Explanation of the sociological patterns of organ donation: An analytical study

Abstract

BACKGROUND:

In many countries, the consent of family members is required for organ donation from brain-dead patients who are potential candidates for organ donation. In this regard, knowing the factors affecting family members’ decision for organ donation can help improve the conditions. This qualitative study aimed to identify the factors affecting family members’ decision-making regarding donation of brain-dead patients’ organs.

MATERIALS AND METHODS:

This research applied qualitative research by focusing on the content analysis approach. The study started from April 2021 in Al-Zahra Hospital in Isfahan and Ayatollah Kashani in Shahrekord and continued until data saturation was reached (September 1401). Participants were assigned to one of three groups: brain-dead patients’ family members who consented to organ donation, brain-dead patients’ family members who declined to consent to organ donation, and people involved in the organ donation process. The sample was selected using the purposive sampling method. The data were collected using unstructured interviews and the field survey method. In this study, a qualitative content analysis with a contractual approach was used to analyze the data.

RESULTS:

The analysis of the collected data using different methods yielded 11 main categories, including 1) unresponsive healthcare system, 2) inadequate support from government systems, 3) weakness of social work organizations, 4) fear of being stigmatized, 5) cultural values, 6) symbolization, 7) perpetuation and the society's attitude, 8) development of personality system and generalism, 9) human values, 10) spiritual maturity, and 11) belief-religious challenges, leading finally to three themes, including 1) structural and functional weakness of systems, 2) sociocultural factors, and 3) worldview.

CONCLUSION:

The findings of the present research were able to identify the roots and social factors affecting Iranian families’ decisions regarding the consent or nonconsent of brain-dead patient members. Health system administrators and organ donation committees in medical sciences universities in Iran can try to solve the shortage of donated organs by using the specific social aspects introduced in this study. It is also recommended to design effective models for more satisfaction of family members for brain death patient organ donation in healthcare based on the underlying concepts of this study.

Introduction

Brain death is the irreversible brain damage usually resulting from head trauma, bleeding in the brain, stroke, or loss of blood flow to the brain after the heart stops working (cardiac arrest).[1,2] Etiologically, brain death can happen due to a primary brain lesion such as cerebral hemorrhages, head trauma, stroke, or in some cases brain malignancies or a secondary brain lesion (usually cardiac arrest with cerebral anoxia).[3] The idea that the organs of deceased people can be donated so that more lives can be saved is many centuries old. In 1950, a kidney was transplanted in a hospital in the United States, and over the subsequent years, organ donation after brain death became the standard.[4]

The brain death phenomenon and the possibility of using the organs of the deceased people for organ transplantation have long been discussed in scientific and social circles. Today, organ transplantation and relevant medical developments are considered as one of the most important human achievements in saving the lives of many people.[5] Transplantation, that is, removing the tissue or living organs cell from one person and placing it in another one while preserving its function is regarded as a definitive treatment for some life-threatening diseases. The first step in organ donation is obtaining one's family consent for organ donation.[6,7] Despite the successful results of organ transplantation, the shortage of organs and people's lack of readiness to donate organs are considered as the main challenges to organ transplantation across the world.[8,9] A report published in 2017 in America showed that less than one-third of patients in need of a transplant eventually receive an organ transplant.[8] Reports in Iran indicate about 24,000 organ transplants were performed from 8,300 donors in 2019.[10]

Although organ donation and transplantation are of paramount importance from the point of view of medical science, this issue has, however, caused many sociocultural, legal, and ethical challenges to different societies.[11,12] The process of organ donation as a social action is affected by various factors, including sociocultural ones. Without knowing factors that influence organ donation and obstacles to this issue, solving the problem of the shortage of transplanted organs is impossible.[13] The issue of organ transplantation is very complex due to the multiple social factors affecting it. Among these factors are religion, culture, community traditions, ethical and legal points regarding an organ removal from the living human body, definition of brain death, and removing the organs from a corpse.[9] One of the important effective factors regarding organ transplantation is the family consent for organ donation. In most countries such as Iran, the organ donation from brain dead patients requires the consent of their family members. Deciding to consent to organ donation is a complex and sometimes difficult process for family members.[14,15] It can be said that the most important limiting factor in organ donation from brain-dead donors is family refusal to consent.[5] Obtaining consent from the family members of the brain-dead patient is the first and the most important part of organ donation process.[16] Several factors can affect the family members’ decision for donation of a brain-dead patient's organs.[14]

