Organ Shortage

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					  BRAIN DEATH DONORS
    (ETHICAL POINTS)

               G.POURMAND, M.D.
             Urology Research Center,
      Medical Sciences/University of Tehran
                   Tehran, IRAN
The 2nd International Congress of Medical Ethics in
                  Iran (Apr. 2008)
   CANADIAN TRANSPLANT NUMBERS
            (1994-2003)
4500




                                                                                                                                                   3990




                                                                                                                                                                       4001




                                                                                                                                                                                           3966
4000




                                                                                                                               3800
                                                                                                           3514
3500




                                                                                       3229
                                                                   2874
                                               2829

3000
                           2522




2500
       2159




                                                                                                                                      1901
2000




                                                                                                                                                                                                  1836
                                                                                                                                                          1803




                                                                                                                                                                              1814
                                                                                                                  1746
                                                                          1632




                                                                                              1623
                                                      1573
                                  1530
              1484




1500
1000
 500




                                                                                                                                                                                                         250
                                                                                                                         225




                                                                                                                                                                                     237
                                                                                                                                                                 195
                                                                                 171




                                                                                                                                             170
                     139




                                                                                                     140
                                         114




                                                             115




   0
       1994                1995                1996                1997                1998                1999                2000                2001                2002                2003

                       Waiting                               Transplanted                                         Died While Waiting
   DONORS, ORGANS & WAITING PATIENTS
Number of Patients

        70,000

        60,000

        50,000

        40,000

        30,000

        20,000

        10,000

             0
             1990    1991   1992    1993    1994   1995   1996      1997   1998   1999



                     Wait List at          Cadaveric             Cadaveric
                     Year End              Transplants           Organ Donors
              THE ORGAN SHORTAGE

   Organ shortage — the main limitation to saving
    lives of critically ill patients — is due to
    individuals and their families not considering
    organ donation out of     fear,

                               ignorance

                               misunderstanding.
    THE CRITICAL ORGAN SHORTAGE

   60 people                          daily transplant,
   13 die                             non-availability of organs.
       5,984 deceased organ donors;
       22,953 lifesaving organ transplants performed in 2000 (17,255
        cadaveric donor transplants, 5,653 living donor transplants);
       77,179 on waiting list as of June 3, 2001;
       5,597 deaths while on Wait List at end of 2000.
    KIDNEY TX WAITING LIST IN ASIA (2002)
   Japan       -       12,974   Waiting Time

   Taiwan      -       7000        Taiwan             – 1.9 yrs

    Saudi Arabia -     4248        Korea              – 2.2 yrs

   Korea           -   4000        Hong Kong          – 4.3 yrs

   Pakistan        -   1650        Singapore          – 5.8 yrs

   Hong Kong       -   1018

   Singapore       -   666          No Waiting list in Iran for

   Bangladesh -        125                   Kidney Tx.
KIDNEY TX WAITING LIST IN THE WORLD (2002)

                Waiting List   # of donors per
                #’s            population

Australia       1,764          10 per 1,000,000



Canada          3,990          13.5 per 1,000,000



United States   75,000         34.3 per 1,000,000
                        DONATION

Deceased donors
    Donor has been declared dead by two physicians
      independent of the transplant team
    Usually occurs only in cases of neurologically determined
      death (the brain stops working 1st but the donor is still on
      artificial support such as a ventilator to allow the other
      organs to maintain a blood supply and remain suitable
      for transplant)
Live donors
    Patient chooses to donate one or part of an organ to
      someone on a transplant waiting list
     Can only occur with organs when removal will NOT cause
      grave harm to the donor
            INCIDENCE OF ESRD IN IRAN

   Prevalence: 357 PMP
   Incidence: 59 PMP

   Currently,
       50% on HD
       47.5% transplanted
       2.5% on PD
WORLD STATUS OF RENAL TRANSPLANTS


Annual Number of kidney transplantations per
million population (pmp) per year -

USA -    52   Predominantly Deceased Donors

Europe - 27   Predominantly Deceased Donors

Asia -   3    Predominantly Living Donors
  The number of deceased donors has increased steadily in recent years.
Between 2003 and 2006, there has been a 24 percent increase in donation
from deceased donors. Living donation rose sharply in the 1990s and has
             remained at a steady level the last few years.
DECEASED DONATION
         DECEASED DONOR RATES

