World Organ Donation Day: Give life, after death

CHENNAI: India’s national organ donation rate is abysmally low at 0.34 per million population (PMP). In Tamil Nadu, the programme led by Transplant Authority of Tamil Nadu (TRANSTAN) (best performing State in the entire country), the rate is still as low as 1.8 donation PMP.

A total of 60 donors, including five in government hospitals donated various organs in Tamil Nadu in 2021, while 55 donors, including four in government hospitals donated in 2020. The numbers were considerably high in 2019, when 127 donors including 22 in government hospitals donated various organs in the State. Until March 2022, 24 donors have donated 139 organs in Tamil Nadu.

Despite significant growth in our health care system in other arenas, experts lament that we’re still primitive and decades behind other developed nations in cadaver transplant.

The process of organ donation is complex, involving ethical, medical, legal, cultural, social, and emotional factors. The chain of donation has multiple links, and it’s as strong and agile as its weakest link. Failure of any one link results in failure of the purpose, the organ donation.

Experts say that there are other additional hurdles including lack of awareness on the process, long waiting list, disbelief in modern medicine and the practice of organ donation itself. If you’ve pledged to donate organs, and declared brain dead by a hospital, the management has a series of processes to follow.

TRANSTAN is informed first. The availability of organs and any related information is circulated among three zones – North, West and South by TRANSTAN.

“If an individual pledges to donate his/ her organs, one of their kin is also mentioned in the donor form. And the kin is made aware of the pledge. In the case of donor death, the kin mentioned in the form can inform and consent on the same,” says Dr Prashanth Krishna, director, Prashanth Hospitals.

Licensed hospitals only

Elaborating on the process followed by hospitals, Dr Prashanth avers that if there’s a prospective recipient within the hospital, organs can be used within the hospital as per the waiting list.

“But that depends on hospital’s license. If the hospital doesn’t have the licence or the prospective recipient, then organs go to a shared pool. In the case of known or unknown donors for live transplantation of kidney and liver, the Directorate of Medical Education (DME) council consults a committee ahead of the live transplantations. Some hospitals have the policy of doing transplants only from related donors,” he adds.

Sensitise families

Doctors and experts say that understanding the process of cadaver organ donation is important and the ease of choosing it is significant for a family in times of grief. It’s better to know about cadaver donation ahead of time, as a sensitised group of people will be easy to approach while grieving, compared to when they usually hear it for the first time, say experts.

Dr Gomathy Narasimhan, senior consultant and renal transplant surgeon, Rela Hospital, explains, “In Chennai, if a family is willing to donate organs, the hospital can begin the process if they have the adequate license. If they don’t, then the management must reach out to other licensed hospitals or NGOs.”

If a patient dies in a hospital, the ICU doctors such as neurologists identify if a patient is brain dead. The grief counsellors talk to the family about transplantation and its benefits.

“If the family agrees to donate, certification is done to confirm the patient’s medical state (brain dead) via the Directorate of Medical Services before transplantation is finalised. TRANSTAN is alerted and the organ is allocated as per the waiting list of the hospital,” she says. “If the family is not willing, certification is not done, and the body is handed over.”

Patients who get the allocated organs are already registered on the waiting list on TRANSTAN. There’s no last-minute registration. The organ allocation can be in different hospitals based on who applies for it through the Vidiyal mobile app. This is followed by organ retrieval surgery. “Transplantations are conducted, and completion of the process report is submitted to TRANSTAN,” adds Dr Gomathy.

More awareness needed

It’s a myth that the government takes ownership of the donated organs, or that the family’s wish would be ignored if they decide against donation.

“In countries like Spain that have a high PMP in organ donation, professionals are trained to explore the wish of the family about organ donation. Both healthcare and non-healthcare professionals are trained to identify opportunities not only in ICU but also in the ER and other hospital wards too,” points out Dr Prabhu Kanchi, nephrologist, Fortis Malar.

In sharp contrast, Tamil Nadu’ s transplant programme is mainly driven by a team of transplant doctors and coordinators rather than professionals involved in patient’s primary care. Most, if not all, are not trained or even primed to think about donation.

Doctors claim there are several aspects to organ donation, including different strata of people involved. This brings a need to educate and create awareness among people including general medical personnel, ambulance drivers, trauma doctors, nurses, emergency consultants and even the public about organ donation.

“Intensifying awareness among medical professionals is the key. Expanding the transplant faculty and infrastructure facilities are the need of the hour. The National Medical Commission and universities should endeavour to include the social aspect of organ donation while teaching medical students, doctors and paramedics,” opines Dr Prabhu.

A beating heart crucial

Experts say that India performs only ‘heart beating but brain-dead donor’ transplants. “From a non-beating heart donor (after cardiac arrest), transplantation is literally non-existent in India, thanks to the lack of infrastructure, medical staff and most importantly training in donor management in such circumstances,” rues Dr Prahu.

Kidneys do well even if they’re from donors whose hearts have stopped beating. “Outcomes are comparable to donation from brain dead donors. This can be a great adjunct to the cadaver transplant programme. Also, India lacks legal guidelines for withdrawal of care for terminally ill patients,” he says.

Dr Gomathy concurs with Dr Prabhu’s assessment, and adds, “The numbers are considerably low in the suburbs. Though there have been discussions about taking any steps to promote organ donation, it’s important to eradicate disbelief among people. Even if one person involved in the registration process of organ donation does not agree to donate, the entire process must be stopped.”

Myths & religious sentiments

Many families in India refuse to consent to organ donation because of religious sentiments. They do not want to mutilate the body or take out any organs of a deceased person.

“It takes time for the family of loved one to understand that there’s an irreversible damage to the brain. It takes about 12-24 hours for them to accept the eventuality. If the heart is still beating in the patient and the blood pressure can be maintained for a few hours using drugs, organs can be retrieved,” explains Dr K Sampath Kumar, senior consultant and HoD-Nephrology, Meenakshi Mission Hospital and Research Centre, Madurai.

But families usually take time to accept loss of a loved one. “The whole process of talking to them through grief counsellors and educating them on the process takes time. So, consent is hard won,” he avers.

There are several myths surrounding COVID-19 too as families don’t know if their loved one can be an organ donor, since he/she had COVID-19 a few months ago. “Organs cannot be retrieved if the infection is active, but if it has been over 6 months, organs can be donated. During the pandemic, transplantations declined because the risk of infection post the transplant was a problem. Immunosuppressants cannot be stopped but if they’re infected with COVID-19, they’re a problem. The whole process gets complicated, and it gets difficult to take the patient through the whole process,” he laments.