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Title of presentationTitle of presentation

Organ and Tissue Donation in Victoria

Presentation to the Legal and Social Issues Standing Committee 8-9-2011

Dr Helen Opdam

Victorian Medical Director of Organ and Tissue Donation

Intensive Care Specialist,Austin Hospital

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Overview

Donation in Australia and Victoria – the scene in 2011 Factors limiting organ donation? Specific challenges in Victoria? Is it possible to increase organ donation and how? Victorian success to date – the reasons Next steps and future challenges

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Organ donation in Australia and Victoria

– the scene in 2011

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The SituationAustralia has had a relatively low donation rate by international standards

Australia is a world leader in successful transplantation outcomes

Our organ and tissue donation rates were static for many years

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International Donor Statistics 2006

Donors PMP

Source: IRODaT (International Registry of Organ Donation and Transplantation)

33.8

26.9 26.423.2 21.7 20.7 20.1

16.3 15.3 15.1 14.1 13.0 11.4 10.5 9.87.2 6.0

18.8 17.7

Spain

USABelg

iumFran

ce Italy

Finland

Irelan

dCze

ch R

epHun

garyNor

wayGerm

any

Sweden

Canad

aPola

ndDen

mark UKAus

tralia

Greece NZ

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30.425.6 23.4 21.7 19.6

15.9 15.1 13.8 13.7 13.3 13.0 12.69.7 9.4

13.914.8

PortugalUSA

Austria

Italy

Czech

Rep

German

y UKLatv

iaHungaryAustr

alia

Canad

aPolan

dNeth

erlan

dsSwitz

erlan

dIre

land NZ

International Donor Statistics 2010

Donors PMP

© ANZOD Registry

Source: IRODaT (International Registry of Organ Donation and Transplantation)

7

889668740736 860

991

204 202 198 259 247 309

16901757

1625 1650 15991716

0

500

1000

1500

2000

2500

3000

05 06 07 08 09 100

500

1000

1500

2000

2500

3000Deceased DonorsTransplantsWaiting List

2005 2006 2007 2008 2009 2010

Number of Deceased Donors Solid Organ Transplantsand Patients on the Waiting List 2005 - 2010

Australia

© ANZOD Registry

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Before transplantation

After transplantation

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Before transplantation

Australia has excellent transplantation outcomes!

5-year survival ratesLiver transplant - 85%

Heart transplant - 77%

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Australia – Cumulative Donors

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Victoria – Cumulative Donors

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Donors PMP – Victoria & other states

Extrapolated for 2011 (July)

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BD & DCD – Australia Cumulative Donors

Extrapolated for 2011 (July)

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Factors limiting organ donation

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The opportunity for organ donation occurs infrequently

A person has to die in specific circumstances for organ donation to be possible

Only 1 - 2% of people who die in hospital can donate organs

Who can be an organ donor?

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No evidence of: Cancer Untreated major infection Other transmissible infectious diseases

(HIV etc.) Diseases making organs unsuitable

Intubated on a mechanical ventilator in theICU or the ED

Brain death or suitable for DCD

Who can be an organ donor?

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... a person has died when there has occurred

a) Irreversible cessation of all function of the brain of the person, or

b) Irreversible cessation of circulation of blood in the body of the person

Definition of death:Human Tissue Act, 1982

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1) Brain death (most common) loss of all brain function (death of the brain) due to

trauma, bleed, anoxia etc. diagnosed by clinical examination or scan showing no

blood flow to the brain

Pathways to donation

Normal flow No flow No flow

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2) Donation after cardiac death (increasing)

death likely to occur soon (within 60 – 90 minutes) of withdrawal of treatment in the ICU

family can be with patient until just after death, patient then needs to be moved rapidly to operating theatre for donation surgery

fewer organs suitable for donation

Pathways to donation

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The Situation for familiesUsually an unexpected and tragic event for a family

Families may have difficulty accepting the poor prognosis and inevitable death, the need to withdrawal treatment and/or the brain death diagnosis

Families may not know what their relative’s wishes were regarding organ donation

Donation may mean the end-of-life care process for a family may be extended by another 12 to 24 hours or more

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Specific challenges in Victoria

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Some Victorian challenges?

Resources / Low intensive care bed numbers

Cultural diversity

Population spread

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Low intensive care bed numbers

CCR: Intensive Care Resources & Activity: Australia & New Zealand 2006/2007

State WA VIC NSW QLD SA

Ventilator beds/100000

4.65 5.8 6.07 6.58 8.39

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Cultural diversity - Victoria

6.5%of Victorians are indigenous

24%were born overseas

44%have at least one parent born overseas

20%speak a language other than English at home

200 languages and dialects spoken

130religions and faiths2006 Census data

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Victorian population ~5.4 million 3/4 in metropolitan Melbourne 1/10 in eight other urban areas

(Geelong, Ballarat, Bendigo, Shepparton, Melton, Warrnambool, Albury-Wodonga, Mildura)

The rest in towns of fewer than 20,000 or in rural areas

Population spread

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2011 ANZOD data: www.anzdata.org.au/anzod

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2011 ANZOD data: www.anzdata.org.au/anzod

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Is it possible to increase organ donation and how?