The deceased donors per million population
per year

   USA -             20.7
   Europe -          15.9
   Asia -            1.1
   South America -   2.6
  COMMON PROBLEMS & PLATFORMS IN
       CADAVER TRANSPLANT

 Incidence of organ failure
 Public and Professionals Attitude to Brain Death
  & Organ Donation
 Legal Aspects
 Trained Transplant Co-ordinators /Counsellors
  COMMON PROBLEMS & PLATFORMS IN
       CADAVER TRANSPLANT

 Media and Scandals
 Reporting of Brain Death
 Hospital Infrastructure
 Religion & Organ Donation
     PROBLEMS WITH CADAVER ORGAN
       DONATION PROGRAM IN ASIA
    Govt. Problem                  No Funding for program


    Hospital problem               No efforts to identify &
                                   maintain “Brain Dead” donors


    Community Problem              No Awareness of “Brain-
                                   Death” Concept

For cadaveric donation,
  ‘ Society remains a crucial aspect in a transplant program’
     MAKE LOCAL SHARING PROTOCOLS

    6 Kidneys have been wasted in the last four years of the 112
    Kidneys shared in the UNOS due to these problems



   Poor Retrieval Technique – 2

   No Blood for Cross Match – 2

   Poor Packing of Organ - 2
PHYSICIANS ATTITUDE TO ORGAN DONATION

    A large proportion of Physicians are indifferent to organ
    donation process.

Reason cited for this were

   Lack of information regarding the donation process (28.7%),

   Concerns about the sale of organs (22.1%),

   Islamic religious beliefs (21.6%)
MEDIA AND SCANDALS




Doctors May Face Murder Charge
                     PUBLIC ATTITUDE

Important misconceptions and fears are –
   Fear of death,

   Belief that removal of organ violates sanctity of deceased

   Concern about being cut up after death,

   Desire to be buried whole,

   Dislike of idea of kidneys inside another person,

   Wrong concept of brain death,

   Idea of donation being against religious conviction
    RELIGION AND ORGAN DONATION
Religion plays major role in promoting Organ Donation.

Common thread that binds all religions of the world –
   Saving of life overrides all objections
   There is no religion that is against organ donation
    What holds back is cultural reservations –
   Ignorance of the process of organ donation,
   Fear of mutilation,
   Lack of emotional support at time of tragedy,
   Fear that organs will be sold or used only by the rich
   Mistrust of hospitals and health professionals
   Myths
         MUSLIMS & ORGAN DONATION

Muslims: the most controversial group -

   Quran does not forbid tissue donation

   Quran states that if by not transplanting an organ or tissue,

    the person will die, then it is permissible to donate. It is

    allowed for an emergency to save life.

   Different interpretations by different religious leaders,

    „ustazs‟ and „ulamas‟
       MUSLIMS & ORGAN DONATION

Fatwas declared in several countries

     Saudi Arabia : 1985 - permit both living related
      and cadaveric donation of organs

     Iran – 1989 (parliament legislation: 2000)

     Pakistan,

     Bangladesh,

     Malaysia - 1995

     Indonesia
   CHRISTIANITY – ORGAN DONATION

STATEMENT BY POPE JOHN PAUL II –
Full support of organ and tissue donation concluded with words
of Jesus narrated by evangelist and physician LUKE:
“give…, and it will be given to you; good measure, pressed down,
shaken together, running over, will be put into your lap (Luke 6 :
38).”
We shall receive our supreme reward from God according to the
genuine and effective love we have shown to our neighbor.
    RELIGIONS AGAINST ORGAN DONATION


   Greek Orthodox, Shinto and Gypsies are three
    religions that do not encourage body donation

   Jehovah‟s witness is another Christian sect
    that is against such acts
               HISTORY OF DEATH

   During ancient times, most people agreed that
    death occurred when a person's heartbeat and
    breathing stopped.
   For the Greeks, the heart was the center of life
   For the ancient Hebrews and Christians, the
    breath was the center of life
                     HISTORY

   In the 12th century, Maimonides pointed
    toward the head, and the loss thereof, as the
    reason for lack of central guidance of the
    soul.
   During the Enlightenment, the necessity of
    heartbeat, breath, and consciousness for the
    definition of life was questioned, leading to
    questioning regarding the definition of death.
            LEGAL DEFINITION OF DEATH

   The cessation of life; the ceasing to exist;
    defined by physicians as a total stoppage of
    circulation of the blood, and a cessation of the
    animal and vital functions consequent thereon,
    such as respiration, pulsation, etc.

