Low Consent Rates Despite High Donor Identification in Pediatric Intensive Care Units: A Multicenter Questionnaire Survey in Japan

Low Consent Rates Despite High Donor Identification in Pediatric Intensive Care Units: A Multicenter Questionnaire Survey in Japan | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Low Consent Rates Despite High Donor Identification in Pediatric Intensive Care Units: A Multicenter Questionnaire Survey in Japan Tomohiro Hiraoka, Norihiko Tsuboi, Shotaro Matsumoto This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9391690/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Pediatric organ shortage remains a critical issue in Japan. While previous literature described religious perspectives and family attitudes toward organ transplantation, institutional practices and epidemiologic data were limited. Methods Between October 1 and November 30, 2025, we conducted a web-based questionnaire survey of intensive care units (ICUs) at 47 facilities affiliated with the Japanese Association of Pediatric Intensive Care (JAPIC), the pediatric division of the Japanese Society of Intensive Care Medicine. The survey included three domains: ( 1 ) ICU characteristics, ( 2 ) patient populations at each step of the organ donation pathway in 2024, and ( 3 ) medical and social protocols related to donor management. Descriptive statistics were used to summarize responses. Results The response rate was 70.2% (33/47). Organ donation protocols were established in all participating facilities, although only 51.5% had prior experience with pediatric organ donation. Among 276 ICU deaths reported in 2024, 68 (24.6%) were identified as potential organ donors. Legal brain-death determination was performed in 16% (8/50) of patients to whom the donation option was presented. The most common reason for not proceeding was family decline (37/50, 74.0%). Nine patients with suspected brain death were discharged alive from the ICU after refusal to proceed with legal brain-death determination while receiving mechanical respiratory support. Arginine vasopressin was commonly used for hemodynamic support and central diabetes insipidus, while corticosteroids and thyroid hormones were selectively administered. Although multidisciplinary teams were involved, primary ICU physicians were responsible for presenting donation options. End-of-life care and organ donation were presented concurrently in most facilities. Conclusions This survey provides the first nationwide epidemiologic description of pediatric organ donation practices in Japan. While potential donors are effectively identified and centralized, low family consent rates represent the principal barrier to increasing pediatric organ donation. Pediatric organ donation intensive care unit brain death organ procurement donor management hormonal replacement therapy Figures Figure 1 Background Organ shortage remains a critical global challenge. In Japan, the disparity between patients awaiting transplantation and available organs is particularly severe, with organ donation rates following brain death remaining among the lowest in developed countries ( 1 ). This gap is even more pronounced in the pediatric population ( 2 ). Pediatric transplantation has a relatively short history in Japan. The revised Organ Transplant Law, enacted in 2010, permitted pediatric organ procurement with family consent through the Japan Organ Transplantation Network ( 3 ). Following the first deceased donor under 18 years of age in 2011, the number of pediatric transplants has gradually increased. Legislative amendments in 2022 relaxed requirements for excluding suspected child abuse cases (allowing institutional review teams to determine eligibility) and removed intellectual disability as an absolute contraindication in young children, resulting in a record high of 25 cases in 2023. Despite this progress, waiting times for heart transplantation remain protracted, averaging approximately 1,496 days in 2024 ( 4 ). Multiple barriers to organ transplantation have been documented, including cultural and religious beliefs, legal regulations, and healthcare system characteristics ( 5 , 6 ). Previous Japanese studies have primarily focused on religious perspectives and family attitudes toward transplantation ( 7 , 8 ). However, institutional practices—such as donor management protocols and approaches to presenting donation options—remain poorly characterized. Furthermore, detailed epidemiological data throughout the organ donation process is available only from a single-center study ( 9 ). This study aimed to characterize the current state of pediatric organ donation in Japan by examining case numbers at each step of the donation pathway and institutional practices at organ-procurement hospitals, thereby identifying barriers to expanding pediatric organ donation. Methods We designed a web-based questionnaire addressing three domains: 1) institutional ICU characteristics (bed capacity, staffing, and donation system infrastructure), 2) the number of patients at each step of the organ donation pathway during the calendar year 2024, and 3) institutional donor management protocols, including hormonal replacement therapy practices and approaches to presenting donation options to families. The questionnaire comprised three sections with eight, fourteen, and seven questions, respectively (Additional file 1). The survey was conducted from October 1 through November 30, 2025, and was distributed to ICU medical directors or designees at 47 facilities affiliated with the Japanese Association of Pediatric Intensive Care (JAPIC), the pediatric division of the Japanese Society of Intensive Care Medicine, representing the majority of tertiary pediatric ICUs caring for critically ill children in Japan. Study information and an electronic consent form were presented at the survey's outset. We used descriptive statistics to summarize institutional characteristics and survey responses. Data were analyzed using Stata version 18 statistical software (StataCorp LP, College Station, TX, USA). This survey was supported by the Grant of National Center for Child Health and Development (2024 B-2) and was approved by the Institutional Review Board of the National Center for Child Health and Development (approval number: 2025-062). Results Thirty-three of 47 facilities (70.2%) completed the survey. Respondent and institutional characteristics are summarized in Table 1 (Section 1 and Questions 1–2 in Section 2). Most respondents were consultant-level or senior intensivists or pediatricians with more than 15 years of clinical experience. Member institutions of the Japanese Association of Children's Hospitals and Related Institutions (JACHRI) comprised 48.5% of respondents, followed by university hospitals (30.3%). All participating facilities had established organ donation protocols, and 81.8% and 51.5% reported prior experience with adult and pediatric organ donation, respectively. Table 1 Characteristics of Respondents and Institutions (n = 33) Respondent Characteristics Department Pediatrics 14 (42.4) Intensive Care Medicine 17 (51.5) Emergency Medicine 2 (6.1) Anesthesiology 0 (0.0) Neurosurgery 0 (0.0) Other 0 (0.0) Position Chief Director 25 (75.8) Attending Staff 8 (24.2) Resident 0 (0.0) Other 0 (0.0) Years after Graduation 6–15 3 (9.1) 16–25 21 (63.6) 26–35 6 (18.2) 36–45 3 (9.1) > 45 0 (0.0) Institutional Characteristics Institution