There are limited studies related to the factors influencing the decisions of family members regarding organ donation of brain-dead patients in Iran. In addition to these previous studies in this field, the experiences and attitudes of the brain-dead patient's family members or healthcare team members were discussed. Considering that Iran is a country with its own culture, customs, and social rituals, the present study investigated the social roots affecting the satisfaction of family members regarding organ donation for brain-dead patients. Having information in this regard can help health policymakers better implement programs related to organ donation and transplantation. The present qualitative study thus aims to investigate factors affecting the family members’ decision regarding donation of brain-dead patient's organs.

Materials and Methods

Study design and setting

This research applies qualitative research by focusing on the content analysis approach. The study started from April 2022 in Al-Zahra Hospital in Isfahan and Ayatollah Kashani in Shahrekord and continued until data saturation was reached (November 2022).

Study participants and sampling

Participants were assigned to one of three groups: brain-dead patients’ family members who consented to organ donation, brain-dead patients’ family members who refused to consent to organ donation, and people involved in the organ donation process. The sample was selected using the purposive sampling method and went on until data saturation was reached, that is, until no new data were obtained in the three last interviews. Finally, a total of 22 people, including the family of organ donors and nurses the head nurses, the supervisor, and the organ procurement team members [Table 1].

Table 1.

Characteristics of the participants

ID	Age	Gender	Role
P1	39	M	Family
P 2	40	M	Head nurse
P 3	51	F	Family
P 4	50	F	Family
P 5	44	M	Nurse
P 6	38	F	Nurse
P 7	49	M	Family
P 8	52	F	Family
P 9	36	M	Supervisor
P 10	53	M	Family
P 11	50	M	Donation team
P 12	48	M	Donation team
P 13	51	M	Family
P 14	40	M	Nurse
P15	36	F	Nurse
P16	29	F	Family
P17	30	M	Nurse
P18	49	M	Donation team
P19	60	M	Family
P20	61	M	Family
P21	58	F	Family
P22	55	M	Family
M±SD	46.318±9.172	-	-

Data collection

The data were collected using unstructured interviews and the field survey method. The interviews were conducted in the hospital in a special room. For this purpose, the participants were contacted and interviewed face to face for 1 hour in a special room after obtaining their consent. Interviews began with a general question such as “May I ask you to talk about your patient and what caused his brain death?” and then went on by asking deeper and more specific questions, such as “How did you decide to donate/not donate an organ?” Clarifying and in-depth questions such as “Can you explain more about this?” were also asked if needed. For field survey, the researcher attended the mentioned hospitals during the study and closely observed the organ donation–related processes and the events that happened in this regard and took notes if necessary.

Data analysis

In this study, content analysis with a contractual approach was used to analyze the data. This approach mainly aims to describe the desired phenomenon in depth. In this method, data are analyzed inductively by researchers. After the recording, the interviews were listened to several times and then transcribed. Next, the transcription of each interview was read several times by two of the researchers and the items irrelevant to the purpose of the study were excluded. The data were then broken down into semantic units (codes) in the form of sentences related to the main meaning. The semantic units were reviewed by researchers several times, and the proper codes for each semantic unit were extracted.

Following this stage, the extracted codes were classified based on the conceptual and semantic similarity and became as small and compact as possible. This action flew in all analysis units and subcategories and main categories. The codes were then put in the main categories which were more general and conceptual, and finally, the main themes were identified.

