Organ donation: England will have “opt-out” system from May 2020
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m752 (Published 25 February 2020) Cite this as: BMJ 2020;368:m752
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The switch to an “opt-out” system for organ donation is eagerly anticipated and represents a positive change [1]. However, it will not solve the organ donor deficit alone. While the policy change has been effective in Wales, a systematic review of 35 countries found the effectiveness of an opt-out system at improving donation rates was variable and in some countries it causes a decrease in donation rates after the change [2]. This may be due to family refusal, which currently prevents a third of potential donors from proceeding to actual donation [3].
Once the system has changed in England, the largest challenge will be family refusal. The “opt-out” system used in England will continue to give families the decision to decline donation and family refusal could increase after the policy change [4].
A change in public attitudes must accompany the law change. The government needs to ensure there is public education about organ donation if they wish to increase organ donation rates. The NHS Blood and Transplant “Pass it on” campaign, which aims to increase awareness of the law change, and to communicate their organ donation decision to their family, is crucial to the success of the change in the law [5]. However, this campaign does not specifically inform people that their family can overrule their decision. Doctors and other healthcare staff must ensure that the public are made aware why family discussions about organ donation are so important, so that the switch to an opt out system is as successful as it can be.
1 Iacobucci G. Organ donation: England will have “opt-out” system from May 2020. BMJ 2020;368:m752. doi:10.1136/bmj.m752
2 Arshad A, Anderson B, Sharif A. Comparison of organ donation and transplantation rates between opt-out and opt-in systems. Kidney Int 2019;95:1453–60. doi:10.1016/j.kint.2019.01.036
3 NHS Blood and Transplant. Organ Donation and Transplantation: Activity report 2018/2019. 2019.
4 Lin Y, Osman M, Harris AJL, et al. Underlying wishes and nudged choices. J Exp Psychol Appl 2018;24:459–75. doi:10.1037/xap0000183
5 NHS Blood and Transplant. Pass it on. 2019.https://www.nhsbt.nhs.uk/pass-it-on/ (accessed 28 Feb 2020).
Competing interests: Matthew H. V. Byrne is a Trustee and Chair of We Are Donors, a charity that aims to educate and increase awareness about organ donation at school and university level. He receives no monetary reimbursement for his role.
Dear Editor
I read with interest the article entitled “Organ donation: England will have “opt-out” system from May 2020” by Gareth Iacobucci in the BMJ, which has highlighted the introduction of opt-out system of organ donation in England and the views of the officials of the BMJ Medical Ethic Committee and NHS Blood and Transplant.1 Increasing organ donation. unquestionably, is the solution to the exponential rise in the number of patients with organ failure and preventing their deaths while waiting for an organ. The opt-out system, approved after public consultation, which is going to be launched in England from 20 May 2020, is an important positive step forward in facilitating organ donation, and has the potential for increasing the number of organs available for transplantation that would save several lives. The proposed opt-out system for England is the “soft opt-out” system where the family members are consulted prior to organ donation and their wishes are honoured, in contrast to “hard opt-out” system as practised in Austria and Singapore, where the donor is presumed to have consented for organ donation unless registered to the contrary, and donation proceeds regardless of their families’ wishes.
It is reasonable to expect increase in the organ donation rate after introduction of opt-out system, but the opt-out system has not translated into increase in organ donation rate universally, at least in the initial stage. Spain is the world leader for the implementation of opt-out system, where “presumed consent” legislation was passed in 1979, but the rise in donor rate was observed after 10 years when a national organisation for organ donation with essential resources was founded to co-ordinate the donation and transplantation process. In Spain, the deceased organ donation rate is 47 per million population (pmp), which is highest in the world. Countries like Sweden (19 pmp), Brazil (17 pmp) and Luxembourg (15 pmp), Bulgaria (6 pmp) have low organ donation rate despite adoption of opt-out system. In UK, the deceased organ rate is 22 pmp. It is important to identify the factors which influence the organ donation in the opt-out system, take advantage of the experiences gained by other countries where opt-out system is already in place and address all relevant issues promptly to facilitate organ donation.2
It is interesting to note that in Wales, where an opt-out system was introduced in December 2015, the donation after circulatory death (DCD) consent rate has improved and is now 68% compared to England 59.8%. Wales has the highest combined donation after brain death and DCD consent rate in the UK at 80.5%, when compared to England (66.2%), Scotland (63.6%) and Northern Ireland (66.7%).3 This is certainly a commendable achievement.
