, the concept itself is somewhat paradoxical. If adherence is the expected outcome, it should prefigure a patient-centred approach, since one can hardly separate people from their circumstances. This means that the patient will have to be an actor and not just a spectator, to be a subject and not an object, to intervene and not just assist, in other words, the patient should not lose his autonomy in the treatment process. Thus, the importance of the patient's action in his/her therapeutic process is equated. The perspective is dialectical between the actors and the various levels of contexts. The concept of adherence has demonstrated shortcomings by denying the patient this possibility. The awareness of the importance of the alliance and negotiation between health professionals and patients in managing the therapeutic regimen gives relevance to the concept of concordance, which aggregates all these attributes.

It is interesting to note that the concept of concordance is harmonised with the new paradigm of care provision, person-centred models, which see the individual as participants in their therapeutic process, according to their preferences, values, and expectations. Concordance implies working in partnership with the person [26].

Trust and negotiation are the foundations for building this partnership, where everyone feels involved, concentrating efforts towards a common goal that is possible to achieve due to the work that each one performs within the partnership. In other words, a relationship between equals with shared objectives, as opposed to a paternalistic approach [27].

A second point to be considered is the nurse-patient relationship, taking into account its importance in obtaining and sustaining agreement. The communication established based on trust, articulated with understanding, tolerance, and respect for the patient's needs, makes that within this framework the care is negotiated and meets the common interests, in a situation of perfect balance [28].

Within the framework of concordance, the understanding between the parties involved in the therapeutic process about the responsibilities from the perspective of assigning the roles that each one will have to assume stands out. The aim is to eliminate the patient's passivity and empower them to make informed decisions.

Imogene King's theory of Goal attainment (1981) highlights, based on its process of interaction-transaction, the nurse's role in helping patients achieve their goals. A key feature of this process is the participation of the nurse and the patient in defining the goals and exploring the resources to achieve them. This is in line with the principles and philosophy of the nursing profession itself, i.e., empowering the patient for self-care [29].

Returning to the issue of therapeutic regime management one can glimpse that skills and competencies are needed to manage the therapeutic regime and that often these skills have to be learned, being in fact a self-care activity. In a situation of interaction between nurse and patient, it is up to both to assess the patient's ability to

#### *Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions DOI: http://dx.doi.org/10.5772/intechopen.110879*

manage his/her therapeutic regimen. Concordance establishes the therapeutic alliance between the patient and the nurse, a relationship of equals, however, the patient is recognised as the expert of his/her own life. Defending this vision, the World Health Organisation (WHO), in the Ottawa Convention (1986), ratified the fundamental right of all people to be part of their own health care. From then on, the patient's autonomy came to occupy a prominent place in nursing care [30].

For both, there are no longer margins or spaces where asymmetric power relations could emerge. In the last 30 years, the relationship between patients and health professionals has undergone important changes, with the patient assuming greater control in his/her health decisions. This relationship is also closely associated with the disease model that dominates each era [31].

The new model of care, centred on the patient and based on a holistic perspective, seeks to explore the patient's perspectives and expectations, and understand them in their particular context. It implies sharing responsibility, involving the patient in decisions, and making him/her responsible for his/her health [32]. This model assumes great importance, especially at a time marked by the upsurge of chronic and lifestyle-related diseases [33].

We thus asked ourselves about the place of concordance in the practice of care in the promotion of behaviours of adherence to the therapeutic regime. Does the model have the effervescence and synergy that have permeated practices in recent decades? (I am only quoting the paternalistic model that still prevails in our health institutions) How have care practices been configured in the new model of care provision?

Authors such as Snowden [26], Gardner [34], point out that concordance is in simultaneity with the principles and values of the nursing profession when they "make the care of people your first concern, treating them as individuals and respecting their dignity" ([35], p. 2).

As a response to a care context marked by the holistic model as opposed to the previous approach, which proved to be an inefficient model, today we witness an interest in the centrality of the patient in the disease process and in meeting their needs. For Beresford [36], in order to optimise concordance, holism should be the goal of care provision and communication should be the heart of patient-centred care [37].

This new model of care is, however, a challenge in clinical settings, as patients move to other settings, whether to other healthcare institutions or to home. This increases the difficulty in negotiating the goals and the means to achieve them.

However, it is important to situate this positions between professionals and patients in a context of growing uncertainty which, from the point of view of care production, are increasing, such as new economic issues and new publics, in which in the same sociological profile of the public different ways of seeing may be inscribed.

However, it is public knowledge that health outcomes improve when patients are involved in their therapeutic process, working together with health professionals, as resources are used more effectively and efficiently. On the other hand, professionals feel more satisfied because their work has contributed to improving those outcomes. For the Health Department, the articulation of these two aspects shows that patients and health professionals are stakeholders in the success of concordance throughout nursing practice [38].

In line with a profession that values the uniqueness of the patient, which favours active listening, and advocates on behalf of the patient, we sought to analyse which nursing interventions are implemented by nurses to promote therapeutic adherence.

According to Giddens' sociology, true shared decision-making results from the sharing of power. For the author, power is defined as the ability to "make it happen", to "produce effects" in the societal world. If power is the ability to influence a course of events, in this particular case of the transition of the recently transplanted patient from hospital to home, resources are any strategies that increase this ability of the patient, that is, that provide the patient with the necessary tools to manage his therapeutic regimen [39].

Interestingly, despite advocating a patient-centred care model, in the concordance equation, the patients' non-participation in their therapeutic process is in the numerator, i.e., the part of the number in which concordance is used by health professionals, in this case, nurses. According to the literature, one of the common complaints of patients is that their opinions, needs, and expectations are not considered in decisions about their health [40].

It thus seems plausible to argue that concordance-based care exponentially increases the chance of adherence, whilst the opposite may eventually contribute to non-adherence to the therapeutic regime.

There is a plethora of studies addressing this issue, showing the magnitude of its intensity on the patient and the health system.

Non-adherence behaviours lead to inadequate control of the disease, putting the patient at great risk due to the emergence of adverse effects.

Dew and colleagues studied the non-adherence rates of all types of organ transplantation, and, strangely, despite the high number of non-adherent transplant recipients across the various dimensions of the therapeutic regimen, the number of kidney transplant representative's non-adherent to immunosuppressive medication rises relative to other recipients (36 cases per 100 patients per Year vs. 7 to 15 cases) [41].

Life expectancy also decreases four times more in the group of non-adherent transplant recipients [42]. We are thus elucidated about one of the striking features of the international reality in the field of adherence to the therapeutic regime, without exception. Added to this is the problem of growing discontinuity between healthcare services (although in recent years there are signs that this trend is being reversed, with a gradual increase in the articulation between healthcare institutions and patient follow-up).

Chronic illness, because it persists over time, requires continuous monitoring by health professionals in order to promote adherence to the therapeutic regime [43].

Two distinct but overlapping notions lead us to the concept of self-management and self-care. Indeed, we found that the term self-management is associated with the term self-care and, precisely in chronic diseases, aims to help patients maintain their well-being. It should be noted that chronic disease follows a trajectory marked by transitions and adaptations that involves a set of activities, such as medication management, adherence to a specific diet, changes in behaviours and lifestyles, which requires the action of the patient and the health professional to ensure an active life and a higher quality of life [44].

This would reinforce the proximity of adherence to the notions of self-management and self-care. We draw attention to the fact that both terms have the same purpose as adherence: to establish care partnerships and enable or empower the patient to take action.

Considering the transition as a medical and nursing phenomenon, nurses should analyse the present and predictable effects of the transition to transplantation. Transplant recipients have many tasks to perform: taking medication (according to medical prescription), changes in lifestyle, including diet, physical exercise, monitoring of signs and symptoms of organ rejection, monitoring of complications (infections), monitoring of fluid intake and elimination, monitoring of blood pressure and blood glucose, performance of complementary diagnostic tests, visits to

#### *Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions DOI: http://dx.doi.org/10.5772/intechopen.110879*

consultations, smoking cessation, management of stress and emotions, and performance of other self-care activities essential to a good health status [6–8].