Trustworthiness

In this research, the validity and reliability of the data were confirmed using four criteria provided by Guba and Lincoln, including credibility, dependability, confirmability, and transferability. Based on this, the long-term contact with the participants gained the participants’ trust and increased the researcher's understanding of the phenomenon of organ donation. The use of member check was used to ensure the researcher's coding and achievement of the main concept of the desired phenomenon. Confirmability was achieved using researcher impartiality, member agreement on the type of coding to achieve primary codes, and comparing the researcher's perception with what the participants had in mind. The reliability of the data was achieved by taking notes from the interviews at the first opportunity and repeatedly listening to the interviews and their transcripts and peer review.[17]

Ethical considerations

All ethical issues in medical science studies were complied with in this research, among which we can refer to obtaining informed consent from participants before being included in the study, independence of participants for participating in the study, and confidentiality. It should also be stated that this study was conducted under the supervision of Isfahan University of Medical Sciences and has an ethics code number of IR.MUI.NUREMA.REC.1400.060 from the Ethics Committee of this university.

Results

The analysis of the collected data using different methods yielded 11 main categories, including 1) unresponsive healthcare system, 2) inadequate support from government systems, 3) weakness of social work organizations, 4) fear of being stigmatized, 5) cultural values, 6) symbolization, 7) perpetuation and the society's attitude, 8) development of personality system and generalism, 9) human values, 10) spiritual maturity, and 11) belief-religious challenges, leading finally to three themes, including 1) structural and functional weakness of systems, 2) cultural and social factors, and 3) worldview [Table 2]. Below are quoted in this context. (The symbol “R” indicates the families who consented to the donation and the symbol “A” indicates the families who did not consent to the organ donation of the brain-dead patient).

Table 2.

Themes, main categories, and sub-categories

Theme	Main categories	Subcategories
Structural and functional weakness of systems	Unresponsive healthcare system	Communication between health team and family The health team empathy with and mental support for the family How to declare the patient to be brain dead? Transparency of professional roles Restoring trust in the organ donation team Knowledge of health team members Not providing the conditions to meet the patient
	Inadequate support from government systems	Financial support and allowances Creating employment for family members Creating social facilities Naming the deceased as a martyr or disabled war veteran Providing psychological and spiritual support Increasing donor volunteers and repoliticization
	Weakness of social work organizations	Association of peers Non-governmental organizations (NGO)
Socio-cultural factors	Fear of being stigmatized	Receiving government financial assistance and facilities Selling body organs
	Cultural values	Opponent relatives The role and contribution of people in decision-making Unmatched role of the mother Organ donation to a person from the same clan Organ donation taboo Maintaining the integrity of the body of the deceased
	Symbolization	Honoring and memorializing the deceased loved one Social respect for family
	Perpetuation and the society's attitude	Power of media Influence of formal education systems
	Development of personality system and generalism	Development of hope and social peace Building a culture of organ donation
Worldview	Human values	Consent to organ donation given by the deceased before his/her death Patient's selfless attitude and personality Tendency toward survival rather than death
	Spiritual maturity	Spiritual consolidation with God Spiritual relaxation of family and patients Giving meaning to the life of fellow human beings
	Belief-religious challenges	Mental suffering and wandering of the deceased Organ donation to a non-Muslim Holding the donor patient responsible for the sins committed by the organ recipient Belief in incomplete physical resurrectionReferencing to the opinion of some religious scholars Hope for a miracle from God

Category 1: Structural and functional weakness of systems

One of the main themes identified in this study was “structural and functional weakness of systems”, which consisted of main categories, including 1) unresponsive healthcare system, 2) inadequate support from government systems, and 3) weakness of social work organizations.

Health team members have the greatest and most important communication with patients and family members. Failure to receive support from these individuals can greatly cause anxiety and confusion in family members of the patients. Things such as health team communication, mental support and empathy provided by the health team to the patient's family, how to declare the patient to be brain-dead, development of awareness and acceptance of the family, transparency of professional roles, the family members’ confidence in the organ donation process, knowledge of the health team members, and providing the opportunity to meet and say goodbye to the patient were among the examples of the healthcare system's support for caregivers.

