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• W4318168375 abstract "ORGAN DONATION AND TRANSPLANTATION IN INDIA The global observatory data on organ donation (OD) and transplantation indicate that 12 666 organ transplants have been carried out in India in 2019, next only to the United States and China. Most transplants in India to date have been from living donors and only 2060 (16.3%) transplants from deceased donors.1 There have been 715 deceased donors following brain death (BD), and organ donor rates remain below 1/pmp.2 With India spending <2% of its gross domestic product on health care, most government hospitals lack the infrastructure and experienced staff to carry out organ transplantation. Of 550 transplant centers in the country, 80% are in private hospitals.3 The responsibility of pushing deceased OD (DOD) forward thus lies with private hospitals. Critical care (CC) teams must therefore find a way to engage with a population that is not only largely unaware of the concept of BD but also constantly questioning costs that are inevitably linked to world-class care. The National Organ and Tissue Transplant Organization (initiated in 2015) has thus far not succeeded in providing a strong impetus for DOD in government hospitals. Thus, the DOD ball, by default, lies in the court of private hospitals. FIRST FEW STEPS We have previously reported on the first successful DOD program in North India (2009).4 A proposal was introduced to Fortis Healthcare covering 30 hospitals across the country and 17 000 employees to step into the DOD space. Fortis Organ Retrieval and Transplant (FORT) was established in 2012 to streamline the process of DOD following the diagnosis of BD in these hospitals. DOD was aligned and integrated into the mission statement Saving and Enriching Lives. The role envisaged for FORT included setting up standard operating procedures, establishing a 24-h helpline, assistance with documentation related to OD, family counseling and support, creation of online organ pledging facilities, multiprofessional education, awareness activities, data collection, and coordination with other agencies involved in OD. NATIONWIDE AWARENESS CAMPAIGN The More to Give campaign was launched to promote awareness of DOD with an annual budget of 40 000 000 rupees (571 000 USD) over 3 y (2016–2018). An independent professional agency was hired to evaluate the reach and impact of the campaign as per International Standards Organization 20252 guidelines. The awareness drive was endorsed by disabled war veterans and film and sports celebrities who had already given so much to the country but had more to give by supporting OD. Delhi Capitals, a Premier League cricket team, endorsed DOD, and an anthem on DOD was released in Hindi. Flash mobs, street plays, and puppet shows were performed in several cities. Donor and recipient stories, panel discussions with experts in DOD, transplant surgeons, and religious leaders, and broadcasts thrice a week by NDTV have been viewed by an estimated 139 million. Awareness talks were organized in schools, colleges, universities, residential societies, and corporates. The estimated readership in print media was 35 million, and 78 million were reached through social media. Simultaneous walkathons, telecast live, were held in 7 cities and 99 000 individuals pledged to donate organs. A short film on DOD was shortlisted for the Cannes film festival in 2017. Wall of Tribute was erected in hospitals to honor organ donors. More to Give received the national award for Health Awareness Campaign for 2016 to 2017. In addition to several awards for the best digital campaign, best use of radio for activation campaign, and best use of television for social welfare, one of the short films on DOD received the highest national honor of the Dada Saheb Phalke award in the Best Public Service Advertisement category in 2017 to 2018. IMPLEMENTATION OF PLAN IN HOSPITALS Fourteen hospitals with ongoing transplant programs were identified (Figure 1). An OD committee was created in each hospital comprising of CC leadership, hospital administration (HA), and nursing. A clinical lead organ donation was earmarked by the CC team. All hospitals applied for or updated the BD committee with the approval of the Appropriate State Authority. A transplant coordinator (TC) was recruited by FORT and for each of the hospitals. Standard operating procedure guidelines on OD were made available on the hospital intranet. Awareness of corporate and regional administrative teams on OD was communicated during their pan-India meetings. The chief executive officer of the organization pledged to donate his organs. Visiting cards of most doctors and support staff in the organization carried a message