Category* University Hospital 10 (30.3) JAAM Accredited Training Facility 2 (6.1) JNS Core/Affiliated Training Facility 1 (3.0) Certified Emergency and Critical Care Center 3 (9.1) JACHRI Member 17 (51.5) None of the above 0 (0.0) ICU Bed Capacity 1–5 0 (0.0) 6–10 16 (48.5) 11–15 11 (33.3) 16–20 3 (9.1) > 20 3 (9.1) ICU Type Open 4 (12.1) Semi-closed 15 (45.5) Closed 14 (42.4) Primary Department Managing Potential Brain-dead Pediatric Patients Pediatrics 15 (45.5) Intensive Care Medicine 14 (42.4) Emergency Medicine 1 (3.0) Anesthesiology 0 (0.0) Neurosurgery 0 (0.0) Other 3 (9.1) Pediatric Organ Donation Protocols Established 33 (100) Not established 0 (0.0) Prior Organ Donation Experience (Including Adult Patients) Yes 27 (81.8) No 6 ( 18 , 2 ) Prior Organ Donation Experience (Pediatric Patients) Yes 17 (51.5) No 16 (48.5) Data are presented as n (%). * Multiple answers allowed. JAAM: Japanese Association for Acute Medicine; JNS: Japan Neurosurgical Society; JACHRI: Japanese Association of Children's Hospitals and Related Institutions. Figure 1 illustrates the number of patients at each step of the organ donation pathway. Approximately one-quarter of deceased pediatric patients (68/276, 24.6%) were identified as potential organ donors. Among patients to whom a donation option was presented (n = 50), only 16% (8/50) progressed to legal brain-death determination. Figure 1 also presents reasons for attrition at each step of the donation pathway. At some institutions, cerebral and brainstem function evaluations were not performed in patients with suspected brain death. Among patients for which donation options were presented, the most common reason for not proceeding to legal brain-death determination was family decline of organ donation (37/50, 74.0%). Nine patients suspected of brain death were discharged alive from the ICU (Questions 4 in Section 2). Organ donation options were presented to all nine families, but all declined legal brain-death determination. Among these nine patients, five underwent newly performed tracheostomy during the ICU stay, one had a pre-existing tracheostomy, and three were discharged from the ICU with endotracheal tubes in place. Table 2 summarized institutional practices regarding hormonal replacement therapy and family communication. Arginine vasopressin was administered for both hemodynamic support and treatment of central diabetes insipidus. Corticosteroid and thyroid hormone were selectively administered to patients considered to have hormonal deficiency, although thyroid replacement was less frequently employed than other hormones. The organ donation process involved multidisciplinary teams at all institutions, although primary ICU team physicians were responsible for presenting donation options. End-of-life care and long-term management were presented concurrently at 72.7% of facilities (24/33), and donation rates were slightly higher in facilities where long-term management was not routinely presented (shown in Table 3 ). Table 2 Institutional Protocols for Donor Management and Family Communication (n = 33) Donor Management n (%) Vasopressin Use* First-line agent for hypotension 6 (18.2) Second-line or later for hypotension 21 (63.6) For central diabetes insipidus 26 (78.8) Not used 0 (0.0) Unknown (no experience) 5 (15.2) Central Diabetes Insipidus Management Vasopressin/Desmopressin 25 (75.8) Free water replacement only 3 (12.1) No intervention 0 (0.0) Unknown (no experience) 5 (15.2) Corticosteroid Administration Routinely administered in all potential donors 4 (12.1) Administered when adrenal insufficiency suspected 23 (69.7) Not used 1 (3.0) Unknown (no experience) 5 (15.2) Thyroid Hormone Administration* Routinely administered in all potential donors 1 (3.0) Administered for documented hypothyroidism 13 (39.4) Administered for cardiac dysfunction 3 (9.1) Not used 9 (27.3) Other 0 (0.0) Unknown (no experience) 7 (21.2) Family Communication n (%) Multidisciplinary Team Members Involved* Palliative care physician 4 (12.1) Psychiatry/psychology 20 (60.6) Physical/occupational therapy 14 (42.4) Laboratory technologists 22 (66.7) Organ donor coordinator 30 (90.9) Social worker 24 (72.7) Child life specialist 12 (36.4) Other 0 (0.0) Unknown (no experience) 2 (6.1) Personnel Who Present Donation Options* Primary ICU team physicians 29 (87.9) Physicians from other departments 9 (27.3) Organ donor coordinator 7 (21.2) Critical-care mediator 1 (3.0) Other 0 (0.0) Unknown (no experience) 0 (0.0) Data are presented as n (%). * Multiple answers allowed. Table 3 The Usual Sequence of Presenting End-of-Life Options and Donation Rates Method Facilities, n (%) Donation/ICU deaths, n (%) Donation/PBD, n (%) ①+②+③ 20 (60.6) 5/150 (3.3) 5/48 (10.4) ①+② 8 (24.2) 3/108 (2.8) 3/19 (15.8) ①+③ 4 (12.1) 0/8 (0.0) 0/1 (0.0) ②+③ 0 (0.0) NA NA NA NA Others 0 (0.0) NA NA NA NA No experience 1 (3.0) 0/10 (0.0) NA NA ① End-of-life care (withdrawal/limitation of life support) ② Organ donation ③ Long-term management (continued aggressive treatment including tracheostomy) ICU; Intensive Care Unit PBD; Potential Brain Death Discussion This multicenter questionnaire survey provides the first comprehensive epidemiological data on pediatric organ donation practices in Japan. Two key findings emerged that characterize the current state of pediatric organ donation and identify the primary barrier to its expansion. First, JAPIC-affiliated institutions effectively identified potential organ donors, indicating that critically ill pediatric patients at risk for brain death are appropriately centralized to specialized pediatric intensive care centers with established donation systems. Second, despite this high identification rate, the proportion of families consenting to proceed to legal brain-death determination was low, with family decline being the most common reason for discontinuation. These findings strongly suggest that the principal barrier to pediatric organ donation in Japan lies not in clinical identification systems or donor management capabilities, but rather in the family consent process itself. The JAPIC-affiliated institutions that participated in this survey were predominantly medium-sized, closed or semi-closed units operated by pediatricians or intensivists, all of which had established organ donation systems. Eight pediatric organ transplants from these ICUs accounted for 40.0% of all pediatric transplants in Japan in 2024 ( 1 ). Given that a total of 306 institutions nationwide are eligible to perform pediatric transplantation ( 10 ), JAPIC-affiliated centers appear to make a substantial contribution to pediatric organ transplantation in Japan. As shown in Fig. 1 , 25.5% (68/276) of ICU deaths met criteria for suspected brain death and subsequent evaluation. However, only 16% (8/50) of families who were approached consented to proceed to legal brain-death determination. This pattern contrasts sharply with reports from other countries with opt-in consent systems, where approximately 10% or fewer of ICU deaths are identified as potential organ donors, yet 50–70% of approached families consent to organ donation ( 11 – 14 ). In the present study, the most common reason for not proceeding to legal brain-death determination was family decline of the donation process. Although religious or cultural factors have been suggested to influence organ donation decisions in Japan ( 6 , 15 , 16 ), earlier surveys indicate