Organ donation has a great importance in saving human lives. In recent years, there has been a trend of kidney donation from non-relative altruistic living donor. Unlike deceased donors, from whom kidneys are obtained after death, or directed living kidney donors, who identify a specific recipient for their organ, living-altruistic kidney donors have no relation or emotional attachment to the recipient. The population of altruistic kidney donors is a special population - people who choose organ extraction surgery are healthy people, with no background diseases or a health problem that require surgical intervention [1].

Since 1988, living unrelated altruistic kidney donation have been accepted in Sweden. In some instances, individuals appear in Swedish hospitals expressing willingness to donate and organ. Historically healthcare in Sweden had no organization regulating these offers [2]. A total of 26 altruistic organ donations were performed in Sweden between 2004-2016; which is 1.7 % of all organ transplant surgeries in Sweden during the 12-year period [2].

In 2004, Spain 2.8% of all organ transplantations generated from altruistic non-related donors [3].

For the past 60 years, kidney transplantation has been available in Israel [4]. Nevertheless, in the early 2000's less than 150 kidney transplants were performed per year, which is an insufficient amount to fulfill needs of end stage renal patients requiring new organs for optimal care. This scarcity led to patients seeking organs in other countries and organ trafficking. This illegal trafficking led to regulation and sanctions prohibiting such illegal actions, based on Istanbul declaration [5].

In Israel, the practice of altruistic organ donation has become popular in the past few years. In 2020, 273 organs were donated from altruistic donors [6]. Traditionally many orthodox Jewish leaders forbid organ transplantation from deceased donors. The primary rationale behind this prohibition stems from the ambiguous definition of brain death, which is considered, among the ultra- religious, as an unacceptable determination of death [7, 8].

While some argument exists regarding nonliving kidney donation, a near harmonious consensus is present amongst all religious authorities encouraging, but not to requiring, living donor kidney donation [9].

Subsequently, a national government-controlled Transplant Center has been created.

Matnat Chaim Encourages Live Kidney Donation Among Orthodox Jews in Israel

An Israeli nonprofit organization, Matnat Chaim, encourages altruistic living kidney donation of Israeli citizens with an emphasis on donors from the Orthodox Jewish community [10].

This organization promotes awareness and motivation to donate organs largely through awareness raising campaigns utilizing though both traditional media avenues and social media. The organization assist potential donors muddle through the health system and physician referrals [10].

The number of live kidney donors increased from 78 in 2010 to 273 in 2020; 1000 since the foundation of non-profit organization [10].

Despite the growing popularity of altruistic living organ donation, medical professionals still perceive this type of organ donation as extreme if not irrational [1].

The nursing staff at the study hospital frequently expressed a belief that families of the altruistic donors and donors themselves expect a preferential treatment towards the donor compared to the other patients. General society as well as health care professionals perceive the motivation of living non- relative altruistic as strange or unnatural [11, 1]. Ambiguities were found on the perception that altruistic donors might be psychologically unstable and thus unsuitable unethically acceptable donors [12].

Sandal (2019) Canadian study found nurses perceive many challenges caring for donors and their families including lack of communication, absence of guidelines, and lack of multidisciplinary involvement, nurses’ lack of information and training, and negative attitudes of professionals toward living donor kidney transplantation [1].

Henderson Canadian study (2003) found that altruistic donors reported being partially motivated to donate an organ by secondary benefits (e.g., time away from work, media attention, and being seen by others in a more favorable light) [12]. These secondary benefits were heavily outweighed by more altruistic motives. A 2009 United Kingdom study looking at 108 nurses and physician perspectives regarding altruistic organ donation found that more than half of respondents supported compensation for expenses incurred (eg, travel expenses, compensation for lost workdays) for donors known to the recipient, and 50.0% supported this kind of compensation when the donor was a stranger [13].

In a similar study conducted in Greece, there was a difference between the positive attitude of doctors and nurses to the donation process. Willingness to be a donor was associated with older age and higher education [14].

On the other hand, the fact that the contribution is altruistic raises the question of the need for preferential treatment. Therefore, the nurses working with this population felt uncomfortable and suffered from moral and ethical conflicts providing care to this unique population of patients. The fact that the contribution is altruistic raises the question if the donor or his family expect preferential treatment.

