Almost half a century after Christiaan Barnard pioneered heart transplants at Cape Town's Groote Schuur Hospital, doctors around the country report increasing difficulty in finding suitable donors, reports Business Day. The annual rate of heart transplants in SA has halved in the past 20 years, falling to a mere 25 in 2013, as the public's lack of awareness, deteriorating medical infrastructure and reservations among healthcare professionals combine with deadly effect.
"We are just not getting the number of referrals we used to," says Groote Schuur Hospital transplant co-ordinator Fiona McCurdie. The problem is not unique to heart transplants: "In the 1990s we were doing almost 100 kidney transplants a year. We are now doing just 50 or 60."
The Organ Donor Foundation says the number of deceased donors has remained virtually unchanged despite population growth, and the number of solid organ transplants has hovered around the 300 mark for the past decade. Solid organs include the lungs, kidneys, heart, liver and pancreas.
"Procuring" organs requires a doctor to identify a potential donor and make a referral to a transplant co-ordinator, who then determines whether a patient is a suitable candidate. If so, the co-ordinator seeks consent from the patient’s family and liaises with colleagues around the country to identify potential recipients.
But, the report says, contrary to popular perception, experts say the biggest impediments to organ donation lie within the healthcare system itself. "A significant proportion of families who would donate are never given the option," says Jean Botha, head of liver transplantation at the Donald Gordon Medical Centre in Johannesburg.
There is no legal obligation for doctors to refer potential donors to transplant co-ordinators. Doctors may choose not to make referrals for personal reasons, be too overwhelmed to remember, or decide to give a bed in intensive care to a patient who has a better chance of living.
Patients who have been declared brain-stem dead are potential donors. They are kept on life-support in ICU to keep their organs healthy until they are harvested. The process is medically challenging, requires specialist knowledge and ties up scant resources.
"On any given day, in any given hospital, be it public or private, there is probably at least one potential donor, but they are not getting referred. If the medical profession were forced by law to report imminent death in our hospitals it would widen the net and lead to more donation," say Botha, suggesting a national procurement organisation could be created. Doctors could report imminent deaths, typically patients who have had a massive heart attack, brain tumour or head injury, he says. The Donald Gordon centre has 700 patients on its solid organ transplant list, most waiting for kidneys.
University of the Witwatersrand bioethicist Harriet Etheredge, who investigated the impediments to organ donation for her PhD thesis, found many healthcare professionals feel deeply uncomfortable about discussing the issue with traumatised families. "If you are a doctor in ICU you have probably developed a relationship with a patient and their family. Telling a family that you've lost their loved one is an incredibly difficult conversation … and many healthcare professionals don't want to add to the family's grief," she is quoted in the report as saying. "Their unwillingness in discussing end-of-life issues certainly has an impact on the actual referrals."
Etheredge also found healthcare professionals often assumed a patient's family would be unwilling to donate because of their religious or cultural background, but these generalisations about group preference don't always hold water.
"Personal beliefs are not as significant a barrier as healthcare professionals think. Some of the people who you think might have reservations are actually quite willing to donate."
Many families decline for religious or traditional values that hold a body must be buried whole. Low public awareness about organ donation means many families take a conservative line and assume it is forbidden when it is not, says Mande Toubkin, GM for transplants at hospital group Netcare. Registering as an organ donor in SA carries no legal weight, and so the decision whether to donate lies entirely with patients' families. In practice, healthcare professionals seek consensus. "If we have even one 'no' from a family member, we will not go ahead," says Toubkin.
[link url="http://www.bdlive.co.za/life/health/2015/03/12/doctors-can-double-transplants-but-donors-arent-there"]Full Business Day report[/link]