Dr. George Jacob,
Senior Specialist, Surgical
gastroenterology, Lakeshore hospital,Kochi.
There is no act
nobler than donating organs by individuals with normal organs to person/persons in whom various organs
such as the liver, kidneys, intestine, pancreas, heart and cornea have
undergone permanent damage, both structurally and functionally, what is called
End Stage Organ Failure. Having said this, there is no area in the medical
field which is more bereft of awareness and acceptance by the public and
fraught with suspicion, ignorance and misunderstanding. What is organ
transplantation? Transplantation of an organ from one person to another is
known as the organ transplant. The person who gives the organ
Is called the Donor while the one
who receives it is called the
Recipient. Organ transplant is done to replace the recipient’s
damaged organ with the working organ of the donor so that the
Recipient could function normally. Organ Transplantation is a boon to
medical industry as it has:
helped in saving the lives of those who would have died
otherwise. There is a great need for human organs for
transplantation. In fact, the
need far exceeds the supply of
transplantable organs. There are several reasons for the shortage of
organs. Perhaps
The most common reason is that people are hesitant to donate
organs due to reasons which may be
financial, religious and more often sentimental and importantly, ignorance of
the concept of organ transplantation, and suspicion of involvement of huge
amounts of money in the procedure, brought about by ‘organ trade’ whereby
organs are sold for large amounts of money for the purpose of
transplantatation, with involvement of ‘middle men’ as does exist even in this
country . There are other reasons as
well: for example,
physicians may neglect to inquire of family members whether
they would consent to donating organs when their loved one
dies, or is declared ‘brain dead’ most often fearing emotional outburst
from them . In other cases, the deceased's wishes to donate his or
her organs may not be known by those in the position to act on
those wishes. This disparity has led to the
formulation of various legislations, attempting to regulate
the scarce resources
(transplantable human organs) and to help
establish an equitable system to allocate the organs where
they can do the most good. Legally, organ donation can take place from
Living, genetically-related individuals (live-related), or from living,
unrelated individuals (live-unrelated)
in special circumstances where no unauthorized
payment is made to the donor; or from cadavers(cadaveric) or
animals (Xenotransplantation).
History of transplantation Live donation
of a single kidney was the first done in 1954, but live
donation of parts of other organs is a relatively recent
innovation since 1980s:first successful heart lung
transplant(1981),first artificial heart transplant(1982) first successful
living- related liver transplant (1989) Baboon heart transplanted into Baby
Faye(1986) first ‘split-liver’ transplant(1996) .a single donor can donate his
organs to more than one needy individuals, for example, each of his kidneys to
two different persons, each half of his liver to two people, his pancreas, heart, lung,
cornea, small intestine, to those others who need them. To date the major source of organs and
tissues in the West has been from cadaveric (brain dead) donors. Living tissue deteriorates
rapidlywhen it loses its blood supply, and organs need to be cooled
and transported for implantation into the recipient within a
limited number of hours. Short transfer time, entailing
removal of organs from ‘beating heart’ donors, was made
possible by the acceptance of ‘brain stem death’ as death. In this
context, it is important to throw light on the concept of brain death.
It is defined as the irreversible loss of function of the brain including the
brain stem, the part of the brain that controls respiration and heartbeat.
Brain death can occur as the result of severe head injury following an accident
or cerebrovascular accidents (commonly called stroke). Three cardinal
features of brain death include: 1.coma or unresponsiveness to deep pain,
2.absence of brain stem reflexes such as coughing, swallowing and gag reflex,
such as lack of response to the pupils of the eyes to light, no deviation of
the eyes to irrigation in each ear with cold water, corneal reflex, pharyngeal
reflex, etc, 3. Loss of spontaneous breathing, which means the person cannot
breathe without the help of a ventilator and that no life is possible without
the ventilator. If the diagnosis of brain death is still in doubt, other
investigations are performed to confirm brain death, such as, Electro
Encephalogram (EEG), which shows absence of any electrical activity in the
brain, and aortic arch angiography, which shows loss of blood supply to the
brain.