For successful implementation of opt-out system, it is important to raise awareness among the public about the details and benefits of the act and the process involved. Personnel involved, such as the intensivists, specialist nurses for organ donation (SNOD), transplant surgeons, ward and theatre staffs and managers should have appropriate training on the subject. It is reasonable to anticipate an increase in the organ donation rate in the opt-out system. Increased donation is very likely to put significant strain on the existing health system, including the manpower (SNOD, intensivists, organ retrieval team, recipient surgical team, ward and theatre staffs), operating theatre resources and hospital beds, which can adversely impact on the delivery of services by other surgical specialties. Expansion of manpower, operating theatre facilities and beds is an essential requirement and should be put in place for achieving successful outcomes of opt-out system.
The introduction of opt-out system for organ donation is an important forward step for the patients with organ failure and is welcomed by the public. It is the responsibility of the government to support the organisations involved in transplantation programme by creating an environment that would facilitate successful implementation of the opt-out system leading to best possible outcomes in the transplant recipients and donor families.
References
1. Iacobucci G. Organ donation: England will have “opt-out” system from May 2020. BMJ 2020;368:m752 doi: 10.1136/bmj.m752 (Published 25 February 2020)
2. Global Observatory on Donation and Transplantation; World Health Organisation Centre on Donation and Transplantation. http://www.transplant-observatory.org/download/2017-activity-data-report/. Accessed February 28, 2020.
3. Organ donation consent rates in Wales highest in the UK. https://gov.wales/organ-donation-consent-rates-wales-highest-uk-0. Accessed February 28, 2020.
Competing interests: No competing interests
Organ donation: the clock is ticking for public awareness
Dear Editor,
The BMJ have highlighted that England will move to an ‘opt-out’ system of consent for organ donation from May 2020.(1) This follows a Department of Health and Social Care consultation which received 17,000 responses, and proposals plan to focus on decision making and public awareness.(2)
Given the media and medical attention of COVID-19, we are concerned that there is not enough being done to highlight this important change in legislation. A 2019 European systematic review found that public awareness of the consent system is lower in ‘opt-out’ countries than ‘opt-in’.(3) Organ donation has considerable implications for the donor’s family, health professionals, health services, and the recipient of the donation.(4) In addition, faith and cultural considerations must be taken into account for effective shared decision making.
Patients from ethnic minorities require visible and accessible information to inform their decision making. The NHS Organ Donation website (https://www.organdonation.nhs.uk/) has information available to patients in different languages, but now is the time for a comprehensive national public awareness campaign to clarify misconceptions, and provide accurate information on areas such as donation exemptions, how friends and families can support organ donation, and changes in decisions about organ donation.
1. Iacobucci G. Organ donation: England will have ‘opt-out’ system from May 2020. BMJ 2020;368:m752
2. Department of Health and Social Care. Introducing ‘opt-out’ consent for organ and tissue donation in England. 2017
3. Molina-Perez A, Rodriguez-Arias D, Delgado-Rodriguez J, et al. Public knowledge and attitudes towards consent policies for organ donation in Europe. A systematic review. Transplant Rev 2019;33(1):1-8
4. Ferguson E, Murray C, O’Carroll RE. Blood and organ donation: health impact, prevalence, correlates, and interventions. Psychol Health 2019;34(9):1073-1104
Competing interests: FM is supported by a NIHR School for Primary Care Research GP Career Progression Fellowship. The views expressed in this response are those of the authors, and not necessarily those of the NHS, NIHR, or the Department of Health and Social Care.