Introduction

Organ-tissue transplantation is the process of transplanting an organ-tissue from a living person, brain-dead person or cadaver to replace an organ-tissue that cannot perform its function (1,2). Organ transplantation is the focus of solution in terms of cost-effectiveness in order to ensure the maintenance of the lives of individuals and to increase the duration and quality of life. Since more than one organ can be removed from the same patient, several people can benefit at the same time. Organ donation is a person’s consent to the use of his/her tissues and organs after the end of his/her medical life with his/her own free will and documenting this consent (3). According to the regulations on organ donation and transplantation in Türkiye, organ donation is legalised by obtaining an “organ donation card” and by the relatives of the patient donating organs after the medical death (1,2).

Insufficient organ donation rates in the world and in our country are still a serious obstacle to organ transplantation (4). Especially lack of information and negative attitudes are the most important obstacles (5). Although trainings are given, announcements are made in the media and the public has become more aware; the difference between the number of donated organs and the number of patients waiting for organs is still continuing (6).

According to the data announced by the Ministry of Health of the Republic of Türkiye, as of November 2023, the number of patients waiting for kidney transplantation is 24,449, the number of patients waiting for liver transplantation is 2,600, the number of patients waiting for heart transplantation is 1,422, the number of patients waiting for lung transplantation is 204, the number of patients waiting for pancreas transplantation is 277 and the number of patients waiting for cornea transplantation is 4,119. However, when we look at the organ donation data, the number of cadaveric donors in 2023 is 1264 and the number of living donors is 4691 (7)

Critically ill patients with life-threatening diseases are closely monitored and treated in intensive cares. The clinical status of the patients and their current diseases play an important role in determining their prognosis. Relatives of patients who are hospitalised in intensive care are worried about their patients (8). Besides, having a patient in intensive care unit may create sensitivity about organ donation and change the perspective. In this study, we aimed to compare the attitudes of relatives of patients’ in intensive care and in regular services, on organ donation.

Material and Method

Characteristic of the research

This is a cross-sectional descriptive survey study applied to the relatives of patients hospitalized Firat University Hospital. Our study was conducted under the principles of the Declaration of Helsinki. The study was completed between January 2024 and March 2024. This study has been approved by the Firat University Non-Interventional Research Ethics Committee (approval date: 09.01.2024, number: 2024/01-36)

Sampling

Interviewers consisted of relatives of patients whose patients were hospitalized in the 3rd level intensive care unit (Group I) and relatives of patients whose patients were hospitalized in regular inpatient services (Group II). One relative of each patient was included in the study. In cases with more than one relative, the relative closest to the patient and continuously contributed to patient care was included.

Collection of data

After explaining the purpose of the study to the patients’ relatives, written informed consent was obtained from the participants. Relatives of patients without written informed consent were not included in the study. To avoid any bias, the questions were asked face to face to the interviewers by research assistants from the department of anesthesiology and reanimation, who had not yet worked in intensive care, had not completed their first year, and did not know the patients and the questions. The average time to answer the questions is 10-12 minutes. The research questions were developed by the researchers as a result of the literature review.

1. Questions (n: 16):
2. Demographic data (age, gender, profession, education, whether there is a patient in intensive care unit, whether there is a relative waiting for organ transplantation) 5 questions
3. Level of knowledge about organ donation (what does organ donation mean, whether there is a legal regulation regarding this, the purpose of organ donation(Multiple choice)) 3 questions
4. Respondents’ thoughts, attitudes and behaviors regarding organ donation (9 questions). The questions: -If you are in favor of organ donation, what is the reason(s)?, -Who or what contributed to your positive view of organ donation?, -If you are negative about organ donation, what is the reason(s)? Were multiple choice questions.

1. Inclusion criteria:
2. Accepting to participate in the study
3. To be hospitalized in the 3rd Level Anesthesiology and Reanimation Intensive Care Units or inpatient wards of Firat University Hospital,
4. Being 18 years or older

1. Exclusion criteria:
2. Refusing to participate in the study
3. Not completing the survey questions
4. Not having any inpatients in Firat University Hospital
5. Having a psychiatric disorder
6. For Group I; The patient has been diagnosed with brain death, for Group II; The patient is hospitalized in oncology, hematology, or palliative services or has a disease with low surveillance
7. Patients with previous intensive care hospitalization

Statistical analysis

To determine the number of patients who should be included in the study in line with the main purpose of our study, a sample size analysis was performed using the G*power (Version 3.1) package program before the study. Literature information and expert opinion were used to analyze sample size determination (9). As a result of the sample size analysis, it was found that a total of 230 patients would be sufficient to be included in the sample for 80% power (1-β=0.80) and α=0.05 error value (95% confidence interval). Our study was completed with a total of 296 patients in case of the possibility of leaving.

