the rate of end - stage failure of several vital organs ( e.g. , kidneys , liver , heart , and lungs ) is increasing expeditiously due to scientific advancements and the ability to sustain brain dead patients over a long period of time ( 1 ) .
organ transplantation is known as the treatment of choice for patients with advanced organ failure ( 2 ) .
annually , more than 100,000 solid organ transplantations are performed worldwide , more than 50% of which are renal transplantation ( 3 ) .
statistical analyses showed that the rate of organ failure is increasing faster than the sources for organ donation , and the imbalance between supply and demand has resulted in long transplant waiting lists ( 1 ) . depending on the types of required organ ,
given the medical and legal barriers to living donors , the use of cadaveric organ donation ( brain dead patients ) as a treatment method is on the rise across the world ; however , this growing trend is not in proportion with organ demand ( 5 , 6 ) .
nowadays , the rate of cadaveric organ donation is 19.4% , 69.5% , 63.1% , 16.6% , and 60.9% in the middle east , europe , america , east asia , and australia , respectively ( 7 ) .
as previously mentioned , the highest rate of cadaveric organ donation belongs to european countries , among which croatia , with over 53.8 per million populations ( pmp ) , spain ( 47.5 pmp ) , and estonia ( 43.9 pmp ) are ranked first to third regarding the use of cadaveric organ donation ( 8) .
iran is one of the industrious countries regarding organ transplantation ; in addition , it is one of the 30 high - demand countries with high rates of renal transplantation ( 9 ) .
currently , the rate of renal transplantation is 12 pmp in iran , and it is ranked 36 in the world , after turkey , saudi arabia , bahrain , and qatar ( 8) . in iran , due to the high rate of organ transplantation and ranking first in the region regarding cadaveric organ donation , living donor transplantation is tried to be replaced with cadaveric organ donation . for this purpose ,
this study aimed to identify the barriers to organ donation in brain dead patients , referred to organ procurement organizations ( opo ) of mashhad university of medical sciences , mashhad , iran .
in this cross - sectional study , data were gathered from medical records of patients who were referred to opos of five hospitals affiliated with the mashhad university of medical sciences , mashhad , iran , during 20062013 .
approximately , 8.6% of the brain dead patients were referred to private hospitals , and the rest were referred to governmental hospitals .
demographic information such as name , age , gender , time interval between admission and brain death , place of residence , religion , admission date , reason for family s refusal to organ donation , and cause of brain death were recorded .
the causes of brain death were categorized as follows : motor vehicle traumas , cerebral hemorrhages ( nontraumatic cases ) , brain tumors , and others ( including drug poisoning , except for drugs affecting the central nervous system , convulsion , and anoxia ) .
the patients were divided into three groups as follows : 1 ) brain dead patients not eligible for organ donation due to medical reasons such as age above 65 years , sepsis , and chronic infectious diseases ( e.g. , hepatitis b or c , and human immunodeficiency virus ) ; 2 ) brain dead patients who were medically eligible for donation , but organ donation was prohibited due to legal reasons such as medical malpractice , lack of access to legal heirs , or private prosecution ; 3 ) potential donors without legal prohibition and with at least one organ appropriate for transplantation .
if they consented to organ donation , the brain dead patient was placed under conservative treatment .
if the patient survived until completing consultation with patient s family and obtaining consent to organ donation , organs were harvested .
based on interviews with experts , reasons for declining organ donation were identified and evaluated separately , and the data were analyzed using chi - square test by spss version 13 ( spss inc .
in this cross - sectional study , data were gathered from medical records of patients who were referred to opos of five hospitals affiliated with the mashhad university of medical sciences , mashhad , iran , during 20062013 .
approximately , 8.6% of the brain dead patients were referred to private hospitals , and the rest were referred to governmental hospitals .
demographic information such as name , age , gender , time interval between admission and brain death , place of residence , religion , admission date , reason for family s refusal to organ donation , and cause of brain death were recorded .
