Improving Organ Donation Rates Goes Beyond Doctors Alone

MOH's Reply 

Straits Times,  11 March 2015
Boosting organ donation goes beyond doctors' role

MONDAY'S commentary talked about the role of doctors in organ donation and its impact on organ donation rates ("Doctors have key role in organ donation").

Organ donation is a personal and emotive issue. Potential brain-dead donor situations are often emotionally stressful for next of kin who are already struggling with the loss of their loved one. Doctors and health-care providers strive to give grieving families the appropriate time, space and respect to deal with their grief and make the necessary end-of-life decisions, including organ donation. Hence, doctors do play an important role in facilitating the organ donation process, in their conversations with the potential donor's next of kin at the end of life, so that the expressed wishes of the donor can be honoured appropriately.

The Ministry of Health (MOH) supports this by regularly conducting training programmes to equip hospital staff with the skills to communicate sensitively and clearly with the family members of potential donors. Hospital staff are on hand to explain the organ donation process, to hear their concerns and to clarify any related issues.

However, a country's organ donation rates are influenced by many other factors. These include public awareness of and buy-in for organ donation, and one's personal and religious views on life and death.

Recognising the importance of increasing the awareness of organ donation, the MOH will also be stepping up its public education efforts this year to remind Singaporeans of the life-transforming benefits that organ donation can bring.

For those who are not covered under the Human Organ Transplant Act (Hota) or wish to donate beyond the four organs covered under Hota, we encourage them to become an organ pledger under the Medical Therapy, Education and Research Act. 

For those who have already decided to be organ donors, we encourage you to inform your next of kin of your decision and empower them to respect your wishes when called upon to do so.

For those who wish to find out more about organ donation, please refer to the MOH website on www.moh.gov.sg

Kwek Tong Kiat (Clinical Associate Professor)
Senior Consultant, Ministry of Health
Senior Consultant, Tan Tock Seng Hospital

Lee Heow Yong (Dr)
Director, Hospital Services Division
Health Services Group
Ministry of Health

-------------------------------------

Straits Times, 9 March 2015
Doctors have key role in organ donation
By Salma Khalik, Senior Health Correspondent

ORGAN transplants have been in the news this past week after reports that the organs of Irish physiotherapist Lisa Orsi, 22, who died after a trek in Indonesia, will be donated to several people here in Singapore, where she had worked since last year.

The number of cadaveric organs retrieved here is pathetically low compared with many countries in Europe. As a result, many people with heart and liver failure here die each year, and thousands with kidney failure are on dialysis.

The Human Organ Transplant Act (Hota) was amended in 2009 to allow the kidneys, heart, liver and corneas to be removed and used for transplant when a person dies, unless the person has opted out, is a minor or is mentally disordered. In spite of that, Singapore, with one of the best healthcare systems in the world, is not among the top 50 countries when it comes to transplants.

The top five countries in the world for cadaveric kidneys Croatia, Spain, France, Austria and Norway get 50 kidneys per million population.

If Singapore could achieve that rate, there should be more than 250 cadaveric kidneys available for transplants each year. Instead, only 17 were available last year, or half the 34 available in 2013. The largest number was in 2006, when 56 cadaveric kidneys were available for transplant still only a fifth of what was possible.

Similarly, for livers, the top five countries Croatia, Spain, Belgium, Portugal and Norway obtained more than 24 livers per million population. That rate would mean over 120 livers a year here, instead of just 13 last year and an all time high of 19 in 2013.

If Singapore could retrieve 120 cadaveric livers a year, there would be no need for anyone suffering from liver failure to go on the wait list and, even worse, die while waiting for a liver to be available. Unlike for kidney failure where patients can still survive for years on dialysis, people whose livers fail will die without a transplant.

There was not a single heart available here last year. Europe and the Americas get more than three hearts per million population each year. As at the end of last year, 23 people here were waiting for a heart transplant.

So, why is the cadaveric rate so low here, especially since there is legislation to enable organs to be retrieved from anyone who dies from any cause? 

Transplant surgeons say one common factor in countries with a low retrieval rate is the lack of buy in by other doctors, particularly those working in the intensive care unit.

To be usable, a liver has to be taken from the body before the heart stops beating. This means doctors must verify brain death in a patient and alert the transplant team. Instead, doctors often just tell the family there is no hope and, with their permission, pull the plug on the life support system and allow the heart to stop.

By doing so, perhaps without realising it, they have also pulled the plug on a patient with imminent liver failure, and perhaps another patient facing heart failure. Both might have been saved if the doctor had done the right thing by ascertaining brain death and allowing the organs to be retrieved.

Two kidneys are also lost to transplant and, although not as serious, that means a poorer quality of life and, very likely, a shorter lifespan for two kidney failure patients.

The Ministry of Health and the various public hospitals need to educate doctors on the consequences of their actions for to deprive organ failure patients of a possible transplant is as good as handing them a death sentence.

Just because the doctors treating dying patients are not personally involved in the treatment of organ failure patients does not make them any less culpable. 

Part of the problem could be fear of resistance or even anger from the family, in spite of the patient not having opted out of Hota. This has happened.

But if the families of dying or brain dead patients were consulted and the situation explained properly, few would deny the use of organs of their loved ones to save someone else's life.

What they need is the assurance that their loved one is not being killed, but is truly dead, before their organs are taken and this is something that doctors need to take time to prove to them. But that is surely time worth taking.

Aside from saving lives with that action, many studies have shown that it is both cheaper for the nation and better for the patient to get a kidney transplant rather than to stay on dialysis.

If more kidneys are available for transplant, Singapore would not need to build a new dialysis centre every few months to cater to the growing number of kidney failure patients.

According to the Global Observatory on Donation and Transplantation, which churned out global numbers in collaboration with the World Health Organisation, the highest number of organ transplants are in Europe and North America, and the lowest in Africa and Asia.

In some African and Asian countries, this could be due to the lack of medical expertise for transplants. But Singapore certainly does not have that excuse. The success rate of transplants here attracts a healthy number of foreign living donor kidney and liver transplant patients every year.

The only reason for the low cadaveric transplant rate is the loss of available organs due to human failure. This is something that needs to be addressed urgently, because it is, literally, a matter of life and death.