What Is Organ Donation

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What is organ donation?
You may have heard of organ donation now and then, but do you really know what it means? You may also have a preconceived notion about what it means to donate organs. For example, a lot of people think that whenever and however they die, their organs can be donated. That is not true. Read on to get all the details.

Organ donation is the process of Retrieving or Procuring an organ from a live or deceased person known as a DONOR. The process of recovering organs is called HARVESTING. This organ is transplanted into the RECEPIENT who is in need of that organ.

There are two types of organ donation – Live Donation & Deceased or Cadaver Donation.

Live Donation is from a healthy and living person. This can only be done in the case of a liver or a kidney (because the liver can grow back to its normal size, and a donor can survive on one kidney). So if a near relative of yours needs a liver or a kidney, anyone in the immediate family can donate to them.

When we talk about pledging your organs or about organ donation, we are talking about Deceased organ donation or cadaver organ donation. This is organ donation from a person who has been declared brain dead by a team of authorized doctors at a hospital. A person is said to be brain dead when there is an irreversible loss of consciousness, absence of brain stem reflexes and no spontaneous respiration.

What is Brain death and how it is related to organ donation?
A brain death results from a severe irreversible injury to the brain or hemorrhage which causes all the brain activity to stop. All areas of the brain are damaged and no longer function due to which a person cannot sustain his/her own life, but vital body functions may be maintained by an artificial support system. This maintains circulation to vital organs long enough to facilitate organ donation. Patients classified as brain dead can have their organs surgically removed for organ donation.

A brain dead person has absolutely no chance of recovering. Brain death is a form of death and is irreversible. To know more about Brain Death-follow this link and watch the short and easy to understand film on What is Brain Death?

Once Brain Death has been declared, you are dead – BUT – your organs are still alive because they have been kept alive through artificial means.

This means that if a person dies at home or anywhere else, and their heart stops beating, they cannot donate their vital organs. The organs of a person who has died a cardiac death (as opposed to brain death) will die within minutes of the heart stopping.

Therefore – The only time you can donate your vital organs is if you are in hospital and have been declared brain dead.

In case of a cardiac death it is possible to donate your corneas and tissues such as bones, skin, veins, blood stem cells, blood and platelets, tendons, ligaments, heart valves, cartilage and even your body.

While the incidence of brain death is obviously less common that cardiac death, it is important to remember that only if everyone is aware about when and how they can donate organs, will donations actually happen in hospitals.

Unfortunately, mostly due to unawareness and prejudices, there is a huge shortage of organs that are needed for transplants. It has been seen in umpteen situations that relatives are hesitant and unwilling to donate the organs of their loved ones, who have been declared brain dead. Normally the transplant coordinator will approach the relatives with information about organ donation and how even in their time of loss, they can actually help another person live. It is tough for the relatives at this point to make a decision especially if they are not familiar with the concept of organ donation

This is the main reason why it is important for the general public to know about organ donation, before they are suddenly faced with the possibility at some point in their lives.

The total number of brain deaths due to accidents is nearly 1.5 lakhs annually. Other causes of brain death would potentially add many more numbers. There is a need of 2 lakh kidneys, 50,000 hearts and 50,000 livers for transplantation every year. Even if 5-10% of all brain deaths are harvested properly for organ donation, there would be no requirement for a living person to donate organs. One person dies of kidney failure every 5 minutes. This amounts to roughly 290 deaths every day due to kidney failure. These numbers suggest that with adequate systems in place, people succumbing to accident-prone injuries could meet a major portion of the demand.

What happens once brain death is declared?
Organ donations require prior consent from the potential donor or the donor’s family. In India, according to the Transplantation of Human Organs Act 1994, the next of kin of the patient will decide whether to donate their organs.

In this situation, the transplant coordinator of the hospital will make the family aware of their patient’s condition and give them the option of donating organs and tissues. The family may or may not agree and can, till the last minute before retrieval, change their mind about donating. It has been noted that a lot of families, even in the face of devastating loss, agree to organ donation to save the lives of others. For them, it is the only good thing that could come out of the death of a loved one, and for this reason alone, it is everyone’s absolute right to be asked if they want to donate.

Organs from deceased donors are matched with different recipients’ blood group and size, offered to the first patient on the waiting list, and if suitable, transplanted.

Who can donate?
Almost anyone of nearly any age and average health can donate an organ. Although anyone who has cancer, HIV or disease-causing bacteria in the bloodstream or body tissues is usually exempt from donation, this is not always the rule.

Decisions about an organ’s usability are made at the donor’s time of death or, in the case of living donors, in the process leading to donation.

Medical Science has made tremendous progress in recent times in the field of transplant surgeries and operations, with organ donation from one person after brain death capable of saving up to 9 lives and improving the lives of many others.

