Increasing Organ Donation: We Can Do Better!

Copyright: © 2013 Lau KK, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. One of the major tasks of the renal transplant community in the contemporary era is to combat the ever growing disparity between available organ donors and the number of patients on the renal transplant wait list. Although living donor transplantation is unquestionably superior to deceased organ transplantation [1,2], the limited number of suitable living donors precludes the use of this option for most patients. As of December 2012 over a hundred thousand Americans were on the wait list to receive a renal transplant; equally distressing was the fact that just over 4000 patients died while on the wait list in 2012 before an allograft could be made available to them [3,4]. These distressing observations should be a call to arms for us to investigate other strategies to increase the availability of deceased donors, while at the same time aggressively promoting living donor transplantation within our community.

One of the major tasks of the renal transplant community in the contemporary era is to combat the ever growing disparity between available organ donors and the number of patients on the renal transplant wait list. Although living donor transplantation is unquestionably superior to deceased organ transplantation [1,2], the limited number of suitable living donors precludes the use of this option for most patients. As of December 2012 over a hundred thousand Americans were on the wait list to receive a renal transplant; equally distressing was the fact that just over 4000 patients died while on the wait list in 2012 before an allograft could be made available to them [3,4]. These distressing observations should be a call to arms for us to investigate other strategies to increase the availability of deceased donors, while at the same time aggressively promoting living donor transplantation within our community.

Legislative Change to Increase Organ Donor Pool
One such attempt is by enacting legislation which presumes that everyone has consented to be an organ donor unless specified otherwise by the individual (the 'presumed consent' or 'opt-out' policy) [5]. Studies from several different countries, especially European countries such as Spain, suggest that the adoption of opt-out policies are associated with higher deceased organ donation rates [5][6][7][8]. In January 2011 a presumed consent bill proposed in New York was withdrawn by its sponsor because of strong opposition [9]. Another similar bill proposed in Colorado was also dropped after facing substantial resistance [10]. Proposals akin to this have also been blocked in Canada and the United Kingdom [11,12]. There is ongoing debate regarding the appropriateness of the presumed consent policy, especially its ethical implications related to human rights and individual autonomy [13,14]. Another potential concern is the public mistrust that such legislation might generate, arising from fear that once people have consented to be organ donors, they might receive less aggressive medical care [15]. Ignoring these sentiments may promote adverse public perceptions of the medical profession and an increase in organ donor availability may not be realised, even if the law does get passed. Therefore, although the opt-out scheme is being seriously considered as an effective way to increase organ donation by the British Medical Association, the feasibility of implementing this policy remains contentious in many other countries including the United States [16][17][18][19]. The consistently unsuccessful legislative efforts thus far in passing the presumed consent law in the United States indicates that this approach needs more public support before further progress can be made [20].

Maximizing Organ Procurement from Potential Donors
One of the other major efforts is the U.S. Organ Donation Breakthrough Collaborative (ODBC), a nationwide collaborative sponsored by the Health Resources and Services Administration (HRSA) to maximize the procurement of potential donor organs, with a target donation rate of 75% or more from eligible donors [21,22]. Organ procurement organizations have partnered with hospitals to implement high leverage changes to advocate for organ donation [23]. These initiatives aim to minimize the failure to identify potential donors and to maximize the consent rate from families since data show that as many as 16 to 27% of potential donor grafts are not procured for a variety of easily addressable reasons such as lack of identification of potential donors by the health care team, or failure to educate and get informed consent from families of possible organ donors [24,25]. The presence of an experienced transplant coordinating team greatly aids in mitigating these logistic obstacles; other strategies include revising and publicizing organ donation criteria and optimizing the critical care management of potential donors to maintain viability of organs without compromising patient care [25][26][27]. Studies have shown that in-house coordinator programs have improved conversion rates for organ donation [28]. Obtaining consent from families for organ donation is another major obstacle. A study that involved 36 organ procurement organizations showed that only 54% of families gave consent for deceased organ donation [25]. There were also marked variations in consent rates by ethnicity, with minorities having much lower consent rates [29]. The use of culturally sensitive and competent transplant coordinators can address some of these discrepancies [28,[30][31][32][33].
Although there was an improvement in the organ disparity numbers during the first few years after the inception of the ODBC, the wait list began to surge over the subsequent years such that the wait list numbers in the US have now increased to 101,160 [4,34]. Obviously, these and other initiatives alluded to above, have not been able to meet the growth in organ demand and as such other interventions are being considered. Some gains have been made, such as by utilizing organs previously thought of as being 'sub-optimal' (extended criteria and non-heart beating donors and the use of pediatric en-bloc kidneys) [35][36][37][38][39] but much work still remains to be done.

Public Education Programs
Efforts have been directed via online registries and licensing bureaus such as the Department of Motor Vehicles in order to bolster enrolment of members of the community as potential organ donors. Providing educational programs to primary care physicians about organ donation and transplantation can also enhance their ability to influence the attitudes of potential donors and increase their commitment to register as donors [40]. Although minority groups have been identified as being less willing to register as donors, recent studies have shown that a multifaceted approach that includes mass media campaigns, point-of-decision interventions and interpersonal interventions may improve registration rates [41][42][43][44].

Financial Incentives
Another potential obstacle to organ donation is the cost incurred by the family of the deceased donor. Experiences from other countries, such as Kuwait, support provision of some financial incentives such as reimbursement for travel and burial expenses, to increase the deceased donor rate. The National Kidney Foundation has also issued a position statement on increasing organ donation and transplantation in the United States in January 2009, hoping to 'end the wait' by eliminating barriers to organ donation, such as reimbursing any additional cost to donor families [45]. Although under the Organ Donation and Recovery Improvement Act (PL 108-216) the federal government has authorized $25 million in program development, including a grant to overcome the financial burden for living donors, similar federal initiatives for deceased donation programs are lacking [46].

Journal of Transplantation Technologies & Research
In summary, although the aforementioned strategies have resulted in some improvement in deceased donor registration rates in the United States, the wait list continues to get larger as demand exceeds supply. In response to this, the HRSA announced a 'Social and Behavioural Interventions to Increase Solid Organ Donation' grant to fund studies to evaluate 'highly promising strategies and approaches that can serve as model interventions for increasing solid organ donation' [47].
The time has come for the medical profession to take up this call to arms and promote the well being of those we have committed to care for.