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Following hematopoietic cell transplantation (HCT), recipients are subjected to extensive genetic testing to monitor the efficacy of the transplantation and identify relapsing malignant disease. This testing is increasingly including the use of large gene panels, which may lead to incidental identification of genetic and molecular information of potential donor origin. Deciphering whether variants are of donor origin, and if so, whether there are clinical implications for the donor can prove challenging. In response to queries from donor registries and transplant centers regarding best practices in managing donors when genetic mutations of potential donor origin are identified, the Medical Working Group of the World Marrow Donor Association established an expert group to review available evidence and develop a framework to aid decision making. These guidelines aim to provide recommendations on predonation consenting, postdonation testing of recipients, and informing and managing donors when findings of potential donor origin are identified in recipients post-transplantation. It is recognized that registries will have different access to resources and financing structures, and thus whenever possible, we have made suggestions on how recommendations can be adapted.

Aims: To explore prospective donors’ attitudes and perceptions towards donating hematopoietic stem cells (HSCs) for novel treatments research and development (R&D). Methods: A survey was launched by Anthony Nolan (AN) to assess prospective donors’ willingness to donate HSCs for novel therapies R&D, and their degree of comfort with the AN collaborating with and receiving payment from external organizations. Results: Most participants (87%) were willing to donate for novel treatment R&D and were comfortable with AN collaborating with external organizations and receiving payment (91% and 80%, respectively). Conclusion: Results reveal an overall positive response towards donating HSCs for R&D. These findings can support stakeholders and policymakers in outlining donation practices that uphold donors’ safety and welfare.

Over the past three decades, the field of stem cell research and development (R&D) has witnessed extraordinary progress, allowing us to envisage a future where cell therapies can be used for the treatment of diseases currently considered incurable. Contemplating such a future also requires reflecting on donors and exploring their readiness to donate hematopoietic stem cells (HSCs) for these purposes. In 2019, seven focus groups took place with members of the public, prospective donors, and donors as part of a project launched by Anthony Nolan (AN), a UK not-for-profit organization and stem cell donor registry. The aim of the project was to assess prospective donors’ and donors’ attitudes towards donating cells for novel treatments R&D. Participants were asked about their donation being used for the treatment of multiple recipients and quality-of-life (QoL) conditions. Some participants viewed donating for multiple recipients as beneficial and could act as a “pull factor” to encourage more donors. Others were keen to position the idea of helping multiple recipients as an “added bonus”. Some expressed worry that such donations might diminish the connection between donors and recipients and drew upon the influential power of “success stories” to encourage and motivate future donors. Most participants considered it acceptable to donate HSCs for QoL conditions. A hierarchy of illnesses formed during the focus groups, as some donors were concerned they might be asked to donate stem cells to enhance and improve the lives of ‘healthy’ people. Responses suggest that the donor-recipient relationship plays a significant role in influencing donation decisions, and that underlying the portrayal of this relationship is a power dynamic. Donors’ agreeableness to donate for QoL conditions is crucial to expand our understanding of stem cell-based therapies. Nevertheless, we must also consider how such donations might impact donor recruitment for transplant patients.

Background: Concerns have been raised surrounding the training of Foundation Doctors on the ethical, legal and professional aspects (ELP) of clinical practice, leading to some to claim a degree of educational neglect. Foundation Doctors are junior doctors in the UK within the first two years of their medical career since graduating from medical school. Approach: Lancaster University and Health Education England North West (HEE NW) introduced a series of training materials specially created to meet the ELP training needs of Foundation Doctors, which were piloted by Foundation Schools. Evaluation: The training was delivered to Foundation Doctors in first and second year of their training either online or in person. The facilitators were clinical senior doctors, and did not have an academic qualification in ELP. Some large Foundation Schools used two training packs to provide an optional ELP day for their Foundation Doctors, whilst individual hospitals within a Foundation School used the training packs to provide training as part of their mandatory weekly training for Foundation Doctors. Feedback was gathered from Foundation Doctors and training facilitators when a training pack was piloted. Implications: Foundation Doctors were able to make links between the messages delivered in the training to their own clinical practice. Foundation Schools have incorporated the training packs into the two-year Foundation Programme, which creates the possibility for ELP training to become standardised across Foundation Schools.

