To our knowledge, this study is among the first to examine the process of requesting tissue donation, and it is the first to examine the interaction between tissue requesters and “undecided” next of kin specifically. These next of kin are those whose donation decisions are most likely to be swayed, whether positively or negatively, by the quality of communication with requesters and the information provided to them. Requesters made at least 1 persuasive statement in most cases (83.2%), most commonly a statement to establish their credibility by associating themselves with the hospital or funeral home, or a statement of altruism aimed at enhancing the NOK’s desire to donate in order to help others. NOK responded positively to these strategies; the number of persuasive statements made by the tissue requester was a significant predictor of the number of statements of approval made by the NOK. The frequency with which persuasive statements were made by requesters is consistent with Anker and Feeley’s study22
in which organ procurement coordinators reported frequently using persuasive messages with families when discussing organ donation.
Both tissue requesters and NOK were more friendly than hostile, and consistent with the interpersonal theory concept of complementarity as well as prior findings on interpersonal behavior during physician-patient consultations, they tended to match one another on affiliation (ie, friendliness elicited friendliness) and complement one another on interpersonal control (ie, dominance elicited submissiveness and vice versa).17,19,23
Frequency of discussion of “key topics” ranged from 2.0% of cases (for discussion of how tissues are distributed) to 40.2% (for discussion of the fact that donation will not delay or affect funeral plans), indicating that these topics, which may affect the NOK’s donation decision, are discussed in fewer than half of cases and sometimes only rarely. Given that the general public generally does not have a good understanding of the tissue donation process, it seems plausible that clearing up misconceptions about donation (eg, that donation would lead to mutilation or other dramatic change in appearance of the body; that donation would preclude the possibility of an open casket funeral) may affect consent rates. We found that, of the topics examined, the only topic significantly associated with NOK behavior was NOK’s ability to choose which tissues to donate. However, although NOK responded positively in interactions in which ability to choose was discussed, it is unclear whether this directly translated into increased rate of consent, or if discussion of other key topics may have affected consent rates despite lack of impact on NOK’s interpersonal behavior. Future research could examine whether discussion of key topics can influence consent rates regardless of any potential impact on NOK’s interpersonal behavior.
Finally NOK were less affiliative when the tissue requester made at least 1 statement of disapproval during the interaction, although the nature of this relationship remains unclear. It is possible that disapproval from the tissue requester elicited a less friendly response from NOK; conversely, it is possible that when NOK were less friendly, this elicited a disapproving response from the requester. Overall, these findings are consistent with the physician-patient literature demonstrating that when the target interactant (patient or NOK) expresses more positive affect and/or is a more active participant in the interaction, the medical information providers (physicians or tissue requesters) provide more information and are more supportive and collaborative.24–26
Because some tissue requesters made multiple requests, hierarchical linear regressions were conducted to control for possible effects of requesters’ characteristics on NOK’s interpersonal behavior. These analyses indicated that when requesters were more affiliative, NOK made more statements of approval and were also more affiliative. This suggests, as mentioned earlier, that positive and collaborative behavior on the part of one party tends to elicit the same from the other. In addition, when tissue requesters made at least 1 statement of disapproval, NOK were less affiliative, more controlling, and also made more statements of disapproval, suggesting that requesters’ disapproval tends to elicit a less collaborative and more negative response from the NOK, and vice versa. Finally, as with the preliminary analyses, requesters’ interpersonal control tended to elicit a complementary response from the NOK (eg, requesters’ dominance elicited NOK’s submissiveness and vice versa), and NOK made more statements of approval when requesters made more persuasive statements. Overall these findings suggest that when tissue requesters are warm and friendly, and establish their credibility by making affiliations with the hospital or funeral home known, NOK tend to respond positively by also being friendlier and more approving, whereas when requesters express disapproval, NOK tend to respond more negatively, which is consistent with interpersonal theory as discussed earlier.
There were some similarities and differences in interpersonal behavior in the current sample of “undecideds” and the total sample as described by Siminoff and colleagues.13,14
In both samples, tissue requesters made statements of reassurance, empathy, and approval relatively frequently, and the most common types of persuasion used involved establishing credibility and framing donation as an altruistic behavior. However, in the current sample, requesters made fewer statements of disapproval and more statements of persuasion. Requesters may have been less likely to make statements of disapproval with undecided NOK because this group excluded those NOK who reported in postrequest interviews that they were not favorable about donation upon receiving the phone call. Regarding persuasion, in the total sample, requesters may have had less of an opportunity or need to use persuasive statements because more of the NOK may have already made a decision, whereas in the undecided sample there was more of an opportunity for requesters to make persuasive statements about donation.
The current study has several limitations. The study used a number of exclusion criteria in order to include only dyads in which the NOK reported being undecided about donation when the requester first broached the topic. However, several of these criteria were based on interview data about the NOK’s initial feelings regarding donation, which were collected 2 months after the request and could have been affected by recall, particularly considering that the request was conducted during an emotional time for the NOK. About three-quarters of both NOK and requesters in this sample were female; this may have influenced the results because males and females may use different interpersonal behaviors during tissue donation requests (although no significant differences between the sexes were found during preliminary analyses). Although past studies have not examined differences between men and women specifically in this context, the physician-patient literature suggests that compared with male physicians, female physicians provide more reassurance and are more likely to discuss psychosocial issues and emotions with patients; further, physicians generally focus more on partnership-building and providing reassurance to their female patients.27
It is therefore recommended that future studies examining larger samples should include a greater proportion of male participants and should investigate possible differences between the sexes in interpersonal behavior during interactions.
In addition, although use of this limited sample of undecided NOK increased the internal validity of the study, the findings may not be generalizable to NOK who already have a preference about donation before discussing it with tissue requesters. Also, the descriptive nature of the analyses make it difficult to determine directionality of effects, and leave us only to conclude that certain types of behaviors tend to co-occur rather than determining if certain behaviors on the part of the tissue requester directly cause or elicit certain other behaviors from the NOK.
The findings of the current study have implications for tissue banks or other organizations involved in selecting and training tissue requesters. Because most individuals have limited knowledge of tissue donation, for most NOK, the interaction with tissue requesters represents their first real introduction to the topic, and the way this information is presented and the manner in which the NOK and tissue requesters interact may affect NOK’s perceptions of donation and the likelihood of consent. Specifically, we found that positive/collaborative behaviors on the part of the requester tend to elicit positive/collaborative behaviors from the NOK and vice versa, and that disapproval by one party tends to elicit a similar response from the other.
Past studies on organ donation have demonstrated that when coordinators are specifically trained to respond sensitively to the families’ needs while guiding them through the decision-making process, consent rates increase.1–4
We hypothesize that similar effects would be found in the area of tissue donation. Thus, communication skills trainings for tissue requesters that focus on (1) increasing affiliative behaviors (eg, being warm, friendly, and empathic), (2) reducing unfriendly behaviors (eg, statements expressing disapproval or criticism), and (3) establishing credibility, may help improve the initial reaction of NOK to both the requester and to tissue donation in general.