Briefly, after kidney transplantation, adaptation to the new condition creates the need for organ recipients, now in a newly acquired situation, to integrate the recommendations of the therapeutic regimen regarding immunosuppressive medication, lifestyles, routines, social roles, and emotional challenges [45].

Indeed, adherence becomes the major reason to ensure the survival of the kidney graft without the trade-off of losing the organ due to inadequate self-care. If patients can understand the importance of therapeutic compliance, they can also begin to understand its implications on their lives at various levels [46].

We cannot but agree with the statement of these authors regarding the relevance of adherence to the therapeutic regimen as a means to counteract the harmful consequences of non-adherence and to recognise the nurse's intervention as vital, as it may contribute to the perception of the change that begins in the transition to the new condition, that is, when the person is admitted for transplantation.

In fact, according to their role in the health team, nurses play a central role in the management of the therapeutic regime, identifying difficulties and constraints, integrating the different aspects of the therapeutic regime, and constituting themselves as partners and resources [17].

According to the WHO, nurses are in a privileged position to diagnose, intervene, and assess results in aspects related to therapeutic adherence [18].

Evidently, the role of nurses is a key element in the framework of therapeutic adherence [47, 48], which calls for educational and behavioural strategies to promote adherence.

In addition to nurses, the presence of other health professionals, family, communities, and society are fundamental to promote adherence. Thus, a field of proposals is created in which the transplanted person will learn to manage his therapeutic regimen according to his needs [36].

Following the above, our objective is to identify the nursing interventions that promote therapeutic adherence amongst kidney transplant recipients, which leads us to the following research question: What are the nursing interventions that promote therapeutic adherence amongst kidney transplant recipients?

In the following section, we aim to answer this question.

#### **3. Nursing interventions to promote adherence therapeutic**

Therapeutic adherence is a current issue and is part of the "habitus" of nursing professionals' actions, with terms such as "information", "education", "partnership", "self-care", and "empowerment" as frames of reference; in short, the essential components for therapeutic self-management.

Aiming to identify in the literature the nursing interventions promoting adherence to the therapeutic regimen, we used Bleser and colleagues' classification for this purpose [49]:


3.Psycho-affective interventions, which include social support from significant others and health professionals.

We also determined the level of intervention according to the ecological model of McLeroy and colleagues [50]. For the authors, interventions can be classified into four levels, namely:


Studies were found in the literature showing education as a resource to empower the patient and enable him/her to self-manage the therapeutic regime.

Several theories and theoretical models are at the basis of these educational programs. And, although adherence to the therapeutic regimen is a multidisciplinary work, in this case we only portray the nurse's role in this process.

**Table 1** shows the interventions developed by nursing professionals to promote adherence to the therapeutic regimen.

The data analysed show us that there are two types of interventions to improve therapeutic adherence: educational and behavioural interventions.

Education is the privileged intervention in most studies, but the way it is administered, and the contents taught show some different contours between the studies.

Information and communication technologies are essential tools for education and training, imposing greater autonomy to the patient.

This generates the need for nursing professionals to develop flexible education programs in which the internet and multimedia resources gain relevance. Video is one of the resources widely used by nursing professionals [51].

Educational interventions promote the knowledge of the person and/or caregiver about the disease and treatment, using a diversity of tools, whether paper-based, audiovisual, social media, or discussion.

On the other hand, behavioural interventions aim to help the person gain skills and/ or competencies through training, counselling to manage their therapeutic regime.

Rocha and colleagues formulate an educational plan that was based on the learning styles of each participant. The methods used varied between subjects, and the


*Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions DOI: http://dx.doi.org/10.5772/intechopen.110879*

**Table 1.**

*Interventions developed by nursing professionals to promote adherence to the therapeutic regímen.*

privileged dimensions were cognitive and behavioural. The results showed an increase in medication adherence from the first to third meeting: 16.9% (in the first), 66.1% (in the second), and 79.9% (in the third). The construction of the educational plan was elaborated collaboratively, taking into account the subject's own characteristics, and demonstrated health gains for the patient [51].

The same attitude was taken by Cotê and collegues. In this case, the authors used information technologies, creating an interactive website—Virtual Nurse. The expected results were achieved, namely medication adherence and self-efficacy. Participants found the individualised education interventions to be personalised, easy to understand and self-efficacy promoting. Medication adherence (11.4, range 1–12) and self-efficacy (81.3, range 0–100) scores were high. Perceived health status and quality of life similarly achieved high scores (8.3, in a range of 0–10) [52].

The study by Russell and colleagues implemented an innovative education system, SystemCHANGE, which included home visits and telephone calls. In this system one can observe negotiation as an essential strategy in goal setting and discussion as one of the means to define resources and solutions to identified problems. The results showed differences between the experimental group and the control group in medication adherence at 12 months (large differences in medians, 0.17, 95% CI, 0.06–0.33, p < .001). Program implementation lasted six months and follow-up was twelve months [15].

However, achieving adherence to therapy, patient involvement and ensuring the survival of the kidney graft requires knowledge and information. This involves informing, educating, and training the patient and/or caregiver to carry out this task. Precisely education and training are fundamental bases for any society.

We have found that listening to the sick person, respecting them, and having an attitude of trust are the bases for adherence. Telephone contact, email, or face-to-face contact are some strategies that facilitate this process. The active involvement of the person in his treatment is the best strategy for its success [53].

The sequence of such actions is reflected in patient autonomy, the elimination of barriers between health professionals and patients, the relationship between the two parties, and the facilitation of access by all citizens to the resources of the health system, the community and society in general.

Although adherence to the therapeutic regimen is an internationally recognised problem and the ways to solve it have already been studied, there are still problems whose impact is negative for the patient and for society.

#### **4. Conclusion**

It can be stated that the issue of adherence to the therapeutic regimen is one of the striking phenomena of kidney transplantation, transversal to all types of organ transplantation, which extends far beyond the simple management of medication, requiring an intervention of all health professionals along the trajectory of the disease in order to empower the patient and/or his family.

Although in recent years there are signs that this trend may be receding in some places, based on a plethora of studies which continue to show the existence of the problem at still high levels of non-adherence, we are generally witnessing the emergence of new models of care which, in themselves, facilitate adherence to the therapeutic regimen.

Within the emerging new models, studies show the importance of the nurses' role in promoting adherence behaviours, which is an inherent characteristic of the

#### *Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions DOI: http://dx.doi.org/10.5772/intechopen.110879*

profession itself. Nursing care is, by its essence, holistic care, based on communication and therapeutic alliance. Negotiation is a sine qua non condition of this process.

Nurses seek to know the response patterns of the ill person and/or caregiver to the disease or problem that affects them, because only in this way they can help them face that situation. The knowledge of the patients and/or caregivers' needs and difficulties and their potential for autonomy allow for the development of a plan adjusted to these needs. Indeed, all clinical practices are guided by the needs of patients, and kidney transplantation is a real challenge for the patient and his or her family, involving many issues that are fundamental for success. Learning to deal with all these aspects requires knowledge acquisition, skills training, and coaching. The emotional needs connected with all the change must be emphasised, in addition to the stress that uncertainty and change provoke. The aim is to work out a plan with the patient and/or caregiver that allows him/her to make a healthy transition and ensure stability for the new role.

Education and counselling were the most commonly developed interventions by nurses after kidney transplantation. However, since most studies focused on medication adherence and the follow-up period did not exceed 12 months, it is important to develop longitudinal studies to measure the long-term effect of these programmes on kidney transplant survival. On the other hand, the heterogeneity of the instruments used does not ensure that a measurement standard is obtained, nor does it allow knowing the true effect of the interventions developed on adherence to the therapeutic regimen and their long-term impact.

#### **5. Implications for practice**

Working on the issue of therapeutic adherence within the new paradigm of health care is essential for the survival of the health system, taking into account the expenditure on health care with chronic diseases resulting from a population living longer and longer. Nurses, due to their characteristics, are equipped with the essential tools to work with patients in the search for the best solutions to their problems/health condition.

