Issues and Organ Donation Scenario in Our Country
Organ donation - One of the Noblest Gift a Human can Give
Dr Ramesh Subedi,
M.D.(Anaesthesia), Dr Hedgewar Arogya Sansthaan
Data from the National Health Portal of India presents a grim picture of healthcare in the country. Annually, 2 lakh people die of liver disease, 50,000 die from heart disease, 2 lakh people await a kidney transplant but only 5,000 get one, over 10 lakh people suffer from corneal blindness and await transplant. 5 lakh people die in India every year because of non-availability of organs for transplant. With 0.08 persons as organ donors per million population (PMP), our country lags far behind compared to countries like the USA, UK, Germany, Netherlands, where the statistics average between 10-30 per million population (PMP). Bureaucratic hurdles, inadequate infrastructure, lack of awareness in society are the major causes of this alarming situation. This article will strive to enlighten and also, discuss the varied issues ailing organ donation scenario in our country.
Organ transplant is a medical procedure where one person’s dysfunctional organ or tissue is replaced by that of a healthy person, thus restoring its function. Organ donation is the process of donating organs or biological tissue to a living recipient, who is in need of a transplant.
There are two different kinds of transplant donations:
- Living Donor Transplant – This occurs when a living person decides to donate his or her organ(s) to someone in need of a transplant. The living donor can be a family member, such as a parent, child, brother or sister, grandparent or grandchild (living related donation). Or it can be someone who is emotionally related to the recipient, such as a good friend, a relative, a neighbour or an in-law (living unrelated donation). The donor undergoes the medical tests and evaluations to check his or her medical compatibility with the recipient, only after which a transplant may take place. The donor’s organs are surgically retrieved and stored in special chemical solutions until transplantation is to occur and the donor’s body is surgically closed. The donor may have to stay under medical care for a few days after organ retrieval has occurred.
Living persons can donate a kidney, blood, bone marrow, portions of the liver, lung, pancreas and intestines and still continue to live a normal life.
- Deceased Donor Transplant – This is when organs from a brain dead individual are transplanted into the body of a living recipient. This kind of transplant initially requires the recipient to register with a hospital where transplants are carried out and wait on a list until a suitable organ is available when he or she is notified. The donor, who is a victim of a fatal injury to the head, is declared brain dead by a board of medical experts. Consent from the donor’s family is obtained before the process of organ procurement is carried out. In the interim, the donor’s body is kept on a ventilator under special medical care, which ensures that his or her heart is still beating and organs are kept alive. The donor’s organs are surgically retrieved and stored in special chemical solutions until transplantation is to occur. The ventilator support is discontinued and the donor’s body is surgically closed and released to the family. According to the law, the prerogative on the decision for deceased donors eventually rests with the next of kin of the deceased.
Organs that can be donated include kidneys, liver, pancreas, lungs, heart, small intestine, uterus, ovaries, while tissue constitutes eyes, skin, bone, bone marrow, cartilage, tendons, veins, nerves, brain, heart valves, middle ear bones, eardrum, and blood. The length of time donated organs and tissues can be kept outside the body, before transplantation is to occur, vary:
Heart : 4-6 hours | Liver : 12-24 hours | Kidney: 48-72 hours | Lung : 4-6 hours
One organ donor can up donate up to 25 different organs and tissues for transplantation. This can save up to 9 lives! Since living donors can only donate a limited list of organs or tissue, it is imperative to increase awareness of and facilitate deceased donations because many more organs can be harvested from a brain dead body.
WHAT IS BRAIN DEATH AND ITS LEGAL ASPECTS
India recognises brain death in the Transplantation of Human Organs Act of 1994. Brain death, technically referred to as brain-stem death is the irreversible end of all brain activity. It usually results from a severe brain injury which can happen after a major road accident, head injury, or a bleed in the brain due to a stroke.
It must be elucidated here that brain death is not coma.
Coma is a state of deep unconsciousness, where the brain continues to function and the person can breathe on his/her own, without the help of a ventilator. Thus, unlike brain death, in a coma, the brain still has the capacity to heal. If there is activity in the brain, the person will not be declared brain dead.
According to the provisions of the Transplantation of Human Organs Act, known as THOA, the protocol for declaration of brain death requires:
- Panel of 4 doctors need to declare the brain death twice in a span of 6 hours. 2 of these doctors must be from a panel approved by the government. This panel includes:
a) Registered Medical Practitioner in charge of the Hospital where brain stem death has occurred.
b) Registered Medical Practitioner nominated from the panel of names sent by the hospitals and approved by the Appropriate Authority.
c) Neurologist/Neurosurgeon (where Neurologist/Neurosurgeon is not available, any Surgeon or Physician and Anaesthetist or Intensivist, nominated by Medical Administrator In-charge from the panel of names sent by the hospital and approved by the Appropriate Authority shall be included.
d) Registered medical practitioner treating the aforesaid deceased person. - Brain death is documented by conducting various tests to distinguish it from comatosed state. These include:
- Absence of pupillary reflex response to light.
