**2.2. Relationship with donors' families**

The changes in the interaction modalities with family members and with the patient, when possible, have been consolidated since 2013 in our ICU; the changes represented a structured intervention. We believe that the new relationship's modalities with the patients' relatives, so far exposed and described in their reliability, have favorably influenced the reduction of opposition to organ donation by the family members of the deceased patient. Our ICU is an 18-bed, multidisciplinary ICU. It is a referral center for acute respiratory failure as well as a trauma center. Relatives of brain-dead patients were approached according to an internal protocol, inspired by NICE guidelines, which temporarily distinguishes two phases: communicating brain death and proposing organ donation. These guidelines deal with delivering the end-of-life communication and developing a supportive relationship with potential beating-heart donors' families [19]. Often, patients who develop brain death did not express their opinion on organ donation during their lifetime. In our ICU all patients and relatives including relatives of brain-dead patients have been approached by the medical staff to establish a relationship since 2013, aiming at making them feel better and understood. The number of acceptances to organ donation in our intensive care was observed before and after the implementation of two major interventions: the opening of the intensive care (project called "OpenICU") to relatives and the introduction of the innovative communication approach mentioned above. Opening ICUs should come about not so much in answer to pressure generated by a growing social awareness, or in simple recognition of a right, but because this policy addresses more comprehensively the issue of respect for the patient, as well as providing more appropriate responses to many needs of both patients and families. It is a decision which requires doctors and nurses to rethink their relationships with patients and their families, which calls for original solutions for each individual situation and which should be subject to periodic checks. Psychotherapists support the relatives in finding a meaning to their experience and to understanding their own reaction and attitude. Further elements could have positively influenced the decline in organ donation, such as:


**2. Our experience and discussion**

94 Organ Donation and Transplantation - Current Status and Future Challenges

Since 2013, as we have recently published, we developed a new communication approach addressed to relatives of patients admitted to the intensive care unit (ICU) ([18], with permission]). It consists of a patient/relative-centered approach, in which doctors, nurses, psychologists and volunteers support relatives throughout the care process. First, they try to acquire information on the family's social and cultural background and adjust the communication accordingly and second, they aim to understand the patient's will, a task that can be challenging in the intensive care context. When the patient first enters the ICU, the physician must give priority to treatment and can only speak briefly to the relatives. He reassures them that there will soon be time to acquire information and ask questions. As soon as the patient's conditions allow an interview with the relatives is performed so as to establish a relationship between the physician and the family. The physician who followed the patient's acute phase, the nurse who is in charge of him or her and a psychotherapist or a psychologist conducts it in a dedicated room. The staff also takes note of the relatives' phone numbers. The following interviews take place in the patient's room. During the first interview, the medical staff harmonizes on the needs and feelings of the family and retraces the patient's history and the recent acute event. This interview also aims to identify the main caregivers and establish the timetable and program for the following days. We applied a well-defined model, which can

**2.1. New communication approach**

be divided into several steps:

**4.** Early involvement of a psychotherapist;

**2.2. Relationship with donors' families**

**5.** Communication to the family in the patient's room;

presence of a psychotherapist and a volunteer;

regard to the family members' emotions and feelings.

**1.** Giving a warm welcome to the patient and his family unit; **2.** Identification of the caregiver among the family members;