In this regard, one of the patient's family members who refused to consent to organ donation said:

“Neither nurses nor physicians talked to us in this regard. Even once we couldn't see up close our ICU patient. Whatever we begged was fruitless. They didn't understand us and our conditions at all. There was also no one to support us. It was obvious that we would pay no attention to their request when such people asked us for organ donation” (Family member, A, 1). Moreover, among other things expressed as a barrier to organ donation in this study was the expectation of family members from the healthcare team to understand and pay attention to the psychological aspects and bereavement of these people.

The feeling that the health team understands caregivers and empathizes with them is one of the important points affecting the perception of the support provided by the healthcare system. One of the patient's family members stated that “… people like us who had a brain-dead patient expect that at least the physician and nurses understand us. Though they deal with these patients, they don't understand us at all, I think. They cannot understand that losing someone you love is the hardest thing in the world … “ (Family member, A, 3).

In this regard, one of the patients’ family members who consented to organ donation stated that “Thanks God we donated our patient's organs, but I remember that many questions were posed to us at that time. They didn't answer many questions accurately. I asked the nurses. Once they said, it's God who decides when we die or not, but your patient is brain-dead. Ok, what does it mean? Perhaps some families refuse to consent to organ donation due to not knowing such information” (Family member, 2, R).

One of the intensive care unit (ICU) nurses who had just started working in this ward said, “I myself don't indeed know much about organ donation and its conditions. Generally, I don't receive too much training. I don't know how to treat with the families of these patients” (Nurse, 3).

Regarding this issue, the person in charge of the organ donation procurement unit of a hospital said, “There were families who got offended and refused to consent to organ donation due to inappropriate behaviors in wards” (The person in charge of the organ donation procurement unit).

Moreover, one of the patients’ family members who had refused to consent to organ donation said, “Perhaps we decided in another way if we received mental support. Nobody supported us. They only made a phone call and said come and donate” (Family member, 14, R).

The governments’ supportive approaches to the health area are regarded as one of the undeniable priorities in societies. The support provided by the government causes the brain-dead patients’ family members to feel more secure. The weaker presence of these supports provided by the government systems is one of the barriers to organ donation from patients mentioned by the participants in the present study. Giving subsidies and allowances to the family, creating employment for family members, creating social facilities, naming the deceased as a martyr or disabled war veteran, and providing psychological and spiritual support are the components of the official support class provided by the government institutions.

One of the patients’ family members who consented to organ donation stated that “Organ donation is a very big and difficult task. This decision was really difficult for us to make. We did this for the sake of ultimate, eternal satisfaction of God, but we expected to receive more support and attention from the government. Every human has some expectations” (Family member, 14, R).

One of the other family members said “I wish the government would do something about us. Now that my husband's organs have been donated, I wish the government would do something about us who have become helpless. This is our life situation. You see, we have nothing. I wish we would be granted a loan, or provided with a job; I wish the government would provide a livelihood basket to us so that we could live the life” (Family member, 17, R).

On the other hand, the family members having a support network composed of nongovernmental organizations and support associations is a component proposed as the need of the brain-dead patients’ family members and is placed in the category of informal support. One of the ICU nurses said,

“It would have a great impact on the decision of these people if there were conditions to introduce these families to organizations to which other families like these people have membership. I think that when people who have the same pain get together, their pain and suffering will be reduced. They understand that there are other people who have experienced the same situation and they are not alone” (Nurse, 6).

Category 2: Sociocultural factors

The other main theme identified in this study was the sociocultural factors. The “sociocultural factors” theme includes five main categories: 1) fear of being stigmatized, 2) cultural values, 3) symbolization, 4) perpetuation and the society's attitude, and 5) development of personality system and generalism.

In this regard, one of the patients’ family members who refused to consent to organ donation said,

“If we did that, they would say tomorrow that they sold their patient's body, or would say they received a house and a car and sold their patient's body. Our decision might have been something else if we didn't fear these words” (Patient's family, 7, A).

Regarding this issue, the person in charge of organ donation procurement unit said,

“Many times, the main family itself gives partial consent to organ donation, but there are some relatives whose opinion is of paramount importance. They disagree, and the family changes its mind. According to my experience, mothers play an important role in this regard. It is approximately done if they give consent” (The person in charge of organ donation procurement unit).

