Marian Ryan, RGN.
Donor Transplant Co-ordinator, Addenbrooke's Hospital NHS Trust, CambridgeOrgan transplantation is now a successful optimum treatment for end-stage organ failure, yet the shortage of donors remains a major problem in most developed countries.
Organ transplantation is now a successful optimum treatment for end-stage organ failure, yet the shortage of donors remains a major problem in most developed countries.
The UK has seen a fall in donor numbers from 875 in 1995 to 710 in 2003. Reasons for this include a reduction in deaths from road traffic accidents (RTAs), increased refusal rates by relatives of potential donors and improved treatment of hypertension, resulting in fewer premature deaths from cardiovascular accidents.
The donor rate in Britain is one of the lowest in Europe, with 12 per million population compared 33.8 in Spain and 18.3 in France.
UK Transplant has the task of increasing donor numbers, particularly by addressing the issue of relative refusals and ensuring that all potential donors are referred to the donor co-ordination service. One initiative is the 'potential donor' audit.
This ensures that all deaths in intensive care units are audited by the transplant co-ordination service, enabling assessment of the potential for donation and to identify and prevent donors being overlooked.
Understandably, there is a great deal of interest in the Spanish system, given its high rate of donation. This is in part due to factors such as Spain's higher death rate from RTAs than the UK's - 14.6/100,000 population compared with 6/100,000 - and possible cultural differences.
Spain has an opting-out system as opposed to than the opt-in system used in Britain. Opt-in gives relatives the option to agree to organ donation at the time of death. This contrasts with presumed consent in an opt-out system, where the family has to expressly opt out.
Although the difference is subtle, it has been argued that in the stressful circumstances of death, a family is less likely to object to the use of their relative's organs if the presumption is that all suitable donors will donate.
The changeover to an opt-out scheme has had mixed results in Europe: in France, the donor rate dropped after the switch, while in Austria donor numbers increased. A change in the law to introduce an opt-out system to Britain has been the subject of much debate, but the proposal was defeated in parliament last June.
Another initiative, to raise awareness about transplantation and to increase donor numbers, is the organ donor registration scheme. The rationale behind this is that families are more likely to agree to donation if they know their relative wished to donate their organs. This data is now available on computer to inform ITUs, before interviewing a family, of whether a potential donor had registered. However, to make a real impact a large proportion of the population has to be registered, a figure that is just 19% at present.
The lack of suitable organs has resulted in efforts by transplant units to maximise the pool of potential donors. For example, there had been renewed interest in non-heart-beating donors from whom kidneys and livers have been transplanted. It has also led to an increase in the number of organs transplanted from living donors. In 2003, 25.3% of UK renal transplants used living donors in marked contrast to Spain, where the rate is 2.9%.
However, neither of these developments is applicable to heart transplantation - the UK has one of the lowest rates in Europe (2.8 per million population compared with 6.8 in Spain and 4.9 in France).
The shortage of organs remains a major problem for the NHS. Patients with heart and liver disease continue to die without hope of transplantation, while more than 5000 patients with renal failure remain on dialysis.
The most likely way of significantly increasing donor numbers remains reducing family refusal rates. Halving the refusal rate last year would have resulted in about 300 more donors and increased the number of renal transplants by more than 33%.
Provision of high-quality public education regarding transplantation, combined with a positive attitude to organ donation in intensive care units, may be the most important factors in reducing relatives refusal rates.