Who decides or certifies that a person is brain
dead? Certification of brain death requires 2 series of
8 tests by four independent doctors, which includes a neurologist and a
neurosurgeon, one of whom has no attachment to the hospital whatsoever and
chosen from a panel of doctors recruited by the government. Moreover, there is
a law existing in India as well, ‘transplantation of human organs act’
(1994), which, 1.accepts brain death as also a definition of death 2.bans
commercial dealings in organs 3. Defines first degree relative (father, mother,
brother, sister, son, daughter and wife) who could donate organs without
permission of the government, apart from this act, there are state
authorization committees that scrutinize all applications for unrelated
transplants. Hospitals conducting transplants are registered with committees
that monitor their functioning. The states Medical Councils have suo moto
powers to investigate malpractice in transplantations.
How does ‘cardiac’ death differ from ‘brain’ death?
Most people understand that death occurs when a person’s heart and breathing
stop. This is called ‘cardiac’ death and is how most people die. Death also
occurs when the brain and brainstem stops functioning completely. This is
called ‘brain’ death and usually occurs when blood supply to the brain cells
gets cut off for a long period of time. When this happens, the brain cells die
permanently; the usual causes of brain death are severe head injury following
an accident, bleeding into the brain, such as in stroke. In a person dying a
cardiac death, the heart does not beat and, is unable to move or breathe and becomes
pale as blood does not flow through the skin. When a person is brain dead, the
heart can function normally, meaning that other vital organs like the liver,
kidneys, pancreas and the intestines continue to receive blood and remains
healthy, meaning further that a brain dead person has vital organs capable of
functioning normally and can be considered for transplantation, provided the
blood supply to these organs can be maintained.
The usual scenario when such a
patient is admitted to an ICU is that the patient is immediately put on
life-saving procedures such as artificial ventilation, administration of drugs
that help maintain the patient’s blood pressure, and therefore blood supply to
the various vital organs, and also to save life, antibiotics, IV fluids,etc. as
days proceed, the clinical course of the patient can worsen or may not show
response to treatment making the treating doctor suspect that the patient is
brain-dead, which he confirms by the tests mentioned above, performed by the
panel of doctors appointed to do them if brain death is confirmed, it means the
patient is technically dead, and is surviving just because, he/she is on life
support, which if continued indefinitely, the patient goes in for a
‘vegetative’ existence, which is a futile and an expensive exercise, one which
entails unnecessary suffering for the patient and unnecessary expense on the
family for a seemingly lost cause. And if discontinued, will surely die. It is
at this point, that the doctor considers the possibility of harvesting organs
from the brain dead patient to be transplanted into deserving patients with
end-stage organ failure. And chooses to discuss with the dear and near ones of
the patient regarding this option. This option may either be considered or
rejected by those concerned, a choice which involves the factors mentioned
above. It is also a time when money transaction between the families of the
recipient and the donor can take place, with the involvement of ‘middle-men’
sullying the nobility of organ transplantation, bringing into the picture the laws
and stringent guidelines put in place to safeguard the legality and healthy
intention of transplantation, for example, the Human Organ Transplantation Act
of 1994,conducting the whole procedure under the auspices, supervision,
authorization and watchful eyes of bodies such as the Society for Organ
Retrieval and Transplantation (SORT), that exists at Kochi to prevent
malpractice and transaction of money. The first liver transplant in Kerala was
performed in one of the major private hospitals of Kochi
on June 27th under the direct supervision and direction of SORT,
recently, ten premier hospitals of Kochi
decided to share organs harvested from brain-dead patients, on the occasion of
the World Kidney Day again under the auspices of SORT. Even at this point, the
physician of the dying patient only considers what is best for the patient and
his family, giving no priority to transplant surgeons and their patients. When
the transplant patient is ready for the donor organ, the transplant center
surgically removes and replaces the failed organ/organs through the following general
procedure: 1. Make an incision on the recipient 2. Cut the arteries and
veins that run to the organ 3. Remove the organ through the incision (explantation)
