Initiatives To Increase Donation

Each year the gap between supply and demand for transplantable organs widens. Many initiatives to increase the supply of organs have been attempted, and new ones surface at a steady pace. Some of these are very localized and are undertaken by a single OPO. Some are statewide or regional and may be the work of coalitions between donation-related entities or may be the result of statewide legislation. There are numerous examples of national initiatives by associations, coalitions, congress, private corporations and others. The goal of each is the same, but the approach is usually varied. Some are designed to improve the consent rate, some are intended to motivate the public to donate, some are oriented toward expanding the medical acceptance criteria, and others are focused on improving the caliber of OPOs and their employees. Unfortunately, the overall success of these initiatives has not been dramatic, but combining several different approaches may ultimately yield measurable results.

The first notable initiative was the Uniform Anatomical Gift Act of 1968. This legislation, which has been adopted in some form by all states, described provisions to allow individuals or their immediate family members to legally give consent to allow their organs to be donated at the time of death. This legislation gave rise to the development of donor cards. Various campaigns promoting the use of donor cards have evolved including the placement of an individual's donation status on the driver's license in most states. Additionally, donor cards are available from many other sources. If appropriately executed, a donor card is considered a legal document.

Several other initiatives related to consent issues also have been implemented. The concept of required request was introduced in the 1980s by an ethicist, Arthur Caplan. This is a process whereby donor hospitals must present the option of donation to all potential donors in their hospitals. Required request was first attempted at the state level and eventually became a federal statute. There has been limited success reported with required request. Unfortunately, the definition of potential donor was left to the donor hospital and, in many cases, the option was not presented because the hospital prematurely or erroneously deemed an individual unsuitable for donation.

As described above, this concept was taken one step further with CMS regulations requiring hospitals to report all deaths to OPOs and with OPOs being responsible for determining donor suitability. Failure to comply with these regulations can cause a hospital to lose its Medicare and Medicaid funding. Although these federal regulations were based on a state law in Pennsylvania that reportedly resulted in a 40% increase in donation over a three-year period, the impact on organ donation nationally has been relatively modest. Recently, the concept of First-Person Consent legislation (also referred to as "Donation by Do- m nor Designation") has been adopted by many states. First-Person Consent allows HI OPOs to recover organs from a person who signed up to be a donor through a registry or a uniform donor card, without the signature of two witnesses or consent from the next-of-kin.

Perhaps the last consent-related initiative is presumed consent. Although not currently practiced in the U.S., the premise of presumed consent is that all individuals are considered organ donors unless there is prior notice of objection to donation by the individual. The rationale for this thinking is that since public attitude polls have demonstrated that most people favor donation, it is safe to assume they are willing to donate unless they give notice to the contrary. This has been tried in other countries with some success, but there has been substantial reluctance to legislate it in the United States. Some states have passed limited presumed consent laws that typically permit donation of eyes or tissues unless there has been a prior notice of objection. In these situations, eyes and tissues are removed without consent from the next-of-kin. There has been limited success in increasing the rate of such donations, but there also have been situations where the family has reacted strongly to the donation that occurred without their consent.

Several local coalitions of OPOs, tissue banks, eye banks, transplant programs, voluntary health associations and other interested individuals have formed. The objective of these groups is to improve local donation rates through education and improved public awareness. There also have been formally organized national coalitions. The Coalition on Donation, formed in the mid 1990s, is a prominent national coalition active today. The objective of this group is to establish one unified national message about organ donation. It has developed donation awareness campaigns that have been widely utilized by OPOs and transplant programs across the country. Other national organizations and all OPOs conduct public education and donor awareness programs. It is difficult to empirically measure the effectiveness of these initiatives, but most agree they are very important and will prove helpful over time.