Some countries, such as the United Kingdom, are aware that the way forward is to educate, inform, and involve the patient and their family, preparing them to take care of themselves. The nurse, as an agent of change and educator, is in the right place and position to develop this role.

At the end of this reflective journey, we found that the issue of adherence to the therapeutic regimen in kidney transplantation leads to several disruptions, namely the change of perspective in the formulation of the care plan and the long-term follow-up of these patients.

The first rupture related to the care plan is to include the patient in the planning process and offer him/her the information and knowledge he/she needs to make a decision based on the best available evidence. The second rupture is to accompany the patient throughout this process, in favour of the idea of a transition process with an extended temporality. The aim is to ensure a transition whereby individuals emerge endowed with autonomy and are able to obtain the desired result: the success of the transplant.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Dilar Costa\* and Joana Silva Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal

\*Address all correspondence to: dilarcosta@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions DOI: http://dx.doi.org/10.5772/intechopen.110879*

#### **References**

[1] Khezerloo S, Mahmoudi H, Sharif Nia H, Vafadar Z. Predictors of self-management among kidney transplant recipients. Urology Journal. 2019;**16**(4):366-371. Available from: https://pubmed.ncbi.nlm.nih. gov/31364096/

[2] Schmid-Mohler G, Schäfer-Keller P, Frei A, Fehr T, Spirig R. A mixed-method study to explore patients' perspective of self-management tasks in the early phase after kidney transplant. Progress in Transplantation. 2014;**24**(1):8-18

[3] Mendonça AEO de, Torres G de V, Salvetti M de G, Alchieri JC, Costa IKF. Mudanças na qualidade de vida após transplante renal e fatores relacionados. Acta Paulista de Enfermagem. 2014;**27**(3):287-292

[4] Pinsky BW, Takemoto SK, Lentine KL, Burroughs TE, Schnitzler MA, Salvalaggio PR. Transplant outcomes and economic costs associated with patient noncompliance to immunosuppression. American Journal of Transplantation. 2009;**9**(11):2597-2606

[5] Hucker A, Bunn F, Carpenter L, Lawrence C, Farrington K, Sharma S. Non-adherence to immunosuppressants following renal transplantation: A protocol for a systematic review. BMJ Open [Internet]. 28 Sep 2017;**7**(9):e015411. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5640118/

[6] Nowicka M, Górska M, Nowicka Z, Edyko K, Goździk M, Kurnatowska I. Adherence to pharmacotherapy and lifestyle recommendations among hemodialyzed patients and kidney transplant recipients. Journal of Renal

Nutrition. Sep 2021;**31**(5):503-511. DOI: 10.1053/j.jrn.2020.12.006. Epub 21 Feb 26.

[7] Gheith AO, El-Saadany SA, Donia SAA, Salem YM. Compliance with recommended life style behaviors in kidney transplant recipients: Does it matter in living donor kidney transplant? Iranian Journal of Kidney Diseases. 2008;**2**(4):218-226

[8] Adhikari U, Taraphder A, Hazra A, Das T. Compliance of kidney transplant recipients to the recommended lifestyle measures following transplantation. Indian Journal of Transplantation. 2018;**12**(1):17

[9] Kostalova B, Ribaut J, Dobbels F, Gerull S, Mala-Ladova K, Zullig LL, et al. Medication adherence interventions in transplantation lack information on how to implement findings from randomized controlled trials in real-world settings: A systematic review. Transplantation Reviews. 2022;**36**(1):100671

[10] Chen T, Wang Y, Tian D, Zhang J, Xu Q, Lv Q, et al. Follow-up factors contribute to immunosuppressant adherence in kidney transplant recipients. Patient Preference and Adherence. 2022;**16**:2811-2819

[11] Stephenson M, Bradshaw W. Kidney transplantation: Interventions to improve medication adherence. Renal Society of Australasia Journal. 2020;**16**(1):8-12

[12] Cossart AR, Staatz CE, Isbel NM, Campbell SB, Cottrell WN. Exploring transplant medication-taking behaviours in older adult kidney transplant recipients: A qualitative study of semistructured interviews. Drugs & Aging. 2022;**39**(11):887-898

[13] Zachciał J, Uchmanowicz I, Krajewska M, Banasik M. Adherence to immunosuppressive therapies after kidney transplantation from a biopsychosocial perspective: A crosssectional study. Journal of Clinical Medicine. 2022;**11**(5):1381

[14] Russell CL, Moore S, Hathaway D, Cheng AL, Chen G, Goggin K. MAGIC Study: Aims, design and methods using SystemCHANGE™ to improve immunosuppressive medication adherence in adult kidney transplant recipients. BMC Nephrology. 16 Jul 2016;**17**(1)

[15] Russell CL, Hathaway D, Remy LM, Aholt D, Clark D, Miller C, et al. Improving medication adherence and outcomes in adult kidney transplant patients using a personal systems approach: SystemCHANGE™ results of the MAGIC randomized clinical trial. American Journal of Transplantation. 2019;**20**(1):125-136

[16] Tang J, Kerklaan J, Wong G, Howell M, Scholes-Robertson N, Guha C, et al. Perspectives of solid organ transplant recipients on medicine-taking: Systematic review of qualitative studies. American Journal of Transplantation. 2021;**21**(10):3369-3387

[17] International Council of Nurses. Catálogo CIPE. Lisboa: Ordem dos Enfermeiros; 2011

[18] Sabaté E. Adherence to Long-Term Therapies:Evidence for Action [Internet]. Geneva: World Health Organization; 2003. Available from: http://www. who.int/chp/knowledge/publications/ adherence\_full\_report.pdf

[19] Denhaerynck K, Dobbels F, Cleemput I, Desmyttere A, Schafer-Keller P, Schaub S, et al. Prevalence, consequences, and determinants of nonadherence in adult renal transplant patients: A literature

review. Transplant International. 2005;**18**(10):1121-1133

[20] Shi L, Liu J, Fonseca V, Walker P, Kalsekar A, Pawaskar M. Correlation between adherence rates measured by MEMS and self-reported questionnaires: A meta-analysis. Health and Quality of Life Outcomes. 2010;**8**:99

[21] Garfield S, Clifford S, Eliasson L, Barber N, Willson A. Suitability of measures of self-reported medication adherence for routine clinical use: A systematic review. BMC Medical Research Methodology. Dec 2011;**11**(1). DOI: 10.1186/1471-2288-11-149

[22] Granger BB, Bosworth HB. Medication adherence: Emerging use of technology. Current Opinion in Cardiology [Internet]. 2011;**26**(4):279- 287. Available from: https://www.ncbi. nlm.nih.gov/pmc/articles/PMC3756138/

[23] Russo HE, Kirsh WD. Populationbased medication adherence programmes: A window of opportunities. World Hospitals and Health Services. 2013;**49**(3):14-17 PMID: 24377142

[24] Cruz RS. Evolução do conceito de adesão à terapêutica. Saúde & Tecnologia [Internet]. 2017;**18**:11-16. Available from: https://journals.ipl.pt/stecnologia/ article/view/561

[25] International Council of Nurses. CIPE ®. Versão 2. Classificação Internacional para a Prática de Enfermagem. Lisboa: Ordem dos Enfermeiros; 2015

[26] Snowden A, Marland G. No decision about me without me: Concordance operationalised. Journal of Clinical Nursing. 2012;**22**(9-10):1353-1360

[27] Green J, Jester R. Challenges to concordance: Theories that explain *Therapeutic Regimen Adherence and Risk of Renal Graft Loss: Nurse Interventions DOI: http://dx.doi.org/10.5772/intechopen.110879*

variations in patient responses. British Journal of Community Nursing. 2019;**24**(10):466-473

[28] McKinnon J. The case for concordance: Value and application in nursing practice. British Journal of Nursing. 2013;**22**(13):766-771

[29] King IM. King's conceptual system, theory of goal attainment, and transaction process in the 21st century. Nursing Science Quarterly. 2007;**20**(2):109-111