However, due to the prevalence of myths surrounding brain death and the lack of awareness in India, majority of people do not take up this noble cause for the benefit of others.

Which organ can be donated?
Let’s take a closer look at the different organs that can be donated. There are six organs that can be donated and transplanted :

1. Kidney — The functioning lifespan of a transplanted kidney is about nine years. Of all organs, kidneys are most in demand and the most frequently donated. Most diseases that affect the kidneys affect both at the same time, so a living donor is generally not at a greater health risk with only one kidney.
2. Liver — The liver is necessary for vitamin storage, removing waste from blood and digestion. The liver is the only organ that can grow cells in order to regenerate itself. A liver can actually be split in two and transplanted into two different people. A living person can have a portion of the liver removed, and the remaining portion will regenerate to almost its full previous size.
3. Heart — A heart will beat about 2.5 billion times in the course of an average lifetime. Once removed from the donor’s body, a heart can only survive for about four hours.
4. Lungs — Single or double-lung transplants can be performed. Additionally, living donors can donate a single lobe from the lungs, though it will not regenerate.
5. Pancreas — It’s possible to make a living donation of a portion of the pancreas and still retain pancreas functionality.
6. Intestine — Although quite rare, a living donor can donate a portion of the intestine.

In addition to organs, you can also donate tissue, blood stem cells, blood and platelets, and even your body.
Tissues : It is composed of layers of cells that function together to serve a specific purpose. It must be donated within 24 hours of death.

Cornea: One of the most commonly transplanted tissues each year is the cornea. It is a transparent covering over the eye — is the eye’s primary focusing component. A cornea transplant restores sight to recipients blinded by an accident, infection or disease. Corneas can be transplanted whole or in parts and require no anti-rejection drugs in the recipient. Corneas from a 75-year-old donor are just as effective as younger corneas.

Bones: Donated bones can be used to replace cancerous bones in the arm or leg in lieu of amputation.

Skin: Among its many uses, skin can be used in grafts for burn victims or for post-mastectomy breast reconstruction.

Veins: Donated veins are used in cardiac bypass surgery.

Other donated tissue includes tendons, ligaments, heart valves and cartilage.

How to pledge your organs and become a donor.

At the moment in India, legally, it is the next of kin of the donor who will decide whether to donate their organs or not. Even if you have pledged your organs, no donation will happen unless the next of kin gives the go ahead. Therefore when you do register anywhere to be an organ donor, it’s very important that you discuss your wish to donate with your family. This is to enable your family to carry out your wishes in case the need arises.

pledge your organs

Also you must remember that at the moment, registering as a donor does not mean that your donor card is a legal entity. It is merely an expression of your wish to be a donor. The card that we will send you does not carry any legal weight. But do keep it with you at all times and make sure you let all you friends and family know about your choice.

If you’re planning a whole-body donation, you’ll need a designated person to contact the institution you’ve selected once you have died.

NGO’s to help.

Organ transplantation procedures for brain death – India
According to the provisions of the Transplantation of Human Organs Act, known as THOA, the protocol for declaration of brain death is as follows :

Any organ donation process must involve the following steps before the actual transplant can occur:

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:

i. Registered Medical Practitioner in charge of the Hospital where brain stem death has occurred.
ii. Registered Medical Practitioner nominated from the panel of names sent by the hospitals and approved by the Appropriate Authority.
iii. Neurologist/Neuro-Surgeon (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.
iv. Registered medical practitioner treating the aforesaid deceased person. The same is recorded on Form 10 of the THO Act 2014. The family’s consent is obtained on Form 8.
Healthy organs are transplanted from the body of the patient as soon as possible.

i. Heart and lungs are the most sensitive organs, and must be transplanted within four to six hours of retrieval.
ii. Liver and pancreas must be transplanted within 12 hours and kidneys within 24 hours of retrieval.
iii. In the interim, all organs are stored at 4°C (in a special preservative solution stored in an ice-filled chamber) to help with preservation.
No payment is made to the donor family, and the recipient is not charged for the organs per se. They of course have to pay the transplantation costs of the hospital. All billing for the donor family stops from the time that they give consent for organ donation.
In special medico legal cases, to declare a person dead and to proceed with organ donation, a post-mortem is required. Therefore, there is an additional requirement of a police representative and a forensic person to examine and approve of the process.

organ donor stories

EVOLUTION OF THE CONCEPT OF BRAIN DEATH?
The concept of Brain Death is very important for those involved in organ transplantation. It is a crucial as it is the first step towards organ retrieval and transplantation. Only when a patient is declared brain dead, can organ retrieval take place. Head injuries from road accidents can account for almost 50% of Brain Deaths. Other situations that can lead to brain death is a stroke or haemorrhage in the brain. Organ donation is an option for relatives of patients who are brain dead. Here is a brief history of how brain death came to identified and declared by doctors across the world