Following hematopoietic cell transplantation, recipients are subjected to extensive genetic testing to monitor the efficacy of the transplant and identify relapsing malignant disease. This testing increasingly includes the use of large gene panels which may lead to incidental identification of genetic and molecular information of potential donor origin. Deciphering whether variants are of donor origin, and if so, whether there are clinical implications for the donor, can prove challenging. In response to queries from donor registries and transplant centers regarding best practice in managing donors when genetic mutations of potential donor origin are identified, the Medical Working Group of the World Marrow Donor Association established an expert group to review available evidence and to develop a framework to aid decision-making. These guidelines aim to provide recommendations on pre-donation consenting, post-donation testing of recipients and informing and managing donors when findings of potential donor origin are identified in recipients post-transplantation. It is recognised that registries will have different access to resources and financing structures. Therefore, where possible, we have made suggestions on how recommendations can be adapted.

Purpose: Finding a balance between the provision of quality individualized care and the ongoing education of junior doctors had been flagged as a concern at a large NHS teaching hospital in the north of England. In response to this, the organization introduced an intervention designed to improve educational culture by providing support to educators, leaders and clinical staff. Method: This article features themed results from eight in-depth interviews with educators, consultants and junior doctors to describe and evaluate the process and impact. Findings: Factors that contributed to a positive educational environment included: trainees and educators feeling valued, the presence of supportive leaders, and the provision of a safe space for learning. Perceived barriers included time constraints, differing motivation, and the generic format of formal education. Participants reflected on how the Wrap Around project helped improve the workplace educational culture and offered suggestions for further improvement including the provision of ongoing feedback to learners about their performance. Originality: Research aimed at recognising and resolving the perceived tensions between the priorities of education and healthcare delivery has been flagged as a gap in the literature. We argue that developing and enhancing collaborative leadership and educational culture within an organization can reduce these tensions for those working on the front line. Future work should focus on addressing the perceived distinction between the two within services.

Umbilical cord blood unit (CBU) “quantity” continues to grow internationally, while cord blood transplantation (CBT) “quality” remains poorly defined and subject to uncertainty. CBT “quality” is affected by both the product (i.e. CBUs) and CBT processes, with “best practice” varying across countries. To improve overall CBT “quality”, we need to better understand the uncertainty associated with CBUs and CBT processes and how staff manage it. In this qualitative study, we conducted in-depth semi-structured interviews with individuals working in CBT in UK and Japan. We found that understanding of CBT quality by the cord blood community is underpinned by the quality of the CBU, the expertise and collaboration of scientific and clinical stakeholders, trust in collection and testing processes and international accreditation. Importantly, we found that local and individual experience is used to manage uncertainty within CBT, and we propose that selection guidelines should acknowledge the extent of uncertainty in decision-making.

Purpose: Finding a balance between the provision of quality individualized care and the ongoing education of junior doctors had been flagged as a concern at a large NHS teaching hospital in the north of England. In response to this, the organization introduced an intervention designed to improve educational culture by providing support to educators, leaders and clinical staff. Method: This article features themed results from eight in-depth interviews with educators, consultants and junior doctors to describe and evaluate the process and impact. Findings: Factors that contributed to a positive educational environment included: trainees and educators feeling valued, the presence of supportive leaders, and the provision of a safe space for learning. Perceived barriers included time constraints, differing motivation, and the generic format of formal education. Participants reflected on how the Wrap Around project helped improve the workplace educational culture and offered suggestions for further improvement including the provision of ongoing feedback to learners about their performance. Originality: Research aimed at recognising and resolving the perceived tensions between the priorities of education and healthcare delivery has been flagged as a gap in the literature. We argue that developing and enhancing collaborative leadership and educational culture within an organization can reduce these tensions for those working on the front line. Future work should focus on addressing the perceived distinction between the two within services.

The UK government and NHS Blood and Transplant have introduced a number of policies and organisational changes to the organ donation system following the 2008 recommendations of the Organ Donor Taskforce, which aim to increase the number of available donor organs and tackle transplant waiting lists. However, little is known about how these policy and organisational shifts influence how healthcare professionals experience delivering end of life care in the context of organ donation. In this paper, we examine ICU, Emergency Medicine, and Theatre staff’s experiences of organ donation in one NHS Trust following the 2008 changes. We focus upon their decision-making when caring for patients at the end of life to highlight the tensions between health professionals' beliefs-in-principle about organ donation and their everyday moral and commonsense practices when caring for patients at the end of life. We explore how we might understand and interpret this ‘troubling’ of organ donation through applying the concept of ‘conscience’, and consider whether a conscientious objection around organ donation could exist.