the causes of brain death were categorized as follows : motor vehicle traumas , cerebral hemorrhages ( nontraumatic cases ) , brain tumors , and others ( including drug poisoning , except for drugs affecting the central nervous system , convulsion , and anoxia ) .
the patients were divided into three groups as follows : 1 ) brain dead patients not eligible for organ donation due to medical reasons such as age above 65 years , sepsis , and chronic infectious diseases ( e.g. , hepatitis b or c , and human immunodeficiency virus ) ; 2 ) brain dead patients who were medically eligible for donation , but organ donation was prohibited due to legal reasons such as medical malpractice , lack of access to legal heirs , or private prosecution ; 3 ) potential donors without legal prohibition and with at least one organ appropriate for transplantation .
if they consented to organ donation , the brain dead patient was placed under conservative treatment .
if the patient survived until completing consultation with patient s family and obtaining consent to organ donation , organs were harvested .
based on interviews with experts , reasons for declining organ donation were identified and evaluated separately , and the data were analyzed using chi - square test by spss version 13 ( spss inc .
all the studied patients were muslims ; the mean age of the patients was 30.2516.52 years .
the occurrence of brain death in the age group of  18 years decreased from 14% ( 39 people ) in 2006 to 11.2% ( 30 people ) in 2013 .
the cardinal causes of brain death were head trauma ( 667 patients [ 65.2% ] ) , ischemic cerebrovascular accident ( cva ) ( 174 patients [ 17% ] ) , anoxia ( 91 patients [ 8.8% ] ) , brain tumor ( 67 patients [ 6.6% ] ) and other cause ( 25 patients [ 2.4% ] ) . the majority ( 69.8% ) of the brain
dead patients was male , and sex ratio did not change significantly during the study . during 20062013
, brain death was not confirmed in eight patients among 1042 declared cases of brain death , who were excluded from the study ; finally , in 1034 patients , brain death was confirmed .
the number of brain dead patients , referred to opos , increased from 129 patients in 2006 to 135 in 2013 . in 2009 , only 104 brain dead patients were referred to opos , which was the lowest number of annual brain death during the study .
the mean interval between admission and brain death was 4.25.06 days during the current study . the majority ( 69.8% ) of the brain
dead patients was male , and sex ratio did not change significantly during the study . in total , the rate of brain death due to trauma decreased from 62% in 2006 to 57% in 2013 ( table 1 ) .
of the confirmed cases of brain death , 212 ( 20.5% ) were medically ineligible for donation , and 86 ( 40.6% ) and 28 ( 13.2% ) of whom had uncorrectable hypotension and infection , respectively .
the other medical reason for declining organ donation was multi - organ failure , which was observed in 59 ( 29.8% ) patients . during the study , the number of patients who were not medically approved for donation diminished from 43 in 2006 to 17 patients in 2013 .
organ donation was not performed in 89 ( 8.4% ) patients due to legal reasons .
more specifically , the organs of 38 ( 42.7% ) , 28 ( 32.2% ) , 19 ( 21.3% ) , and 4 ( 4.6% ) of the patients were not donated because of unavailability of legal heirs , having nationality of other countries , private prosecution , and medical malpractice , respectively . in these cases ,
the initial interview was performed with families of 733 patients with legal heirs in the third group . during the interview , 82 ( 11.2% )
organ donation was carried out in 344 ( 52.8% ) patients , while organ donation was not authorized for the rest of the cases .
the rate of organ donation increased during the study ; that is , the rate of organ donation was 119 and 225 cases before and after 2008 , respectively .
the most important reasons for families refusal were not accepting the brain death ( 20.1% ) , fear of organ donation to non - coreligionists ( 8.1% ) , fear of organ trafficking ( 5.5% ) , belief in miracles ( 12% ) , fear of corpse mutilation or deformation ( 4% ) , adverse reaction of others ( 2% ) , asking for money ( 3% ) , and view of clergies ( 3% ) ; no reason was spelt out by 42.2% of the families .