**3.** Taking care of the patient and relatives in a multidisciplinary way;

**6.** Giving information on the patients' clinical conditions by the physician, the nurse and in

**7.** Communication between the family and the psychotherapist and volunteer, with special

The changes in the interaction modalities with family members and with the patient, when possible, have been consolidated since 2013 in our ICU; the changes represented a structured intervention. We believe that the new relationship's modalities with the patients' relatives, so far exposed and described in their reliability, have favorably influenced the reduction of opposition to organ donation by the family members of the deceased patient. Our ICU is an 18-bed, multidisciplinary ICU. It is a referral center for acute respiratory failure as well as a The Open ICU is realized when the whole team aims to abolish all of the unnecessary limitations at a temporal, physical and relational level. Opening the ward to family members allows patients and their relatives to be actively involved, fueling the healing process through affection and contact with their beloved. Besides, it helps patients to better tolerate hospitalization. When the Open ICU first opened, an innovative concept was introduced: interview with relatives no longer took place in a separate and impersonal "medical staff room." It was moved into the patients' room. This gave the opportunity for relatives to be physically close to their beloved while receiving bad news. This physical nearness soothes the relatives' grief. Being in the patients' room means sharing the environment with him or her: they hear the same sounds, feel the same temperature and see the same colors. The patient, his family and the physician now share the same scene. The relationship is still asymmetrical as the physician decides what to do and is trusted. However, the patient and his family are now considered as central elements of the scene. In fact, during the interview, there is an exchange of information between the physician and the family; the former is open to questions and doubts expressed by relatives, reducing errors related to a subjective interpretation of reality. Rather than speaking to the patient's family, the physician speaks with the patient's family. Conducting the interview in the patient's room also facilitates questions on machines and therapies with which relatives are not familiar. Apart from verbal expressions, body language (which comprehends movements toward or from the patient, facial expressions, position of the relatives in the room) is part of the relationship between physician/nurse and the patient's family. In this regard, the interview taking place in the patient's room recalls the historical role of the doctor, who visited patients at home. Just as in the past, the doctor moves toward the patient. This movement is symbolically meaningful in the relationship. We think it is also important to recognize the emotions of both the family and the physician, who are all involved by seeing the patient while the interview takes place. The physician, the patient and the relatives recreate a family unit, giving more humanity to a very difficult moment that involves communication of the ICU patient's condition.

mention must be addressed to nurses. Nurses are probably the health-care professionals who spend more time with patients. Because of the Open ICU, they often work while relatives are in the room and most of the time not in the presence of physicians. For these reasons, they are in charge of explaining to the relatives what physicians told them during the interview. Their relationship with the patient and with relatives is unique and contributes meaningfully to the care-taking process. Even though they are not professionals, volunteers act as a connection between the world outside the hospital and the ICU. When nurses and physicians are occupied in emergencies or in routine clinical activity, relatives find an important referral in

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Potential donor patients' family members receive a favorable impact from the host, support and relationship strategies described so far. When brain death is declared, the family is entrusted by the care team to a dedicated team of the organ procurement. Relatives of brain-dead patients were approached according to an internal protocol, inspired by NICE guidelines, which temporarily distinguishes two phases: communicating brain death and proposing organ donation. These guidelines deal with delivering the end-of-life communication and developing a supportive relationship with potential heart-beating donor families.

**Suggested locations:** doctor's office, conference room, relatives meeting room, no hallways

**Meeting participants:** intensive care specialist in charge of the decedent's care, nurse appointed to provide specific support, physician and nurse in charge of the transplant coordination system, family members wishing to be informed and psychotherapist. It is crucial that both staffs are present during this phase: the medical staff in charge of the patient, which will

**Environment arrangements:** sitting in a circle, if possible, access to phone calls, paper handkerchiefs, glasses and water. Avoid placing writing desks between the speakers and the relatives. Do not behave/act with detachment or indifference: avoid folded arms, fisting and fiddling; do not look away from the interlocutor; do not speak in a formal or distant way.

**Delivering the communication (how and when):** only after the first observation to assess the patient's death according to the Italian legislation. The assessment declaration is clearly and simply formulated by the intensive care specialist: "The EEG tracing we've just performed reveals the absence of brain electrical activity, there are no reactions to external stimulation, and the patient is not able to breathe autonomously. These circumstances unfortunately describe a death diagnosis. The legal-medical procedure to assess brain death has just started, and it will go on for 6 hours. At the end of the 6 hours, we will stop the artificial respiration procedure that is now keeping the heartbeating." A summary of the patient's clinical and therapeutic history can be added. Verify that relatives understand the meaning of brain death.

**Developing a supportive relationship:** give the family the appropriate time to react to the communication. Do not try to control or limit their reaction. Let them express rejection, denial,

The end-of-life communication recognized the following seven details:

introduce the transplant coordination system staff.

incredulity, anger, violent anger, desperation and so forth.

volunteers.

and common areas.