[30] Robnik M, Blenkuš DMG, Blenkuš MV, Robnik M, Gabrijelčič M. 30 Years after the Ottawa Charter: Is it Still Relevant in the Face of Future Challenges for Health Promotion? [Internet]. EuroHealthNet Magazine.; 2016. Available from: https:// eurohealthnet-magazine.eu/30 years-after-the-ottawa-charter-is-itstill-relevant-in-the-face-of-futurechallenges-for-health-promotion/?gclid

[31] Jewson ND. The disappearance of the sick-man from medical cosmology, 1770-1870. International Journal of Epidemiology. 2009;**38**(3):622-633

[32] Ishikawa H, Hashimoto H, Kiuchi T. The evolving concept of "patientcenteredness" in patient–physician communication research. Social Science & Medicine. 2013;**96**:147-153

[33] Global Status Report on Noncommunicable Diseases 2014: Attaining the Nine Global Noncommunicable Diseases Targets; A Shared Responsibility—World | ReliefWeb [Internet]. reliefweb.int.. Available from: https://reliefweb.int/ report/world/global-status-reportnoncommunicable-diseases-2014 attaining-nine-global?gclid=Cj0KCQiA jbagBhD3ARIsANRrqEv8e0Nr6DULq BVX8E6qMYvuPIK-2ABYKwfQOcgu\_ mvY0X1mrFVh4dgaAluIEALw\_wcB

[34] Gardner CL. Adherence: A concept analysis. International Journal of Nursing Knowledge. 2014;**26**(2):96-101

[35] Nursing & Midwifery Council. The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates [Internet]. NMC. Nursing and Midwifery Council; 2018. Available from: https://www.nmc.org.uk/ standards/code/

[36] Beresford MJ. Medical reductionism: Lessons from the great philosophers. QJM: An International Journal of Medicine [Internet]. 2010;**103**(9):721-724. Available from: https://academic.oup.com/qjmed/ article/103/9/721/1581110

[37] Smith J, Bekker H, Cheater F. Theoretical versus pragmatic design in qualitative research. Nurse Researcher. 2011;**18**(2):39-51

[38] Department of Health. Equity and excellence: Liberating the NHS [Internet]. 2010. Available from: https:// assets.publishing.service.gov.uk/ government/uploads/system/uploads/ attachment\_data/file/213823/dh\_117794. pdf

[39] Giddens A. Studies in Social and Political Theory (RLE Social Theory). Routledge: Taylor & Francis Group; 2014

[40] Coulter A, Collins A. Making Shared Decision-Making a Reality No Decision about Me, Without Me [Internet]. 2011. Available from: https:// www.kingsfund.org.uk/sites/default/ files/Making-shared-decision-makinga-reality-paper-Angela-Coulter-Alf-Collins-July-2011\_0.pdf

[41] Dew MA, DiMartini AF, De Vito DA, Myaskovsky L, Steel J, Unruh M, et al. Rates and risk factors for nonadherence to the medical regimen after adult solid

organ transplantation. Transplantation. 2007;**83**(7):858-873

[42] Chrisholm-Burns MA, Spivey CA, Wilks SE. Social support and immunosuppressant therapy adherence among adult renal transplant recipients. Clinical Transplantation. 2010;**24**:312-320

[43] Yazdi Zadeh F, Moeini M, Shafie D. Evaluation of the Effect of Adherence to Treatment Regimen Program on Quality of Life in Atrial Fibrillation Patients Hospitalized in Shahid Chamran Hospital in Isfahan in 2017 [Internet]. 2019. Available from: http://saber.ucv.ve/ ojs/index.php/rev\_lh/article/view/16751

[44] Lorig KR, Holman HR. Selfmanagement education: History, definition, outcomes, and mechanisms. Annals of Behavioral Medicine [Internet]. 2003;**26**(1):1-7. Available from: https://academic.oup.com/abm/ article/26/1/1/4630312

[45] Jamieson NJ, Hanson CS, Josephson MA, Gordon EJ, Craig JC, Halleck F, et al. Motivations, challenges, and attitudes to self-management in kidney transplant recipients: A systematic review of qualitative studies. American Journal of Kidney Diseases. 2016;**67**(3):461-478

[46] Been-Dahmen JMJ, Beck DK, Peeters MAC, van der Stege H, Tielen M, van Buren MC, et al. Evaluating the feasibility of a nurse-led selfmanagement support intervention for kidney transplant recipients: A pilot study. BMC Nephrology. 27 Apr 2019;**20**(1):143. DOI: 10.1186/ s12882-019-1300-7

[47] Rodriguez G, Utate M, Joseph G, St. Victor T. Oral chemotherapy adherence: A novel nursing intervention using an electronic health record workflow.

Clinical Journal of Oncology Nursing. 2017;**21**(2):165-167

[48] Wang J, Yue P, Huang J, Xie X, Ling Y, Jia L, et al. Nursing intervention on the compliance of hemodialysis patients with end-stage renal disease: A meta-analysis. Blood Purification [Internet]. 2017;**45**(1-3):102-109. Available from: https://www.karger.com/ Article/FullText/484924

[49] De Bleser L, Matteson M, Dobbels F, Russell C, De Geest S. Interventions to improve medication-adherence after transplantation: A systematic review. Transplant International. 2009;**22**(8):780-797

[50] McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Education Quarterly [Internet]. 1988;**15**(4):351-377. Available from: https://journals.sagepub.com/ doi/10.1177/109019818801500401

[51] Rocha DF d, Figueiredo AEPL, Canabarro ST, Sudbrack AW. The importance of educational interventions for adherence to the immunosuppressant treatment program to kidneytransplanted patients. ConScientiae Saúde. 2018;**17**(3):273-280

[52] Côté J, Fortin M-C, Auger P, Rouleau G, Dubois S, Boudreau N, et al. Web-based tailored intervention to support optimal medication adherence among kidney transplant recipients: Pilot parallel-group randomized controlled trial. JMIR Formative Research. 2018;**2**(2):e14

[53] Bugalho A, Carneiro AV. Intervenções para aumentar a adesão terapêutica em patologias crónicas. Lisboa: Centro de Estudos de Medicina Baseada na Evidência; 2004

#### **Chapter 2**

## Empower the Science of Organ Donation by Multidisciplinary Collaboration

*Wenshi Jiang, Xiaotong Wu, Liansheng Ma, Jing Shu, Juan Yan, Liming Yang, Yajie Ma and Xiangxiang He*

#### **Abstract**

Inter-discipline is formed by the interpenetration and integration of multiple disciplines, which has become a notable trend involving interdisciplinary activities and a combination of research and development. Learned from experience worldwide, the management mode for organ donation and procurement activities varies among countries, but the core of the disciplinary construction of organ donation remains the same. The theoretical basis and practice of organ donation is not purely a matter of coordination, but its ground of knowledge is built upon multidisciplinary integration and its implementation relies on a joint-effort approach and requires collaboration of multiple teams. From the sociological viewpoint, organ donation represents the gift of life for transplant patients, which founds the key element in enhancing the harmony of society. While, from a practical perspective, its professionalism has been widely recognized by the international medical community. As a complex medical and social act, organ donation is a medical-centered subject with sociological, humanistic, ethical, psychologic, and juristic attributes. This chapter will provide an overview of how multidisciplinary collaboration empowers the science of organ donation, followed by the summary of recent efforts taken in China in pursuit of this goal as an example.

**Keywords:** organ donation, multidisciplinary integration, organ procurement organization, brain death, ICU

#### **1. Introduction**

The interdisciplinary approach connects interdependent knowledge and skills from more than one subject area to examine a central theme, which can be adopted to effectively address new problems and challenges facing mankind and represents a general trend in the disciplinary and professional development. In the real world, it is sometimes difficult to further develop knowledge without mutual penetration and supplementation between disciplines. Complex problems have to be solved through the synergy of multiple ideas, methods, tools, and instruments, requiring collaboration and cooperation among multidisciplinary professionals. Quite a few examples

including the discovery and application of penicillin show that scientific and technological advances are the outcomes of interdisciplinary cooperation.