Analyzes were evaluated in SPSS (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL) 22 package program. Descriptive data were presented as n, % values for categorical data and mean±standard deviation (mean±standard deviation) values for continuous data. Chi-square analysis (Pearson Chi-square) was used to compare categorical variables between groups. The statistical significance level was accepted as p<0.05 in the analyses.

Outcomes

Primary outcome: To observe if the sensitivity of relatives of patients in intensive care units about organ donation has increased.

Secondary outcomes: 1)To observe which factors effect the attitudes of relatives about organ donation; 2)To observe how much they know about organ donation.

Results

A total of 296 participants who all of them were Muslims, 145 (49%) women and 151 (51%) men, were included in the study, with a mean age of 41.3±13.6 years (min=18-max=78). When the professions and education of the participants were analyzed, 31.1% were unemployed, 47.3% were middle school graduates and below, and 52.7% were high school graduates and above. The participants who had a relative in intensive care unit were 49,7%. While 4,4% of the participants had a relative waiting for organ transplantation, 58,8% did not know anyone about this. (Table 1).

While 48.3% of women and 51% of men had a relative in intensive care unit, there was no significant difference between them (p=0.640). The ages of those with relatives in intensive care unit were found to be significantly higher than the ages of those without relatives (p=0.007). Fifty per cent of those who were not working, 88.2% of those who were health workers, 54.5% of those who were teachers, 39% of those who were self-employed/employees and 39% of those who were civil servants had a relative in intensive care unit and there was a significant difference between them (p=0.004) (Table 2).

Participants responded to organ donation as “Taking an organ from a dead body and transplanting it into a living one” were 17,2%. Responded as “Taking an organ from a living one and transplanting it into another one” were 16,2%. Accepted both answers as correct were 60,5% and 6,1% stated that they did not know about it. While 26.4% of the participants stated that there is a legal regulation on organ donation in our country, 11.8% stated that there was not and 61.8% said that they did not know. While 16.6% of the participants stated that the purpose of organ donation is “to improve the quality of life of the transplant recipient”, 79.7% stated “to save the life of the transplant recipient”, 1.7% stated “financial gain” and 2% stated that they did not know. In this question, there was a significant difference between the groups regarding the main purpose of organ donation (p=0.006). (Table 3).

The rate of Group I (87.8%) being worried about not being able to find an organ, and needing an organ transplant was significantly higher than the rate of Group II (68.5%) (p<0.001). The overall rate of support for organ donation in Group I (75.9%) was significantly higher than the rate of Group II (18.7%) (p<0.001) (Figure 1). The rate of Group I agreeing to donate their organs in case of brain death of a relative (58.5%) was significantly higher than the rate of Group II (17.7%) (p<0.001).

The rate of Group I who wanted their organs to be donated by their relatives after death (68.7%) was significantly higher than the rate of Group II (19%) (p<0.001). The rate of Group I who would consider donation in case a family member needed organ donation (75.5%) was significantly higher than the rate of Group II (21%) (p<0.001). Among the reasons for having a positive attitude towards organ donation, the rate of saying “Saving the lives of people in need” (p<0.001), “I think it is a conscientious duty” (p<0.001) and “One day I or my relatives may need organ donation” (p=0.001) were found to be significantly higher among the Group I.

The rate of Group I to say “media” (p<0.001) and “voluntary organizations” (p<0.001) on their positive attitude towards organ donation was found to be significantly higher than the rate of Group II.

The reasons of a negative attitude of Group II, towards organ donation were found to be significantly higher with the answers “Organ donation after brain death disfigures the body”, “My religious beliefs do not allow it”, “Because my family members do not look favorably” and “I do not have enough information about this issue yet” (Table 4).

While 78.2% of those who consider organ donation accept to donate their organs after the brain death of their relatives, none of those who do not support organ donation accept to donate their organs (p<0.001). While 89.4% of those who are considering organ donation accept the donation of their organs by their relatives after death, none of those who do not support organ donation do not accept to donate their organs. (p<0.001). While 97.2% of those who consider organ donation accept to donate their organs in case a member of their family is in need, 2.4% of those who do not support organ donation accept to donate their organs (p<0.001) (Table 5).

Discussion

As in the past, in the modern era, the level of organ donation is not sufficient for patients waiting for transplantation. Lack of information and awareness, false beliefs, and attitudes prevent us from reaching sufficient numbers in organ donation. Our study was conducted with relatives of patients hospitalized in intensive care units and inpatient wards in a tertiary care hospital. We showed that relatives of patients who are hospitalized in intensive care are more sensitive about organ donation and this sensitivity caused them to have positive attitudes towards organ donation.