In order to understand the expressed nursing dilemmas about the needs for preferential care towards altruistic donors, it is important to investigate the attitudes of the nurses exposed to this patient population.

Purpose

To examine the perspective of the nursing staff towards population of altruistic kidney donors and their families.

A descriptive, quantitative cross-sectional survey of nurses working in hospital departments caring for altruistic organ donors and their families, primarily, surgical department, Operating Theater, and recovery room. This population of nurses was chosen as they encounter this specific type of patients- altruistic organ donors in their daily work and provide guidance and care.

Survey tools: Questionnaire for the nursing staff (contains 14 questions). The questions were developed based on literature review. The investigators used questions based on VIP (very important people) questionnaires and their families' desire for preferential treatment and the accompanying ethical dilemmas. A group of administration, research and organ donor coordinator nurses were involved in constructing the questionnaire. The investigators decided the factors to study and went through each item to ensure its construct validity. Three questions focused on the perception of nurses if they felt that altruistic donors expected preferential treatment, one question related to nurses feeling ethical personal dilemma caring for these patients and lastly nurses' views on eliciting donor/ family communication concerning the organ donation. After the questionnaire preparation, expert validity was insured by testing on health care individuals from each participating hospital department. Several minor modifications were made before final distribution. Questionnaire internal consistency validity for the questionnaire Cronbach alpha was 0.84.

Inclusion Criteria: all nurses caring for altruistic donors and their families from

Three Departments: General Surgery, Recovery Room, Operating Theatre.

Exclusion Criteria: nurses not having contact with altruistic donors or their families.

A research team distributed the questionnaire to the nurses working in recovery room, Operating Room and Surgical Department B. All nurses were invited to contribute to the study. The questionnaires were distributed to all nurses during each department staff meeting and completed

questionnaires were placed in a sealed envelope. Each sealed envelope was collected by the researchers and data was transcribed into an excel form.

Ethical Approvals

The Hospital's ethics Committee approved the study.

Data was collected from 77 participating nurses. (Table 1). Most participants were women (73.90%), with a mean age of 35.9 years. The majority of participants were married (65.23%), with a third being single (30.56%) and the rest divorced (4.21%).

Table 1: Averages, frequencies, and relative percentages for the demographic characteristics of the sample.

*** The rate of the nurses from OR who responded to the questionnaire from all OR staff is only 30%, but from the nurses who participate in the donation and transplantation surgery response rate is 100%.

The majority of participants were Jews (58.33%), about a third were Muslims (30.56%), while the rest of the participants were Christians (6.94%) or others (4.17%).

Most participants defined their level of religiosity as traditional (40.85%) while third were secular (33.80%), about one-fifth were religious (23.90%) and the rest were ultra-Orthodox (1.45%).

Just over a third of the participants worked in the operating room (43.24%), while just under a third worked in the general surgery department (29.73%) or in the recovery room (27.03%).

The average seniority in the participants' profession was 10.01 years, 41 participants working full-time (71.90%) and 16 part-time (28.10%).

General Distribution of Research Question Answers

(Table 2) describes the percentage of positive and negative answers to the research questions. Most participants did not respond positively to the research questions.

Table 2: Percentages of answers to the research questions.

Table 3: Relationships between answering research questions YES comparison between departments- OR, Recovery Room, General Surgery.

Table 4: Relationships between nurses' age and answering YES research questions.

Table 5: Relationship of professional experience and answering YES research questions.

Slightly less than half of the participants responded that they think an altruistic donor needs to be treated differently compared to other patients (44%), nurses initiating a conversation with the donor and his family about the donation (41.6%), or that the nurses' believed that the altruistic donor expected to be treated differently (38.57%).

About one-third of respondents answered that they expected preferential attitude from the altruistic donor (30.14%), and about one-fifth answered that they coped with ethical dilemmas during donor care (23.23%) or that there were things that could be improved in caring for the altruistic donor / family (22.95%).

Relationships Between Demographic and Professional Characteristics and Answering to The Research Questions

The relationships between the research questions and the demographic and professional characteristics were assessed using Chi-square tests.