Umbilical cord blood unit (CBU) “quantity” continues to grow internationally, while cord blood transplantation (CBT) “quality” remains poorly defined and subject to uncertainty. CBT “quality” is affected by both the product (i.e. CBUs) and CBT processes, with “best practice” varying across countries. To improve overall CBT “quality”, we need to better understand the uncertainty associated with CBUs and CBT processes and how staff manage it. In this qualitative study, we conducted in-depth semi-structured interviews with individuals working in CBT in UK and Japan. We found that understanding of CBT quality by the cord blood community is underpinned by the quality of the CBU, the expertise and collaboration of scientific and clinical stakeholders, trust in collection and testing processes and international accreditation. Importantly, we found that local and individual experience is used to manage uncertainty within CBT, and we propose that selection guidelines should acknowledge the extent of uncertainty in decision-making.

Purpose: Finding a balance between the provision of quality individualized care and the ongoing education of junior doctors had been flagged as a concern at a large NHS teaching hospital in the north of England. In response to this, the organization introduced an intervention designed to improve educational culture by providing support to educators, leaders and clinical staff. Method: This article features themed results from eight in-depth interviews with educators, consultants and junior doctors to describe and evaluate the process and impact. Findings: Factors that contributed to a positive educational environment included: trainees and educators feeling valued, the presence of supportive leaders, and the provision of a safe space for learning. Perceived barriers included time constraints, differing motivation, and the generic format of formal education. Participants reflected on how the Wrap Around project helped improve the workplace educational culture and offered suggestions for further improvement including the provision of ongoing feedback to learners about their performance. Originality: Research aimed at recognising and resolving the perceived tensions between the priorities of education and healthcare delivery has been flagged as a gap in the literature. We argue that developing and enhancing collaborative leadership and educational culture within an organization can reduce these tensions for those working on the front line. Future work should focus on addressing the perceived distinction between the two within services.

The UK government and NHS Blood and Transplant have introduced a number of policies and organisational changes to the organ donation system following the 2008 recommendations of the Organ Donor Taskforce, which aim to increase the number of available donor organs and tackle transplant waiting lists. However, little is known about how these policy and organisational shifts influence how healthcare professionals experience delivering end of life care in the context of organ donation. In this paper, we examine ICU, Emergency Medicine, and Theatre staff’s experiences of organ donation in one NHS Trust following the 2008 changes. We focus upon their decision-making when caring for patients at the end of life to highlight the tensions between health professionals' beliefs-in-principle about organ donation and their everyday moral and commonsense practices when caring for patients at the end of life. We explore how we might understand and interpret this ‘troubling’ of organ donation through applying the concept of ‘conscience’, and consider whether a conscientious objection around organ donation could exist.

This study aims to explore the perceptions of foundation doctors (FDs) in the United Kingdom (UK) surrounding raising concerns in the workplace. An online survey was sent to all FDs in the UK between February and March 2018. Respondents were asked what they had observed or experienced that had been ethically challenging during their foundation training. The qualitative responses were coded into themes. Reasons why FDs wished to raise concerns in the workplace included disagreements about clinical decisions within the team, insufficient availability of resources, lack of senior colleague support and having to work beyond their competencies. Challenges faced by FDs when raising concerns included organisational resistance to change, difficulties in communicating ideas to those higher up in the hierarchy and the emotional stress of whistleblowing regarding senior colleagues. Perceived consequences of raising concerns included negative impact on FDs’ reputation and career, and fear of bullying. To overcome these barriers, changes within organisations at all levels must take place in order to provide an environment where FDs are encouraged to raise concerns and thus make positive changes to their work environments for themselves, their colleagues and patients.

This paper investigates the medical law and ethics (MEL) learning needs of Foundation doctors (FYs) by means of a national survey developed in association with key stakeholders including the General Medical Council and Health Education England. Four hundred sevnty-nine doctors completed the survey. The average self-reported level of preparation in MEL was 63%. When asked to rate how confident they felt in approaching three cases of increasing ethical complexity, more FYs were fully confident in the more complex cases than in the more standard case. There was no apparent relationship with confidence and reported teaching at medical school. The less confident doctors were no more likely to ask for further teaching on the topic than the confident doctors. This suggests that FYs can be vulnerable when facing ethical decisions by being underprepared, not recognising their lack of ability to make a reasoned decision or by being overconfident. Educators need to be aware of this and provide practical MEL training based on trainee experiences and real-world ethics and challenge learners’ views. Given the complexities of many ethical decisions, preparedness should not be seen as the ability to make a difficult decision but rather a recognition that such cases are difficult, that doubt is permissible and the solution may well be beyond the relatively inexperienced doctor. Educators and supervisors should therefore be ensuring that this is clear to their trainees. This necessitates an environment in which questions can be asked and uncertainty raised with the expectation of a supportive response.