HISTORY
Two French physicians in 1959 first recognized Brain Death on patients being ventilated in the intensive care units, and called it coma depasse (a state beyond coma). In 1968, an Ad Hoc Committee of Harvard Medical School defined brain death as irreversible coma with the patient being totally unreceptive and unresponsive with absence of all cranial reflexes and no spontaneous respiratory efforts during a 3 minutes period of disconnection from the ventilator. How much of brain needs to be actually dead before death can be diagnosed has been debated over the years. Experiments have shown that a few cubic centimetres of tissue called œbrainstem which is located beneath Aqueduct of Sylvius anteriorly and floor of fourth ventricle posteriorly is the vital section of the brain that determines consciousness and ability to breathe spontaneously. (This is the section of you head which is near your neck). Destruction of these tissues is what determines brain death. Once the brain stem dies, the whole brain has dies.

CURRENT SITUATION

However, in certain countries, the whole brain including the brainstem needs to die to diagnose the state of ‘irreversible death’ and requires four vessels (carotid and vertebral) angiography and Isotope studies of the cranium. This can be a cumbersome exercise to undertake in an intrinsically unstable patient. In contrast, the tests that determine brainstem death are more clinical and over the last 30 years have proven to be simple, clinical, fool proof and capable of confirmation. In 1988 the Irish working committee on Brain Death in its memorandum said, “if the brainstem is irreversibly lost, what goes on elsewhere in the brain is immaterial and Life cannot return”. In this situation the heart can continue to beat and keep the circulation of some of the essential organs, provided the patient is kept adequately ventilated and hemodynamic stable. However, this state can be only maintained temporarily and eventually cardiac a systole occurs in all the patients.

In the short time between the onset of brain death and cardiac death (when the heart also stops beating in addition to the brain being dead, which could be as less as a day or as much as 3-4 days), is the time that organs have to be retrieved and transplanted into waiting recipients. Countries around the world have developed their own systems that efficiently and transparently retrieve organs and transplant them into others. UNOS in the United States is one of them.

In India the story is different. India recognises brain death in the Transplantation of Human Organs Act of 1994. (Insert hyperlink to the act). Regulatory authorities in each state are empowered to look into the whole process of organ donation for both live related (or unrelated) and cadaver organ donation and transplantation.

Unfortunately only three states – Tamil Nadu, Karnataka and Maharashtra have government run deceased organ donor networks that ensure that all hospitals are connected to a centralised waiting list and organs are distributed efficiently.

LEGAL ASPECTS IN BRAIN DEATH CERTIFICATION

According to the provisions of the Transplantation of Human Organs Act1, known as THOA, the protocol for declaration of brain death requires:

  1. 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/Neuro-Surgeon (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. The same is recorded on Form 10 of the THO Act 2014. The family’s consent is obtained on Form 8.

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.

ESTABLISHING BRAIN DEATH DIAGNOSIS

The aim is to establish that the patient has absent brainstem reflexes and is apnoeic. The testing itself is straightforward. There are certain preconditions that should have been fulfilled to make sure that the tests are performed on the right patients and at the right time. These are as follows:

Patient should be comatose and on ventilator support. The cause of irreversible structural brain damage should be known. Functional reversible causes of a non-functioning brain stem should have been ruled out. These causes include.

  • Primary Hypothermia
  • Alcohol intoxication
  • Neuromuscular blockades (like use of muscle relaxants)
  • Use of central nervous system depressant drugs like use of sedatives
  • Severe metabolic or endocrinal disturbances.
  • Patient should have no circulating therapeutic levels of any drug that could cause coma

Establishing loss of ‘Brainstem reflexes’ at the bedside: – Absence of brain stem function is essential for establishing the diagnosis of Brain death (Fig -2). In a brain stem dead patient cranial nerve reflexes (Table-II) are tested to observe their motor response to a sensory input.

TESTS FOR ESTABLISHING BRAIN DEATH

The absence of brain stem function is documented by conducting the following five tests:

  • 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

Pupillary Reflexes: To check for absent pupillary response to light, bright pen torchlight should be used in a darkened room. It should be made sure that no eye drops to dilate the pupils have been used in the four hours previously. The pupils may not be necessarily fixed and dilated in the brainstem dead patients; however there should be no pupillary response to light.

Corneal Reflexes: Moist cotton tipped swab should be used and firm pressure should be applied to the cornea without damaging it.