One of the provisions of the National Organ Transplant Act of 1984 is that buying or selling human organs is prohibited. However, there is an initiative, albeit controversial, to increase public participation in donation designed to induce individuals with financial incentives. These incentives take various forms with the most direct being a cash payment to the immediate next-of-kin of the donor. Others are less direct and include proposed payments for funeral expenses, tax deductions, donations to named charities, life insurance policies, and a plethora of other types of compensation. Proponents argue that everyone benefits from organ transplantation except the donor; therefore the donor's family should be reasonably compensated. They also argue that it is logical to think that more people will be motivated to donate if they are paid than if they are not. Opponents argue that removing altruism will prey on those in lower socioeconomic positions and may actually reduce the donor pool. There is also a concern that family members may be less than forthright about the donor's medical history when tempted with h compensation for the donation. Public opinion polls and focus groups have dem-4 onstrated a lack of enthusiasm for financial incentives, and some individuals have I stated they would not participate for reasons other than altruism. Whether or not financial incentives would increase donation remains to be seen. However the biggest obstacle to financial incentives must be addressed before they can even be tested. One of the provisions of the National Organ Transplant Act of 1984 is that buying or selling human organs is prohibited.

A number of medically oriented initiatives have been attempted to increase the availability of donor organs. For example, in the late 1980s surgeons from Loma Linda University Medical Center began a series of transplants utilizing organs recovered from anencephalic infants. As they and others explored this possible source of donor organs, they encountered a number of obstacles. First, determination and declaration of brain death in anencephalics does not fit traditional guidelines. Second, in 1989 the UNOS Board of Directors endorsed a policy developed by its ethics committee discouraging the use of anencephalic infants as donors. Third, the results of transplants from anencephalic donors were poor when compared to organs recovered from traditional organ donors. The use of anen-cephalic infants as organ donors has become essentially nonexistent in recent years.

One fairly successful approach to increasing the organ supply has been to broaden the criteria for donor acceptance, but only to the extent that donation can occur without negatively impacting transplant outcomes. As transplantation technology has evolved, transplant physicians have discovered that donor organs that had previously been considered unacceptable are often quite suitable for transplantation. It is not surprising that as donor management and post-transplant care of the recipient have improved, so has the ability to use organs from "expanded donors" a term coined by transplant professionals in the mid 1990s. There are many examples of expanded donors, and undoubtedly the list will continue to grow. Acceptance of organs from older donors, donors with some degree of hypertension, non-heartbeating donors, Hepatitis C positive donors, and other expanded donors all have been used effectively given the appropriate donor/patient circumstances. Some disagreement remains regarding acceptable donor criteria, but this approach has received much interest and has been proven effective in many centers.

Increasing donation by improving the proficiency of procurement personnel and the performance of OPOs has been an ongoing goal of procurement professionals. While it may be difficult to quantify the impact of this approach, its effect can only be positive. After several years of development, the American Board of Transplant Coordinators (ABTC) conducted its first certification exams in 1988.

This voluntary certification is designed to measure competency for transplant clinical coordinators and transplant procurement coordinators. A few years later, the AOPO instituted voluntary accreditation of OPOs. Members of its Accreditation Committee conduct a site visit with each OPO seeking accreditation. They rigorously scrutinize all aspects of the OPO's operations and score them against standards that were developed by the AOPO. Many of the nation's OPOs have been accredited by the AOPO, while others are actively pursuing accreditation.

In 1996, the AOPO completed its first financial benchmark process for its par- m ticipating members. This was a comprehensive analysis of OPO finances. The ob- HI jective was to provide to each OPO a comparison of the finances of similar OPOs. I National statistics also were made available to participants and presented to members of the association at its annual meting. The concept was to share information that would allow OPOs to determine whether or not they were allocating resources in a manner that would result in high performance. For example, if a low-performing OPO determines that it allocated a substantially lower percentage of its resources to marketing than did higher-performing OPOs, it may adjust that allocation accordingly. Simply stated, this is a process that can help to reveal best financial practices with the hope of improving the overall performance of participating OPOs.

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