Moreover, one of the other family members said, “The organ donation, we consented for, was not effective for us but for our city, I think. We already had such cases in our city and saw how people respect them! This encouraged us itself. The same was for us post-donation. We did it for the sake of God, however, people went out of their way for us. We are highly respected by the local people and the people of the surrounding areas because of what we did” (Family member, 15, R).

Furthermore, one of the other family members of patients believed “What we did is a model for others. Obviously, what we did has changed our behavior and the behavior of those around us in society. The friends and acquaintances respect us more. What we did had actually positive effects on them” (Family member, 17, R).

Category 3: Worldview

One of the main themes determined in this study was “worldview”. Worldview consisted of three main categories: 1) human values, 2) spiritual maturity, and 3) belief-religious challenges. This theme showed that human values, such as altruism and benevolence, religious and spiritual values, and beliefs specific to Iranian society play a key role in the decision-making process of brain-dead patients’ families on organ donation.

One of the participants in this study said,

“My son had said several times donate my organs if anything ever happened to me (family members cried). We had his wish realized. For what should we refuse when he wanted?” (Family member, 15, R).

Among other things accepted as a decision-making facilitator and human value by families who consented to organ donation was the belief that their loved one would live on by giving life to others. One of the participants stated:

“In our opinion, my daughter's heart had better live on. When we denoted her organs, we knew at least that her organs would be alive. This made us feel better” (Family member, 12, R).

Another participant believed that “A body that is placed inside the ground usually starts to decay immediately. We'd better do something to keep his body alive. When his heart beats, my loved one is thus alive” (Family member, 14, R).

Paying attention to spiritual dimensions of life was also among the factors affecting the family members’ decision. One of the patients’ family members who consented to organ donation said,

“God Himself knows that we did it just for the sake of His satisfaction. We are a very religious family. God's satisfaction was important for us. God was the owner of that body, why should we become a barrier?” (Family member, 13, R).

One of the other patients’ family members who consented to organ donation noted: “It was important for us that we did a divine thing. We were sure that by doing so we would please God. What is more important than God's satisfaction? We thank God for giving us the power to make such a decision” (Patient's family, 14, R).

The families of the donor patients believed that organ donation will bring peace of mind to the patients and their family. In this regard, one of the family members said,

“Our child was very young. Losing a child is a very heavy grief. It was really difficult for his mother, but it became easier for us to bear our loved one's death post- organ donation. I think God Himself helped us and answered us” (Family member, 13, R).

Another family member who participated in the interview said, “Organ donation caused us to better cope with the death of our loved one. I think we had done a great job that made us relax” (Family member, 16, R).

On the other hand, giving life to a fellow human being was one of the reasons for accepting organ donation in the studied society. This was of paramount importance for family members. Regarding this issue, one of the patients’ family members said,

“We put ourselves in the shoes of the person in need of organ transplantation whose life depends on it. Our father would not become alive again, but could save the life of someone else by organ donation. I think nothing is worth more to a human being than this. Our sense of philanthropy was a factor affecting the decision we made” (Family member, 19, R).

However, some religion-related barriers also affected the family members’ decision. Some of the participants in this study stated that by organ donation, the whole soul of the deceased did not enter the other world, and a part of it would remain in this world given the remaining organs, leading to the mental suffering and wandering of the deceased. One of the family members said,

“Obviously, it is impossible. Could it be possible that half of the body be on the ground and half inside the ground? This way his soul would be wandered. The soul wouldn't rest in peace. We refused to donate organ for his spiritual peace” (Family member, 8, A).

On the other hand, some of the family members believed that as per their family and collective culture, the body whose organs have been donated would be resurrected incompletely in the other world, at the Day of Judgment and bodily resurrection, and would thus suffer a lot.

“What about the other world? His heart is in one body and his kidney in another one. The deceased himself was also a believer. These organs should bear witness on the Day of Judgment. When we come alive in the other world, how did the deceased want to have a complete body? It is not difficult to understand” (Family member, A).