on DOD saying, “I support organ donation. Workshops were organized on early identification of potential donors (PDs), donor optimization (DO), family counseling, family support, and documentation. A total of 441 participants completed the 5-d certified course on transplant coordination for doctors, nurses, HAs, and TCs, which was held annually with MOHAN Foundation, based on a syllabus approved by the National Organ and Tissue Transplant Organization. National summits were held annually on various themes of OD with invited expert faculty from Spain, the United States, the United Kingdom, and Australia, often under the aegis of the International Society of Organ Donation and Procurement and the Indian Society of Organ Transplant.FIGURE 1.: Details and location of hospitals carrying out organ transplants that have been involved in the Fortis Organ Retrieval and Transplant program.Possible, potential, eligible, and actual donors were defined as per WHO criteria.5 All possible donors were closely monitored by staff from CC, and those who developed clinical signs of BD in the form of nonreactive pupils and loss of other brain stem reflexes were termed as PD. The treating team and OD committee were informed, and a DO protocol was started. In the absence of contraindications to DOD, the first set of tests for BD, including the apnea test, was carried out by the BD committee. The donor’s family was informed about the possibility of BD, ascertained by a team of 4 doctors. The TC, assisted by staff from HA, took over the grief counseling of the family and introduced them to the concept of OD. Confirmatory tests for BD were performed 6 h following the initial tests, and the family was counseled for DOD by a team comprising of TC and HA with expert inputs from treating teams as necessary.6 Billing was discontinued once the family understood the concept of BD irrespective of their decision to go ahead with the donation. Families of all patients who passed away in the hospital were counseled by nurses trained for cornea donation.7 A DOD Huddle to celebrate the hard work carried out by various departments followed a successful donation. ORGAN DONATIONS There were 113 donors including, 110 from 12 transplanting hospitals and 3 from a single nontransplanting center. The median age of donors was 47 y (range 13–77); 67 (59.2%) were male. The cause of BD was stroke in 76 (67%), head injury in 34 (30%), brain tumor in 3 (2.2%), and ischemic encephalopathy in 1 (0.8%). A total of 352 organs was retrieved, including 188 kidneys, 90 livers, 44 hearts, 12 lungs, and 1 pancreas. Organs could not be retrieved in 1 actual donor because the liver showed a 1-cm lesion that turned out to be hepatocellular carcinoma on frozen section. The variation in numbers of organ donors in various hospitals across the country could be attributed to differences in state legislation, awareness level of the population, and the motivation level of CC teams. Hospital-1, with a highly professional and devoted team, accounted for 44% of all donors and 42% of all organs retrieved. The annual distribution of organ donors is shown in Figure 2. The decline in numbers over the last 2 y was largely due to the COVID-19 pandemic.FIGURE 2.: Annual distribution of number of deceased organ donors.CHALLENGES AND WAYS TO ADDRESS THEM OD does not happen on its own. The process of DOD needs to be supported on a tripod of relevant legislation, public awareness, and best hospital practices. In India, The Transplantation of Human Organs Act 1994 and the Transplantation of Human Organs and Tissues Act 2011 still need to be adopted by 12 out of 28 states and 2 out of 8 union territories, where the declaration of BD becomes legally untenable. Moreover, BD is defined only in the context of DOD in these acts. Doctors in ICU are unsure of what to do when the relatives refuse DOD, as there is ambiguity on the legal position on switching off ventilators.8 A uniform definition of death that encompasses both circulatory death and BD, delinking the declaration of BD declaration from DOD, is required.9 A lack of clarity in law on the use of ancillary tests confirming BD in situations where apnea test is not feasible compounds the issue.10 There is a need for around-the-year awareness campaigns. We have shown that such campaigns are feasible and have considerable reach, albeit at considerable costs. Such initiatives should be part of a national campaign budgeted in the National Organ Transplant Program. Meanwhile, contributions from all corners, no matter how small, should be welcomed and acknowledged, as they would go a long way toward the national goal of achieving the tipping point on awareness toward DOD. Teams from CC are the backbone of deceased donation, and