Besides, there are a few gimmicks that help improve the family's comprehension and memorization of information:


The interview with relatives has several functions: it is informative, it is clarifying and it contains the family's emotional reactions. This last one is paramount in an ICU, where patients' deaths or losses of functional capacities can take place unpredictably. Historically, trust in doctors has been an unconditional feeling. During emergencies and critical events, families have no choice but to trust physicians, who are in charge of their relative's lives. Nevertheless, this trust must be respected and preserved because it is no longer unconditional. Nowadays, it is based on the physician's empathy with the relatives' emotions and on giving explanations to their worries and questions. By taking the family's emotions in charge, the physician creates a trustworthy relationship with them and can then make realistic predictions of survival and prognosis with them, also facing the topic of terminal illness. Many patients experience anxiety because of hospitalization and the impending threat to their lives. Similarly, psychotherapists help relatives to decrease their level of anxiety, allowing them to experience the ward as a more "human place," where there is space for relationships with the caregivers, who respond to help requests and throughout which emotions can be shared. The physician respectfully listens to the patient's or relatives' worries, allowing them to elaborate their emotions. At the same time, the physician conveys clear information authoritatively, though in a sensitive and truthful way. This is identified by Castagna as a counseling relationship, through which individuals develop awareness of their experiences and needs. Thanks to such relationship, patients manage to handle a challenging moment of their life by expanding their inner strength, even when reduced by critical illness. By communicating, we improve our shared knowledge, the so-called "common sense," the essential precondition to the existence of a community. Among the multidisciplinary team, a special mention must be addressed to nurses. Nurses are probably the health-care professionals who spend more time with patients. Because of the Open ICU, they often work while relatives are in the room and most of the time not in the presence of physicians. For these reasons, they are in charge of explaining to the relatives what physicians told them during the interview. Their relationship with the patient and with relatives is unique and contributes meaningfully to the care-taking process. Even though they are not professionals, volunteers act as a connection between the world outside the hospital and the ICU. When nurses and physicians are occupied in emergencies or in routine clinical activity, relatives find an important referral in volunteers.

Potential donor patients' family members receive a favorable impact from the host, support and relationship strategies described so far. When brain death is declared, the family is entrusted by the care team to a dedicated team of the organ procurement. Relatives of brain-dead patients were approached according to an internal protocol, inspired by NICE guidelines, which temporarily distinguishes two phases: communicating brain death and proposing organ donation. These guidelines deal with delivering the end-of-life communication and developing a supportive relationship with potential heart-beating donor families.

The end-of-life communication recognized the following seven details:

which relatives are not familiar. Apart from verbal expressions, body language (which comprehends movements toward or from the patient, facial expressions, position of the relatives in the room) is part of the relationship between physician/nurse and the patient's family. In this regard, the interview taking place in the patient's room recalls the historical role of the doctor, who visited patients at home. Just as in the past, the doctor moves toward the patient. This movement is symbolically meaningful in the relationship. We think it is also important to recognize the emotions of both the family and the physician, who are all involved by seeing the patient while the interview takes place. The physician, the patient and the relatives recreate a family unit, giving more humanity to a very difficult moment that involves communica-

Besides, there are a few gimmicks that help improve the family's comprehension and memo-

**1.** Communicate one piece of information at a time, in a specific, accurate and coherent way, "need to be honest, but should aim to mitigate the stress rather than exacerbating the fear

The interview with relatives has several functions: it is informative, it is clarifying and it contains the family's emotional reactions. This last one is paramount in an ICU, where patients' deaths or losses of functional capacities can take place unpredictably. Historically, trust in doctors has been an unconditional feeling. During emergencies and critical events, families have no choice but to trust physicians, who are in charge of their relative's lives. Nevertheless, this trust must be respected and preserved because it is no longer unconditional. Nowadays, it is based on the physician's empathy with the relatives' emotions and on giving explanations to their worries and questions. By taking the family's emotions in charge, the physician creates a trustworthy relationship with them and can then make realistic predictions of survival and prognosis with them, also facing the topic of terminal illness. Many patients experience anxiety because of hospitalization and the impending threat to their lives. Similarly, psychotherapists help relatives to decrease their level of anxiety, allowing them to experience the ward as a more "human place," where there is space for relationships with the caregivers, who respond to help requests and throughout which emotions can be shared. The physician respectfully listens to the patient's or relatives' worries, allowing them to elaborate their emotions. At the same time, the physician conveys clear information authoritatively, though in a sensitive and truthful way. This is identified by Castagna as a counseling relationship, through which individuals develop awareness of their experiences and needs. Thanks to such relationship, patients manage to handle a challenging moment of their life by expanding their inner strength, even when reduced by critical illness. By communicating, we improve our shared knowledge, the so-called "common sense," the essential precondition to the existence of a community. Among the multidisciplinary team, a special

**4.** Verify that family members have understood what is explained to them.

tion of the ICU patient's condition.

