August 29, 2003

The greatest gift, part three of three

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Dr. Ravi Chari, center, performs a liver transplant Wednesday. He is assisted by Dr. James G. McDowell, left and Karin Mayes, RN. Dana Johnson.

The greatest gift, part three of three

In the final installment of the series on organ, tissue and bone marrow donation, liver transplant surgeon Dr. Ravi S. Chari, talks about the entire process of organ donation, from a donor’s death to the recipient’s transplant operation.

As a transplant surgeon, I see every day what it means to have more people who need transplants than we have organs for them: when an organ is available, our patients have a good chance at a normal life; without a donor organ, my patients die waiting.

That stark difference is the result of the fact that as transplant lists grow long with more and more people who can benefit from a transplant, the number of donors does not keep up with the need.

Donor organs can come from the living, in the case of, for example, kidneys. Donor organs can also come from people who have died — transplant surgeons, with our unfortunate sense of style, refer to these as “cadaveric donors”— and who have made their wish to be a donor clear and whose families carry out those wishes.

Living organ donation has increased substantially in the last several years, and those donations (you read about one of them last week in the Reporter, from donor Tim Gilfilen of the Medical Art Group) have heroically saved many patients. But living donors will never meet the needs of those on the transplant list. The most important factor that would give those on the organ waiting list a chance to live is to increase the number of people who agree to sign a donor card to donate after death.

Organ donation in those circumstances becomes a way to bring someone else life under circumstances of extreme tragedy. Stroke, car accidents, or shootings are the most common causes of these abrupt, tragic deaths. Through tragedy, the family may enable their deceased family member to perform a last selfless act. In-so-doing, there can be a positive outcome from the tragic circumstances that surrounded the death of their loved one.

It has become clear to me that one of the most important things all of us can do is make sure our intentions with respect to organ donation are well understood by our family members. Many individuals sign their driver’s license to indicate their desire to be an organ donor, but, vital as this is, it is not enough. The remaining family members must know and express the wishes of their loved one before organ donation can occur. The emotional turmoil surrounding the death of the loved one is not the time to determine whether or not a person should become an organ donor.

Some who I talk to about transplantation are surprised at the number of people who can be helped by one donor. Patients are eligible to donate their organs for those individuals who need heart, lung, liver, pancreas and kidney; also, tissues such as the cornea, bone, and skin can be used. Even in cases where someone may have had a heart attack as a mechanism of death, the heart valves may still be used as these can be used as tissue grafts. The lungs can be used for one or two individuals. Kidneys usually go to two separate individuals, and the pancreas can be used to help someone with diabetes. Skin is essential for individuals with wide-spread burn who needs skin coverage to prevent the chance of infection and fluid loss, and corneas and bone grafts can be used for those patients with need. Within this list, the family can decide which organ or organ system they want to contemplate for donation.

It is also important for family members to know that the process of organ donation does not delay the funeral, it does not cost them extra and it does not prevent an open casket funeral.

Organ donation, de-mystified

When I talk to people about my job as a transplant surgeon, I sometimes hear from them concerns about the process by which a person becomes an organ donor. One of the things I am most devoted to is educating others about this process. I believe the more everybody knows and the more comfortable people are with how transplants happen, the more people who will agree to be donors and the more lives will be saved.

The legal framework for organ donation was created in the Uniform Determination of Death Act of 1981. One of the most important items in this law was the establishment of a legal framework upon which a patient can be declared “brain dead.” This means that there is no brain activity, and all the basic reflexes that nature has given us to sustain life — even at the most primitive level — are totally absent.

When brain death has occurred or is imminent, the team caring for the patient calls the organ procurement agency to help with possible organ donation. No patient will ever receive compromised care so that he or she can be a donor — the team taking care of the patient, which is separate from the transplant team, will continue to do everything possible to save his or her life. In that period when the brain has ceased function (‘brain death’) but the other organs are still functioning, organs can be removed for transplant. In the United States, there is an understanding that no person is presumed to be an organ donor unless they state otherwise.

After the gift of donation has been decided, and the consent signed, the organs are matched through the national system operated by United Network of Organ Sharing (UNOS). Regionally, organ procurement agencies are set up to ensure the rational distribution of organs; this system also guards against any illegal ‘sale’ of organs. There are 11 regions in the country, and within each region, there is an active waiting list for all organs.

Prior to the actual organ procurement, however, the organ procurement agency works with UNOS to find the patient who is the best match for the available organ. For the heart, lungs and liver, the need is determined by severity of illness. In kidneys, a compatibility matching system determines which organs will be most compatible with recipients, and these are favored because outcomes have been proven to be better when compatibility is higher.

Once the list has been generated determining organ allocation, the individual centers are contacted and offered the organ for a recipient. This is done individually for the heart, lungs, liver, pancreas and kidneys. Obviously, not every donor will be able to donate every organ. For example, people with advanced heart or lung disease can have their heart and lungs eliminated from consideration.

After all organs are allocated, when the organ harvest occurs in a center distant to the recipient center, the donor procurement teams for all the organs are coordinated in such a way that they arrive in the operating room at the same time. The patient’s actual time of death is when the brain activity has stopped, not when the heart is stopped. When the teams have assembled, preparations are made in the operating room with catheters placed in the appropriate vessels to perfuse the organ with preservation solution that will allow the organs to be maintained. Every minute is vital: the heart should be transplanted in four to six hours, the lungs similarly within four to six hours, the liver in eight to 12 hours, the pancreas in 18-24 hours, and the kidney in 24-30 hours.

Under UNOS guidelines, the identity of the donor is not revealed to the recipient. If over time the recipient has a desire to contact the donor’s family, this can be coordinated through the local organ procurement agency and UNOS. Often a very touching moment, the donor’s family can recognize the benefit, while the recipient is able to give thanks to the family that in a hour of deep grief, saw fit to extend a lasting gift on behalf of their loved one.

I am passionate about this because people who need transplants are my patients. They are also husbands, wives, brother, sisters, mothers, and fathers; they are our neighbors and friends, and we all can do something that can help these people live.