that more than 60% of parents would be willing to consider organ donation for their children after receiving appropriate explanations from healthcare professionals ( 8 ). In contrast, previous studies have shown that physicians may provide insufficient explanations about brain death, partly due to limited educational opportunities in end-of-life care ( 17 , 18 ). In this context, a substantial clinical burden is placed on primary physicians, who must manage severely ill patients while simultaneously assuming responsibility for both organ procurement and presenting donation options, despite the presence of multidisciplinary healthcare teams, as demonstrated in this survey. Furthermore, from a regulatory perspective, the absence of legislation mandating referral or the routine presentation of donation options when potential donors are admitted to the ICU may result in fewer donation requests ( 19 ). In this study, no organs were donated from the facilities where donation options were not routinely presented, which support this hypothesis. Of note, long-term management strategies, including tracheostomy, were proposed in approximately three-quarters of these patients. This situation arises from provisions in Japanese law whereby brain death is not uniformly regarded as legal brain death unless organ donation is pursued ( 20 ). Indeed, five of nine potential donors in this study were discharged alive from the ICU. Hormonal replacement therapy practices were largely consistent with the Japanese guidelines and international standards for managing potential organ donors ( 21 – 23 ). Vasopressin was administered for both maintaining circulation and central diabetes insipidus, while free water replacement alone was applied for central diabetes insipidus cases in three facilities. Corticosteroid and thyroid hormone were administered when necessary. This study has several limitations. First, the participants who responded to the questionnaire represented only a subset of facilities where pediatric organ donation is permitted. Therefore, caution is required when interpreting the results of this study. However, because JAPIC specializes in pediatric intensive care and its member institutions accounted for a sufficient proportion of pediatric transplants in 2024, the findings may still reflect current practices. Second, sampling bias can have occurred, as facilities that are more proactive in organ procurement and donation requests were more likely to participate. Consequently, practices favoring organ donation may be overrepresented, while negative or cautious attitudes may be underrepresented. Third, questionnaire surveys are inherently subject to response bias, including social desirability, recall, and acquiescence biases, as well as misinterpretation of questions and limited depth of responses, all of which can influence the results. Finally, since end-of-life care is not standardized and requires case-by-case decision-making, its complexity may not have been fully captured through fixed-response questionnaire items. Conclusion This questionnaire survey conducted among JAPIC-affiliated institutions has shown the epidemiological characteristics and management trends of pediatric organ donation in Japan. Although patients requiring terminal care were effectively centralized to pediatric ICUs, a substantial family decline in organ donation consent was observed. To achieve a more comprehensive and reliable understanding of pediatric organ donation practices in Japan, larger-scale studies covering all pediatric organ procurement institutions are warranted. Abbreviations ICU intensive care units JAPIC the Japanese Association of Pediatric Intensive Care JACHRI the Japanese Association of Children's Hospitals and Related Institutions Declarations Ethics approval and consent to participate: This study was approved by the Institutional Review Board of the National Center for Child Health and Development (approval number: 2025-062). Study information and an electronic consent form were presented at the survey's outset. Consent for publication: Not applicable. Competing interests : The authors declare that they have no competing interests. Funding: This survey was supported by the Grant of National Center for Child Health and Development (2024 B-2) Author Contribution All authors conceptualized and designed the study, carried out the initial analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript. Acknowledgements: Not applicable. Data Availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. References database I. WORLDWIDE ACTUAL DECEASED ORGAN DONORS 2024 (pmp) 2025 [Available from: https://www.irodat.org/?p=database . Nishimura N, Kasahara M, Ishikura K, Nakagawa S. Current status of pediatric transplantation in Japan. Journal of Intensive Care. 2017;5(1):48. Current status of organ donation and transplantation [Internet]. 2025 [cited 2025-12-20]. Current status of organ donation and transplantation [Internet]. 2024 [cited 2025-11-27]. Available from: https://www.jotnw.or.jp/datas/newsletter/ . Kanyári Z, Cservenyák D, Tankó B, Nemes B, Fülesdi B, Molnár C. Knowledge and Attitudes of Health Care Professionals and Laypeople in Relation to Brain Death Diagnosis and Organ Donation in Hungary: A Questionnaire Study. Transplant Proc. 2021;53(5):1402-8. Collin M, Karpelowsky J, Thomas G. Pediatric transplantation: An international perspective. Semin Pediatr Surg. 2017;26(4):272–7. Okita T, Hsu E, Aizawa K, Nakada H, Toya W, Matsui K. Quantitative Survey of Laypersons' Attitudes Toward Organ Transplantation in Japan. Transplant Proc. 2018;50(1):3–9. Ichikawa K. Attitude of Japanese Parents towards Pediatric Brain Death and Organ Transplantation. Journal of Japanese Society of Emergency Pediatrics. 2018;17(1):41–50. Chisato Akita MS, Ken Yakame, Yosuke Nakano, Saori Aiga, Tadashi Oi, Sanae Sato, Tatsuya Kawasaki. The Prevalence of Pediatric Brain-death Patients and the Factors That Prevent Organ Donation in a Children's Hospital: A Descriptive Study. The journal of the Japan Pediatric Society. 2025;129(4):561–6. Ministry of Health L, Welfare. The 67th Health Science Council Disease Control Subcommittee Organ Transplantation Committee: Meeting Materials. Tokyo, Japan: Ministry of Health, Labour and Welfare; 2024. Kirschen MP, Francoeur C, Murphy M, Traynor D, Zhang B, Mensinger JL, et al. Epidemiology of Brain Death in Pediatric Intensive Care Units in the United States. JAMA Pediatrics. 2019;173(5):469–76. Blood NHS, Transplant. Transplant Activity Report 2024/25. London, United Kingdom: NHS Blood and Transplant; 2025. DonateLife. Statistics in Australia 2025 [Available from: https://www.donatelife.gov.au/all-about-donation/statistics-in-australia#Latest-stats . Palsson TP, Sigvaldason K, Kristjansdottir TE, Thorkelsson T, Blondal AT, Karason S, et al. The potential for organ donation in Iceland: A nationwide study of deaths in intensive care units. Acta Anaesthesiol Scand. 2020;64(5):663–9. Oliver M, Woywodt A, Ahmed A, Saif I. Organ donation, transplantation and religion. Nephrol Dial Transplant. 2011;26(2):437–44. Da Silva IR, Frontera JA. Worldwide barriers to organ donation. JAMA Neurol. 2015;72(1):112–8. Seino Y, Kurosawa H, Shiima Y, Niitsu T. End-of-life care in the pediatric intensive care unit: Survey in Japan. Pediatr Int. 2019;61(9):859–64. Araki T, Ichikawa K, Nishiyama K, Niitsu T, Yamamoto T, Taneichi H, et al. Survey of Attitudes Toward Brain Death and Organ Transplantation Among Pediatric Healthcare Professionals (Second Report). Journal of Japanese Society of Emergency Pediatrics. 