To promote interdisciplinary integration, many countries have introduced encouraging policies, launched series of state-level disciplinary research projects, and set up interdisciplinary professional degrees at the college level [1, 2]. Meanwhile, academic activities themed on multidisciplinary integration can be seen more frequently in the recent decade, and more clinical guidelines have been jointly compiled by a multidisciplinary panel of experts to achieve thoughtful solutions to the questions concerned.

Empirical evidence has proven that the knowledge basis of organ donation (OD) is a medical-centered subject with sociological, humanistic, psychological, ethical, and juristic attributes. It represents a typical example of multidisciplinary collaboration driving professional development in the field. In this chapter, we try to explain the necessity and feasibility of adopting multidisciplinary collaboration to advance the OD disciplinary system by analyzing the nature of its bottleneck problems and the key processes, with an introduction of current efforts taken in China to reach such a goal.

#### **2. The necessity of promoting the building of OD discipline system through multidisciplinary collaboration**

The professionalism of the OD discipline has been widely recognized by the international academic community, as exemplified by the establishment of the International Society of Organ Donation and Procurement (ISODP) and national/ regional professional associations for OD in different countries [3]. This recognition indicates the necessity and feasibility of the building of the OD discipline system as the core to guide daily practice and create academic environment.

The overall goal of building the OD discipline system is to protect the legitimate rights and interests of donors and their families, maximize the transplant benefit of recipients and promote harmonious development of human society through establishing a sound scientific theoretical system with distinct characteristics of social humanity to guide actions and practices. Meanwhile, upon which it also drives, in a sustainable fashion, both the development of professional skills and qualified personnel. The establishment and development of the OD discipline system are in conformity with the goal of "self-sufficiency" in organ donation and organ transplantation (OD and OT).

Empirical evidence shows that the establishment of such a theoretical system and its operation practice requires the collaboration of multidisciplinary expertise and the support of multiple teams. We will explain the details in the paragraphs below and the fact that the OD discipline and OT discipline can develop with their own focus and are mutually reinforcing.

#### **2.1 The solution to bottleneck problems of OD requires the multidisciplinary effort**

The sustainable and sound development of OD and OT has been a concern of the international community and local governments, which has been driven by two main factors [4].

Firstly, organ shortage is still a common issue worldwide, despite the fact that the global number of OTs has been increasing in the recent decade. According to data

#### *Empower the Science of Organ Donation by Multidisciplinary Collaboration DOI: http://dx.doi.org/10.5772/intechopen.107130*

collected by the WHO Global Observatory on Organ Donation and Transplantation, there are more than 1,200,000 patients on a current transplantation waiting list, while only 120,000–130,000 transplants are performed a year globally [5]. In recent years, the outbreak of the COVID-19 pandemic has had a great impact on people's daily life and has posed grave challenges to the building and operating efficiency of OD and OT systems in all countries. In the circumstance that the burden of disease and transplantation demand did not decline, the global OT number in 2020 declined by 17.6% compared with that in 2019 [5].

Secondly, donated organs are valuable national resources, giving OD an attribute of social public welfare [6] and its natural links to society. As advocated in the WHO guiding principles on human cell, tissue, and organ transplantation (WHO guiding principles) [7], OD and OT activities should be strictly regulated by the government of member countries, and illegal organ trading should be prohibited. In order to achieve "self-sufficiency" and sustainability of OT, the development of OD and OT programs needs to be based on legal and ethical requirements, with maintaining equity, transparency, accessibility, high quality, and patients' safety at the core.

By further analyzing the nature of the above requirements, it is not difficult to identify a more in-depth demand: The development of the OD program does not only depend on any single community but also requires the support and participation of multiple parties from various sectors and knowledge transferred from multi-disciplines.

#### **2.2 The whole process of OD requires collaboration among multi-teams**

The management mode of organ procurement varies in different countries. Whether built inside medical institutions or being independent outside the hospital, the Organ Procurement Organization (OPO) represents a professional team/organization responsible for the procurement, distribution, and coordination of organ & tissue donation activities at the practical level. The OPO is composed of professionals from different fields such as intensive care medicine, transplantation medicine, anesthesiology, nursing, bioengineering, sociology, psychology, medical ethics and information technology, etc. Its mission and goals are to maximize local donation rate and the number of transplantable organs so as to save more transplant patients and improve their living quality. OPOs and the transplant coordinators serve as a bridge for overall coordination in the entire process at the institutional and individual levels, respectively. Such a collaborative network covers multidisciplinary teams within medical institutions, such as the health care teams in the intensive care unit (ICU), emergency department, neurology department, neurosurgery department, laboratory, transplantation centers, and also expanded to other relevant governmental sectors beyond medical institutions [3].

The following text will focus on the key processes of OD and elaborate on the required multidisciplinary expertise and the involvement of multidisciplinary professional teams.

#### *2.2.1 Identification and referral of potential donors*

The clinical procedure of OD begins with the identification of potential donors. The potential donor identification rate determines the total scale of organs for transplantation [8]. Identification of potential donor and referral by the health care team to the OPO should occur in a timely manner. A timely referral is built upon a working mechanism of OD within donor hospitals with OPO [9]. In the United States (US), in addition to the fact that Centers for Medicare and Medicaid Services (CMS) require each imminent death should be referred by hospitals to the OPO for assessment, OPO will sign a contract with every single donor hospital in its donation service area to consolidate such partnership [10]. In the Netherlands, the roles of emergency physicians, neurosurgeons, and neurologists were clearly defined for the identification of potential organ donors [11]. In China, the health authority has included the potential donor reporting rate as one of the key performance indicators in the accreditation of third-grade hospitals [12].

In addition, research results have illustrated the importance of the ICU team's attitudes and recognition toward OD, as well as the active participation in OD to improve OD rate and organ procurement efficiency [13, 14]. Spanish recommendation even advocates that intensive care to facilitate OD (ICOD) is a legitimate practice that should be considered as part of the health care service portfolio of any country that has a regulated OD and OT system [15].

#### *2.2.2 Death determination*

All OD cases must strictly adhere to the internationally recognized ethical principle of "Dead Donor Rule". Either neurological or circulatory standards are adopted in death determination, such clinical practice has to be performed in accordance with local clinical protocols and legal and ethical requirements.

Although there exists global variability in brain death (BD) diagnosis, donation after brain death (DBD) still represents the main organ source of transplantation, accounting for 77.2% of global deceased donation in 2019 [5]. In this chapter, we focus on the BD determination.

Various protocols and guidelines for BD diagnosis have made clear requirements on the clinical criteria, operational specifications, and personnel for determining BD [16]. As for "who can certify", the World Brain Death Project report [17] provides a minimum recommendation. The physician performing the BD determination must be certified to practice medicine and trained in BD diagnosis. The determination team needs to include a neurologist, a neurosurgeon, an anesthesiologist, and an intensivist at least.

Although personnel in charge of OD and OT cannot take part in the process of death determination, whether the BD diagnosis can be carried out in a timely manner may have impacts on the subsequent step of the OD procedure and result in the donor loss. Thus, it can be seen that the support of neurological expertise and the involvement of a team specialized in performing BD determination are indispensable in this critical aspect of death determination.

#### *2.2.3 Evaluation and maintenance of potential donors and organs*

Potential donor evaluation is one of the key parts of OD workflow, which includes clinical assessment of the donor and organ viability, as well as the risk assessment of the donation process.

Clinical assessment involves risk assessment of donor-driven infectious disease to recipients and assessment of organ viability [18]. For detection of malignancies, it is necessary to know whether the donor has a history of malignancy diagnosis, chemotherapy, and surgery [19]. As for screening of infectious diseases, viral infections such as hepatitis, herpes, human polyomavirus, and acute neoplastic virus; bacterial

#### *Empower the Science of Organ Donation by Multidisciplinary Collaboration DOI: http://dx.doi.org/10.5772/intechopen.107130*

infections such as acute infections, bacterial sepsis, meningitis, pulmonary infections, urinary tract infections, and multidrug resistant bacteria; and other pathogenic infections such as fungal infections, parasitic protozoan, and nematode infections, and prions need to be included [20]. In the case of evaluating elderly or marginal donors, cooperation between OPO medical specialists and transplant surgeons with extensive experience is needed. The entire medical evaluation also requires the professional support from the fields of laboratory medicine, infection, oncology, medical imageology, and pathology.