**2.** Explain the patient's priorities in that moment;

96 Organ Donation and Transplantation - Current Status and Future Challenges

**3.** Invite the family member to ask questions;

rization of information:

and uncertainty";

**Suggested locations:** doctor's office, conference room, relatives meeting room, no hallways and common areas.

**Meeting participants:** intensive care specialist in charge of the decedent's care, nurse appointed to provide specific support, physician and nurse in charge of the transplant coordination system, family members wishing to be informed and psychotherapist. It is crucial that both staffs are present during this phase: the medical staff in charge of the patient, which will introduce the transplant coordination system staff.

**Environment arrangements:** sitting in a circle, if possible, access to phone calls, paper handkerchiefs, glasses and water. Avoid placing writing desks between the speakers and the relatives. Do not behave/act with detachment or indifference: avoid folded arms, fisting and fiddling; do not look away from the interlocutor; do not speak in a formal or distant way.

**Delivering the communication (how and when):** only after the first observation to assess the patient's death according to the Italian legislation. The assessment declaration is clearly and simply formulated by the intensive care specialist: "The EEG tracing we've just performed reveals the absence of brain electrical activity, there are no reactions to external stimulation, and the patient is not able to breathe autonomously. These circumstances unfortunately describe a death diagnosis. The legal-medical procedure to assess brain death has just started, and it will go on for 6 hours. At the end of the 6 hours, we will stop the artificial respiration procedure that is now keeping the heartbeating." A summary of the patient's clinical and therapeutic history can be added. Verify that relatives understand the meaning of brain death.

**Developing a supportive relationship:** give the family the appropriate time to react to the communication. Do not try to control or limit their reaction. Let them express rejection, denial, incredulity, anger, violent anger, desperation and so forth.

**Medical personnel cope with reactions caused by the end-of-life communication:** keep a silent and empathic behavior. Take care of actual necessities such as drinking, making telephone calls and handkerchiefs. Listen empathically to the relatives' memories on the patient's life and on the history of the illness that caused his death (accident dynamics, health-care delays, diagnosis mistakes, disappointed expectations on surgery and treatments, family problems, and so forth). Do not make obvious or inappropriate statements such as: "I'm so sorry for you," "I can understand your pain," "I know you're angry and I understand this," and so forth.

hospitals in Italy. As one of the five level-1 regional hospitals in Lazio, it has approximately 1600 beds and 95,000 accesses per year. It is one of the leading centers for identification of patients who have been declared dead with neurological criteria. Our intervention could have a beneficial effect on the rate of consent to organ donation (COD) by the relatives of brain-dead patients. To test this hypothesis, we compared the rate of COD before and after the implementation of the protocol into our ICU [13]. In our work we analyzed the family consent rate (potential and real donors' ratio) before and after the introduction of the new communication protocol. We observed that a consent rate increased from 71% in the preintervention period (2007–2012) to 78.4% in the post-intervention period (2013–2015) with a specific increase of 82.75% from 2014 to 2015. In 2017, we observed a consent rate of 78.6% with a steady rise in the number of identified potential donors. At the same time we registered the regional consent rate of 68.1 and 73.1% in 2016 and 2017, respectively. During these periods, no significant variation of organ donation consent has been recorded at a national level. Our center has kept a constant commitment in increasing the observation rates, keeping the opposition to COD rate unvaried at first and then contributing to reduce it significantly. On the whole, the center's opposition rate compared with both national and regional average is significantly lower: 2017: national, 28%; regional: Lazio, 27%; our ICU, 21% (**Figures 1** and **2**).

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**Figure 1.** Brain deaths.

**Visiting the bed:** the nurse was appointed to support the family or the transplant nurse coordinator introduced themselves and their job. They take the relatives wishing to visit the patient to the patient's bed. Group visits are allowed (according to the size of the patient's room), preferably after the first reactions to the communication of death. The nurse answers to every question about heartbeat after death in a simple way: ".heartbeats and blood pressure are still being monitored because the heart is beating. We are sending oxygen to the heart artificially with a ventilator that is pumping air into the lungs but, unfortunately, there is no brain activity. The patient is not able to breathe autonomously and his chest is still moving just because of the ventilator." The nurse can offer the assistance of a religious person to administer the last rites and pray with the family.

A donation proposal recognized a following four details:

**Suggested location:** doctor's office, conference room, relatives' meeting room, no hallways and common areas.

**Participants:** intensive care specialist in charge of the patient's care, nurse appointed to provide specific support, physician and nurse in charge of the transplant coordination system, family members wishing to be informed and psychotherapist.