2017;16(1):111–5. Soyama A, Eguchi S. The current status and future perspectives of organ donation in Japan: learning from the systems in other countries. Surg Today. 2016;46(4):387–92. Takenori Suga KY, Tomoya Hanada, Shinpei Kawachi,, Yuji Yamagami TT. 4 pediatric cases of hypoxic–ischemic encephalopathy who achieve long–term survival after judgement of brain death. Nihon Kyukyu Igakukai Zasshi: Journal of Japanese Association for Acute Medicine. 2020;31(9):397–403. Kotloff RM, Blosser S, Fulda GJ, Malinoski D, Ahya VN, Angel L, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med. 2015;43(6):1291–325. New England Donor S. Organ & Tissue Donation Reference Manual. Waltham, MA, USA: New England Donor Services; 2021. Kuroda Y, Doi K, Yokobori S, Atsumi T, Nakamura K, Naito H, et al. Intensive Care Manual 2025 Edition for Patients with Irreversible Total Cerebral Dysfunction. Journal of the Japanese Society of Intensive Care Medicine. 2026;33(Supplement1). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9391690","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628596697,"identity":"5312954a-aa37-4b11-a14a-0d1f65602b88","order_by":0,"name":"Tomohiro Hiraoka","email":"","orcid":"","institution":"National Center for Child Health and Development","correspondingAuthor":false,"prefix":"","firstName":"Tomohiro","middleName":"","lastName":"Hiraoka","suffix":""},{"id":628596698,"identity":"c42826e4-bebf-4dc8-960a-086710b522e1","order_by":1,"name":"Norihiko Tsuboi","email":"","orcid":"","institution":"National Center for Child Health and Development","correspondingAuthor":false,"prefix":"","firstName":"Norihiko","middleName":"","lastName":"Tsuboi","suffix":""},{"id":628596703,"identity":"1d3f7213-e13d-4d64-9e34-405246f48f1a","order_by":2,"name":"Shotaro Matsumoto","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYJADxgdAIoHhAIjNg08hM5iUALEMSNbCJoHQggfotp8//Jk3x6aOn4H9WXVBjV0e3wH2iw8YZO7g1GJ2JplNmndbmoRkA4/Z7RnHkoslD/AUGzDwPMOt5UAyGzPvtsMSBvffsN3mbTiQuOEAT5oEA89h3FrOP2b+DNZygP1ZMXFabiQzSEO0MJgxQ7SwHyOg5bGZ5NxtaZIzG3iMpXmOJSfOPMzDbJCAzy/nEx9/eLvNhh8YYg8/89TYJfYdb3/44GMP7hDDAph5DBgSew6QooWB/QEDww/StIyCUTAKRsGwBgDLwVSBl/SwqQAAAABJRU5ErkJggg==","orcid":"","institution":"National Center for Child Health and Development","correspondingAuthor":true,"prefix":"","firstName":"Shotaro","middleName":"","lastName":"Matsumoto","suffix":""}],"badges":[],"createdAt":"2026-04-12 05:08:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9391690/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9391690/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107834494,"identity":"28ae8482-1d11-48de-a5a9-d8f66d480eff","added_by":"auto","created_at":"2026-04-26 15:45:41","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":280919,"visible":true,"origin":"","legend":"\u003cp\u003ePatients flow through the organ donation pathway\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9391690/v1/d16eb1c886c5e0352138ad50.jpg"},{"id":107872237,"identity":"dc8851e8-c46c-4a9f-9bcb-1954261ea169","added_by":"auto","created_at":"2026-04-27 07:56:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":683854,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9391690/v1/6e38475d-4557-4228-a8b3-d1c08bd9663f.pdf"},{"id":107870184,"identity":"e92aa2aa-cf66-47c8-8cd2-3ecb200490c6","added_by":"auto","created_at":"2026-04-27 07:39:05","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":141887,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-9391690/v1/e81c794657cad980d9f78e64.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Low Consent Rates Despite High Donor Identification in Pediatric Intensive Care Units: A Multicenter Questionnaire Survey in Japan","fulltext":[{"header":"Background","content":"\u003cp\u003eOrgan shortage remains a critical global challenge. In Japan, the disparity between patients awaiting transplantation and available organs is particularly severe, with organ donation rates following brain death remaining among the lowest in developed countries (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This gap is even more pronounced in the pediatric population (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePediatric transplantation has a relatively short history in Japan. The revised Organ Transplant Law, enacted in 2010, permitted pediatric organ procurement with family consent through the Japan Organ Transplantation Network (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Following the first deceased donor under 18 years of age in 2011, the number of pediatric transplants has gradually increased. Legislative amendments in 2022 relaxed requirements for excluding suspected child abuse cases (allowing institutional review teams to determine eligibility) and removed intellectual disability as an absolute contraindication in young children, resulting in a record high of 25 cases in 2023. Despite this progress, waiting times for heart transplantation remain protracted, averaging approximately 1,496 days in 2024 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMultiple barriers to organ transplantation have been documented, including cultural and religious beliefs, legal regulations, and healthcare system characteristics (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Previous Japanese studies have primarily focused on religious perspectives and family attitudes toward transplantation (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, institutional practices\u0026mdash;such as donor management protocols and approaches to presenting donation options\u0026mdash;remain poorly characterized. Furthermore, detailed epidemiological data throughout the organ donation process is available only from a single-center study (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThis study aimed to characterize the current state of pediatric organ donation in Japan by examining case numbers at each step of the donation pathway and institutional practices at organ-procurement hospitals, thereby identifying barriers to expanding pediatric organ donation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe designed a web-based questionnaire addressing three domains: 1) institutional ICU characteristics (bed capacity, staffing, and donation system infrastructure), 2) the number of patients at each step of the organ donation pathway during the calendar year 2024, and 3) institutional donor management protocols, including hormonal replacement therapy practices and approaches to presenting donation options to families. The questionnaire comprised three sections with eight, fourteen, and seven questions, respectively (Additional file 1). The survey was conducted from October 1 through November 30, 2025, and was distributed to ICU medical directors or designees at 47 facilities affiliated with the Japanese Association of Pediatric Intensive Care (JAPIC), the pediatric division of the Japanese Society of Intensive Care Medicine, representing the majority of tertiary pediatric ICUs caring for critically ill children in Japan.