4. Take the new organ and insert it into the body through the incision 5.
Connect the organ to the artery and vein 6. Close the incision once this is
over the incision on the cadaver is also closed, by which time the brain dead
person would be dead from the cardiac point of view, and the body is returned
to the relatives, treating it with utmost respect and dignity or to the legal
authorities such as the police or the coroner for medico-legal proceedings if
the cause of brain death was a road traffic accident or injury, in which case
the transplantation will take place only with the permission of the
coroner.
Indian Scenario: In India,
as in rest of the world, there is a gross disparity between need for
transplantable organs by patients suffering from end- stage organ failure and
availability of organs; unofficial statistics reveal that there are 1000 deaths
everyday due to failure of an organ. Of the 8 million deaths in India every
year, at least 20,000 are believed to be potential organ donors. However, less
than 150 actually become donors! The remaining 19,850 donors are lost. At an
average of 5 organs per donor that could have been transplanted, 1 million
organs are needlessly burnt or buried. The disparity can be overcome only if
cadaveric organ donations increase.
This can be brought about by 1.
Education-the government has a huge role to play in this aspect, the government
of Tamil Nadu has an Organ Donor programme which it propagates with the help of
certain hospitals; people should realize that organ donation is a social
responsibility, and the idea of ‘the gift of life’ must be ingrained into
public thinking and psyche through advertisements, especially by the
government, media, both visual and print, by prominent personalities of society
2. Mandated choice, wherein citizens would have to indicate their wishes
regarding organ transplantation, perhaps on income tax return forms or driving
licenses, as in the US, when a person dies, or is declared brain dead, the
hospital must comply with their written wishes regardless of what their family
may want, enforcing the individual autonomy of the organ donor a simple
signature consenting to donate organs can make a world of difference and gift
life to patients and their families.3. Presumed consent, as is the policy in
many European nations. Where their citizens’ organs are taken after they die or
are declared brain dead, unless a person specifically requests not to donate
while still living, advocates of presumed consent maintain that it is every
person’s civic duty to donate organs once they no longer need them (i.e., after
they die or are brain dead) 4. Incentives, as is frequently practiced in the US, various
incentives are offered to the family of the cadaver donor, such as assistance
with funeral costs, donation to a charity in the deceased person’s name,
plaques or memorial
In the US, the Uniform Anatomical Gift Act
(1987) requires every hospital to ask each patient on or before admission to
the hospital as to weather the patient has pledged to donate his organs or
tissues; it is believed that as the result of this, in that country, the
awareness of organ donation and number of donors increased substantially.
Major
Hospitals in Kerala offer transplantation of the liver, kidney, heart, hair, cornea,
bone marrow, at much cheaper rates compared to the West, as the result of which
the state is fast becoming a much sought out place for transplant surgery. But
our state, in spite of it’s high literacy rate has yet to be completely aware
of the concept of organ donation and transplant surgery, the biggest onus for
this being on the shoulders of the government; every citizen of this land must
become aware that every person in need of an organ should be in a position to
receive one, and to achieve this, must be willing to donate, as organ
donation is not about death, but rather about life, that organ donation is
a social and a moral obligation.
Tamil
nadu the torch-bearer in organ donation: Two years ago, Dr
Pushpanjali Ashokan in Tamil Nadu donated all organs of her son Hithendran,
declared brain dead following a road accident. This incident served as a
turning point and the state now ranks number one in multiple organ donation.
"Even though you are losing a loved one after brain death yet you can feel
comforted that his organs are going to stay in somebody's body. In fact this
way he's going to live again." said Dr Ashokan.
Last year, Tamil Nadu alone registered 59 cadaver
transplants. This is 10 times the national average.
