Article by Dr Avnish Seth, M.D. D.M.(Gastroenterology) Director, Fortis Organ Retrieval & Transplant (FORT)
Socially relevant issues like education for the girl child, global warming, rainwater harvesting, saving the tiger etc. are increasingly being discussed in India. As a society, caring for others and altruism come easily to us. Then why did organ donation after brain death take a back seat for all these years? The reason was lack of awareness among doctors, para-medical staff and the general population, a restrictive law and absence of a system of applying and sharing of organs in most states. Despite the above, one hears of more and more examples of organ donation leading to the precious gift of life. Organ donation rate after brain death has increased from 0.05 per million population in 2006 to 0.26 per million population in 2013, though this is still a far cry from over 30 per million in some Western countries. In 2013 we had 310 donations after brain death in the country, resulting in transplantation of 542 kidneys, 256 livers, 25 hearts and 22 lungs. These are not small numbers in a country where, till a few years ago, organ donation was synonymous with donation of a kidney or part of the liver from a living donor, often with considerable donor morbidity.
The felt need
In India, less than 5000 kidney transplants are carried out annually against an estimated requirement of over 175,000. Similarly, only 1000 liver transplants are performed every year in a country where over 100,000 perish due to end stage liver disease, mostly related to preventable causes like hepatitis B and hepatitis C. The annual requirement of hearts is estimated to be around 50,000 and lungs about 20,000. Organ transplantation as a treatment option was seldom discussed. But now, all that is gradually changing. The availability of medical expertise, infrastructure, resources and increasing awareness on organ donation has resulted in several successful organ transplant programs across the country, though the availability is limited to a privileged few.
In brain death, injury occurs to the brain so that the brain dies but the heart continues to beat for a few hours or days and the vital blood supply to the organs is maintained. The diagnosis of brain death is based on simple bedside tests performed by a team of four doctors and repeated after 6 hours. The fact that brain death is death and is irreversible, is a concept which is difficult to communicate to a grieving family, specially when the heart can be seen beating on the monitor. Time is at a premium as gradual deterioration of all organs and tissues is inevitable as the capacity of the body to repair damaged cells is lost and the heart eventually stops beating. Once the family consents to donation, a single heart beating brain-dead donor can save nine lives by donating the kidneys, lungs, heart, pancreas small bowel and the liver, which can be split into two. Tissue donation, on the contrary is possible after death when the heart stops beating, and the cornea, heart valves, bones and skin could be donated.
The Transplantation of Human Organs Act 1994, provided for the regulation of removal, storage and transplantation of human organs for therapeutic purposes in India. The Act recognized the concept of brain death and gave legal sanction for deceased organ donation, but failed to provide the much-needed boost to altruistic organ donation. For several years India remained the favored destination for organ tourism where, organs from needy living donors were sold to anyone who was willing to pay the price. The Transplantation of Human Organs and Tissues Rules 2014 has brought about several changes to streamline the process of declaration of brain death and organ retrieval.
1) Families of patients with brain death were not being approached for organ donation, as there was no mandate. It is now mandatory for the treating doctor to ascertain whether the potential donor had pledged to donate organs during lifetime and to approach the relatives for organ donation, irrespective of previous pledge.
2) Declaration of brain death and organ retrieval was permitted only in hospitals approved for organ transplantation. Now declaration of brain death organ retrieval is allowed from any hospital with ICU facility. However, such hospitals need to apply for sanction for non-transplant organ retrieval centers.
3) Presence of neurologist or neurosurgeon was mandatory in the 4-member team for declaration of brain death. With the new rules, when a neurologist or neurosurgeon is not available in a hospital, any physician, anesthetist or intensivist, nominated by the medical administrator in charge of the hospital can be the member of the board of medical experts for certification of brain death.
4) In patients with medico-legal requirements, like in all patients with head injury, the procedure for clearance from police and postmortem authorities has been simplified. Following retrieval of organs, the postmortem is carried out expeditiously, even beyond office hours.
5) There was no clarity on who would pay for the donor maintenance or organ retrieval charges. It has now been clarified that the cost of donor maintenance, retrieval of organs and tissues, their transportation and preservation, may be borne by the recipient or institution or government or non-government organization as decided by respective state or union territory.
6) It is now essential for hospitals carrying out organ transplantation to employ transplant coordinators and their qualifications have been specified.
Organ retrieval and allotment
Organs are a national resource and must be treated as such by all. Systems must be in place to make sure that organs, once donated, are optimally utilized. It is important to realize that organs cannot be stored but can only be transported in special solutions and sterile ice to be transplanted into suitable recipients. Most surgeons prefer to transplant the heart within 4 to 5 hours of its removal; the lungs within 8 hours, liver and small intestine in 12 hours, pancreas in 18 hours and kidneys in 24 hours. Rapid transit of organs between hospitals is, thus, a vital cog in the wheel of saving human lives. Liaison with local police authorities is important to ensure that there is no delay in police clearance in medico-legal cases and for provision of green corridor for rapid transit of organs.
Myths about organ donation
The reasons for lack of deceased organ donation in India are poorly understood. Even though illiteracy and strong social and religious beliefs were thought to be responsible, many of us believe that lack of awareness not only in the general population but also amongst doctors and para-medical staff is the main reason.
Role of Fortis Organ Retrieval & Transplant (FORT)
FORT has been established with an aim to promote and streamline the process of organ donation following brain death. FORT provides 24-hour referral service for organ and tissue donation and assistance with documentation and procedures related to the same (firstname.lastname@example.org ; helpline +91-8447743868). Other functions include carrying out awareness drives with schools, police, corporates and media and also training for transplant coordinators. One can pledge to donate one’s organs by making an organ donor card. The organ donor card has no legal standing. It helps in spreading the message of organ donation and is an expression of one’s desire, which the family members should be made aware of.
What needs to be done?
The country needs to take up organ donation as a priority and the medical community has to take the lead. Brain deaths occur in up to 30 percent patients who die of head injury or stroke, but go unrecognized or unreported. The policy of ‘Declare All-Approach All’ has to be followed by all and it should be mandatory to file a monthly return with the appropriate state authority.