The other part of the evaluation process includes a general review of personal, social, and medical information of the potential donor as well as information regarding his/her family status and next of kin. The transplant coordinators need to screen and analyze risk points at hand and seek professional help from ethical and legal experts, social workers, and religious figures, if necessary.

Donor management is the longest-lasting step of the entire process and one of the key factors affecting the quality of organs and the transplant outcome [21]. ICU specialists have the professional advantage of carrying out donor maintenance thanks to their background and clinical experience [22]. Studies indicate that the engagement of ICU medical staff in donor management with an aggressive approach can improve the organ utilization rate and organ quality [23].

#### *2.2.4 Communication with the family of the potential donor*

As one of the core steps in OD procedure, family communication is considered a serious and professional matter. The family's distrust of the communicator and the content of the conversation is one of the major reasons for the refusal to donate. The family trust is built upon continuous communication and empathy demonstrated by the communicators. Effective communication with the donor's family requires knowledge reserves of medicine, ethics, law, psychology, social humanities, narrative medicine, communication, etc., close cooperation between coordinators and the health care team, as well as timely coordination among sectors such as traffic police, the forensic team, airlines company, civil affairs, and funeral institutions [24].

In addition to providing families with professional advices in a respectful, honest, cooperative, and empathetic manner during the process, psychological knowledge is needed to grasp the fluctuating psychological state of the family. Communication about death diagnosis and medical condition requires professional medical knowledge and then needs to be transferred to the family in an easy-to-understand way with communication skills. At the same time, traditional cultural and religious views also influence their willingness to donate to some extent. Positive arguments of traditional culture and religion on OD need to be invoked to guide the family to make appropriate decisions based on respecting their religious and cultural beliefs [24].

#### *2.2.5 Organ allocation*

Although organ allocation policies vary among countries in detail, all of them are based on the principle of fairness, equity, and transparency. The WHO guiding principles require that the allocation of organs, cells, and tissues should be guided by clinical criteria and ethical norms, not financial considerations [7]. The WMA Statement on Organ and Tissue Donation (The WMA Statement) regulates those policies governing the management of waiting lists should ensure efficiency and fairness [25]. Therefore, to balance the gains and losses posed by different dimensions, the

research and development of organ allocation policies should be conducted by a panel of experts in multiple fields such as transplantation medicine, biomedicine, health economics, public health, statistics, ethics, law, etc.

To ensure the implementation of organ allocation is inconsistent with the targeted manner and adheres to the predefined allocation rules, the calculation of the matching list and the allocation processes afterward shall be carried out via an informative system [6]. Unlike any other data registries, the informative system for organ allocation has specific application characteristics such as faithful implementation of allocation policies, and real-time assistance in clinical decision-making. The design, development, and maintenance of the allocation system require a panel of medical experts as well as technical support of professionals in mathematics, information science, and computer science.

#### *2.2.6 Organ procurement and preservation*

A sound and reliable process of organ procurement, preservation, and transportation can improve the utilization of donated organs, and ensure the safety of the recipients [26]. According to the EU Guidelines on Quality and Safety of Transplanted Organs (6th edition) (The EU Guidelines) [27], a joint-effort approach among OPO, the donor hospitals, and the surgical team is required. In addition, the importance of establishing a specialized organ surgical team is emphasized in the EU Guidelines, which, if possible, shall consist of surgeons specializing in abdominal and cardiopulmonary organ retrieval, physician for anesthesia, and technicians responsible for organ perfusion preservation [27].

#### *2.2.7 Education and publicity*

Studies suggest that donation rates can be effectively increased through various types of campaigns for different targeted groups [28]. The WMA statement indicates that public awareness of OD should be raised through multifaceted and multilevel media awareness and public campaigns [25]. Through long-term and effective social publicity, it is expected to gradually create a favorable cultural and social atmosphere for OD.

Multilevel and multichannel popularization and publicity require strict standards and the guidance of communication knowledge, which itself is a multidisciplinary integration of narrative medicine, sociology, psychology, journalism, and communication. The promotion of OD requires the participation of ambassadors of OPOs, medical practitioners, media workers, educators, volunteers, and university (medical) students, etc.

#### **2.3 Improvement of operational efficiency and service quality requires the support of multidisciplinary and multi-team professionals**

The "conversion rate" is considered a key indicator to measure the professionalism and performance of the involved teams in the OD process. The "conversion rate" refers to the number of actual donors over the total number of potential donors, which is in contrast to the proportion of donor loss. The "critical pathway for deceased organ donation" systematically describes 13 common causes of donor loss (**Table 1**) [9]. In addition to objective factors (e.g., patients with contraindications


**Table 1.**

*Reasons why potential donors do not become actual donors (donor loss causes).*

to OD), some of these causes are related to the level of awareness and expertise of practitioners engaged in different steps along the process. These causes of donor loss can be improved by providing professional training to practitioners. But it is further illustrated here that potential donors cannot be converted into actual donors or the organ quality and the rights of recipients cannot be protected without the support of relevant expertise and the involvement of professional teams.

#### **3. OD discipline built upon multidisciplinary integration**

The construction of discipline includes building of theoretical system, carriers, talent training and career path, academic environment, and scientific research innovation.

#### **3.1 Building of theoretical system**

The multidisciplinary integration of OD discipline is reflected at two levels, which is firstly reflected in the integration of knowledge in the area within the medical domain (transplantation medicine, critical care medicine, neurology, infection, oncology, and pathology). The second level of multidisciplinary integration is the integration of knowledge in the area of law, ethics, public health, humanities, health economics, management, psychology and communication, etc. [3]. The multidisciplinary knowledge base supporting multi-team collaborative practice meets the fundamental needs of the construction of OD discipline.

#### **3.2 Building of carriers**

Although management models used in different countries vary, administrative organizations at all levels for OD and OT, donor hospitals, OPOs are practice bases of OD discipline.

The essence of multidisciplinary-supporting in OD practice indicates that effort should not only be paid for the construction of any single carrier for OD program with high operating efficiency but also for the long-term work collaboration mechanism between carriers. In the OD context, a collaboration mechanism means an efficient network of collaborations, at the institutional level, between community, OPO, medical institutions, hospice institutes, relevant government sectors, charities, and academic organizations, as well as at the individual level, volunteers, social workers, ICU teams, coordinators, medical experts, transplantation teams, legal medical experts, undertakers, scientific researchers, and other professionals.

#### **3.3 Path of talent training and professional development**

The building of the OD discipline requires the active engagement of multidisciplinary professionals and needs to train a host of application-oriented composite professionals and make them the main force for driving the development of the field.

A transplant coordinator is a profession derived from the development of the OD program and is key to promoting multi-team coordination and cooperation in the process of OD [29]. As the work of OD coordinators involves many aspects, efforts shall be made to strengthen their multidisciplinary theoretical reserve and develop their comprehensive abilities. Meanwhile, coordinators in different countries vary in their professional background, employer, requirements on qualification review, performance management system, etc. Actions should be taken to effectively utilize local occupational planning and policies on talent training, arrange and establish an appropriate professional development path and a system of occupational promotion for OD coordinators, and establish corresponding knowledge, ability, and technology training system in accordance with different features and work needs in different stages of career development. These actions are the fundamental guarantee for the continuous growth of the OD talent team and the basic guarantee for steady development of local OD [29].

#### **3.4 Academic environment and scientific research innovation**

In terms of creating a favorable academic environment, specialized international and national/regional associations related to OD have been created, and their members are experts and scholars in emergency and critical care medicine, neurology, OPO, transplantation medicine, oncology, ethics, law, medical humanities, hospital management, communication, sociology, health economics, public health management statistics, etc.