\u003c/p\u003e \u003cp\u003eStudy information and an electronic consent form were presented at the survey's outset. We used descriptive statistics to summarize institutional characteristics and survey responses. Data were analyzed using Stata version 18 statistical software (StataCorp LP, College Station, TX, USA). This survey was supported by the Grant of National Center for Child Health and Development (2024 B-2) and was approved by the Institutional Review Board of the National Center for Child Health and Development (approval number: 2025-062).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-three of 47 facilities (70.2%) completed the survey. Respondent and institutional characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (Section 1 and Questions 1\u0026ndash;2 in Section 2). Most respondents were consultant-level or senior intensivists or pediatricians with more than 15 years of clinical experience. Member institutions of the Japanese Association of Children's Hospitals and Related Institutions (JACHRI) comprised 48.5% of respondents, followed by university hospitals (30.3%). All participating facilities had established organ donation protocols, and 81.8% and 51.5% reported prior experience with adult and pediatric organ donation, respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Respondents and Institutions (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRespondent Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDepartment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatrics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(42.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntensive Care Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(51.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnesthesiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePosition\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChief Director\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(75.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttending Staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(24.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eYears after Graduation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(63.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(18.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInstitutional Characteristics\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInstitution Category*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUniversity Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(30.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJAAM Accredited Training Facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJNS Core/Affiliated Training Facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCertified Emergency and Critical Care Center\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJACHRI Member\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(51.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone of the above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICU Bed Capacity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(48.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eICU Type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSemi-closed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClosed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(42.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrimary Department Managing Potential Brain-dead Pediatric Patients\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePediatrics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(45.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntensive Care Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(42.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnesthesiology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeurosurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePediatric Organ Donation Protocols\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstablished\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot established\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrior Organ Donation Experience (Including Adult Patients)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(81.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrior Organ Donation Experience (Pediatric Patients)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(51.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(48.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Multiple answers allowed.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eJAAM: Japanese Association for Acute Medicine; JNS: Japan Neurosurgical Society; JACHRI: Japanese Association of Children's Hospitals and Related Institutions.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the number of patients at each step of the organ donation pathway. Approximately one-quarter of deceased pediatric patients (68/276, 24.6%) were identified as potential organ donors. Among patients to whom a donation option was presented (n\u0026thinsp;=\u0026thinsp;50), only 16% (8/50) progressed to legal brain-death determination. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e also presents reasons for attrition at each step of the donation pathway. At some institutions, cerebral and brainstem function evaluations were not performed in patients with suspected brain death. Among patients for which donation options were presented, the most common reason for not proceeding to legal brain-death determination was family decline of organ donation (37/50, 74.0%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNine patients suspected of brain death were discharged alive from the ICU (Questions 4 in Section 2). Organ donation options were presented to all nine families, but all declined legal brain-death determination. Among these nine patients, five underwent newly performed tracheostomy during the ICU stay, one had a pre-existing tracheostomy, and three were discharged from the ICU with endotracheal tubes in place.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarized institutional practices regarding hormonal replacement therapy and family communication. Arginine vasopressin was administered for both hemodynamic support and treatment of central diabetes insipidus. Corticosteroid and thyroid hormone were selectively administered to patients considered to have hormonal deficiency, although thyroid replacement was less frequently employed than other hormones. The organ donation process involved multidisciplinary teams at all institutions, although primary ICU team physicians were responsible for presenting donation options. End-of-life care and long-term management were presented concurrently at 72.7% of facilities (24/33), and donation rates were slightly higher in facilities where long-term management was not routinely presented (shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInstitutional Protocols for Donor Management and Family Communication (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDonor Management\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVasopressin Use*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst-line agent for hypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(18.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecond-line or later for hypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(63.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFor central diabetes insipidus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(78.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown (no experience)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(15.