Plan would add to pool of potential donors
■ An IOM report calls for more education on donation and says that to reduce transplant demand, people should take better care of themselves.
By Susan J. Landers — Posted May 22, 2006
Washington -- A large, relatively untapped store of transplantable organs from deceased donors exists that could help shrink the gap between the tremendous need and the scant supply, according to a new Institute of Medicine report. These organs reside in the bodies of the many thousands of people who die each year of cardiac arrest.
Currently, most people in the United States who are pronounced dead according to circulatory criteria are not considered potential organ donors. Instead, organs from deceased donors overwhelmingly come from people who have died in hospitals where they were pronounced dead according to neurological criteria.
But both declarations of death should open the door to the possibility of donation, said panelists who drafted the report, "Organ Donation: Opportunities for Action."
Among recommendations from this panel of physicians, nurses, lawyers and ethicists was one urging that federal agencies, hospitals, transplant centers and professional societies implement initiatives to increase donation rates after circulatory determination of death, or DCDD.
At least 22,000 people each year who die of cardiac arrest are potential donors, according to the report, and the effective use of this resource could greatly boost the supply of organs. Last year, 7,593 deceased donors, most of whom were declared brain dead, contributed 21,215 organs to individuals on waiting lists.
"It's ironic that we've used such a structured approach to transplantation to include only those who die of brain death," said Lewis Goldfrank, MD, professor and chair of emergency medicine at New York University School of Medicine, and a panelist. "Most people die of cardiac failure."
If more individuals made their decisions to be donors known to their families, and if emergency departments developed the necessary protocols to maintain the health of the organs, there could be a vast influx of usable organs, Dr. Goldfrank said.
The concept of donation after cardiac death is widely accepted in Europe, particularly in the Netherlands, and a few U.S. hospitals also have developed protocols to facilitate such donations. The protocols cover the need for quick action before organs become unusable, as well as the ethical issues that might arise.
American Medical Association policy promotes organ procurement after cardiac death yet cautions that the decision to donate must be voluntary and that no conflict of interest should exist between physicians caring for the patient and those on the transplant team.
Washington Hospital Center in Washington, D.C., did go the extra mile to develop a standard of practice in 2002 called the Non-Heart Beating Organ Donor, to cover donations after cardiac death, said Pat McCabe, RN, MSN, a clinical specialist in critical and emergency services at the hospital. "In the past, we were mainly looking at brain-dead patients, so this gave us another option."
Through the hospital's organ procurement organization, the Washington Regional Transplant Center, donors declared dead after cardiac arrest have contributed kidneys, pancreases, livers and small bowels. Although still catching on, the hospital's new protocol already has produced an expansion of donors. In 2004, there was one DCDD donor from a total of 22 donors, and in 2005 there were three such donors from among 36.
Although this growth is promising, more community education is still key, the report stated. Physicians should talk to patients about becoming organ donors, noted Debra Schwinn, MD, professor of anesthesiology, pharmacology/cancer biology and surgery at Duke University in Durham, N.C. Dr. Schwinn served on the IOM panel.
Families also should be included in donation decisions because they sometimes overrule a patient's desire to donate, she said. "Talking among families about such decisions would constitute a very healthy step in our society."
End-of-life discussions also could provide an appropriate time for such discussions, Dr. Goldfrank said. The knowledge that organ donation is possible can be life-affirming, he said. "People dying could be given the opportunity to say, 'I can do something with my body. It's not just finished. I can donate and help other people.' "
The IOM panel also recommended that data be gathered on living donors -- there were nearly 7,000 last year. "The committee felt it was time to address the issue of appropriate controls and ask, 'Are the living donors being supported to the highest degree?' " said panel member Danny O. Jacobs, MD, MPH, professor and chair of Duke's Dept. of Surgery.
"Independent advocacy teams were recommended," Dr. Jacobs said. "Not because of great concern about the level of advocacy provided now, but to see whether we could do a better job." In its policy on living donors, the AMA also has recommended that they be assigned advocates to help in weighing their decisions.
The position is protective, Dr. Schwinn said. "Altruistic donors are a very special group of people, and we owe it to them to know what the actual risks are when they make their decision. We don't have that data now."
But with more than 90,000 people now on the waiting list, the supply is not likely ever to catch up with the demand despite everyone's best efforts. For that reason alone, people should care for the organs they have, the report's authors noted.
"We should do whatever we can to lead a healthier lifestyle," Dr. Schwinn said.