These associations regularly launch academic research and activities participated by multiple parties, produce high-quality scientific publications, guidelines, and expert consensuses related to organ and tissue donation, organize and take part in multidisciplinary forums and offline academic seminars, so as to create a favorable academic environment for building the OD multi-discipline system and continuously promote the professional development of OD.

#### *Empower the Science of Organ Donation by Multidisciplinary Collaboration DOI: http://dx.doi.org/10.5772/intechopen.107130*

The common research goals in OD-related scientific research tasks include how to maximize the outcomes linked to the mission of the OD program. These key indicators include the donor per million population (PMP), the donor conversion rate, authorization rate, the organ utilization rate, the degree of efficiency of the management mode and the collaborative network, and satisfaction of donor**'**s family or relevant practitioners. The involvement of multi-discipline teams in these researches enhances the ability to find comprehensive solutions to the questions concerned. With regard to technical innovation, recent years have seen the development of technologies such as regional perfusion, ex vivo perfusion, mechanical preservation, and tissue regeneration to provide better conditions for organ viability and quality. Advances in biochemistry and tissue engineering have provided technical support to improve the quality and utilization of donor organs. Besides, with the development of aeronautical engineering technology, the concept of organ transportation by unmanned aircraft systems has been put into practice [3], indicating the enormous potential and value brought by the "medical + engineering + information" integration in the process of building of the OD discipline.

#### **4. China's efforts**

Over the past decade, China has made breakthroughs in OD and OT. Since the launch of the national program for deceased OD in 2010 and continuously driven by the patients**'** demands for transplantation, China has formed a national ethical OD and OT system in line with WHO guidelines and international standards [3]. China has become the second largest country in the world in terms of an annual number of OD and OT [5]. As of August 2022, the number of deceased organ donors has exceeded 40,000, and over 120,000 organs have been donated for saving life [30].

However, similar to other countries, China is still faced with the huge gap between supply and demand for OT. Meanwhile, China's PMP, 3.6 in 2020, is globally at the middle level [5], indicating room for improvement. The lack of a complete scientific theoretical system to guide professional and career development in OD is one of the reasons for the current results, rather than Asian or traditional cultures. In addition, the current number of transplant coordinators in China is insufficient, with around 2,000 certified coordinators [3] serving a population of 1.4 billion. Actions should be taken to implement countermeasures of talent attraction and talent encouragement for the field. To study and solve bottleneck problems facing the country, the work team consisting of multidisciplinary experts has made a proposal and reached a consensus on promoting OD discipline building through multidisciplinary integration and support.

#### **4.1 Policy support**

In recent years, China has advocated the development strategy of interdisciplinary collaboration and introduced a raft of policies, making multidisciplinary penetration and integration of interdisciplinary professionals a general trend [31]. Moreover, Chinese laws and regulations related to OD and OT advocate that administrative departments, red cross societies, and medical institutions at all levels and medical professionals shall support and take an active part in the work of OD. The introduction of these policies provides multidisciplinary integration and development of OD with institutional support [32, 33].

#### **4.2 Tasks and actions**

#### *4.2.1 Building of OPOs*

The degree of specialization of the operating carrier and its talent team is the basis for maintaining the efficient operation of the OD system. In 2013, advocated by the national health commission, China started building of OPOs nationwide [34], which, together with donor hospitals, become the carriers and initial base for the practice of the OD discipline. Subsequently, more than 130 OPOs have been developed either in a hospital-based or an independent institutional structure [35]. The standards for building, operation, and management of OPO and the indicators matrix of quality control for organ procurement have been also released by the national health commission [34].

#### *4.2.2 Building of talent team*

For the talent development of OD, the multidisciplinary knowledge and skill enhancement of professionals have been emphasized in its training model and contents in recent years. China has been exploring educational models for different target groups in practice, and the talent training includes the following aspects:

At the national level, comprehensive training courses and qualification tests are provided by China OD administration center for transplant coordinators, forming a national training and qualification system.

At the regional level, professional training is conducted by academic associations and OPOs for medical and nursing staff of critical care units, as well as public charity publicity and education activities for communities, schools, nursing homes, etc.

In terms of linking with the educational system, China has made explorations and practices in integrating education related to OD in the higher education system. The China-Europe Knowledge Transfer and Leadership in Organ Donation (KeTLOD) has established OD higher education (postgraduate) programs in seven Chinese universities to provide a master's course on organ donation [36]. In addition, a number of universities and colleges have introduced undergraduate elective courses on OD and OT [37]. In regions such as Zhejiang province, "popular science articles regarding OD " has been included in secondary school textbooks to popularize relevant concepts [38].

#### *4.2.3 Academic environment*

At the academic level, China has established professional associations for OD, which consist of medical experts from departments related to OD and OT, as well as scholars from medical ethics, law, social humanities, health economics, psychology, mass communication, biological tissue engineering, and anatomy. An expert consensus on development of a multidisciplinary supporting system for OD has been reached. Under the supervision of these associations, the scientific papers, consensus, guidelines, and books focused on the theme of multidisciplinary integration have been published, and academic activities with the participation of experts from multiple fields have been organized on a regular basis.

#### **4.3 Social engagement**

In terms of public education and publicity of OD, from the public-welfare publicity activities initiated by the administrative department, news media, and various

public-service organizations to individual**'**s spontaneous publicity activities, the concept of OD has been popularized. April has been granted as the memorial month for organ donors in the country. As of August 2022, the number of voluntary organ donor registrants in China has exceeded 4.9 million [30].

#### **5. Conclusion**

The construction of the OD discipline system is in line with the fundamental requirement of promoting sustainable development of OD and OT. Promoting the OD discipline development is of positive significance for enhancing the professional identity of OD practitioners and the credibility of the OD undertaking.

According to its attribute of public welfare and work characteristics of the OD undertaking, its disciplinary building needs interdisciplinary support. Through years of efforts, China has been improving relevant laws and regulations, besides, it strives to boost interdisciplinary collaboration of OD through diversified popularization and publicity, comprehensive training for professional teams, and creation of a collaborative network with more extensive multidisciplinary support and engagement.

In summary, whether to cope with the bottleneck problems in the development of OD, or to improve the efficiency of work system and the quality of medical services by taking key measures to meet the demands in the whole process, it shows the necessity and feasibility of promoting the building of OD-related disciplines through multidisciplinary collaboration. Therefore, under the strategy of multidisciplinary development, we need to center around safeguarding the rights of donors and their family members and protecting recipients' rights to health, focus on the quality of the work of OD and OT, effectively integrate resources, give full play to professional forces in different fields, build an OD discipline system that meets the professional medical requirements, and fully shows the features of social humanity, thereby promoting the standardized, systematic, and professional development of OD. It is a common topic requiring policymakers, experts, and practitioners in the field to think deeply and make research, explorations, and practices persistently. We believe, by adhering to the coordinated multidisciplinary development strategy, the visible progress of the organ donation discipline in the future would be the result of the joint-effort gained from interdisciplinary collaboration and innovations.

#### **Acknowledgements**

We would like to express our special thanks to the National Health Commission of China and the Red Cross Society of China for their administrative support in establishing the national program of deceased organ donation & transplantation and the development of a data collection system. We would like to extend our sincere gratitude to the pioneers in the field including Prof Jiefu HUANG, Prof Bingyi SHI, Prof Shusen ZHENG, Prof Yongfeng LIU, Mr. Fengzhong HOU, etc. for their professional leadership in the reform of the Chinese organ transplantation in the last 10 years. Appreciation is also given to the Shanxi Provincial Organ Procurement and Allocation Center for logistics support of the study.