the cardinal reasons for declining organ donation in the studied cases were fear of organ donation to non - coreligionists and not accepting brain death , respectively . in case of declining organ donation ,
it was refused by all heirs in 81.3% ( 253 families ) of the cases . among the legal heirs , the strongest opposition to organ donation
was observed in the patients mothers ; mothers were the only persons who refused organ donation in 45 cases ( 14% ) , which reduced from 10% to 1% by the end of the study .
during the past half - century , organ transplantation has been considered as an effective treatment for end - organ damage .
such procedures have resulted in higher quality of life and longevity of tens of thousands of patients with end - organ damage , and demand for organ transplantation has been on the rise ever since . however , the number of available transplanted organs does not correspond with the demand , and an organ shortage crisis has been a major concern worldwide . this problem is more prevalent in developing countries where patients with end - organ damage are in more critical condition ( 11 , 12 ) .
cadaveric organ donation in the eastern mediterranean region is less common compared with european countries , the united states , and the western pacific ( 13 ) .
factors such as unbalanced distribution of healthcare facilities , lack of priority of prevention over treatment , poor governmental support of organ transplantation , inadequate knowledge of the medical community and public awareness regarding organ donation , and lack of medical team cooperation are among the shared features of the countries located in the eastern mediterranean ( 14 , 15 ) .
countries such as iran , turkey , saudi arabia , kuwait , tunisia , jordan , and lebanon have consistent , active medical programs in the field of cadaveric donation of different organs , including the liver , heart , pancreas , and lungs .
higher per capita income in these developing countries is the main reason for the rising trend of organ donation and transplantation .
however , most of these countries are faced with the disproportionate rate of available donor organs to the current demand ( 10 , 15 , 16 ) . according to our findings , the number of cases referred to organ transplant centers ( i.e. , patients with brain death per year ) was not significantly different during the course of the study . due to the lack of reliable statistics regarding the total number of diagnosed brain deaths during our research , the percentage of referred cases to organ procurement units could not be determined .
similar studies performed in iran , philippines , germany , and singapore have reported no significant changes in the number of referrals to organ procurement units with diagnosed brain death ( 1721 ) . in this regard , the rate of referred cases with brain death to organ procurement units has been reported to range between 63.8%93.6% in european countries .
for instance , this rate has been reported to be 90% in belgium and 63.8% in sweden . in belgium ,
the total number of potential organ donors increased from 289 cases in 1990 to 640 cases in 2013 ( 22 ) .
considering the development of organ procurement and transplant networks in the region , the number of brain death diagnoses was expected to increase during the course of the current study .
lack of development in this regard could be attributed to the inadequate knowledge of nurses , physicians , and healthcare personnel about brain death and organ donation ( 2224 ) . during the course of the present study ,
the number of suitable organ donors was observed to increase due to the older age and use of  marginal  donors .
use of marginal donors for organ transplantation in our study was similar to that of other countries in the world . according to our findings ,
although the number of cases against organ donation was relatively unchanged , rate of consent to organ donation increased from 34.8% in 2006 to 69.2% in 2013 . according to similar studies in iran , rate of organ donation
furthermore , higher satisfaction with organ donation in iran could be attributed to the rising number of organ procurement units and enhanced public knowledge about this medical procedure ( 8) . in the current research , mean age of the patients with brain death was 30.1516.504 years , which increased from 17.3529.42 years in 2006 to 17.1432.30 years in 2013 .
this is consistent with the findings of similar studies in the world , which have highlighted the increasing mean age of organ donors ( 20 , 25 , 27 , 3033 )
. increased age of patients with brain death could be attributed to the variable causes of this condition ( 8 , 28 , 29 ) , the most important of which are severe head trauma ( 65.5% ) , cerebrovascular accident , brain tumors , and anoxia .
this is in line with the results of similar studies in this regard ( 19 , 25 , 33 ) .