**Environment arrangements:** sitting in a circle, if possible, access to phone calls, paper handkerchiefs, glasses and water. Avoid placing writing desks between the speakers and the relatives.

**Delivering the communication (how and when):** The organ and/or tissue donation proposal follows in all cases the death communication, the bed visit and the last farewell. Before the donation proposal, it is advisable to give a brief summary of the patient's clinical conditions, focusing on the seriousness of initial conditions and prognosis. The donation proposal is communicated in a direct and simple way: "we propose to you an act of solidarity toward people who are in critical conditions. We propose to donate organs of your relative." Provide detailed information on the organ donation process and on its potential benefits. The proposal can be followed by a moment of privacy for the family to discuss and decide.

The Italian Transplant Coordination System monitors, audits and oversees organ donation, harvesting and transplant in our country. The Italian Transplant System controls organ donation, allocation and transplant; it is organized into three levels: National (National Transplant Center), Regional (Regional Transplant Center) and Hospital (Hospital Transplant Center). The Fondazione Agostino Gemelli Hospital Catholic University is one of the major regional hospitals in Italy. As one of the five level-1 regional hospitals in Lazio, it has approximately 1600 beds and 95,000 accesses per year. It is one of the leading centers for identification of patients who have been declared dead with neurological criteria. Our intervention could have a beneficial effect on the rate of consent to organ donation (COD) by the relatives of brain-dead patients. To test this hypothesis, we compared the rate of COD before and after the implementation of the protocol into our ICU [13]. In our work we analyzed the family consent rate (potential and real donors' ratio) before and after the introduction of the new communication protocol. We observed that a consent rate increased from 71% in the preintervention period (2007–2012) to 78.4% in the post-intervention period (2013–2015) with a specific increase of 82.75% from 2014 to 2015. In 2017, we observed a consent rate of 78.6% with a steady rise in the number of identified potential donors. At the same time we registered the regional consent rate of 68.1 and 73.1% in 2016 and 2017, respectively. During these periods, no significant variation of organ donation consent has been recorded at a national level. Our center has kept a constant commitment in increasing the observation rates, keeping the opposition to COD rate unvaried at first and then contributing to reduce it significantly. On the whole, the center's opposition rate compared with both national and regional average is significantly lower: 2017: national, 28%; regional: Lazio, 27%; our ICU, 21% (**Figures 1** and **2**).

**Figure 1.** Brain deaths.

**Medical personnel cope with reactions caused by the end-of-life communication:** keep a silent and empathic behavior. Take care of actual necessities such as drinking, making telephone calls and handkerchiefs. Listen empathically to the relatives' memories on the patient's life and on the history of the illness that caused his death (accident dynamics, health-care delays, diagnosis mistakes, disappointed expectations on surgery and treatments, family problems, and so forth). Do not make obvious or inappropriate statements such as: "I'm so sorry for you," "I can understand your pain," "I know you're angry and I understand this,"

**Visiting the bed:** the nurse was appointed to support the family or the transplant nurse coordinator introduced themselves and their job. They take the relatives wishing to visit the patient to the patient's bed. Group visits are allowed (according to the size of the patient's room), preferably after the first reactions to the communication of death. The nurse answers to every question about heartbeat after death in a simple way: ".heartbeats and blood pressure are still being monitored because the heart is beating. We are sending oxygen to the heart artificially with a ventilator that is pumping air into the lungs but, unfortunately, there is no brain activity. The patient is not able to breathe autonomously and his chest is still moving just because of the ventilator." The nurse can offer the assistance of a religious person to

**Suggested location:** doctor's office, conference room, relatives' meeting room, no hallways

**Participants:** intensive care specialist in charge of the patient's care, nurse appointed to provide specific support, physician and nurse in charge of the transplant coordination system,

**Environment arrangements:** sitting in a circle, if possible, access to phone calls, paper handkerchiefs, glasses and water. Avoid placing writing desks between the speakers and the

**Delivering the communication (how and when):** The organ and/or tissue donation proposal follows in all cases the death communication, the bed visit and the last farewell. Before the donation proposal, it is advisable to give a brief summary of the patient's clinical conditions, focusing on the seriousness of initial conditions and prognosis. The donation proposal is communicated in a direct and simple way: "we propose to you an act of solidarity toward people who are in critical conditions. We propose to donate organs of your relative." Provide detailed information on the organ donation process and on its potential benefits. The proposal can be

The Italian Transplant Coordination System monitors, audits and oversees organ donation, harvesting and transplant in our country. The Italian Transplant System controls organ donation, allocation and transplant; it is organized into three levels: National (National Transplant Center), Regional (Regional Transplant Center) and Hospital (Hospital Transplant Center). The Fondazione Agostino Gemelli Hospital Catholic University is one of the major regional

and so forth.

and common areas.

relatives.

administer the last rites and pray with the family.

