Organ Donation Opportunities for Action (2006) / Chapter Skim
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1 Introduction
1 Introduction
Pages 15-44
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. The success of organ transplantation as a treatment option, the rising incidence of related or contributory medical conditions, improvements in immunosuppressive medications, and other factors have resulted in a rapid escalation in the waiting list for transplantation2 in recent decades.
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The statistics on the transplant waiting list are continually updated, and as of March 24, 2006, there were 91,214 transplant candidates3 on the waiting list, of whom 65,917 individuals (approximately 70 percent of the waiting list) were candidates for kidney transplantation.
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To address its charge, the committee held five meetings and gathered information by holding a scientific workshop (see Appendix B for the workshop agenda) and two public comment sessions, talking with numerous individuals in the organ transplantation field, and conducting a literature review.
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. Clarifying Criteria for Determination of Death The early transplants were generally the result of donations of kidneys from living donors or donations of organs from deceased donors who had been declared dead following the irreversible cessation of circulatory and respiratory function (DeVita et al., 1993)
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· Established the Organ Procurement and Transplantation Network to be run by a private nonprofit entity · Provided grants to expand regional organ procurement organizations · Prohibited commercial transactions in organs · Established the Task Force on Organ Transplantation 1986 Omnibus Budget Reconciliation Act · Required hospitals participating in Medicare or Medicaid to institute a "required request" policy 1987 Amended UAGA · Enacted in 25 jurisdictions (NCCUSL, 2005) · Provided explicit priority to the intention of donors over that of their relatives · Prohibited the sale of body organs · Included required request provisions 2004 Organ Donation and Recovery Improvement Act (Public Law 108-216)
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The growing demand for organ transplantation, controversies regarding the allocation of organs, and concerns about payment for organs prompted congressional hearings on organ transplantation in the early 1980s. The resulting federal legislation, the National Organ Transplant Act of 1984, prohibited the sale of human organs; established a task force to address organ donation and allocation issues; and established the Organ Procurement and Transplantation Network (OPTN)
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Reprinted courtesy of the Association of Organ Procurement Organizations. medical eligibility of potential donors; coordinating the recovery, preservation, and transportation of donated organs; and educating the public about organ donation (UNOS, 2006)
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Most current U.S. transplantations from deceased donors result from deaths determined by neurologic criteria.
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estimated the number of potential deceased organ donors (neurologic determination of death) in the United States in 1998 to be 16,796; the actual number of deceased donors in 1998 was 5,793.
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That study estimated that each year in the United States there is a national pool of 10,500 to 13,800 potential donors for whom death is determined by neurologic criteria. As seen in data from 2002 and 2003 (Table 1-1)
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. TABLE 1-2 Deceased Organ Donors, Potential Versus Actual Criteria Used to Annual Number of Actual Number Determine Death Estimated Potential Donors of Donors, 2003a Circulatory determination of death Uncontrolled 22,000b 17c Controlled Unknown 236 Neurologic determination of death 12,000d 6,178 aData provided by OPTN-UNOS as of September 8, 2005 (see Chapter 5, Table 5-2)
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. INTERNATIONAL PERSPECTIVE Most countries around the globe also face such problems as long waiting lists for organ transplantation and challenges with the allocation of scarce organs.
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Among the major changes instituted in Spain are an active donor detection program conducted by well-trained transplantation coordinators; an extensive transplant coordination network linking national, regional, and hospital efforts; hospital-level coordinators; increased economic reimbursement for hospitals; professional and public education efforts; systematic death audits conducted in hospitals; and a focus on expanded-criteria donors and on donation after circulatory determination of death (Matesanz, 1998, 2003, 2004)
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Rep. Italy Latvia USASpain Greece Zealand FinlandFrance Australia Norway Denmark Canada Croatia Germany Sweden Poland Hungary Slovenia BelgiumIreland PortugalAustria Switzerland New Netherlands Czech FIGURE 1-4 Numbers of deceased donors per million population for various countries, 2004.