Relationships Between Answering Research Questions by Department

The results show that there was a greater prevalence of participants who worked in general surgery ward (66.67%) in comparison to operating room (43.33%) and recovery ward nurses (15.00%), (χ2 (2) = 40.74, p <.01) answered that an altruistic donor deserves preferential treatment compared to other patients. There was a greater prevalence of nurses in surgical department (54.55%) who answered that there was an expectation of altruistic donors expecting preferential treatment, compared to the operating room (21.43%) and recovery room (21.05%), (χ2 (2) = 25.71, p <.01) nurses. There was a higher prevalence of participants in the operating room (33.33%) who answered that they felt an ethical dilemma when treating an altruistic donor, compared to surgical department B (23.81%) and recovery department (10.00%), (χ2 (2) = 12.11, p = .01) nurses (Table 3).

Relationships Between Answering Research Questions by Age

The results show that there were statistically significant differences between young nurses compared to older on their opinions about altruistic donors deserving preferential treatment, and the donor and family having preferential attitude. Younger nurses also initiated more conversations compared to older nurses and this population felt that the care could be improved. Older nurses have statistical significantly ethical dilemmas treating altruistic donors (Table 4).

Relationships Between Answering Research Questions According to Professional Experience

The results show that statistically significant differences between years of experience and believing that altruistic donors deserved preferential treatment compared to participants. As seniority increased, there was a lower incidence of nurses experiencing expectation from altruistic donors for preferential treatment (χ2 (2) = 46.88, p <.01) (Table 5).

The current study aims to examine the perspective of the nursing staff in three different hospital departments towards population of altruistic kidney donors and their families. The findings reveal that working in a specific hospital department and other characteristics affect nurses' perspectives.

Operating Room (OR) nurses reporting ethical dilemma might be explained by their view that kidney donor surgery is mutilation of the body and that the surgery might have complications and find this difficult to understand why a healthy person would want to undergo this mutilation and possible decline in health. A Spanish study found fear of mutilation of the body impact negative attitudes about deceased organ donation is [15]. A qualitative Swedish study found that operating theatre nurses are willing to participate in the organ donation process despite the fact that the nurses expressed that organ procurement surgery could be perceived as disagreeable and considered it as inducing dual emotions [16]. In addition, nurses' witnessing peri-operative blood loss and transfusion incidence leading to surgical complexity and/or the quality of the donor organ are intraoperative factors significantly associated with complications after living organ donation [17].

In this study we found that nurses working in surgical wards compared to OR and recovery room teams believed that the altruistic donor patient expects preferential care. We must emphasize that the question was phrased asking the nurses' beliefs that the patients deserve preferential treatment not that the patients demand this type of treatment compared to OR and recovery room. Ward nurses spend more time with their patients therefore lengthier

exposure to the patients and their perceptions. An Indian study exploring 140 physicians' attitudes towards altruistic donors found that the majority 60% of the respondents approved that live donors should be given incentives for donating their kidney [18]. The literature is rich with papers looking at the "unpopular patient", however very little is published about the preferred patients. Literature exploring treating "VIP"- Very Important Person patients, are often those who hold celebrity status, or perceived connections, stimulate awe in those who care for them [19]. Altruistic donors may be perceived in the eyes of the treating teams as types of "celebrities".

In this study population, the elder (older than 50 years) nurses and those working in OR had ethical dilemmas caring for altruistic donors. According Patricia Brenners' theory of novice to expert nurse- younger nurses have yet to develop their professional attitudes and perceive the patient in their own personal perceptive [20]. An Israeli study exploring 10 transplant coordinators working over 20 years in this role found these nurses suffered from moral distress. When talking with potential altruistic donors this population felt very uncomfortable because they believed that it is better for the donor not to donate an organ at all. Transplant coordinators' experience daily moral dilemmas and therefore suffer negative feelings and emotional pain while fulfilling their job [21].

Summary

Altruistic organ donation is increasing. We need to prepare the public and medical teams to cope with this unique "patient" population. Are they considered patients if they have no disease or trauma? A dissonance exists between the altruistic donors' belief that they are preforming a selfless act and medical teams' perceptions that this act is irrational. Does this dissonance affect care provided in the medical organization? These are questions that need to be addressed. They can be addressed through training and educating medical care teams, extensive research, and open dialogue between invested parties.

Disclosures: The Authors Have No Conflict of Interests.

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