A donation proposal recognized a following four details:

98 Organ Donation and Transplantation - Current Status and Future Challenges

family members wishing to be informed and psychotherapist.

followed by a moment of privacy for the family to discuss and decide.

and ongoing message exchange, aimed to understand each other, the communication is integrated in our social realities and we can define this process as "transactional." In the transactional process the people involved in the act of communicating are actively and simultaneously sending information as well as receiving them. Participants perceive their communication as intentional. The information transfer between them takes place in a particular situation affected by relationship and culture. The speaker and the audience are co-communicators in the process with equal responsibility and power to create, as well as understand, a message. People encode their messages based on their own unique perceptions. Our past experiences, values, attitudes, knowledge, culture and feelings all influence our messages and also the way we interpret the messages of others. These influences are our unique perceptions or the way we see things around us. Before messages can be transmitted to another person or group, we must encode these messages. When the message is encoded it's ready to be transmitted or sent to another person or group. The receiver must then interpret the message, by filtering the new information through his past experiences, culture, attitudes, values, knowledge and feelings. This interpretation is called decoding the message. The receiver decodes messages based on his perceptions, which are different from the sender. The sender needs to make sure that the receiver understood the message; therefore, it is the receiver's job to convey a message back. The receiver's reply to the sender is called feedback. The feedback allows the sender to ensure that the original message was interpreted correctly by the receiver. Feedback helps the communicators make sure that the message has been decoded correctly. Once the cycle has gone full circle, it will repeat itself for as long as the conversation continues. We could even say that sender and receiver change roles throughout the process depending on who is sending the message and who is responding to feedback. The location and the time (the situation) in which communication takes place are relevant and they influence the encoding and decoding process. The latter is paramount in an ICU, where deaths or losses of functional capacities of patients can take place unpredictably. Historically, trust in doctors has been an unconditional feeling. The clinician should know all the elements described that are particularly relevant in the relationship with the potential donors' families. Family members often have difficulty understanding the condition of brain death. Their loved one still has a beating heart and a present breath (although assisted by the machine). The elaboration of death in this condition is not always simple. The doctor also needs to share the consent to the donation as soon as possible with the relatives. A narrative approach can be very useful to create a relationship of trust and support. The critical event causing the current situation is reported as telling a child a story already known. The narrative will describe the growing role of health-care workers who enter the history of the relatives and of the beloved. The care practitioners make supportive statements around non-abandonment and decision-making. We advise to remember the continuous need of feedback and of narrative approach. We also believe it is essential that ICU clinicians receive family-centered communication training as an element of critical care training to improve clinician self-efficacy and family satisfaction. These explanations promote a relationship in the here and now when both health-care practitioners and family members experience a state of stress and intense emotions. Knowing and seeing what is happening to the loved one, feeling part of and understanding the healing process is preferable to the anxiety generated by what is "unknown." Family members are forced by their relative's illness into an unwanted role, which provokes discomfort, dependence and anxiety. The relative is

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**Figure 2.** Opposition rates.