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In Denmark in the 1980s and Germany in the 1990s, many believed that prolonged public debates over the determination of death by neurologic criteria led to declines in organ donation rates (Matesanz, 1998)
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Today, as more people choose to become living donors, there is a need to distinguish between living and deceased donors. The term cadaveric has been used in the past but has an impersonal connotation (a dead body intended for dissection)
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HRSA is a major federal funder of research and initiatives to increase organ donation rates in the United States. HRSA's Division of Transplantation is responsible for administering the federal contracts for OPTN and for the Scientific Registry of Transplant Recipients, which collects and analyzes
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The National Institutes of Health (NIH) funds grants for organ transplantation research that primarily focus on biomedical studies of improvements in surgical techniques for transplantation, understanding immunerelated processes, and improving graft survival.
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Professional organizations, including the Association of Organ Procurement Organizations, the American Society of Transplantation, the American Society of Transplant Surgeons, and the Organization for Transplant Professionals, are active in professional education and also work to promote organ donation through advocacy and public education efforts. THE ECONOMIC VALUE OF INCREASING THE ORGAN SUPPLY Numerous clinical studies have documented the benefit to patients of organ transplantation in terms of life expectancy and quality of life.
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used published estimates of the costs of and quality-adjusted life years gained from kidney, liver, and heart transplants to calculate the monetary value to society of a deceased organ donor, assuming that each donation results in 1.55 kidney transplants, 0.37 heart transplants, and 0.76 liver transplants. They estimated that a deceased organ donor is associated with a gain to transplant recipients of 13 quality-adjusted life years (summed across the transplanted organs)
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They have found that an additional deceased organ donor yields a gain of 30.8 life years for these patients (summed across the transplanted organs) , assuming that each donation results in 1.4 kidney transplants, 0.80 liver transplants, 0.20 lung transplants, and 0.30 heart transplants.
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Although not all the medical conditions necessitating organ transplantation can be prevented, preventive interventions and the treatment of contributory diseases as early as possible have the potential to reduce significantly the demand for organ transplantation.
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and families to transplanta tion Posttransplantation · Increase knowledge of · Immuno- · Coverage for (post-event) posttransplantation suppressive immunosuppres care therapies, other sive drugs and posttransplanta- posttransplanta tion care tion-related health care Desired end result · Limit the number of · Increased access · Minimization of transplantations to follow-up disruption in · Improve the care of care daily routines those receiving · Provision of transplants care for a rapid · Mitigate adverse recovery consequences · Rehabilitation ON THE HORIZON A variety of technological advances in development might improve organ viability or diminish the need for living or deceased organ donation.
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The subsequent chapters examine changes in the organization, processes, and interactions of hospitals and OPOs (Chapter 4) ; expanding the pool of potential organ donors through donation after circulatory determination of death (Chapter 5)
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Facilitate Familial Decisions to Donate · Improve family support · Improve donation discussion and request efforts · Integrate organ donation into end-of-life care Provide Incentives to Donate Type of Incentive received Incentive received incentive prior to death after death Financial: Direct · Cash payment to donor · Cash payment to family or estate · Futures market Indirect · Reduction in life or · Income tax deduction or credit health insurance premium · Payment of medical expenses · Payment of funeral expenses · College education benefits for children · Life insurance · Contribution to a charity Nonfinancial: Reciprocity · Eligibility for future transplant Preferred · Priority for future · Preferred status for family members status transplant Community recognition Expand Populations of Potential Donors · Donation after circulatory determination of death · Expanded criteria for suitability of organs
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2003. Waiting for organ transplantation: Results of an analysis by an Institute of Medicine committee.
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2000. Non-Heart-Beating Organ Transplantation.
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2004. Procuring organ donors as a health investment: How much should we be willing to spend?
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2003. Estimating the number of potential organ donors in the United States.
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