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Increasing the donation rate

Possible by: 1) Expanding the donor pool

2) Identifying all potential organ donors in hospitals and ensuring that the option of organ donation is raised with family

3) Higher consent rates

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Increasing the donation rate

Possible by: 1) Expanding the donor pool

2) Identifying all potential organ donors in hospitals and ensuring that the option of organ donation is raised with family

3) Higher consent rates

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1) Expanding the donor pool

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1) Expanding the donor pool

Broadening medical suitability criteria (marginal and higher risk donors)

Donation after cardiac death (DCD)

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Broadening suitability criteria Suitability criteria becoming more permissive

Also depends on recipient characteristics (e.g. transplant urgency)

Risk of transplantation versus ….risk of not receiving a transplant

Note: Hepatitis B or C, history of IV drug use or cured malignancy are NOT contraindications

Refer ALL potential donors to the Victorian Organ Donation Agency for assessment

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Age limitsLungs 2 – 65yrs

Kidneys 1 – 75 (80)yrs

Liver 1 – 75 (80)yrs

Pancreas 10 – 50yrs

Heart 2 – 60yrs

Intestine < 55yrs

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Age limitsLungs 2 – 65yrs

Kidneys 1 – 75 (80)yrs

Liver 1 – 75 (80)yrs

Pancreas 10 – 50yrs

Heart 2 – 60yrs

Intestine < 55yrs

75

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BD & DCD – Australia Cumulative Donors

Extrapolated for 2011 (July)

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DCD - Victoria & other States

July 2011

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Victorian DCD Hospitals

July 2011

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Increasing the donation rate

Possible by: 1) Expanding the donor pool

2) Identifying all potential organ donors in hospitals and ensuring that the option of organ donation is raised with family

3) Higher consent rates

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2) Identification and request

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2) Identification and request Identifying all potential organ donors in

hospitals

Ensuring that the option of organ donation is raised appropriately with family

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Measure the potential for organ donation

Determine rates of consent, request

Identify missed donation opportunities – where and why they occur

Use this information locally and nationally Assess performance, identify barriers to donation,

implement change

Purposes of hospital death audit

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Death audits* - Outcome Over 90000 deaths reviewed 1 in 5 potential organ donors – not identified and/or

organ donation not requested‒ Few missed donors with confirmed brain death‒ Modest number of patients in whom brain death may

have been present but not confirmed‒ Largest group were those with imminent brain death

who have treatment withdrawn

* Victorian death audit 2002-2008 &National Organ Donation Collaborative 2006-2009

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69 yo with intracranial haemorrhage Past health history:

Irregular heart rhythm - on warfarin, high blood pressure

Tuesday 7pm: Headache, slurred speech. Ambulance – poorly conscious (GCS 4), intubated.

8.26pm: Emergency department – Right pupil enlarged and not constricting to light, sedation started

9pm: Both pupils now dilated and not constricting to light

CT brain: Multiple regions of haemorrhage with extension into ventricular system and marked cerebral oedema

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……….. continued Neurosurgical review – surgery will not help, will die. Poor

prognosis conveyed to family 10.45pm: Family spoke to GP who explained in their language the

patient’s condition 11.30pm: Entire family present. Patient extubated, breathing

but irregular and poor effort 11.52pm: Patient has no respiration or palpable pulse. Priest

giving last rites.

(May have been a suitable kidney / liver donor)

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Call ICU registrar or consultant for assessment regarding the potential for organ and tissue donation – (contact details)

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Increasing the donation rate

Possible by: 1) Expanding the donor pool

2) Identifying all potential organ donors in hospitals and ensuring that the option of organ donation is raised with family

3) Higher consent rates

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3) Increasing consent

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3) Increasing consent Consent rate ~ 57% (Australian audits*)

Consent rate lower than that expected from public surveys

Consent rate lower if family discussion held by a junior rather than a senior doctor*

Consent rate higher if request made by someone knowledgeable about and supportive of organ donation

* Victorian death audit 2002-2008 &National Organ Donation Collaborative 2006-2009

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Community and consent90% of Australians support organ and tissue donation

30% of Australians don't discuss their donation wishes with their family

Some families don’t give consent because they do not know the wishes of their loved one

Families rarely overrule a person's wishes if they know what they are

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What can we do?