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCentral Diabetes Insipidus Management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVasopressin/Desmopressin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(75.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFree water replacement only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown (no experience)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(15.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCorticosteroid Administration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRoutinely administered in all potential donors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdministered when adrenal insufficiency suspected\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(69.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown (no experience)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(15.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThyroid Hormone Administration*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRoutinely administered in all potential donors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdministered for documented hypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(39.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdministered for cardiac dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot used\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(27.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown (no experience)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(21.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily Communication\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMultidisciplinary Team Members Involved*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePalliative care physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(12.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePsychiatry/psychology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(60.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical/occupational therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(42.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLaboratory technologists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrgan donor coordinator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(90.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSocial worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(72.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChild life specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(36.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown (no experience)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePersonnel Who Present Donation Options*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary ICU team physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(87.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysicians from other departments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(27.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrgan donor coordinator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(21.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCritical-care mediator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown (no experience)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e* Multiple answers allowed.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Usual Sequence of Presenting End-of-Life Options and Donation Rates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFacilities, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eDonation/ICU deaths, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eDonation/PBD, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e①+②+③\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(60.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5/150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5/48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(10.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e①+②\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(24.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3/108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3/19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e①+③\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(12.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e②+③\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0/10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e① End-of-life care (withdrawal/limitation of life support)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e② Organ donation\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e③ Long-term management (continued aggressive treatment including tracheostomy)\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eICU; Intensive Care Unit\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003ePBD; Potential Brain Death\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis multicenter questionnaire survey provides the first comprehensive epidemiological data on pediatric organ donation practices in Japan. Two key findings emerged that characterize the current state of pediatric organ donation and identify the primary barrier to its expansion. First, JAPIC-affiliated institutions effectively identified potential organ donors, indicating that critically ill pediatric patients at risk for brain death are appropriately centralized to specialized pediatric intensive care centers with established donation systems. Second, despite this high identification rate, the proportion of families consenting to proceed to legal brain-death determination was low, with family decline being the most common reason for discontinuation. These findings strongly suggest that the principal barrier to pediatric organ donation in Japan lies not in clinical identification systems or donor management capabilities, but rather in the family consent process itself.\u003c/p\u003e \u003cp\u003eThe JAPIC-affiliated institutions that participated in this survey were predominantly medium-sized, closed or semi-closed units operated by pediatricians or intensivists, all of which had established organ donation systems. Eight pediatric organ transplants from these ICUs accounted for 40.0% of all pediatric transplants in Japan in 2024 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Given that a total of 306 institutions nationwide are eligible to perform pediatric transplantation (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), JAPIC-affiliated centers appear to make a substantial contribution to pediatric organ transplantation in Japan.