Overall, support for organ donation was 48%. When a relative was diagnosed with brain death, 37.8% agreed to donate their organs; 43.6% wanted their organs to be donated after death; and 48% would consider donating if a family member needed organ donation. The findings of this study demonstrate that attitudes toward organ donation significantly influence individuals’ decisions to donate the organs of their relatives in the event of brain death, to allow their organs to be donated by their relatives after death, and to donate their organs if a family member is in need. A large majority of those who support organ donation are willing to donate their relatives’ organs in the event of brain death (78.2%), to allow their organs to be donated after death (89.4%), and to donate their organs if a family member is in need (97.2%). In contrast, none of those who do not support organ donation are willing to donate their relatives’ organs or allow their organs to be donated, and only 2.4% are willing to donate their organs if a family member is in need. These differences are statistically significant (p<0.001), clearly indicating the extent to which attitudes toward organ donation impact donation decisions. Our findings were similar to the study conducted by Cotrau et al. in 2023 with the relatives of intensive care patients (10).

In this study, our aim was to evaluate the attitudes of relatives who had patients in intensive care units, towards organ donation. Our findings showed that those with relatives of patients in intensive care tended to give more positive answers about organ donation. Participants with patients in intensive care gave significantly higher positive answers to the questions of supporting organ donation in general and agreeing to donate their own or a relative’s organ after death (75.9%; 68.7%; 58.5%). The reasons for positive attitudes toward organ donation in this study were; Saving lives of people (62,5 %), worrying that one day he will need an organ transplant (31,4 %), Thinking that it’s a conscientious duty ( 25,7 %), In the study conducted by Hernández et al, relatives of patients with patients in intensive care unit had a more negative view of organ donation and perhaps the participants wanted their patients’ body integrity to remain intact (11). Having a relative in intensive care is a cause of psychological stress and emotional exhaustion. Asking them to donate organs can of course be an additional responsibility and challenge for them. However, their life expectancy regarding their patients may also increase their sensitivity and change their attitudes towards organ donation.

Many factors play a role in attitudes towards organ donation. These are demographic parameters as well as the level of knowledge about organ donation (12,13). In a study conducted by Colak et al. in our country, the reasons for not participating in organ donation were religion (25%), anxiety about suffering (28%), fear (20%), life after death (87%), and traditions and customs (15%) (14). In our study, the reasons why the participants had a negative view of organ donation; 102 of them were lack of sufficient information (34.5%), 66 were because of religious beliefs (22.3%), and 63 were because of the thought that family members would not be favorable (21.3%). When we looked at our demographic data, the age of Group I was higher than the other group. In the literature, although Goz et al. (15) reported that age did not change the attitude toward organ donation, Cohen et al. (16) reported that age and attitude were positively correlated. However, in many other studies, it was observed that older people donated fewer organs, and they associated this with the high comorbidities of elderly patients (17,18). In our study, relatives of patients in the intensive care unit were older and had more positive attitudes towards organ donation. We think that the critical illnesses of patients in intensive care were also effective in this.

Many studies have shown that the level of education can change knowledge about organ donation and attitude towards organ donation (19-21). According to Zhang et al., people with higher education levels were more informed about organ donation and had more positive attitudes (22). In our study, 52% of the participants were high school and university graduates. We did not observe a significant difference in education level between the groups. About 60% of the participants answered the meaning and purpose of organ transplantation correctly and there was no difference between the groups. Despite this, approximately 73% of all participants did not know whether there is a legal regulation on organ transplantation in our country. This is consistent with the low level of organ donation in our country and shows the importance of emphasizing education.

A clear explanation of transplantation and organ donation and a clear understanding of the subject is as important as education (23). In this way, fears can be reduced. It should not be forgotten that what is unknown is doomed to be rejected. Indeed, in our study, we found that the first reason for negative attitudes towards organ donation was lack of information. In the study conducted by Cotrau et al. 52% of the participants did not know that brain death was irreversible and lack of understanding of brain death was stated as the main reason for organ donation refusal (10). In a study by Ramadurg et al., it was shown that providing education about organ donation increased the level of knowledge and changed attitudes and beliefs about donation (24).

When we look at the literature, studies show that there is a positive relationship between the level of awareness about organ donation and the willingness to donate (25). Informing the patient’s relatives that everything medically possible is being done for the patient may positively affect their attitudes toward organ donation. Studies have shown that early and appropriate physical communication with families, a respectful and empathetic approach, and providing psychological relief positively change the attitudes of patients’ relatives towards donation (26,27). In this context, to increase the positive perspective on organ donation, we aimed to spend more time with patients’ relatives in our intensive care unit to inform them about this issue and to reassure them.