       Black’s Law Dictionary (4th edition)
    UNIFORM DETERMINATION OF DEATH

   An individual who has sustained either

       Irreversible cessation of circulatory and respiratory
        functions
       Irreversible cessation of all functions of the entire
        brain, including the brain stem is dead. A
        determination of death must be made in
        accordance with accepted medical standards.

               Uniform Determination of Death Act (1980)
                                 BRAIN DEATH

   In 1959, patients were described as being in
    "coma depasse" or beyond coma.

   In 1967, the first successful heart
    transplantation took place, with the organ
    coming from a brain-dead, beating-heart donor.
          Farrell MM and Levin DL. Critical Care Medicine. 21(12):1951-65, 1993 Dec.
    ‫ا‬                          ‫فك‬          َ
... ً ‫... و مَن اَحياها َ َاَ نما اَحيَا الناسَ جميع‬

  And he who saves a man’s life shall be
 considered as one who has saved the life
          of mankind as a whole
             
Imam        Khomeini‟s
(the supreme leader
of    Iran)    positive
response to the letter
of the Iranian ex-
minister of Health on
the permissibility of
organ donation from
brain death patients.
    IRAN FACTS:
   The oldest organ transplant (Cornea) was performed in 1314 (1935).

   The first kidney transplantation was performed in Shiraz in 1346 (1967).

   The total number of transplants in 2005 was 19501 kidneys, 203 livers, 104 hearts,

    13 lungs, 28362 corneas, 1468 bone marrows, 1382 heart valves and 1283 bone

    transplants.

   One, five and ten years survival rate is reported to be 92.8%, 83.7% and 73.3%,

    respectively.



   Iran is the only country who doesn‟t have any waiting list for kidney transplant & the

    patients can receive the necessary organ in less than 2 months.
    ENCOURAGING PEOPLE TO DISCUSS
          ORGAN DONATION

When the wishes of the deceased are not known, only 50%
  of people will agree to organ retrieval from their relatives


Encouraging people to speak about organ donation and
  transplantation and to make their wishes known to their
  relatives could change the picture resulting in 93-94% of
  people allowing donation
       PROJECT POSITIVE ASPECTS

Many donor relatives have stated that donating
 their loved one's organs does not make the
 pain of their death disappear

Bereaved families can experience comfort that
 their loved one's gift gave another person a
 second chance at life
    PRESENCE OF FAMILY MEMBER DURING
          BRAIN DEATH TESTING

   Most families faced with brain stem death of a relative find the
    concept difficult to understand and have trouble in accepting
    that their relative is actually dead
   Family members were given choice to be or not to be present
    during brain stem death testing
   It is suggested that presence of family members during brain
    stem death testing not only helps families to accept this concept
    of death but also promotes the grieving process
    ACTION REOUIRED – MUSLIM COUNTRIES

    Most people are ill- informed about their religions attitude
     towards organ donation.

    More public education needed to change cultural beliefs and
     practices although Islam does not forbid Organ or tissue
     donation

    Constantly addressing masses through media by religious
     head may help to improve sentiments
               CONSENT FOR DONATION

   Pre-mortem – via Donor Cards, Driving License

   Consent of his family following death

   Some form of a combination of the two are necessary

   „Supererogatory permission‟ - Underlying premise of such a
    consent would be that “organs of dead people are public
    goods”, and donation must be considered “similar to other
    compulsory civil obligations” within society
        The permission is a moral rather than a legal requirement
               MANDATED CHOICE


   This requires people to state their ‟willingness
    to donate or not‟ when filing some state of
    institutional return such as a driving license or
    income tax form.

   The information would be kept on a central
    register, accessible at time of death
     PROMOTE ORGAN DONATION AMONG
             BLOOD DONORS

   Study shows that blood donors have better knowledge of
    organ donation and are more willing to donate their organs
    and sign an Donor card than general public.

   A substantial proportion of blood donors have not signed a
    Donor Card.

   It would be useful to design promotion programs to facilitate
    blood donors' participation in organ donation.
                        CONCLUSION

Organ Shortage is a Crisis, however the Crisis has a Cure
   We need to Network and start thinking of sharing resources,
expertise and organs
   Set up Collaborative projects
   Use Television Media for Promotion
   Get Religious heads to Participate regularly
   Have Transparency in program
   Set up regional Transplant coordinators Forums

				
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posted:11/19/2010
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