|Year : 2021 | Volume
| Issue : 2 | Page : 166-168
A directed deceased donation that never was - A case report
Avnish Kumar Seth, Twinkle Singh
Fortis Organ Retrieval and Transplant, Fortis Memorial Research Institute, Gurugram, Haryana, India
|Date of Submission||16-May-2020|
|Date of Decision||22-Nov-2020|
|Date of Acceptance||10-Feb-2021|
|Date of Web Publication||30-Jun-2021|
Dr. Avnish Kumar Seth
Fortis Memorial Research Institute, Sector 44, Gurugram - 122 002, Haryana
Source of Support: None, Conflict of Interest: None
The family of a 48-year-old female with brain death requested for directed donation of a kidney to her brother. Failure to comply with the wishes of the family due to medical reasons resulted in the withdrawal of consent for the donation of all organs. The status of deceased directed donation is discussed and a checklist suggested for the same in India.
Keywords: Deceased directed organ donation, deceased organ donation, organ donation, organ donation India
|How to cite this article:|
Seth AK, Singh T. A directed deceased donation that never was - A case report. Indian J Transplant 2021;15:166-8
| Introduction|| |
Directed deceased donation (DDD) is a request made by the donor family for the allotment of an organ to a specific recipient for transplantation. We describe our experience with a family who were keen on DDD but withdrew consent for donating all organs once the higher risk of transplanting a kidney with raised creatinine was explained.
| Case Report|| |
A 48-year-old female, known hypertensive for 10 years, developed sudden loss of consciousness at a town, 80 km from the National Capital Region. She was rushed to a nearby hospital, where a plain computed tomography scan of the head revealed a large brain stem hemorrhage with mass effect [Figure 1]. With a Glasgow Coma Scale of 3 (E1M1V1), she was placed on a ventilator and managed medically. The following day, brain stem reflexes were absent and the family was explained the concept of brain death (BD) and organ donation. We received a call from the brother of the patient, explaining that he was on maintenance hemodialysis and was registered for deceased donor kidney transplantation (DDKT) with the National Organ and Tissue Transplant Organization (NOTTO) through our hospital. He went on to say that the family would be willing to donate all organs provided they were assured that one kidney would be allotted to him. We explained that DDD was rare in the country and that we would first have to get in touch with the treating team to ascertain the condition of the patient and then with NOTTO for permission to shift to our hospital for the process of declaration of BD and organ retrieval. The patient was on low-dose noradrenaline with urine output of 50 ml/h, white blood cell (WBC) count of 25,200/cmm, creatinine 1.5 mg/dl, and sodium 143 mEq/L. The chest radiograph was normal. We requested the reluctant treating team for upgrading the antibiotic and initiating donor maintenance protocol. The three requirements from NOTTO, namely precedence of DDD in the country, registration details of prospective recipient for DDKT, and his photographic proof of being the brother were complied with. The patient was shifted to our hospital and the first set of tests for BD confirmed the absence of brain stem reflexes. Laboratory results now showed WBC count 21,280 per cmm, creatinine 4.2 mg/dl, and sodium 152 mEq/L. The family was counseled on the need for donor optimization and risks and prolonged recovery time associated with transplanting the kidney. They refused to accept the higher risk, did not proceed with the donation of any of the organs, and left against medical advice.
|Figure 1: Plain computed tomography scan of the head showing large brain stem hemorrhage with mass effect (twinkle, crop from the top to remove the name of patient and hospital)|
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| Discussion|| |
The concept of DDD is not universally accepted as there are several ethical considerations. The proponents point to how a lease of life to a near one, amidst the loss of another, helps in alleviating the grief in the family. Furthermore, donation and transplantation of other organs would save many lives. On the other hand, the others argue that the WHO Guiding Principle 9 (distributive justice and equity) on allocation based on medical need and not financial or other considerations is violated and the sanctity of the waiting list is compromised. In the US, DDD is legal in accordance with the Uniform Anatomical Gift Act and over 100 such transplants are carried out annually. The donation of a heart from daughter, Patti Szuber to her father, Chester Szuber, attracted considerable attention in 1994. In 2009, the family of a fan directed the donation of a kidney to superstar Natalie King Cole. The United Kingdom, on the other hand, is more circumspect about the concept of DDD. In an oft-quoted situation, when Laura suffered hypoxic brain damage following an asthma attack, her organs were donated, but her mother, Rachel Leake, was not allotted a kidney. Conditional donation is different from directed donation as allocation has riders such as race, religion, nationality, age, and use of alcohol or drugs by the recipient. Conditional donation is discouraged universally.
There is an acute shortage of organs in India with an organ donation rate of below 1 per million population. According to the Global Observatory on Organ Donation and Transplant, only 875 deceased donors were recorded in India in 2018. In this situation, the fact that DDD potentially benefits seven other recipients, merits serious consideration. In India, the Transplantation of Human Organs and Tissues Act 2011 and Rules 2014 are silent on DDD., In 2016, intervention by the Ministry of Health and Family Welfare, Government of India, allowed directed donation of a kidney from a brain dead doctor to his brother, after the state authority at Maharashtra had refused to do so. One has to tread carefully on the path of DDD. We must limit ourselves to the allotment to near relatives and must not go ahead with DDD if the concerned family is aggressive about their intent or not willing to donate other organs. Any suspicion of financial considerations or failure to firmly establish first-degree relationship should lead to rejection. Health being a state subject in India, all states need to publish a government order clarifying their position on DDD.
The person who is directing the donation is often so besieged by the single-minded pursuit of his or her intent at transplanting the chosen one, that altruism, the basic premise in “gifting a life” is readily compromised if the request does not materialize. The family must understand at all times that despite the best intentions and arduous logistical exercise by the donation teams, it may not always be possible to transplant due to last-minute medical issues, including a failed cross-match. In such situations, a DDD initiated living donor kidney paired donation (KPD) has been recently described. In living donor KPD, a living kidney donor who is otherwise incompatible with the recipient donates a kidney to another pair so that a more compatible kidney from that pair is available for transplant. This mutual exchange precludes the requirement of ABO-incompatible kidney transplantation with the associated increased risk and cost. In case of DDD, if the kidney is incompatible, the organ would still be allocated to the same recipient to initiate an exchange so that the previously incompatible recipient would receive a compatible live donor kidney. Something similar may be more challenging but not impossible to achieve in the evolved living donor liver transplant programs in India.
Withdrawal of consent for donation of all organs where when the family realized that their loved one was being deprived of a kidney in our patient is a case in point. Shifting of a possible donor on a ventilator for declaration of BD is to be discouraged and smaller hospitals should be encouraged to apply for sanction for nontransplant organ retrieval centers. Donor optimization guidelines, as suggested by the position statement of the Indian Society of Critical Care Medicine, must be adhered to. A suggested checklist on various aspects of proceeding with DDD in India is shown in [Table 1].
|Table 1: Ten points suggested checklist for deceased directed donation in India|
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| Conclusion|| |
Allocation of organs in a setting of DDD is important in a country like India where a huge gap exists between demand and supply. However, DDD must be carried out keeping in mind the principles of allocation including impartial justice, efficiency and transparency.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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