In previous studies, the attitudes of relatives of intensive care unit patients towards organ donation were found to be more positive, supporting our study (28,29). Tontus reported that if the participants’ relatives required organ transplantation, they responded more positively about donation (30). In our study, the relatives of patients in the intensive care unit reported significantly higher anxiety (87.8% vs. 68.5%, p<0.001). We think that the critical process of intensive care patients and the concerns of patient relatives are effective in this. We think that our findings provide important clues about the factors affecting the positive attitudes of relatives of patients in the intensive care unit towards organ donation.

Participants who were positive about organ donation in order stated that; the media (38.2%), healthcare professionals (30.7%), and voluntary organizations (18.2%) were primarily effective in this regard. Salim et al. showed that the media increased public awareness of organ donation (31). In this context, in addition to more effective use of the media and press organs to increase awareness of organ donation, utilizing the knowledge and experience of healthcare personnel to ensure the flow of accurate information in these sources will increase effectiveness. Likewise, we believe that voluntary organizations, together with health professionals, can raise public awareness by organizing continuous campaigns, seminars and trainings on this issue.

Religious beliefs are another important factor affecting people’s attitudes and decisions about organ donation (32,33). The teachings and beliefs of different religions can offer different perspectives on organ donation and shape individuals’ decision to donate. Holman et al. found that Orthodox (73%) and Catholics (77%) had a more favorable view of organ donation than Protestants (43%) (34). But according to Goz et al. religion did not affect this issue (15). The majority of Turkish people believe in Islam, and both religious scholars and the Directorate of Religious Affairs have stated that organ donation is compatible with Islam. In the Qur’an, in Surah Maide, Verse 32, it is stated that ‘Whoever saves one life is as if he/she has saved all human beings’ (35). In the article written by Sharif, it is stated that Muslims have the perception that they do not own their bodies or organs and that they do not have the right to give their organs to others (36). Muslims remain divided on this issue (37). In a multicenter study conducted by Demırkiran et al., it was emphasized that religious beliefs negatively affected the attitude toward organ donation and this could be overcome by informing the public (38). All of the participants in our study were Muslims and 22.3% of them thought that their religious beliefs would not allow organ transplantation. Only 6.4% of those with a positive view on organ donation stated that they had benefited from religious scholars. These rates show that religious scholars have a great responsibility. Understanding religious teachings about organ donation, effective communication with religious communities, and dissemination to the public are important to raise awareness about organ donation and increase donation rates.

Considering the reality of our country, the impact of the results arising from geographical location should not be ignored. Two extreme examples are Spain and Iran. According to the 2018 data of the International Registry of Organ Donation and Transplantation (IRODaT- UOBTK), cadaveric organ donation is estimated in millions; 48 in Spain, 11.1 in Iran, and 7.47 in Türkiye (39). While living donors are predominant in Iran, cadaveric donors are predominant in Spain. Spain’s “opt-out” system has been effective in increasing organ donation. In Iran, religious and cultural factors play an important role, whereas in Spain the general acceptance and awareness of the society encourages organ donation. While Spain adopts a more systematic approach to organ donation coordination and education, in Iran this process is based on individual donations (40).

This study has some limitations. Since it is a single-center cross-sectional study, it does not provide a universal generalization. In addition, psychological factors affecting the attitudes of patients’ relatives towards organ donation may also need to be examined in detail. The survey was administered to relatives of ICU critically ill patients, but not patients diagnosed as brain dead; results may vary in patients diagnosed as brain dead. Another limitation is that the study was conducted in two groups of relatives of patients with and without ICU patients, but the diagnoses of the patients were not examined separately.

Conclusion

We can say that the attitudes of relatives of patients with patients in intensive care towards organ donation are more positive than those who do not have patients in intensive care. It is seen that the critical condition of patients in intensive care increases the sensitivity of the relatives. We believe that education and awareness-raising activities on organ donation should be carried out more intensively and effectively, especially by politicians, educators, health professionals and clergy. Considering that all our participants are Muslims, the clergy have a big role to play.

Specially designed questionnaires that aim to assess people’s knowledge and attitudes towards organ donation and transplantation are crucial for identifying effective educational strategies to increase organ donation. The media and voluntary health organizations also need to educate the public from the perspective of scientific knowledge. We believe that psychological support, empathy, respect, and early communication with relatives can also have positive effects.

Ethical approval

This study has been approved by the Firat University Non-Interventional Research Ethics Committee (approval date: 09.01.2024, number: 2024/01-36). Written informed consent was obtained from the participants.

Author contribution

Study conception and design: GA. GÖ, FÇ, AA; data collection: GA, FÇ, AA, GÖ, İD, FD; analysis and interpretation of results: GA, İD, FD, FÇ; draft manuscript preparation: GA, FÇ, AA, GÖ, FD, İD. The author(s) reviewed the results and approved the final version of the article.

Source of funding

The authors declare the study received no funding.

Conflict of interest

The authors declare that there is no conflict of interest.