Facts

Short Notes I prepared for the Big Questions on BBC 1 in February 2012

Short Notes I prepared, for my own use, in the lead up to my appearance on the Big Questions on BBC 1 in February 2012.

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Should organ harvesting be easier? [The title of the Big Question]
Firstly anyone who has ever been involved in donation, and met a donor family, would never use the word harvest. It implies the dead are objects of consumption rather than individuals who are probably offering the greatest gift one person can give to another, in peacetime. We would never use such disrespectful terms about a soldier who died. 


Firstly deceased organ donation is never easy, it occurs at a moment of tragedy and requires the death of someone. If easy means improving the support and care we can give to the donor and their family, then yes we must make it easier. If easier means, society claiming a right to the organs and ignoring the needs and dignity of the dying, then no it should not be easier.


How do doctors diagnose death / are they really dead?
Doctors confirm death in three different ways depending on the circumstances they are called upon to make the diagnosis.

In forensics or at the scene of an accident - one can often see quite clearly, just by looking at the body, that death has occurred

In the home or in the hospital doctors will listen to the heart and look for signs of breathing to confirm that death has occurred.

Each year there are a small number of intensive care patients who have sustained such a terrible brain injury that in any other circumstance would have resulted in their heart stopping, but because they are being treated with breathing machines and other technologies, their heart is still beating. In this rare circumstance, and we are talking about 1600 patients per year, two senior intensive care doctors or neurosurgeons, can examine the patient for signs of brain activity. If they find no brain activity capable of sustaining life, then the patient has died. This is where the term brain death comes from.


Who can be an organ donor?
I think people will find the number surprisingly low. Of the 600,000 people who die in the UK every year only about 4000 have a chance to be an organ donor. The reason is simple. The moment you stop breathing and your heart stops, the other organs in your body start to die. And every minute that organ doesn't receive blood, it becomes more and more damaged.  Such that if we take an organ, like the liver, within twenty minutes of no blood supply, it will have become so damaged, it won't be possible to transplant it. So in reality, organ donation can only ever happen if the person is receiving intensive care treatment, and having their breathing and circulation supported. Because only then is there the time for a specialised surgical team to travel to the hospital, and make preparations in the operating theatre to carry out the organ donation.

Last year, of that 4000 potential who can donate, only 1000 did so. It's my job, just as it is of every health professional, to make sure that the other 3000 potential donors and their family, were given the opportunity, in an empathic and caring manner, to make that choice. That's where a great deal of work has occurred over the last few years in supporting health professionals in the emergency department and the intensive care to identify donors and then make this approach to the family.

We should however, never forget that apart from organs, many more people who die in hospital may be able to donate, corneas, heart valves and other tissues of the body. The opportunity to give the gift of sight, is an amazing gift to give.


What are the types of donation?
Well there is living donation of organs. Which accounts for about half of all donations.

Donation of tissues, such as life saving heart valves and life transforming tissues, such as corneas, tendons, cartilage and bone, can all be removed up to 24 hours after death.

Donation after Neurologically (Brain) Determined Death (DBD) vs Donation after Circulatory Determined Death (DCD)?
It is probably easier to explain the difference by example.

A patient might have a severe head injury or catastrophic bleed in their brain and this will mean they will require intensive care treatment and be put on a breathing machine. Over the next few days the intensive care doctors might suspect that the brain injury is so overwhelming that the brain has died, but because the patient is being treated with breathing machines and other technologies, their heart is still beating. In this rare circumstance, and we are talking about 1600 patients per year, two senior doctors, usually from intensive care or neurosurgery, will examine the patient for signs of brain activity. If no brain activity is found capable of sustaining life, then the patient has died. This is where the term brain death comes from. If it is the wish of the patient to be an organ donor, than it's possible they will be able donate heart, lungs and other organs, so they may save the life of up to six people.

Another patient, may have suffered a similar injury to their brain. They too, will require intensive care treatment and be put on a breathing machine. But in this example the brain injury might be catastrophic, but not enough to completely destroy the areas of the brain that sustain life. Never-the-less the doctors caring for the patient (and there is always more than one senior doctor involved) might conclude that the patient is, in the end, not going to survive and the treatment is not helping. They will discuss this with the family and if it is appropriate, intensive care treatment will be ceased and a natural death allowed to proceed. In this circumstance, if it is the wish of the patient to be an organ donor, than the intensive care team can delay the withdrawal of the intensive care treatment until a specialised surgical team travel to the hospital, and make preparations in the operating theatre to carry out the organ donation. The intensive care treatment will then be ceased, and once the person's heart stops and death has occured, the deceased is moved rapidly to the operating room for the surgeons to carry out the organ donation. At the moment hearts can't be donated in this circumstance, but usually around three people have their lives saved by this type of donation.

Some quotes I believe
Organ donors, and their families, are heroes. I think organ donation is the greatest gift one person can give to another in peacetime.

There needs to be a balance between the dignity of the donor and their end of life wishes, and the needs of those requiring organ transplantation.

Organ donation is not a solution but it is an answer.

Once a family says yes to organ donation, it initiates one of the most complex medical process in the NHS. Since multiple organs may be being donated, then multiple specialised surgical teams will have to be mobilised, potentially coming from anywhere in the UK, while recipients are notified, sometimes having to be prepared for general anaesthesia, even before the donation has taken place. 

The whole process will take a minimum of 12 hours, often more. Now 12 hours may not seem a long time, when we are sitting comfortably but if you are a family, watching your loved one for days, with very little sleep and in one of the worst tragedies of your life, with young children perhaps to care for, this length of time may be too much. 
Every family that says yes in this circumstance is making a sacrifice, that prolongs their agony. Their motivation is in my experience, two fold; to honour the wishes of their loved one, and a desire to help others. 

Facts
For the past six years there has been year on year increases in the number of deceased donors and for the first time ever there has been a fall in the transplant waiting list.

34% over four years.

18.5 million people on the ODR, 30% of the population.

Damaged organs at retrieval - 1.6%

UK now ahead of Germany in international comparison.

UK consent/authorisation rates for 2010/11 are

Potential DBD donors 65%
Potential DCD donors 51%

All potential deceased donors (DD, ie DBD and DCD combined) 57%

All potential DD on ODR 84%
All potential DD NOT on ODR 49%


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Scotland and the Southwest of England have the best consent rates in the UK.
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