In Search of Ways to Boost Organ Donations

Despite programs to encourage people to donate their organs for transplant, most state initiatives aren’t working to enlarge the pool of potential donors.

Researchers writing in JAMA Internal Medicine earlier this month said the only thing that seems to work is when states create a fund to promote organ donations.

According to the Organ Procurement and Transplantation Network (OPTN), more than 123,000 patients are on organ transplant waiting lists in the U.S. About 21 people die every day in the U.S. die waiting for a transplant.

Reuters reported on the study, which analyzed a variety of state programs from 1988 through 2010 directed at increasing organ donations from living or deceased donors. They included public education, time off from jobs and tax benefits for donors and revenue pools to promote organ donation.

The researchers compared states that had such policies with those that did not.

The number of states adopting at least one donation policy rose from seven in 1988 to 50 in 2010. By the end of the study period, six states had adopted all of the policies.

Organ donations and transplants increased from 5,909 in 1988 to 14,504 in 2010, according to the data. The only program shown to increase transplantations was the creation of a revenue pool to spur donations, which raised those numbers by about 5%, largely from organs donated by deceased people.

“Unfortunately, the strategies haven’t been effective,” Dr. Paula Chatterjee told Reuters. She was the study’s lead author, from Brigham and Women’s Hospital in Boston.

Admittedly, the study had limitations, such as the fact that different states have different degrees of implementation of policies that could affect the results. The researchers said data on how local communities implement policies should enable them to see which strategies are most effective.

In a companion paper in JAMA Internal Medicine, Dr. Lynne Warner Stevenson focused on patients awaiting a new heart. “I’ve been taking care of patients before and after heart transplants for about 30 years,” she told Reuters, “and I’ve been realizing that my patients are waiting longer and longer.” Stevenson is director of the heart failure program at Brigham and Women’s Hospital.

Her paper tallied the number of heart transplants in the U.S. in 2014 to be about equal to the number in 1994, but showed that the number of people on the waiting list had increased.

Stevenson said about 7,000 people will be listed for a heart transplant, but only about 2,200 hearts will be available.

The larger waiting-list numbers reflect the fact that there are more transplant centers now, and broader criteria for transplant candidates – patients 65 years and older are now included as are those with a body mass index greater than 30 (defined as obese). People with complicating conditions, such as diabetes and a history of smoking also can be added to the list.

“As the transplant waiting list has become longer and waiting times have increased,” Stevenson wrote, “the major route to heart transplants has become deterioration to the most urgent priority status, which accounts for 10% of patients on the waiting list but two-thirds of transplants.”

“We really are overselling transplants, and that’s irresponsible for us,” she told Reuters, and suggested reducing new listings for heart transplants to balance the waiting list. That will take cooperation from patients and physicians.

It’s always tricky to decide who deserves a life-saving resource when there aren’t enough to go around. As Stevenson wrote, “The ethics of allocating hearts for transplant have always recalled the classic lifeboat dilemma of how many people can be allowed to board an already overcrowded lifeboat without sinking the ship and everyone on board. As transplant physicians, we advocate with the best intentions on behalf of our own patients rather than denying transplants to those less likely to benefit. In recognizing our responsibilities as stewards of scarce donor hearts, we should reduce new listings for heart transplants, thus restoring balance to the waiting list and keeping the lifeboat afloat.”

A commentary accompanying both research papers suggested that different methods should be tested to reward people for donating organs. (See our blog, “Why Should Organ Donors Suffer for Their Selflessness?”) “We’ve crossed that line – productively so – years ago,” said Dr. Sally Satel, one of the authors. “We pay for cadavers. … Then of course there are sperm and eggs.”

Instead of a lump sum of cash that would promote an organ free market, the commentary writers suggest in-kind rewards that would come later; for example, donation to a retirement fund, an income tax credit or a tuition voucher. They say such delayed gratification would be beneficial and dissuade people from activing impulsively.

But Chatterjee believes more numbers should be crunched about local policies before reward programs are considered.

Maybe, but the demand for body parts is not going ebb, and the supply is out there, waiting to be tapped.

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