Shortage of organs for transplantationBMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7037.989 (Published 20 April 1996) Cite this as: BMJ 1996;312:989
- Celia Wight,
- Bernard Cohen
Crisis measures must include better detection and maintainence of donors
Of all the problems foreseen in the pioneering days of organ transplantation, a shortage of donor organs was not even remotely considered as a barrier to progress. Such has been the success of transplantation over the past two decades that organ shortage is now considered the major limitation. This week sees the publication of an extensive study by the British Transplantation Society's working party on organ donation.1 Chaired by Professor John Fabre, the working party examined a variety of issues influencing rates of organ donation in Britain.
Clearly, the fact that fewer young people now die because of road traffic accidents or intracranial haemorrhage is a cause of donor loss that must be welcomed. However, the report highlights the fact that many medical and financial practices still mitigate against the efficient identification and recruitment of organ donors. In particular, the lack of intensive care beds means that many potential donors are not being ventilated, with the decision depending on locally devised prognostic criteria. As a result, waiting lists for renal transplantation continue to rise, putting increasing pressure on dialysis budgets. While it would be inappropriate to increase budgets for intensive care purely to reduce dialysis costs, most authorities agree that the number of intensive care beds in Britain is inadequate in comparison with other western European health services.2 3
Given the inadequacy of intensive care facilities, the working party recommends several initiatives to address the current shortage of donors, including interventional (elective) ventilation, greater use of non-heart beating donors, better training of staff, and better transplant coordination, all of which would require better funding.
Interventional ventilation—ventilating, solely for the purpose of organ donation, a comatose patient who is close to death from severe brain damage—runs up against legal and ethical impediments; it is imposed on an individual not for his or her own good but specifically to benefit others, and as such it could be considered an assault. The working party has recommended legislation to circumvent this legal impediment.
The report states that “in most countries of the European Community, seriously ill, comatose patients are routinely admitted to an intensive care unit while undergoing investigation, often while ventilated. In such circumstances interventional ventilation is not necessary.” To many outside Britain, the idea that seriously ill, comatose patients are not routinely admitted to an intensive care unit seems extraordinary. The authors of the report point out that in Britain, reimbursement for costs at the donor intensive care unit is £1000, compared with as much as £40000 in Spain. One can but speculate how a much higher level of reimbursement might change the mind-set of those currently charged with managing intensive care units in Britain.
The Spanish system of organ procurement comes in for special comment. Despite a dramatic decrease in fatal road traffic accidents,4 organ donation rates in Spain reached 27 per million population in 1995, in contrast with 15.8 per million in Britain. Spain itself attributes this success to its transplant coordination network, which has a different philosophy from that in Britain. In Britain, transplant coordinators are based in renal transplant centres, while in Spain they are based at the site of organ donation. The prime function of the Spanish local donation team is to detect potential organ donors within intensive care units at an early stage and to monitor the medical progress through to a diagnosis of brain death and subsequent organ donation. The success of this policy is evident from the donation rates achieved. Whether or not such a system might be adopted in Britain, the report highlights the inadequacy of Britain's current transplant coordinator network and emphasises that a major expansion of coordination is “one of the most important and urgent needs.”
The working party highlights the urgent need for improved funding, not only to increase intensive care facilities and improve coordination networks but also to increase surgical staffing and provide teams qualified to undertake asystolic donation. However, the report fails to address those measures that could be undertaken within existing budgets to maximise the country's current donation potential. Measurable increases in organs have been achieved in other countries by introducing mechanisms for donor detection, staff education, and donor maintenance.4 5 Our own experience with the European Donor Hospital Education Programme in over 30 countries around the world has shown that simple education policies on requesting organ donation can considerably improve organ donation rates.6 Data presented to the British Transplantation Society on a controlled evaluation of the programme in the north west region of Britain confirm this positive effect (RA Sells, personal communication).
A multinational effort to address all areas of the donation process is now being piloted in selected hospitals throughout the world. This programme, called Donor Action, seeks to introduce the best practices from around the world for the benefit of staff who may be involved in treating potential organ donors and patients on transplant waiting lists. It provides a comprehensive package of tools, resources, guidelines, and training to help a donating hospital diagnose its own potential for organ donation and improve its own donation practices. After a diagnostic review, areas of weakness can be identified and the appropriate management and educational changes introduced.
The working party's report highlights the desperate need for increased funding to improve rates of organ donation in Britain. Its recommendations are to be warmly welcomed. However, the transplant community should also consider whether practices existing elsewhere in Europe could help to improve the supply of organs for transplant within the budgetary constraints of the NHS. Unfortunately such considerations were outside the remit of this report.