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Journal of the Academy of Hospital Administration

Coordination - A sine qua non for (cadaveric) Organ Transplantation

Author(s): Hem Chandra*, Shakti Gupta**, Sidhartha Satpathy***

Vol. 12, No. 2 (2001-07 - 2001-12)

Introduction

Death is a fact of life! But, the loss of some one we love is the hardest fact of life to accept and face. It is an emotional and distressing experience. In the consuming grief which follows, it is difficult to imagine that anything positive could emerge, such as organ donation.

In the past, death was declared only when the heart stopped beating. Advances in medical Sciences now allow death to be determined very precisely by measuring brain functions. When brain activity has totally ceased, breathing and heart function can no longer continue independently, and the individual is truly dead. Brain function is essential for human life, hence the death of the brain implies means then the person is dead. Brain death is a condition in which all indications of brain function have permanently ceased. Usually a patient with brain stem death is an ideal organ donor, as they are put on ventilators which allow temporary independent functioning of lungs and heart.

Prompted by the World Health Organisation, and under pressure from the media which boldly exposed organised racquets of human organ trafficking1,2; the government of India introduced the Transplantation of Human Organs Bill in August 1992; which was passed in the Parhament in 1994; and came into force with a gazette notification in 1995.3; The objective was to regulate the removal, storage and transplantation of human organs for therapeutic purposes, and for prevention of commercial dealings in organs.

Over the last 20 years, improved surgical techniques, organ preservation and transplant immunology have made the transplant of kidneys, heart, lungs, liver and pancreas viable approaches to the management of various diseases. However, an acute shortage of suitable donor organs is a major limiting factor in the clinical management of these patients in both developed and developing nations4,5,6. The vital organs which can be donated are the kidneys, heart, lungs, liver and pancreas

Heart and liver donation are a matter of immediate life and death. Donated kidneys eliminate the two or three times-a-week dialysis treatment which is expensive, time consuming and not without complications. Besides, the quality of life is greatly improved. A donated pancreas may 'cure' a person's diabetes. Donated eyes not only provide corneas or sight restoring corneal transplants, but also vital eye tissue for other surgical procedures and for the research into blinding disorders. Bone donations may avert a need for amputation while skin donation may save the life of a severely burnt person. A single cadaver donor can thus provide a new lease of life to several humans in distress.

Organs can be procured from two sources, live related donors and cadaver organ donors. In the living donor programme, blood relatives like brother, sister, parents, children and first cousins are preferred, due to moral, legal and ethical issues. For renal transplants they are the preferred source as the tissue is likely to have a good match. Living donors can donate only a few organs like one kidney a portion of the pancreas and a part of the liver.

On the other hand, a cadaveric donor can donate all organs after brain death. Anyone, regardless of caste, creed, culture, sex and age, is a potential organ donor following irreversible brain stem damage. A potential organ donor is person who, besides satisfying criteria for brain death, is being maintained on ventilator with an intact circulation, has adequate organ function, no major sepsis (infection), and has no malignancy other than braintumor. This condition is always determined by physicians who have no role in organ procurement or transplantation. A transplant team will however assess the medical suitability of the potential donor before organs are actually taken out for transplant.

Though in our country, most religions support organ donation and have no ethical objections to it , sometimes, religious and cultural influences deter families and indviduals from taking such decisions. Under Islam, it is the practice for bodies to be buried as quickly as possible after death. Therefore, requests for post-mortem examinations and organ donation are often refused. In spite of all "ifs" and "buts", a person's wish to donate organs after death should be respected by the family members. Of course, if relatives consent, organs can be removed.

Organ donation is a humane and fine gesture one can make to save another's life. By pledging to donate ones organs after death, a person can contribute enormously in providing a new lease of life to those in need of an organ transplant. Truly speaking, coordination is the essence of cadaveric organ transplantation. Organ procurement from a cadaver is the first objective of the process, which has two components (a) motivation of the near relatives (b) to make use of organ procured by joint effort of administration and clinician. The present study is an overview of socio-administrative aspect of cadaveric transplantion and is based on events which occurred during the transplantation at a super speciality tertiary care hospital.

The authors got an opportunity to coordinate the social and administrative aspects of cadaveric transplant programme in the hospital. The chronological sequence of events are as follows :-

Observation

The patient was a female Staff Nurse who met with a Road Traffic Accident (RTA) on night of 31st December 1997 and was immediately rushed to a private hospital and treated there in ICU for ten days but could not survive. She was declared brain dead at AIIMS, New Delhi and organs were transplanted into three patients on the night of 10-11 January 1998.

The first component of "coordination" which motivated the family of deceased for organ donation was achieved at the private hospital, where the relatives were mentally prepared for organ donation as she was a fit case to be declared as "Brain death". The role as "Duty Officer" and "Socio Administrative Coordinator" for successful transplantation programme during the night was real experience in the field.