\u003c/p\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, 25.5% (68/276) of ICU deaths met criteria for suspected brain death and subsequent evaluation. However, only 16% (8/50) of families who were approached consented to proceed to legal brain-death determination. This pattern contrasts sharply with reports from other countries with opt-in consent systems, where approximately 10% or fewer of ICU deaths are identified as potential organ donors, yet 50\u0026ndash;70% of approached families consent to organ donation (\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In the present study, the most common reason for not proceeding to legal brain-death determination was family decline of the donation process. Although religious or cultural factors have been suggested to influence organ donation decisions in Japan (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), earlier surveys indicate that more than 60% of parents would be willing to consider organ donation for their children after receiving appropriate explanations from healthcare professionals (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In contrast, previous studies have shown that physicians may provide insufficient explanations about brain death, partly due to limited educational opportunities in end-of-life care (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In this context, a substantial clinical burden is placed on primary physicians, who must manage severely ill patients while simultaneously assuming responsibility for both organ procurement and presenting donation options, despite the presence of multidisciplinary healthcare teams, as demonstrated in this survey. Furthermore, from a regulatory perspective, the absence of legislation mandating referral or the routine presentation of donation options when potential donors are admitted to the ICU may result in fewer donation requests (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In this study, no organs were donated from the facilities where donation options were not routinely presented, which support this hypothesis.\u003c/p\u003e \u003cp\u003eOf note, long-term management strategies, including tracheostomy, were proposed in approximately three-quarters of these patients. This situation arises from provisions in Japanese law whereby brain death is not uniformly regarded as legal brain death unless organ donation is pursued (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Indeed, five of nine potential donors in this study were discharged alive from the ICU.\u003c/p\u003e \u003cp\u003eHormonal replacement therapy practices were largely consistent with the Japanese guidelines and international standards for managing potential organ donors (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Vasopressin was administered for both maintaining circulation and central diabetes insipidus, while free water replacement alone was applied for central diabetes insipidus cases in three facilities. Corticosteroid and thyroid hormone were administered when necessary.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, the participants who responded to the questionnaire represented only a subset of facilities where pediatric organ donation is permitted. Therefore, caution is required when interpreting the results of this study. However, because JAPIC specializes in pediatric intensive care and its member institutions accounted for a sufficient proportion of pediatric transplants in 2024, the findings may still reflect current practices. Second, sampling bias can have occurred, as facilities that are more proactive in organ procurement and donation requests were more likely to participate. Consequently, practices favoring organ donation may be overrepresented, while negative or cautious attitudes may be underrepresented. Third, questionnaire surveys are inherently subject to response bias, including social desirability, recall, and acquiescence biases, as well as misinterpretation of questions and limited depth of responses, all of which can influence the results. Finally, since end-of-life care is not standardized and requires case-by-case decision-making, its complexity may not have been fully captured through fixed-response questionnaire items.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis questionnaire survey conducted among JAPIC-affiliated institutions has shown the epidemiological characteristics and management trends of pediatric organ donation in Japan. Although patients requiring terminal care were effectively centralized to pediatric ICUs, a substantial family decline in organ donation consent was observed. To achieve a more comprehensive and reliable understanding of pediatric organ donation practices in Japan, larger-scale studies covering all pediatric organ procurement institutions are warranted.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintensive care units\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJAPIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethe Japanese Association of Pediatric Intensive Care\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eJACHRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethe Japanese Association of Children's Hospitals and Related Institutions\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e This study was approved by the Institutional Review Board of the National Center for Child Health and Development (approval number: 2025-062). Study information and an electronic consent form were presented at the survey's outset.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003e \u003cb\u003eCompeting interests\u003c/b\u003e:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis survey was supported by the Grant of National Center for Child Health and Development (2024 B-2)\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors conceptualized and designed the study, carried out the initial analyses, drafted the initial manuscript, and critically reviewed and revised the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003edatabase I. WORLDWIDE ACTUAL DECEASED ORGAN DONORS 2024 (pmp) 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.irodat.org/?p=database\u003c/span\u003e\u003cspan address=\"https://www.irodat.org/?p=database\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishimura N, Kasahara M, Ishikura K, Nakagawa S. Current status of pediatric transplantation in Japan. Journal of Intensive Care. 2017;5(1):48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurrent status of organ donation and transplantation [Internet]. 2025 [cited 2025-12-20].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurrent status of organ donation and transplantation [Internet]. 2024 [cited 2025-11-27]. 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Quantitative Survey of Laypersons' Attitudes Toward Organ Transplantation in Japan. Transplant Proc. 2018;50(1):3\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIchikawa K. Attitude of Japanese Parents towards Pediatric Brain Death and Organ Transplantation. Journal of Japanese Society of Emergency Pediatrics. 2018;17(1):41\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChisato Akita MS, Ken Yakame, Yosuke Nakano, Saori Aiga, Tadashi Oi, Sanae Sato, Tatsuya Kawasaki. The Prevalence of Pediatric Brain-death Patients and the Factors That Prevent Organ Donation in a Children's Hospital: A Descriptive Study. The journal of the Japan Pediatric Society. 2025;129(4):561\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health L, Welfare. The 67th Health Science Council Disease Control Subcommittee Organ Transplantation Committee: Meeting Materials. Tokyo, Japan: Ministry of Health, Labour and Welfare; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirschen MP, Francoeur C, Murphy M, Traynor D, Zhang B, Mensinger JL, et al. Epidemiology of Brain Death in Pediatric Intensive Care Units in the United States. JAMA Pediatrics. 