Organ donor debate tied to Medicare contracts

Feds put Medicare at stake over donor efforts

Hospital critical care units can play a vital role in resolving the serious shortage problem of transplantable human organs in the United States. But they are allowing a precious natural resource to slip through their fingers by literally ignoring opportunities for organ procurement at the most appropriate time.

That’s the view of a growing number of organ procurement officials who see hospitals as a vital missing link in an increasingly noisy debate between the federal government — particularly the U.S. Department of Health and Human Services (HHS) in Washington, DC — and nonprofit organ donation interests.

Essentially, the debate centers on how long a terminally or critically ill patient will have to wait to get a badly needed heart, kidney, or lung, who that lucky patient will be, and which state or region will be the one chosen over others.

HHS issued new rules earlier this year that would create a single, national donor list that rations available organs to the neediest individuals first. The rules effectively replace the present system of doling out organs through a network of 63 organ procurement organizations (OPOs) that act as regional centers. Each center essentially sets up its own criteria in determining which patients are first to get available organs.

The single donor list replaces the current patchwork quilt of lists, priorities, and eligibility standards for organ recipients with one set of criteria. The government, however, left the decision of how patients will be selected and added to the list up to the medical community.

Critics of the HHS plan, for example, the Richmond, VA-based United Network for Organ Sharing (UNOS), declare that the new regulations will increase the average waiting period for an organ transplant by years due chiefly to the number of individuals on the national list. It also will reduce survival rates in the overall population by nearly 10%.

The current average waiting time varies from region to region depending on demand and availability of needed organs, say donation officials. UNOS is the principal government contractor charged with managing the nation’s organ procurement system.

Critics also claim that patients who are most in need but have a poor survival outlook may not make the best transplant candidates. And they claim the new rules do not take into account whether children or the aged should take precedence in selections.

Partly for this reason, a Louisiana federal judge imposed a temporary injunction on the HHS plan in September pending an Oct. 14 hearing on a lawsuit, which was filed against the agency by the state’s attorney general.

Fairness of the donation system

The debate, itself, doesn’t directly concern hospitals or their ICUs. It has more to do with how fair and efficient is the system of patient selection and organ distribution. But the debate does raise questions about why there continues to be an alarming shortage of organs available for donation. And some critics are pointing their fingers at hospitals’ levels of interest and commitment to the process.

Many critics, including UNOS, say that there would be no inequity in the system if human organs were more plentiful. Everyone in need of an organ transplant would have one. Critics inevitably place part of the blame on hospitals.

At least one-fourth of all potential organ donation opportunities are missed annually by hospital personnel who simply overlook asking families of terminally ill patients to donate their relative’s organs. Most of the oversight is due to poor training and a relative lack of commitment by the hospital community to organ donation.

"Hospitals aren’t responding in an organized way," says Carol L. Beasley, MPMM, managing director with The Partnership for Organ Donation. The Boston-based nonprofit research and advocacy group is studying ways to improve the nation’s organ procurement system. "Even transplant centers, which are on the front lines of the organ donation process, are doing no better than anybody else."

The federal government is determined to get hospitals more actively involved in the organ donation system. Earlier this year, the Health Care Financing Administration in Baltimore issued a set of directives essentially requiring that hospitals meet certain requirements for procuring and donating human organs as a condition of participation in the Medicare program. About one in five hospitals routinely donate organs. Some 300 facilities regularly perform organ transplantation.

The directives are fairly straightforward and focus on two key mandates:

1. Hospitals are required to notify a local OPO of all deaths that occur in the hospital. The aim is to increase an OPO’s opportunity to determine the suitability of every potential organ donor. The reporting also will enable OPO officials to gather data on death rates at an individual hospital in order to concentrate on certain facilities with high donor potential and work with families of potential donors. The regulation affects all 5,200 U.S. hospitals. There are about 2.1 million hospital deaths reported annually.

2. Hospital ICUs are expected to designate an individual or team to work directly with families of terminally ill patients in obtaining permission to allocate the deceased’s organ to the national donor list. But the stipulation also requires that providers undertake formal training for the designated donor specialist or team.

"This is where the rubber meets the road for ICUs in all this talk about organ donations," says Beasley. "All this yackety-yak may cross the radar screen or may not. But conditions of participation in Medicare make the issue fairly clear for hospitals." Staff training and communication with OPOs make a difference in the rate of successful donations, Beasley adds. (See bar graphs, above left.)

But some hospitals respond to claims they aren’t doing enough by saying that the organ donor issue is too complex to describe in simple either-or terms. "People don’t understand this issue. There is a lack of knowledge not only from the public but among local elected officials and even physicians," says Jane Keihm Hooker, RN, associate director of patient care services at the University of Maryland (UM) Medical System in Baltimore.

Speaking to families about organ donation spills over into someone’s personal beliefs, convictions, and biases either for or against a donation, says Hooker. "The medical profession isn’t geared for end-of-life decisions. We find it hard to approach families to say, We give up. There’s nothing more we can do for your son or daughter. So how about donating their organs to help someone else’s son or daughter.’ It’s not something we as health professionals have been trained to do," Hooker adds. (See survey of physicians’ and nurses’ responses to organ donation, p. 125.)

Although Hooker acknowledges that hospitals generally have done a poor job of supporting organ donor programs, she also notes that institutions can be successful at implementing internal programs that achieve results. In 1997, UM launched an education program to encourage families and physicians to be more involved in organ donation.

Working with the local OPO and neighboring Johns Hopkins Hospital, UM officials began an educational outreach effort to teach the community and potential donors’ families about the donation process. Included were religious and philosophical factors underlying the decision and medical conditions that would bar a patient from donating, including a history of drug or alcohol abuse or HIV infection.

The program also works with critical care physicians and nurses regarding what to consider when approaching families, how these decisions will affect those relatives and their religious convictions, and the emotional factors underlying the death of a loved one and organ donation.

The program has shown early signs of success, according to Hooker. The number of families that gave a yes response to a donation request has climbed to 34% over 24 months from 13% before any formal effort was started. Officials are now studying how the donor advocates got families to agree and eventually will investigate shortcomings that led other families to refuse.

"Working with the families is crucial to the process," Hooker says. "You only get one chance to get either a yes or no from them. You have to know what you’re doing," she concludes.