Events on 10-11 January 1998:

  • Received call from faculty Hospital Administration, Incharge Transplantation programme AIIMS about "Brain dead" patient at a private Hospital at about 2.00 p.m. on 10.1.98
  • Arrangement to send a team of doctors from CTVS department and a medical social worker along with ventilator in equipped ambulance.
  • Confirmation received from the private hospital regarding shifting of patient to AIIMS.
  • Heads of Department of surgery, GI surgery and CTVS were informed to be ready for transplant surgery on arrival of the patient.
  • Blood bank and HLA lab were simultaneously informed for tissue matching
  • Patient was received at AIIMS at about 8.15 p.m. and admitted in CTVS ICU.
  • Medical Superintendent, HOD Hospital Administration, Faculty I/C transplantation programme, transplantation team and all associated team members were informed about arrival of patient.
  • Patient was again reassessed and declared "Brain dead" by a team of four doctors in accordance with statutory requirements.
  • Consent was taken from the family for removal of organs for therapeutic purpose and kidneys and heart were transplanted in three patients, but the liver could not be utilized in the absence of a suitable recipient.
  • Relatives of the deceased were consoled and made comfortable by providing proper accommodation and food with in the hospital.
  • A letter of thanks with appreciation for the supreme sacrifice and humanity shown by the family for saving three lives was handed over to family along with death certificate.
  • Dead body was handed over to family with due respect and honour on 11th morning and suitable transportation was made available to send dead body to airport.

Discussion

The initial counselling regarding psychosocial aspect of the organ donation was done at the private Hospital. As AIIMS also promotes cadaveric transplantation programme, it was decided to accept the brain (stem) dead patient . The complete transplantation programme took about 17 hours. Heart and both Kidneys were fully, used but liver could not be used due to non availability of suitable recipient. The team work was well organized and hence it took least time. The aggrieved family of the patient was well looked after, which gave them a positive feeling for the sacrifice they have offered. The dead body was handed over with dignity and appreciation to the relatives which made them confident for further social welfare activities, rather than thinking negatively.

The role of the Resident administrator in the Department of Hospital Administration who co-ordinated the complete programme was appreciated, and yielded a sense of satisfaction.

Conclusion

The organ procurement from a brain stem dead patient is a psychosocial effort, and utilization of the organ under difficult conditions needs lot of socio administrative inputs. The job is equally tough and an important part of transplantation programme which should not be neglected.

In view of the acute shortage of live donor organs world wide, it is imperative that more emphasis should be laid on Cadaver Transplant programmes and motivating people for organ donation after death. Keeping pace with the changing times the United network for Organs Sharing (UNOS) Region-I transplant Centres have modified allocation procedures since September 1996 to achieve a balance between increasing the opportunity of renal transplantation for those patients with long waiting times and promoting local donor availability7. Newer approaches like computer modelled allocation programmes by the Eurotransplant International Foundation; and "old for old" concepts are also being tried out in developed European countries as measures to decrease waiting times8. Similarly, exchange donor programmes by liberalising transplatation laws in Korea have also shown promising results5. Whatever be the method of allocation, it can safely be presumed that co-ordination of the myriad activities that take place before, during after the transplantation programme will hold the key to success.

References

  1. "Price tag for various parts of the body; The Organ Bazaar". India Today. July 31, 1990 : 16-22.
  2. United News of India (UNI). India suffering from silent "Kidney drain". The Times of India, 1995 Jan 17; 5 (Col 1-2)
  3. Transplantation of Human Organs Rules 1995. Ministry of health and Family Welfare Notification no. 5080 (E) dt. 4rth Feb 1995 : In Gazette of India (extraordinary) Part II, Section 3(i); 11-9.
  4. Smits JNA, Houwellingen H.C, De Meester J, Persijn GG, Claas F.H.J. Analysis of the Renal Transplant waiting list. Transplantation 1998 Nov. 15; 66 : 1146-53.
  5. Park K, Moon JI, Kim S.I, Kim YS. Exchange donor program in kidney transplantation. Transplantation 1999 Jan 27; 67: 336-8.
  6. Naqvi SAJ. Nephrology services in Pakistan. Nephrology Dialysis Transplantation 2000; 15: 769-771.
  7. Delmonico F.L, Harmon WE, Lorber MI, Gogyen J, Mah H, Rohrer RJ et al. A new allocation plan for renal transplantation. Transplantation 1999 Jan 27; 67 (2) : 303-9.
  8. De Meester J, Persijn GG, Claas F HJ, Frei V. In the queue for a cadaver donor kidney transplant; new rules and concepts in the Euro transplant International Foundation. Nephrology Dialysis Transplantation 2000; 15: 333-8.

* Associate Medical Supdt. SGPGI Lucknow.
** Addl. Prof. Hospital Admn. AIIMS, New Delhi.
*** Asstt. Prof., Hospital Admn., AIIMS, New Delhi.

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