Many family members of nondonor patients believed that the spirit of their patient would be separated from his body with organ donation and provided to the receiving patient. The donors had also mental concern over the issue that the patient's organ would remain alive and could be provided to non-Muslims and sinners. In this regard, one of the patients’ family members who refused organ donation said,

“See, suppose that we gave consent to organ donation; tell me how we could assure that the receiving patient is a righteous person. Primarily, what if we donated our sister's heart to a bad man? Whose fault is the sin committed by the patient who has received the heart transplant?” (Family member, 10, A).

Moreover, one of the influential members affecting the family's decision concerning organ donation who refused organ donation stated that “You would also refused organ donation if you were in the shoes of this family and didn't know to whom this donated organ would be transplanted. Suppose it would be transplanted to a murderer, wouldn't the deceased be held responsible at the Last Judgment” (Patient's family, 7, A).

In one of the interviews, the chief nursing officer said, “There was a family who had a nodding acquaintance with us. They contacted me more than 20 times post- organ donation to assure that their patient's organs would be used correctly. We don't know the fact. It is important for families … “ (Ward 4 chief nursing officer, ICU).

Discussion

The family members consent to donation of the brain-dead patient's organs is a special process with its own complications. This qualitative study showed that many organizational, individual, psychological, sociocultural, spiritual, and religious factors can affect the family's decision regarding donation of a brain-dead patient's organs.

One of the main themes obtained in this study was the structural and functional weakness of systems, indicating that the weakness of systems involved in the provision of proper conditions for family members and inadequate training and support for them will result in their refusal for organ donation. This theme indeed shows the importance of the organizational behavior and existing atmosphere in health and medical organizations and the support provided by formal and informal organizations to the family. In this regard, the results of the study by Manzari et al.[18] showed that failure to communicate properly, inadequate training and support, and informing family members about the situation are among the main factors affecting the family decision regarding organ donation. Another study in this regard showed that the lack of supportive atmosphere for families of the brain-dead patient's candidate for organ donation will significantly affect their decision regarding organ donation.[19] In line with the present study, the results obtained by Abbasi et al.[20] showed that these patients’ family members are not well informed about brain death and brain death–related processes by healthcare providers, and the lack of knowledge plays an inhibiting role in their decision. This theme showed that the decision for organ donation is affected by the behavior and performance of service provider systems. The approach of these systems to identifying these families, dealing correctly with these families, and creating a supportive atmosphere can encourage these families to donate organs. This is an important issue which has received scant attention in previous studies. Health and medical organizations can play an effective role in organ donation by modifying their current structures and processes for such patients and their family members. Najafizadeh et al. (2019)[21] concluded that the most important reason for Iranian families’ refusal for organ donation is a lack of comprehension of brain death and financial expectations. Pourhosein et al. (2019)[14] believed that as socioeconomic factors significantly affect the Iranian families’ decision about organ donation, improving governmental supports, such as providing insurance coverage, holding mourning sessions, and receiving psychological support after organ donation seem necessary. Accordingly, planning for legislation and having strategies to support these families appear to be essential.

The governing sociocultural atmosphere for the society is considered a powerful factor toward human actions that affects the people's decision-making either consciously or unconsciously. The “sociocultural factors” theme obtained in the present study showed that humans are affected by sociocultural factors in making the important decision on organ donation from one of their loved ones. This theme indicated that several sociocultural factors, such as special customs, cultural taboos and stigmatization, the entry of influential people, especially the mother, into the process of consent, social incentives, and media culture building affect the families’ decision on organ donation. Some of the findings in this section are in agreement with those of previous studies in this regard. For example, in their study, Abbasi et al.[20] reported culture and cultural challenges to have a considerable effect on family members’ decision about organ donation. The study by Manzari et al.[18] showed that the particular people, such as the family's mother, play a significant role in making this decision. One of the significant things in this theme that was not mentioned in previous studies was the social fear about the stigma of selling organs. Stigma is known as one of the social factors, and it means having a characteristic or an attribute through which a person or a group's norms differ across the society, causing them to be discredited and distinguished from other social groups. Many families in this study were afraid of the stigma of selling their patient's organs. This fear had become the reason for their refusal for organ donation. This finding can be attributed to the specific sociocultural context of the present study. Moreover, the mass media's attention to this issue can be effective in reducing and eliminating this fear.