In our opinion, in order to suggest behavioral strategies to the care team involved in the assistance of potential donors and their family members, the following factors must be taken into account: family members are facing an acute event and high stress conditions; they may find different nursing teams and different people giving information they first learn about the lifethreatening conditions and then about the death of the beloved. In this sudden critical situation, they are asked to take the place of the dear deceased, to make decisions about his body on his behalf. Family members have an extreme difficulty in contacting a condition of understandable reality. This is worsened by the fact of being in an unknown place, with unknown faces managing with emotions and personal convictions. Clinicians in the ICU should use structured approaches to communication including active listening, expression of empathy and considering the importance of explanation care. Communication is the process of sending or receiving messages through verbal and non-verbal means; therefore, an information field may consist of one or more subfields of information items such as thoughts, emotions and ideas. When, among individuals or among an individual and a group, there is a collaborative and ongoing message exchange, aimed to understand each other, the communication is integrated in our social realities and we can define this process as "transactional." In the transactional process the people involved in the act of communicating are actively and simultaneously sending information as well as receiving them. Participants perceive their communication as intentional. The information transfer between them takes place in a particular situation affected by relationship and culture. The speaker and the audience are co-communicators in the process with equal responsibility and power to create, as well as understand, a message. People encode their messages based on their own unique perceptions. Our past experiences, values, attitudes, knowledge, culture and feelings all influence our messages and also the way we interpret the messages of others. These influences are our unique perceptions or the way we see things around us. Before messages can be transmitted to another person or group, we must encode these messages. When the message is encoded it's ready to be transmitted or sent to another person or group. The receiver must then interpret the message, by filtering the new information through his past experiences, culture, attitudes, values, knowledge and feelings. This interpretation is called decoding the message. The receiver decodes messages based on his perceptions, which are different from the sender. The sender needs to make sure that the receiver understood the message; therefore, it is the receiver's job to convey a message back. The receiver's reply to the sender is called feedback. The feedback allows the sender to ensure that the original message was interpreted correctly by the receiver. Feedback helps the communicators make sure that the message has been decoded correctly. Once the cycle has gone full circle, it will repeat itself for as long as the conversation continues. We could even say that sender and receiver change roles throughout the process depending on who is sending the message and who is responding to feedback. The location and the time (the situation) in which communication takes place are relevant and they influence the encoding and decoding process. The latter is paramount in an ICU, where deaths or losses of functional capacities of patients can take place unpredictably. Historically, trust in doctors has been an unconditional feeling. The clinician should know all the elements described that are particularly relevant in the relationship with the potential donors' families. Family members often have difficulty understanding the condition of brain death. Their loved one still has a beating heart and a present breath (although assisted by the machine). The elaboration of death in this condition is not always simple. The doctor also needs to share the consent to the donation as soon as possible with the relatives. A narrative approach can be very useful to create a relationship of trust and support. The critical event causing the current situation is reported as telling a child a story already known. The narrative will describe the growing role of health-care workers who enter the history of the relatives and of the beloved. The care practitioners make supportive statements around non-abandonment and decision-making. We advise to remember the continuous need of feedback and of narrative approach. We also believe it is essential that ICU clinicians receive family-centered communication training as an element of critical care training to improve clinician self-efficacy and family satisfaction. These explanations promote a relationship in the here and now when both health-care practitioners and family members experience a state of stress and intense emotions. Knowing and seeing what is happening to the loved one, feeling part of and understanding the healing process is preferable to the anxiety generated by what is "unknown." Family members are forced by their relative's illness into an unwanted role, which provokes discomfort, dependence and anxiety. The relative is

In our opinion, in order to suggest behavioral strategies to the care team involved in the assistance of potential donors and their family members, the following factors must be taken into account: family members are facing an acute event and high stress conditions; they may find different nursing teams and different people giving information they first learn about the lifethreatening conditions and then about the death of the beloved. In this sudden critical situation, they are asked to take the place of the dear deceased, to make decisions about his body on his behalf. Family members have an extreme difficulty in contacting a condition of understandable reality. This is worsened by the fact of being in an unknown place, with unknown faces managing with emotions and personal convictions. Clinicians in the ICU should use structured approaches to communication including active listening, expression of empathy and considering the importance of explanation care. Communication is the process of sending or receiving messages through verbal and non-verbal means; therefore, an information field may consist of one or more subfields of information items such as thoughts, emotions and ideas. When, among individuals or among an individual and a group, there is a collaborative

**Figure 2.** Opposition rates.

100 Organ Donation and Transplantation - Current Status and Future Challenges

vulnerable and asking for help; the doctor and the nurse, who are experts in medical care, take him or her in charge. Developing a good therapeutic and empathic relationship with the family, taking care of their emotional issues during this process, appears to lead families to opt for donation. The relationship with the care practitioners and family members can allow the creation of a sense of reality of the place and the moment. Then, it can make the relative aware of himself, of the event, of recognizing roles and responsibilities, to give permission to emotions and decision-making power to what is recognized as right and achievable. When considering patients in critical conditions admitted in the ICU, the care-taking process of the medical staff is addressed toward relatives more than toward patients, who continue to receive highquality care. Clinically speaking, the communication-based relationship has a central role and a positive action on health improvement in the care process [18].

[2] http://www.transplant-observatory.org

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