the success or failure of the program is determined by their professionalism and intent. Lack of self-belief and refusal to go the extra mile, despite organizational intent, led to limited results in some hospitals. Less than 800 deceased donors in a year in a country with 95 000 ICU beds suggests that PDs either are not identified or, if identified, do not progress along the pathway of testing for BD, DO, counseling, and DOD. Challenges faced at the hospital level and suggestions to overcome them are summarized in Table 1. TABLE 1. - Suggested actions to counter the challenges faced in organ donation at hospitals Parameter Target Suggestions Positive attitude and ownership toward OD program Hospital administration OD to be included in mission statement of organizationChief executive officer to lead by example by pledging to donate organsVisiting cards from the organization to carry message in support of ODHospital directors to inaugurate all training sessions Neurology and neurosurgery First to be informed by CC team on suspicion of BD in their patientTo be present in the first counseling of family on occurrence of BDTo feature in short films explaining the concept of BD CC Team Clinical lead organ donation earmarked from CC team to own and mentor the program Overcoming “donation hesitancy,” early identification of possible donors and donor optimization CC team Standard operating procedure to be made on OD and to be readily availableODC to be constitutedAll patients with BD, irrespective of contraindication to OD, to be reported early to ODCDonor optimization protocol to be initiated early Declaration of BD CC team Testing for BD, including apnea test, to be encouraged as part of routine end of life care practice. Consent of family not required for testingTraining activities on declaration of BD, engaging with famlies and documentation Counseling of family for OD Transplant coordinators Training of TCs and periodic experience sharingDedicated room for counseling to be made availableTeam approach to counseling Awareness activities and liaison General population Around-the-year awareness events to be organized, both live and on social and digital mediaFAQs on OD to be available in patient waiting areas and on hospital websiteOrgan pledging facility to be made availableBoard on “required request” on OD to be placed outside each ICULiaison with police for assistance in rapid transit of organs and clearance in medico-legal deaths Tissue donation Hospital staff Protocol of counseling for CD following each death in hospital builds culture of engaging and supporting families during their hour of grief Team building Hospital staff Invites to members of ODC, BDC, TCs, and transplant teams for all events related to ODActive participation by transplant teams in awareness activitiesInauguration of events and participation in TV talk shows by CC team members“Organ donation huddle” following each successful ODAwards for best performing hospitals in OD and CD Quality assessment Hospital staff Quarterly internal audits and annual external audits for best practices in OD and tissue donation BD, brain death; BDC, brain death committee; CC, critical care; CD, cornea donation; OD, organ donation; ODC, organ donation committee; TC, transplant coordinator. SUMMARY Two facts emerge clearly from our endeavor. First, there are 2 types of hospitals in the country: those that believe in and carry out DOD and the others that do not. The laws are the same for all. What differs is the intent. Second, strategies toward awareness of an organization and implementing best practices can significantly impact rates of DOD. The impact of these strategies will become evident in months to years. Interventions, however, are not uniformly effective in all parts of the country. Hospitals located in Punjab and West Bengal continued to struggle despite organizational interest, a reflection of the fact that some states need to do more toward facilitating DOD. The number of donors seen at our hospitals may appear small at first glance; however, these are significant in the context of the low DOD rate nationwide. Moreover, it is the first donation, achieved in 13 hospitals, that is the most difficult and the one that breaks the ice. Low utilization of heart, lung, pancreas, and small bowel reflects the fact that the number of programs performing these transplants is still limited. Our data report on the first series of private hospitals with a structured program on OD. Hopefully, others will follow." @default.
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• W4318168375 title "Overcoming Challenges of Deceased Organ Donation in Indian Private Hospitals" @default.
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