- Absence of corneal reflexes.
- Absence of vestibulo-ocular reflex.
- Absence of cranial nerve response to pain.
- Absence of gag and cough reflexes.
- Positive apnea test.
The certifying clinicians must have no interest or benefit in any way from transplantation of cadaver donor organs. The legal time of death in these circumstances is taken as the second set of brainstem death tests. The certification should be done on laid out forms as per the act. In a medico-legal case, a forensic expert is also required for the certification. The medical director or medical superintendent of the hospital should finally countercheck and sign the form. It is only after these formalities have been completed, should ventilatory support be discontinued or organs retrieved.
According to law, doctors are required to take the family members’ consent before retrieving organs, even if the brain-dead patient has pledged his or her organs. After the Transplantation of Human Organs Amendment Act, 2011 was implemented, the treating physician now has to examine the patient for being brain dead and if found so, he/she must sensitize and make the family aware about organ donation.
THE CHALLENGES
Organ donation in India is faced with a number of hurdles. To begin with, finding a donor match is difficult. This is compounded by lack of awareness, decreasing trust in medical institutions and legal tangles.
Lack of awareness is one of the major impediments to organ donation in the country. There are many myths around the organ donation process which range from religious issues to financial and emotional aspects. This has to be reiterated here that no part of the total expenditure is to be borne by the donor family. Also, the organ retrieval process ensures that the donor’s body is attributed a great deal of respect and no disfigurement is allowed.
Another reason people hesitate to come forward is the mistrust creeping in the public mind regarding medical institutions. Reports of illegal organ trade has in a big way influenced people against the whole idea of donating organs. Inspite of the Act itself being so stringent as to slow down the organ donation process, the general public still seem to have a lot of misconceptions in their mind regarding illegal organ trading. Also, the high expenditure in transplant surgeries precludes its access to a major chunk of the population and adds to the general belief that such organ donation initiatives are only meant for the high and mighty.
Also, the stringency of the Act and bureaucratic hassles delays the entire endeavour. The process of declaring a person brain dead is cumbersome. Arranging the logistics for the certification board to meet is obviously time consuming. Keeping in mind that the person’s organs may only be kept alive for a limited period of time, the initiative is often never undertaken by doctors. Unfortunately there is no organ donation network in most states in India which connects hospitals, or a centralized registry of recipients, which makes the task even more cumbersome for doctors
Bureaucratic hassles and red tape add to the challenge. According to existing rules, if the potential donor is not related to the person who needs the organ, the transplant needs to be approved by a state-level committee or if that fails, by a hospital committee that includes government officials. Time is the essence in most cases of organ transplant from brain dead donors. Administrative delays
The next challenge is that it is often difficult for family members to accept their loved one is brain dead. On a life support system, the body is warm to touch and the heart is beating, which makes it difficult for doctors to convince the family members to donate the organs of their relative. Even if the family is ready to donate organs, superstitions and misconceptions become impediments.
Another problem is that there are too few surgeons and hospitals equipped for transplants. Ventilators for preserving the organs of a brain dead person and intensive-care unit personnel trained to manage such situations are prerequisites for a transplant.
THE HOPE
Organ donation is a way of passing on life. Many Non-Governmental Organisations, Patient Self Help Groups and even the Government have started campaigns to increase awareness. Registries supported by the state governments, Tamil Nadu Network of Organ Sharing and Kerala Network on Organ Sharing have substantially increased organ donation in south India.
13 August is celebrated every year in the country as Organ donation Day. Let us pledge our organs so someone can have a better life long after we are gone. It is only through our individual and collective efforts that we can give a new lease of life to the people who deserve a second chance of life.
HOW TO BECOME A DONOR
To be an organ donor, it is important to register by signing up for Organ Donation. One needs to fill a prescribed consent form, which can either be downloaded from the website of the Dadhichi Deh Dan Samiti and get it signed by the family member or the person expected to be present at the time of such condition so that the person is apprised of the pledge. In case of deceased donation, a consent form from the lawful custodian of the body after the death of the patient is required.
The Donor card/ Registration Card so procured, is not a legal binding and it is the next of kin who will decide whether to donate organs or not. Therefore when someone registers to be an organ donor, it is very important to discuss the wish to donate with the family. This is to enable the family to carry out his or her wishes in case the need arises.