This paper investigates the medical law and ethics (MEL) learning needs of Foundation doctors (FYs) by means of a national survey developed in association with key stakeholders including the General Medical Council and Health Education England. Four hundred sevnty-nine doctors completed the survey. The average self-reported level of preparation in MEL was 63%. When asked to rate how confident they felt in approaching three cases of increasing ethical complexity, more FYs were fully confident in the more complex cases than in the more standard case. There was no apparent relationship with confidence and reported teaching at medical school. The less confident doctors were no more likely to ask for further teaching on the topic than the confident doctors. This suggests that FYs can be vulnerable when facing ethical decisions by being underprepared, not recognising their lack of ability to make a reasoned decision or by being overconfident. Educators need to be aware of this and provide practical MEL training based on trainee experiences and real-world ethics and challenge learners’ views. Given the complexities of many ethical decisions, preparedness should not be seen as the ability to make a difficult decision but rather a recognition that such cases are difficult, that doubt is permissible and the solution may well be beyond the relatively inexperienced doctor. Educators and supervisors should therefore be ensuring that this is clear to their trainees. This necessitates an environment in which questions can be asked and uncertainty raised with the expectation of a supportive response.

Clinical ethics can be viewed as a practical discipline that provides a structured approach to assist healthcare practitioners in identifying, analysing and resolving ethical issues that arise in practice. Clinical ethics can therefore promote ethically sound clinical and organisational practices and decision-making, thereby contributing to health organisation and system quality improvement. In order to develop students’ decision-making skills, as well as prepare them for practice, we decided to introduce a clinical ethics strand within an undergraduate medical curriculum. We designed a programme of clinical ethics activities for teaching and assessment purposes that involved using ethical frameworks to analyse hypothetical and real-life cases in uni- and inter- professional groups. In this paper, we draw on medical student feedback collected over 6 years to illustrate the appeal to students of learning clinical ethics. We also outline the range of benefits for students, healthcare organisations, and the field of clinical ethics arising from tomorrow’s doctors experiencing clinical ethics early in their training. We conclude by briefly reflecting on how including clinical ethics within tomorrow’s doctors curricular can secure and continue future engagement in clinical ethics support services in the UK, alongside the dangers of preparing students for organisational cultures that might not (yet) exist. We anticipate the findings presented in the paper will contribute to wider debates examining the impact of ethics teaching, and its ability to inform future doctors’ practice.

This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a (business) case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence-base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospital.

This study aims to explore the perceptions of foundation doctors (FDs) in the United Kingdom (UK) surrounding raising concerns in the workplace. An online survey was sent to all FDs in the UK between February and March 2018. Respondents were asked what they had observed or experienced that had been ethically challenging during their foundation training. The qualitative responses were coded into themes. Reasons why FDs wished to raise concerns in the workplace included disagreements about clinical decisions within the team, insufficient availability of resources, lack of senior colleague support and having to work beyond their competencies. Challenges faced by FDs when raising concerns included organisational resistance to change, difficulties in communicating ideas to those higher up in the hierarchy and the emotional stress of whistleblowing regarding senior colleagues. Perceived consequences of raising concerns included negative impact on FDs’ reputation and career, and fear of bullying. To overcome these barriers, changes within organisations at all levels must take place in order to provide an environment where FDs are encouraged to raise concerns and thus make positive changes to their work environments for themselves, their colleagues and patients.

This paper advances the case for a ‘sociology of donation’. We aim to establish that there is a need for such a sociology, to bring together the many, often disparate, elements that make up the theorizing, practice and experience of donation. We argue that bringing together different forms of donation illuminates the distinctive place both in social meaning and regulation that the body and its products hold. In developing this, we are primarily focusing on the donation of body parts and body products within high-income countries. We will first outline the standard western accounts of donation, and consider how relevant these are to donation practices and policies in the twenty first century. We will then critically discuss how a sociology of donation can be used to further current understandings of ‘donation’ and identify the challenges facing such a proposal, posing questions to encourage reflection on research practices in this area. Finally, we will explore what a sociology of donation might entail.