Public awareness and education

Ensuring that the organ donation discussion with families in hospitals is managed by informed and trained individuals

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Victoria’s success to date – the reasons

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Victoria’s success

National funding and implementation of the reform

Victoria’s prior participation in the National Organ Donation Collaborative (2006 – 2009, 7 hospitals)

Victorian audit of deaths to identify barriers to donation (pilot 1998/99, ongoing since 2002)

Strategy focused on the three areas where it is possible to increase donation (donor identification and request, consent, expanding the donor pool)

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Victoria’s success

New hospital staff – fractionalised FTE

Other initiatives such as the Volunteer program

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New hospital-based staff

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Victorian Hospital-based staff

Medical Hospital Nursing

1.0 Alfred Hospital 1.5

1.0 Royal Melbourne Hospital 1.5

1.0 Austin Hospital 1.5

0.8 Monash Medical Centre 1.2

0.8 St Vincent's Hospital 0.8

0.5 Box Hill Hospital 0.5

0.5 Dandenong Hospital 0.5

0.5 Frankston Hospital 0.5

0.5 Geelong Hospital 0.5

0.3 Northern Hospital 0.8

0.5 Royal Children's Hospital 0.5

0.3 Western Hospital 0.8

Maroondah Hospital 0.5

Albury/Wodonga Health 0.5

Ballarat Hospital 0.5

Bendigo Hospital 0.5

Epworth Private Hospital 0.5

Latrobe Regional Hospital (Traralgon) 0.5

Mildura Base Hospital 0.5

Sale (Central Gippsland Health Service) 0.5

Shepparton (Goulburn Valley Health) 0.5

Wangaratta (Northeast Health) 0.5

7.7 Total FTE 15.6

David Pilcher (0.1)Alvin Teo (0.5)Steve Philpot (0.4)

Bill Silvester (0.4)Steve Warrillow (0.2)Daryl Jones (0.2)Sarah Rickman (0.2)

Johnny Millar (0.5)

Himangsu Gangopadhyay (0.2)Nick Kokotsis (Maroondah) (0.3)

Bernadette Hickey (0.4)Sandra Neate (0.4)

John Green (0.1)Graeme Duke (0.1)Andrew Casamento (0.1)

Gopal Taori (0.4)Felix Oberender( (0.2)David Ernest (0.2)

Forbes McGain (0.3)

Subhash Arora (0.3)Fabrice Pierre (0.2)

Mainak Majumdar (0.5)

David Green (0.5)

Shena Graham (0.6)Maureen Cushnie (0.5)Zillah Day-Smith (0.4)

Jodi Vuat (0.5)

Bridget O'Bree (0.5)

Kathryn Coumans (0.5)

Monica Dowling (0.8)

Nicola Stitt (0.6)Karli Brkljacic (0.6)

Lyn Ireland (0.5)

Julie Clark (0.5)Tracey Mackay (0.6)Vicki Rippon (0.4)

Elizabeth Skewes (0.4)Jacinta Schlitz (0.4)

Yasna Lara (0.5) Kylie Chambers (0.3)

Samantha Brean (0.5)

Ros Roberts (0.5)

Tracy McConnell-Henry (0.5)

Carolyn Hargreaves (0.5)

Catherine Chanter (0.3)Kristie Campbell (0.2)

Jane Morse (0.5)

Jaspreet Sidhu (0.5)

Sofia Sidiropoulos (0.5)Leanne McEvoy (0.5)Louise Bourke (0.5)

Damien Hurrell (0.5)

Joanna Forteath (0.5)

Shymala Sriram (0.2)Treena Quarin (0.2)Tom Rechnitzer (0.2)Rohit D’Costa (0.4)

Gwenda Dortmans (0.5)

Natalie Gaffy (0.25) Angela Walter (0.25)

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Victorian Volunteer Program50 DonateLife Volunteers

Metro City – 10 East – 6 West – 4 North – 4 South – 7 Geelong – 7

Regional East (Gippsland) – 1 West (Ballarat, Bendigo, Gisborne,

Mildura, Warrnambool) – 5 North (Benalla, Mansfield, Tatong,

Wodonga) – 4 South (Moe) – 2

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Victoria’s success Supportive relationships – DonateLife in Victoria (DLV),

Department of Health, Blood Service (host of DLV), Organ and Tissue Authority, Transplant units, Hospitals

Highly committed Agency staff that include: Operations and clinical managers

Organ donor coordinators (8.0 FTE)

Education coordinator, Communications advisor

Donor family support coordinator

Audit coordinator, Administrative staff

Medical consultants

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Next steps and future challenges

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Next steps and challenges

1) Implementation of DCD in further hospitals

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Victorian DCD ImplementationHospital Activation dateAlfred Active (2006)Austin Active (2007)Royal Melbourne Active (2008)Western Active (2010)Geelong Active (2011)Northern Sep‐11Dandenong Nov‐11Epworth Private Nov‐11Frankston Nov‐11Monash Medical Centre Nov‐11Royal Children's Nov‐11St Vincent's Nov‐11Mercy for Women (neonates) 2012Box Hill 2013Maroondah 2013Royal Hobart (Tasmania) 2012

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Next steps and challenges

1) Implementation of DCD in further hospitals

2) Ensuring that there is no loss of a donor due to inability to facilitate a donation (surgical retrieval services, access to ICU beds)

3) Managing the ongoing growth – staffing, resourcing

4) Supporting regional hospitals – barriers to transferring patients to Melbourne for donation

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Where are we going?

Organ and tissue donation as a routine part of end-of-life care

Every potential donor is identified and every family is properly informed and supported to make a decision about donation

Families know each others wishes regarding donation

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Questions?