The organ donation taskforce has made wide-ranging recommendations that would make a rapid rise in donation ‘entirely possible’. Nerys Hairon reports
The Department of Health published a report last week by the organ donation taskforce (ODT), containing 14 recommendations with the aim of increasing organ donation in the UK by 50% within five years (ODT, 2008). This would mean an additional 1,200 transplants a year. The government said it would back the taskforce’s recommendations and confirmed £11m of funding to support it next year, with more to follow (DH, 2008).
The development follows a call from prime minister Gordon Brown for a ‘long-overdue’ debate on reform of organ donation procedures (10 Downing Street, 2008).
Writing in The Sunday Telegraph, Mr Brown said he wanted to discuss adopting a policy of presumed consent (or ‘opt-out’) for organ donation. This would enable surgeons to automatically use organs, subject to family agreement, of all patients who have not specifically opted out of the donation system.
In September 2007, health secretary health Alan Johnson asked the taskforce to examine the issue of presumed consent. A separate report on this issue will follow in the summer. For more information on presumed consent and organ donation in general, see www.dh.gov.uk
The UK-wide organ donation taskforce was established in 2006 to identify barriers to organ donation and recommend actions to increase donation and procurement within the current legal framework.
The taskforce points out that Spain has the highest organ donation rate in Europe at 35 donors per million of population. The UK has one of the lowest rates at just 13 per million population. Countries that have adopted aspects of the Spanish model have since seen an immediate and rapid rise in organ donation, and the taskforce argues it is ‘entirely possible’ for the same to happen in the UK.
In 2006–2007 more than 3,000 patients in the UK received an organ transplant but another 1,000 died while waiting or after being removed from the waiting list because they had become too ill. The active transplant waiting list stands at 7,235 and is rising by approximately 8% each year (ODT, 2008).
The taskforce stresses, however, that this list does not reflect the extent of need, as many clinicians are reluctant to list more patients than are realistically likely to receive organs.
The taskforce says three barriers to donation in the NHS need to be overcome to achieve a 50% increase in organ donation after death within five years. These barriers are:
Donor identification and referral;
Organ retrieval arrangements.
The report attributes the UK’s poor donation rate partly to some relatives’ refusal to give consent but adds that both the public and professionals are being let down by the system itself.
While praising the high-quality care provided by critical care and transplant service staff, the report proposes a radical shift from existing arrangements, recommending the recruitment of around 100 extra donor transplant coordinators (DTCs). Together with other measures to improve donor coordination services, this could result in a 10% increase in the consent rate for donation (DH, 2008).
For a summary of the report’s 14 recommendations see p24 (to see them in full, visit www.dh.gov.uk):
A UK-wide organ donation organisation should be established;
The establishment of this organisation should be the responsibility of NHS Blood and Transplant;
Outstanding legal and ethical issues should be resolved urgently to ensure that all clinical staff can work in a clear framework of good practice;
All parts of the NHS must embrace organ donation as a usual instead of an unusual event, and local policies based on national guidance should be put in place;
Minimum notification criteria for potential organ donors should be introduced across the UK and reviewed after 12 months;
Donation activity in all trusts should be monitored – rates of potential donor identification, referral, approaches to families and consent should be reported;
Brain stem death (BSD) testing should be carried out in all patients where this is a likely diagnosis, even if organ donation is an unlikely outcome;
Financial disincentives to trusts that facilitate donation should be removed through the development of appropriate reimbursement;
The current network of DTCs should be expanded and strengthened through central employment by a UK-wide organisation, and extra coordinators should be employed;
A UK-wide network of dedicated organ retrieval teams should be established in order to ensure timely, high-quality organ removal from all heartbeating and non-heartbeating donors.
All clinical staff likely to be involved in the treatment of potential organ donors should receive mandatory training on donation, with regular updates;
Appropriate ways should be identified for personal and public recognition of individual organ donors to be given, where desired;
The most effective methods to promote organ donation to the general public and, specifically, to BME groups should be identified and implemented urgently;
The DH and the Ministry of Justice should develop formal guidelines for coroners on organ donation.
Making donation usual
The taskforce explains that for many trusts, organ donation is an infrequent event and, because of this, it could become an ‘afterthought’ or be seen as an optional extra.
Organ donation should become usual rather than unusual and be a normal part of end-of-life care for appropriate patients, with timely consultation of the NHS organ donor register and appropriate involvement of the DTC. The report recommends in addition that intensive care should not be the only focus – all areas where end-of-life care is provided should be included.
The Spanish model has shown the importance of a clinical champion in each hospital, responsible for ensuring that all opportunities for donation are realised.
The report recommends that this person should be partnered by a non-clinical donation champion.
Monitoring and protocols
The taskforce discusses the importance of identifying potential donors, and both auditing and monitoring this.
An important measure is the conversion rate – that is, the proportion of patients suitable for donation who are identified and whose wishes (and/or those of their families) are both established and fulfilled.
The identification of potential organ donors and their notification to the new UK organisation should be in response to defined criteria that identify, at the appropriatestage, all patients whose death is expected.
The taskforce endorsed proposals for a national protocol for the notification of potential organ donors as follows:
When no further treatment options are available or appropriate, and there is a plan to confirm death by neurological criteria, the DTC should be notified as soon as sedation/analgesia is discontinued, or immediately if the patient has never received either. This notification should take place even if clinical staff believe that donation (after death has been confirmed by neurological criteria) might be contraindicated or inappropriate;
Where there has been a catastrophic neurological injury, when no further treatment options are available or appropriate and there is no intention to confirm death by neurological criteria, the DTC should be notified when a decision has been made by a consultant to withdraw active treatment. This decision should be recorded in a dated, timed and signed entry in the case notes. This notification should take place even if clinical staff believe that death cannot be diagnosed by neurological criteria, or that donation after cardiac death might be contraindicated or inappropriate.
The taskforce states that these proposals are an acceptable but minimum description of what is deemed necessary, and that they should be implemented in all acute trusts. It adds that these clinical notification proposals should be seen as part of the overall strategy, which should ensure that all potential donors are identified and referred.
Main issues to be resolved
Source: ODT (2008)
Department of Health (2008) Fifty Per Cent Increase in Organ Donation Possible Within Five Years. DH press release, 16 January 2008. www.dh.gov.uk
Organ Donation Taskforce (2008) Organs for Transplants: A Report From the Organ Donation Taskforce. London: DH.
10 Downing Street (2008) PM calls for organ donation debate. www.number10.gov.uk