according to statistics , rate of brain deaths due to head trauma has declined from 70% in 2006 to 57% in 2013 .
this could be due to several factors , such as the reduced rate of road traffic accidents , enhancement of immediate medical care , and higher awareness of drivers , which have resulted in the lower rate of traumatic brain injury leading to brain death ( 34 ) .
this finding has been confirmed in previous studies ( 25 , 27 , 33 ) . in the present study ,
56.1% of the patients with consent to organ donation were shia ( official state religion in iran ) , while 10.6% were non - shia .
on the other hand , the main reason for refusal of organ donation in non - shia individuals was disagreement for donating organs to individuals of other religious backgrounds .
this finding could be explained through considering the effect of ethnicity on the intention for organ donation ( 35 ) . in the current study
, we also investigated the causes of disagreement with organ donation in the families of patients with brain death .
in most of the cases , families were reluctant to mention their reasons for disagreement ( 42.2% ) , which could be due to the inadequate knowledge or unsettling mental state of the family at the time of the survey .
the most common reason for the refusal of organ donation was the denial of brain damage as the actual death of the patient .
moreover , believing in miracles was reported as another cause of disagreement with harvesting the organs of brain dead patients .
in general , the families of patients with brain death believed that the condition could be reversed either through medical interventions or by a miracle .
previous studies have investigated the causes of agreement or refusal of organ donation reporting similar results ( denial of the death of patient and believing in miracles in families ) ( 19 ) . in the present study
, we evaluated the reasons for the disagreement of the relatives of brain dead patients with organ donation . according to our findings
, most of the disagreements came from the mother of the patient ( 15% of all the cases ) , which denotes the significance of emotional factors in the process of organ donation .
analysis of the collected data indicated that rate of maternal opposition decreased during the course of our study ( from 15.6% in 2006 to 3.1% in 2013 ) .
this finding is indicative of the improved performance of coordinating teams in dealing with the families of patients with brain death in healthcare facilities .
according to the results of the current research , denial of brain death was the most important cause of disagreement with organ donation , the rate of which had no significant difference during the course of the study .
uniformity of the attitudes of society members toward organ donation could be a sign of the inefficacy of the mass media , as the most essential sources of information , in raising social awareness about organ donation .
it is recommended that diagnosis rate of brain death and medical criteria for organ donation had no significant difference during the course of the present study .
however , compared with the first year of the research , the number of donor organs increased more than twofold at the end of the experiment . considering the mortality patterns in developing countries , such as iran and other mediterranean regions , enhancement of medical services and accurate identification of cases with brain death could eliminate the need for organ donation from living donors or after cardiac death .
 introductionorgan transplantation is the treatment of choice for some diseases . 
 however , the need for cadaveric organ donation has either plateaued or is on a decreasing trend in some countries , especially in developed ones . in this study 
 , we aimed to identify the barriers to organ donation in brain dead patients , who were referred to the organ procurement organizations ( opo ) in northeast iran.methodsin this cross - sectional study during 2006 to 2013 , data were collected from medical records of brain dead patients . 
 demographic information , cause of brain death , the process of obtaining informed consent , and the reasons for declining organ donation were obtained from the opo records . 
 the data were analyzed using chi - square test by spss 13 software.resultsof 1034 brain dead patients , 751 cases ( 72.6% ) were eligible for organ donation , and , ultimately , 344 cases underwent organ donation . 
 the rate of organ donation increased during the course of the study ; medical and legal reasons as well as family refusal to authorize donation were the main barriers to the process.conclusionbased on the pattern of mortality , the need for living donors in developing countries , such as iran and other countries in the mediterranean region , can be reduced by improving the quality of healthcare , efficient identification of brain death , and obtaining consent with appropriate strategies . 
1. Introduction
2. Material and Methods
2.1. Research design and setting
2.2. Data collection and analysis
3. Results
4. Discussion
5. Conclusions