2019;173(5):469\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlood NHS, Transplant. Transplant Activity Report 2024/25. London, United Kingdom: NHS Blood and Transplant; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonateLife. Statistics in Australia 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.donatelife.gov.au/all-about-donation/statistics-in-australia#Latest-stats\u003c/span\u003e\u003cspan address=\"https://www.donatelife.gov.au/all-about-donation/statistics-in-australia#Latest-stats\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalsson TP, Sigvaldason K, Kristjansdottir TE, Thorkelsson T, Blondal AT, Karason S, et al. The potential for organ donation in Iceland: A nationwide study of deaths in intensive care units. Acta Anaesthesiol Scand. 2020;64(5):663\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOliver M, Woywodt A, Ahmed A, Saif I. Organ donation, transplantation and religion. Nephrol Dial Transplant. 2011;26(2):437\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDa Silva IR, Frontera JA. Worldwide barriers to organ donation. JAMA Neurol. 2015;72(1):112\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeino Y, Kurosawa H, Shiima Y, Niitsu T. End-of-life care in the pediatric intensive care unit: Survey in Japan. Pediatr Int. 2019;61(9):859\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAraki T, Ichikawa K, Nishiyama K, Niitsu T, Yamamoto T, Taneichi H, et al. Survey of Attitudes Toward Brain Death and Organ Transplantation Among Pediatric Healthcare Professionals (Second Report). Journal of Japanese Society of Emergency Pediatrics. 2017;16(1):111\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoyama A, Eguchi S. The current status and future perspectives of organ donation in Japan: learning from the systems in other countries. Surg Today. 2016;46(4):387\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakenori Suga KY, Tomoya Hanada, Shinpei Kawachi,, Yuji Yamagami TT. 4 pediatric cases of hypoxic\u0026ndash;ischemic encephalopathy who achieve long\u0026ndash;term survival after judgement of brain death. Nihon Kyukyu Igakukai Zasshi: Journal of Japanese Association for Acute Medicine. 2020;31(9):397\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKotloff RM, Blosser S, Fulda GJ, Malinoski D, Ahya VN, Angel L, et al. Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement. Crit Care Med. 2015;43(6):1291\u0026ndash;325.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNew England Donor S. Organ \u0026amp; Tissue Donation Reference Manual. Waltham, MA, USA: New England Donor Services; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKuroda Y, Doi K, Yokobori S, Atsumi T, Nakamura K, Naito H, et al. Intensive Care Manual 2025 Edition for Patients with Irreversible Total Cerebral Dysfunction. Journal of the Japanese Society of Intensive Care Medicine. 2026;33(Supplement1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":false,"email":"","identity":"journal-of-intensive-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Journal of Intensive Care","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"VoR Journals","inReviewEnabled":false,"inReviewRevisionsEnabled":false},"keywords":"Pediatric organ donation, intensive care unit, brain death, organ procurement, donor management, hormonal replacement therapy","lastPublishedDoi":"10.21203/rs.3.rs-9391690/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9391690/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePediatric organ shortage remains a critical issue in Japan. While previous literature described religious perspectives and family attitudes toward organ transplantation, institutional practices and epidemiologic data were limited.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e Between October 1 and November 30, 2025, we conducted a web-based questionnaire survey of intensive care units (ICUs) at 47 facilities affiliated with the Japanese Association of Pediatric Intensive Care (JAPIC), the pediatric division of the Japanese Society of Intensive Care Medicine. The survey included three domains: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) ICU characteristics, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) patient populations at each step of the organ donation pathway in 2024, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) medical and social protocols related to donor management. Descriptive statistics were used to summarize responses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe response rate was 70.2% (33/47). Organ donation protocols were established in all participating facilities, although only 51.5% had prior experience with pediatric organ donation. Among 276 ICU deaths reported in 2024, 68 (24.6%) were identified as potential organ donors. Legal brain-death determination was performed in 16% (8/50) of patients to whom the donation option was presented. The most common reason for not proceeding was family decline (37/50, 74.0%). Nine patients with suspected brain death were discharged alive from the ICU after refusal to proceed with legal brain-death determination while receiving mechanical respiratory support. Arginine vasopressin was commonly used for hemodynamic support and central diabetes insipidus, while corticosteroids and thyroid hormones were selectively administered. Although multidisciplinary teams were involved, primary ICU physicians were responsible for presenting donation options. End-of-life care and organ donation were presented concurrently in most facilities.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis survey provides the first nationwide epidemiologic description of pediatric organ donation practices in Japan. While potential donors are effectively identified and centralized, low family consent rates represent the principal barrier to increasing pediatric organ donation.\u003c/p\u003e","manuscriptTitle":"Low Consent Rates Despite High Donor Identification in Pediatric Intensive Care Units: A Multicenter Questionnaire Survey in Japan","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-26 15:45:38","doi":"10.21203/rs.3.rs-9391690/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"67379012428883350454037692674356055815","date":"2026-05-04T12:07:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T20:12:42+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T16:28:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282350445762158482019427087390472104454","date":"2026-04-23T21:53:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"243991082747879208725028945501619241086","date":"2026-04-17T03:44:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-16T22:39:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T22:40:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-13T22:40:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Intensive Care","date":"2026-04-12T04:55:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":false,"email":"","identity":"journal-of-intensive-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Journal of Intensive Care","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"VoR Journals","inReviewEnabled":false,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8332dee8-ebd6-4f56-bcdf-ca59bbf245de","owner":[],"postedDate":"April 26th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"67379012428883350454037692674356055815","date":"2026-05-04T12:07:05+00:00","index":16,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-26T15:45:38+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-26 15:45:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9391690","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9391690","identity":"rs-9391690","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}