Background: Withholding and withdrawing treatment are deemed ethically equivalent by most Bioethicists, but intensivists often find withdrawing more difficult in practice. This can lead to futile treatment being prolonged. Time-limited trials have been proposed as a way of promoting timely treatment withdrawal whilst giving the patient the greatest chance of recovery. Despite being in UK guidelines, time-limited trials have been infrequently implemented on Intensive Care Units. We will explore the role of time in Intensive Care Unit decision-making and provide a UK perspective on debates surrounding time-limited trials. Methods: This qualitative study recruited 18 participants (nine doctors, nine nurses) from two Intensive Care Units in North West England for in-depth, one-to-one semi-structured interviews. A thematic analysis was performed of the data. Results: Our findings show time is utilised by Intensive Care Unit staff in a variety of ways including managing uncertainty when making decisions about a patient’s prognosis or the reversibility of a disease, constructing relationships with patients’ relatives, communicating difficult messages to patients’ relatives, justifying resource allocation decisions to colleagues, and demonstrating compassion towards patients and their families. Conclusions: Time shifts the balance towards greater certainty in Intensive Care Unit decision-making, by demonstrating futility, and can ease the difficult transition for staff and families from active treatment to palliation. However, this requires clear and open communication, both within the Intensive Care Unit team and with the family, being prioritised when time is used in decision-making.

Background: The delivery of patient care in the United Kingdom is under increasing financial pressure. The need to continuously improve service delivery while making financial savings is challenging. Alongside this, National Health Service (NHS) Trusts must provide a suitable educational environment that meets the needs of all learners while meeting performance standards and targets set by external regulating authorities. This research addresses the gap in literature concerning educational culture in the NHS. Methods: This case study examines the delivery of postgraduate medical education in the workplace. Semi-structured interviews were conducted with 6 lead educators in the Medical Division of a North West NHS Trust to glean their insights into what works and what needs to change. Results: A thematic analysis of the transcripts revealed a number of factors that facilitated and hindered educational opportunities for doctors in training, including the role of leadership, the demands of external regulatory authorities, and the pressures on frontline staff to deliver safe, personal, and effective care. Conclusion: Opportunities for developing a collaborative approach between educational and clinical leaders and the individuals delivering education in the workplace to enhance the educational environment are discussed. Finally, an evaluatory toolkit based on the themes emerging from the data is proposed, as a resource for other health care organisations to help improve the delivery of workplace-based medical education.

This paper advances the case for a ‘sociology of donation’. We aim to establish that there is a need for such a sociology, to bring together the many, often disparate, elements that make up the theorizing, practice and experience of donation. We argue that bringing together different forms of donation illuminates the distinctive place both in social meaning and regulation that the body and its products hold. In developing this, we are primarily focusing on the donation of body parts and body products within high-income countries. We will first outline the standard western accounts of donation, and consider how relevant these are to donation practices and policies in the twenty first century. We will then critically discuss how a sociology of donation can be used to further current understandings of ‘donation’ and identify the challenges facing such a proposal, posing questions to encourage reflection on research practices in this area. Finally, we will explore what a sociology of donation might entail.

Background: Withholding and withdrawing treatment are deemed ethically equivalent by most Bioethicists, but intensivists often find withdrawing more difficult in practice. This can lead to futile treatment being prolonged. Time-limited trials have been proposed as a way of promoting timely treatment withdrawal whilst giving the patient the greatest chance of recovery. Despite being in UK guidelines, time-limited trials have been infrequently implemented on Intensive Care Units. We will explore the role of time in Intensive Care Unit decision-making and provide a UK perspective on debates surrounding time-limited trials. Methods: This qualitative study recruited 18 participants (nine doctors, nine nurses) from two Intensive Care Units in North West England for in-depth, one-to-one semi-structured interviews. A thematic analysis was performed of the data. Results: Our findings show time is utilised by Intensive Care Unit staff in a variety of ways including managing uncertainty when making decisions about a patient’s prognosis or the reversibility of a disease, constructing relationships with patients’ relatives, communicating difficult messages to patients’ relatives, justifying resource allocation decisions to colleagues, and demonstrating compassion towards patients and their families. Conclusions: Time shifts the balance towards greater certainty in Intensive Care Unit decision-making, by demonstrating futility, and can ease the difficult transition for staff and families from active treatment to palliation. However, this requires clear and open communication, both within the Intensive Care Unit team and with the family, being prioritised when time is used in decision-making.