Vestibulo-ocular Reflexes: testing involves instilling 20ml of ice-cold water into the external auditory canal and looking at eyeball movements of either eye for about a minute. No eyeball movement indicates absence of reflex. Presence of ruptured eardrums or discharge from the ear prevents this test from being performed.

Gag and Cough Reflexes Test: requires temporary disconnection from the ventilator. A cotton tipped swab can be used to stimulate the posterior pharynx to look for a response. Experienced ICU staff usually notice a progressive loss of response during the evolution of brainstem death when performing the routine suction of airways and oropharynx.

Grimacing of the face to a painful stimulation: is a normal response and this is absent in brainstem death situation. A firm supra-orbital pressure (trigeminal nerve) should be used to check this cranial reflex. Pin pricks should not be used to test this response.

Dolls Head Eye Phenomenon: (testing for oculo-cephalic reflex) This is one test that can be done to know if the brainstem is still alive. If this test is positive than other tests to establish brain death can be postponed. One may need to disconnect the patient from the ventilator for 15 to 20 second to perform this test. To do this test the physician holds the patients head between his hands and moves the head from side to side through1800. The clinician should hold the head to one side for 3 to 4 seconds and look at the simultaneous eye movement to that side. A similar movement is done to the opposite side and eye movement is noticed. In a normal fully alert individual and in a cadaver the eyes move with the head and there is only a very fractional delay. If the cerebral hemispheres are damaged but brain stem is still alive there will be an obvious deviation of the eyes to the opposite side for a second or two followed by a release phenomenon when the eyes will get realigned to the side of the head. This test should not be done if cervical fracture is suspected.

The plantar response: may continue to be present in brain death patients along with spinal reflexes and should not be tested. The decorticate and decerebrate posturing is absent, however on occasions it may be difficult to differentiate these from complex spinal reflexes.

Apnoea Test: The aim of apnoea test is to establish death of the respiratory centre in the brainstem (Table III). This is the ultimate test to establish brainstem death. It demonstrates that the spontaneous respiratory response fails to occur even in the absence of stimulatory drive from CO2. For this test the patient is disconnected from the ventilator for 10 minutes. However, to avoid hypoxia to vital organs, 100% oxygen is given for 5 minutes before disconnection from the ventilator. Even during the test period, 100% oxygen is given through a tracheal catheter. In the patient who is brain dead the carbon dioxide tension increase at a rate of 2mm/min (0.3 kPa/min) during apnoea testing. If the initial CO2 tension before testing is about 40mmHg (5.3 kPa) then arterial CO2 tension after 10 minutes is likely to be 60mmHg (8 kPa). However, a rise to 50mmHg in CO2 tension is acceptable and should provide sufficient stimulatory drive for spontaneous respiration in an intact respiratory centre. In patients with chronic airway disease or severe chest trauma, the apnoea test maybe difficult to perform.

In children, there remains uncertainty about the reliability of clinical brainstem testing. In neonates especially, organs for transplantation should not be removed in the first seven days of life with beating hearts. Radioisotope brain scanning has been recommended under the age of one year when brain stem death certification is required.

REQUEST FOR ORGAN DONATION 

Brain death is relatively a new concept and making request for organ donation in these circumstances can be an extremely difficult task for a doctor or a nurse to undertake. If the decreased carries, a Donor Card (a card the size of a credit card expressing their desire about organ donation) the task of asking for organ donation becomes easier.

In Tamil Nadu a simple protocol was devised called Ramachandra Protocol when asking for organs. In this protocol Eyes ‘ were first requested for and only if the relatives agreed, other organs were asked for. In the tragic circumstance it was felt that by asking for the eyes first the relatives were less likely to get upset with a request for organ donation (Table-IV).

Usually the organ donation request is made in the time interval between the diagnosis of brain death and discontinuation of the ventilator. If the relatives are agreeable the process of organ donation is under taken and vital organ like heart, lungs, liver, pancreas and kidneys are removed for transplantation. Corneas should be kept moist and eyelids should be closed and retrieval surgery can be done for up to 12 hours after cardiac standstill. Other tissues like heart valves, skin, bone and cartilages can be removed for up to 48 hrs after death. The process of organ donation and transplantation requires co-ordination between different teams operating almost simultaneously and sometimes in different locations. It may require getting surgeons from different specialties together for both donor and recipient surgery.

Generally, there is no bar to organ donation and one or the other organ or tissues can be donated at any age. However, it is important to do some essential virology screening before accepting the donor. All potential donors will require a virology screen to prevent possible transmission of disease from donor to the recipient (Table.VII). The next of kin should be made aware that this is necessary; if there are any objections these should be respected. However, it does mean that donation cannot then take place.

Related Links:
Brain Death – Your questions answered