The other thing identified in this study as the factor affecting society people's attitude toward organ donation was the role of the media and educational systems. Majidi and Aghaei stated that the readiness to donate organs can be increased by culture building. One of the solutions is to address this issue in the media and in ways that raise people's awareness regarding “brain death”, “coma”, and the differences between the two. Definitely, to achieve the desired results in the programs made about organ donation, physicians and experienced experts in this field should be recruited, because incorrect notification will have destructive results and effects. It is the duty of mass communication and media to inform about missions; however, the media seems to have a low contribution to information provision about brain death and organ donation.[22] One of the factors affecting the decision about organ donation in this study was generalism in family members. This component was identified by the family members’ belief in inducing social peace and developing the culture of organ donation in the society. Consistent with the findings of the present study, Abdollahi and Shoukranifard stated that generalism has the greatest contribution to explaining organ donation.[23]

The other theme obtained in the present study was “worldview”. The world view is considered as the human attitude and type of orientation toward life, composed of basic principles, ethics, values, norms, and beliefs. Accordingly, the type of decision-making and the manner in which people decide about organ donation are affected by their worldview. The family and patient's beliefs with a humanistic and ethical approach such as the consent for organ donation given by the deceased before his/her death, the patient's selfless personality, and tendency toward survival rather than death were among the categories included in this theme and played a positive role in the family members’ decision-making about organ donation. Moreover, spiritual consolidation with God, religious beliefs, families and their patients’ spiritual relaxation, and giving meaning to the life of fellow human beings were also in this theme. The previous research in this regard also shows approximately the same results. The results of a study in 2018 also confirm some of the findings of this study. In that review study, the consent of the deceased person has been introduced as one of the main factors affecting the consent of family members to organ donation.[24] The study by Saxena et al.[25] in India showed that giving life to a fellow human being and tendency for survival rather than annihilation are among the main reasons for family members’ consent to organ donation from patients who are potential candidates for organ donation. The significant point in this part is the dual role of religious beliefs regarding the consent to organ donation. Some religious beliefs such as the family members’ belief in the spiritual wandering of the patient after organ donation and incomplete physical resurrection, concern over the patient's organ transplant to a non-Muslim person, the possibility that the donor patients would be held responsible for the sins committed by the organ recipient, and referencing to the opinion of some religious scholars indicating the noncanonicality of organ transplantation were among barriers to organ donation. In this regard, the study by Abbasi et al.[20] conducted in Iran yielded the same results such that the participants in the study mentioned the physical resurrection and the patient's organ being alive in the body of a sinner as the barriers to organ donation. The specific beliefs of Iranian society in this regard seem to be in need of special attention. Organizations can provide the required consultations to the family members with the aid of relevant people in this field, such as the clergy, and encourage the family members to donate organs.

Limitations

This study took place in Iran and in a particular region with its own specific culture and social customs. Therefore, attention should be paid to this issue when interpreting and using the results of this study.

Conclusion

Several factors affect the consent of family members of patients who were potential candidates for organ donation. These factors are either facilitators or barriers. Moreover, some factors such as religious beliefs play a dual role such that they are facilitator in some cases and inhibitor in other cases. Explaining the factors proposed in the present study can help managers and policy makers in this area to better plan to encourage families to consent to organ donation from patients who are potential candidates for organ donation. The correct communication between the care and treatment staff and families, providing spiritual and mental supports to them, identifying influential people, public, and media training, and recruiting the clergy to eliminate the religious barriers are among factors to be considered by managers and policy makers in this regard.

Financial support and sponsorship

The present study is part of a Ph.D. thesis in nursing that was approved by Isfahan University of Medical sciences.

Conflicts of interest

There are no conflicts of interest.