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Expanding the organ donor pool

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Dr. Viv Rao
Dr. Viv Rao, Chief, Cardiovascular Surgery, Peter Munk Cardiac Centre and transplant surgeon, Multi-Organ Transplant Program, UHN, is the lead author of a study examining the effects of donation after cardiac death on transplant activity in Ontario. (Photo: PMCC)

Adopting a Canadian policy of determining death by the absence of circulation has increased donation by 57 per cent in Ontario in 12 years, says a new study led by Dr. Viv Rao, Chief, Cardiovascular Surgery, Peter Munk Cardiac Centre.

Dr. Rao, who is also a heart transplant surgeon in the MultiOrgan Transplant Program at University Health Network, compared transplant activity in three distinct eras, from 2002 to 2014, spanning the time before the donation after cardiac death (DCD) policy to after the policy was adopted in Ontario in 2006.

In the recent study published in the Canadian Medical Association Journal (CMAJ), he found the total number of organ donors increased from 132 to 233 per year, with a cumulative total of 2,258 deceased donors and 6,763 deceased-donor transplants. Over the three successive eras, the proportion of DCD donors also increased, with DCD accounting for 21 per cent of overall donor activity in the most recent era, ending in March 2014.  

"Ontario now enjoys one of the highest rates of DCD in North America", writes Dr. Rao, adding that DCD has been the most important development in efforts to expand the donor pool.​

In DCD, death is declared on the basis of cardiopulmonary criteria (irreversible cessation of circulatory and respiratory function) rather than the neurologic criteria used to declare "brain death" (irreversible loss of all functions of the entire brain, including the brain stem). Such donations usually involve patients who are on a ventilator as the result of irreversible brain or spinal cord injuries or end-stage musculoskeletal disease.

DCD is practiced in the U.S. and Europe, including the United Kingdom, where DCD donors comprise about 40 per cent of all deceased donations. This approach was followed until about 1968, when a brain-based definition of death was adopted.

In an accompanying commentary, Dr. Sam Shemie, a critical care physician at the Montreal Children's Hospital, adds that donation after neurological determination of death does not appear to have been adversely affected by DCD.

Both types of donations have increased, he writes, pointing out that donation-focused personnel, such as physicians and nurse coordinators, have also improved the organ donation system.

"This DCD resource has always been there," notes Dr. Les Lilly, Medical Director, Gastrointestinal Transplantation. "But for years and years the organs of these patients have been buried with them, and although there is minimal activity in their brain stem, you can't live with just a brain stem. These are patients who don't wake up."

The impact on increasing donation is huge, says Dr. Lilly, noting that brain death accounts for about 1.5 per cent of hospital deaths. For most patients, death occurs due to cardiac death after life support is removed.  

In Ontario, at any point in time, there are 1,500 patients waiting for an organ transplant, and someone dies every three days while waiting. Currently, about 30 per cent of Ontarians have registered consent to donate.

You can register online at www.BeADonor.ca, the provincial site administered by Trillium Gift of Life network. 

Did you know?

In 2006, Sarah Beth Therien changed organ and tissue donation in Canada.  After suffering a catastrophic heart attack at the age of 32, her parents made the agonizing decision to withdraw life support. They also wanted to honour Sarah's last wish to become an organ donor.

However, Sarah Beth did not meet the criteria of brain death needed for organ donation at that time. With the support of Trillium Gift of Life and the Ottawa Hospital, Sarah Beth became Canada's first donation after cardiac death (DCD) donor. DCD allows for organ donation after life support is removed, rather than having a patient die while on a ventilator.

Two people received her kidneys, and dozens were helped by the gift of her tissue. ​

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