### **Funding**

There has been no dedicated funding for this study.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Wenshi Jiang1 \*, Xiaotong Wu1 , Liansheng Ma2 , Jing Shu3 , Juan Yan4 , Liming Yang<sup>5</sup> , Yajie Ma1 and Xiangxiang He1

1 Shanxi Provincial Organ Procurement and Allocation Center, Taiyuan, China

2 First Hospital of Shanxi Medical University, Taiyuan, China

3 Zhejiang Xin'an International Hospital, Hangzhou, China

4 Shanxi Medical University, School of Humanities and Social Sciences, Taiyuan, China

5 The Sixth Hospital of Shanxi Medical University, Taiyuan, China

\*Address all correspondence to: wenshi.jiang@hotmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Wang Z, Peng D, Ma X. From interdisciplinarity to interdisciplinarity: The case of the United States and its insights. Science Bulletin. 2021;**66**(9):9

[2] Xue Z, Zhang Z. A review of interdisciplinary research systems. Library and Information Work. 2020;**64**(14):14

[3] Professional Committee of Human Organ and Tissue Donation, China Association for the Promotion of Human Health Science and Technology. Organ donation: A new multidisciplinary discipline in China in the new era. Organ Transplantation. 2020;**11**(5):614-621. DOI: 10.3969/j. issn.1674-7445.2020.05.015

[4] Rudge C, Matesanz R, Delmonico FL, et al. International practices of organ donation. British Journal of Anaesthesia. 2012;**1**(1):20

[5] GODT. Global observatory on donation and transplantation. 2022. Available from: http://www.transplantobservatory.org/. [Accessed: July 14, 2022]

[6] Huirui L. Why does the system fail? -- Research on the justice of organ donation distribution under multiple logics. Sociological Research. 2020;**1**:26

[7] Noel L. WHO guiding principles on human cell, tissue and organ transplantation. Transplantation. 2010;**90**(3):229-233

[8] Dong J, Xuyang L, Wang H, et al. Interpretation of guide to the quality and safety of organs for transplantation: Identification and referral of potential donors. Organ Transplantation. 2020;**11**(3):395-399. DOI: 10.3969/j. issn.1674-7445.2020.03.013

[9] The critical pathway for deceased donation: Reportable uniformity in the approach to deceased donation. Transplant Multinational. 2015;**4**:24

[10] Ehrle R. Timely referral of potential organ donors. Critical Care Nurse. 2006;**26**(2):88-93

[11] Witjes M, Kotsopoulos A, Otterspoor L, et al. The implementation of a multidisciplinary approach for potential organ donors in the emergency department. Transplantation. 2019;**103**:2060

[12] National Health Commission of the People's Republic of China. Evaluation criteria for tertiary hospitals (2020 version). (EB/QL). 2020

[13] Roels L, Spaight C, Smits J, et al. Critical care staffs' attitudes, confidence levels and educational needs correlate with countries' donation rates: Data from the Donor Action Database. Transplantation International. 2010;**23**(8):842-850

[14] Fang Q, Wu XL, Wang F. Organ donation and critical care medicine. Chinese Medical Journal. 2019;**99**(35):4

[15] Martín-Delgado MC, Martínez-Soba F, Masnou N, et al. Summary of Spanish recommendations on intensive care to facilitate organ donation. Chinese Medical Journal. 2019;**19**:1782-1791

[16] Shemie SD, Hornby L, Baker A, et al. International guideline development for the determination of death. Intensive Care Medicine. 2014;**6**:40

[17] Greer DM, Shemie SD, Lewis A, et al. Determination of brain death/death by neurologic criteria: The world brain death project[J]. Jama. 2020;**324**(11): 1078-1097

[18] Xie L, Qiuxiang X, Xianpeng Z, et al. Interpretation of Guide to the Quality and Safety of Organs for Transplantation: Evaluation and selection criteria for donors and organs. Organ Transplantation. 2020;**11**(4):487-491. DOI: 10.3969/j. issn.1674-7445.2020.04.011

[19] Lin J, Shixin L, Yang Y. Interpretation of guide to the quality and safety of organs for transplantation: Risk of malignant tumor transmission. Organ Transplantation. 2020;**11**(3): 400-404. DOI: 10.3969/j.issn.1674- 7445.2020.03.014

[20] Bogen Y, Lei Z. Interpretation of guild to the quality and safety of organs for transplantation: Risk of infectious disease transmission. Organ Transplantation. 2020;**11**(2): 282-287. DOI: 10.3969/j.issn.1674- 7445.2020.02.016

[21] Sun X, Dong J, Qin K, et al. Optimizing donor clinical management strategies and promoting scientific research on donor management. Organ Transplantation. 2019;**10**(6):731-734. DOI: 10.3969/j. issn.1674-7445.2019.06.018

[22] Pan A, Wang P, Xie C, et al. A key strategy for ICU-assisted organ donation as a relay for life. Organ Transplantation. 2020;**11**(2):288-292. DOI: 10.3969/j. issn.1674-7445.2020.02.017

[23] Zhu Y, Cai C, Guan X. Donor management of organ donation in ICU. Chinese Electronic Journal of Intensive Care Medicine. 2017;**3**(2):6

[24] Preparation Group of Expert Consensus on Communication with Families of Organ and Tissue Donors. Expert consensus on communication with families of organ and tissue donors. Organ Transplantation. 2021;**12**(6):651-661. DOI: 10.3969/j. issn.1674-7445.2021.06.003

[25] World Medical Association. WMA Statement on Organ and Tissue Donation [EB/OL]. 2020. Available from: https://www.wma.net/policies-post/ wma-statement-on-organ-and-tissuedonation/

[26] Huibo S, Wang X, Xu J, et al. Interpretation of guide to the quality and safety of organs for transplantation: Organ procurement, preservation and transportation. Organ Transplantation. 2020;**11**(2):276-281. DOI: 10.3969/j. issn.1674-7445.2020.02.015

[27] European Committee (Partial Agreement) on Organ Transplantation (CD-P-TO) EDQM. Guidelines on the Quality and Safety of Transplant Organs. 6th ed. Beijing: Science Publishers; 2019;**6**(2)

[28] Madden S, Lucey MR, Neuberger J. Does publicity affect organ donation? Transplant International. 2020;**33**:1146-1148

[29] Yang S, Xiaoqin T, Gao X, et al. Consideration on the professional construction of organ donation coordinator team. China Journal of Transplantation. 2012;**6**(2)

[30] China Organ Donation Administrative Center. Available from: https://www.codac.org.cn. [Accessed: August 2, 2022]

[31] Academic Degrees Committee of China State Council. Notice on the Issuance of the Measures for the Establishment and Management of Interdisciplinary Subjects (for Trial

*Empower the Science of Organ Donation by Multidisciplinary Collaboration DOI: http://dx.doi.org/10.5772/intechopen.107130*

Implementation) [A/OL]. 2022. Available from: http://www.gov.cn/ xinwen/2021-12/06/content\_5656041. htm

[32] Law of the People's Republic of China on the Red Cross Society (revised 2017) [EB/OL]. 2022. Available from: http:// www.npc.gov.cn/npc/c12435/201702/5cb cc78a701b4a8dbf3bd0a6701659e2.shtml

[33] General Committee of the Red Cross Society of China, National Health and Wellness Commission. Notice on the issuance of the Measures for the Administration of Human Organ Donation Coordinators [A/OL]. 2022. Available from: https://www.redcross. org.cn/html/2021-05/78447.html

[34] Huang W, Ye QF, Fan XL, et al. Development and history of organ procurement organization in China. Medical Journal. 2021;**42**(2):173-178

[35] Jiang W et al. The first independent provincial OPO in China: The Shanxi Experience. Transplantation. 2022;**106**(6):1093-1095

[36] China-Europe Organ Donation Leadership Training and Expertise Transfer Program, Jiang WS, Ballester C. Exploration and practice of a higher education model for organ donation. Chinese Journal of Transplantation. 2019;**13**(3):201-205

[37] Ling S-B, Chen J-L, Wei Q, et al. The impact of general education on organ donation and organ transplantation on improving humanistic literacy of college students. China Higher Medical Education. 2021;**5**:2

[38] China Human Organ Donation Management Center. Human organ donation knowledge into high school textbooks in Zhejiang Province. 2022. Available from: https://www.

codac.org.cn/contentdon/work\_ dynamics/20220104/1030335092.html. [Accessed: January 04, 2022]

Section 2
