Physician involvement critical to increasing organ donations

Experts debate how to get doctors to be more a part of the process.

By Victoria Stagg Elliott, amednews staff. Feb. 11, 2002.

As the list of people waiting for transplants grows longer, physicians more than ever are being considered central to the challenge of raising public understanding about organ donation and meeting this important public health need.

However, many experts maintain that the first step will require education, answers and training within the profession.

Barriers for physicians
Links

"Physicians have nothing to be proud of in this area," said Michael A. Scotti Jr., MD, senior vice president of professional standards at the American Medical Association. "All of our patients will die. We need end-of-life training, and nowhere is this education more needed than in the area of organ donation. We will save many, many lives, and what we accomplish in this area will have a lasting impact."

He was speaking at a joint meeting held last month between the AMA and the federal Health Resources and Services Administration to brainstorm about getting physicians more involved in organ donation. The results will be published in a white paper in conjunction with National Organ and Tissue Donor Awareness Week April 21-27.

"The number of donated organs has not gone up, and physicians are fifth or sixth when it comes to information about organ donation," said Priscilla Short, MD, former program director of the AMA's biomedical science and clinical research division. "Maybe that's part of the problem."

But the barriers to changing physician behavior are significant. According to results from several physician focus groups, physicians are concerned about jeopardizing a family's trust, and fear perceived or actual conflict of interest that could even lead to lawsuits.

Many of the focus group participants were also not aware of the regulations and protocols that govern organ donation, and there are significant turf issues. Organ donation is a team effort between physician, health care providers and organ procurement organizations, but who does what is not always clear.

Who does what, when, how?

"It came through over and over how important relationships are," said Lynne Doner, a consultant based in Virginia who organized the focus groups. "Relationships with the [organ procurement organizations], relationships with other health care providers, relationships with patients and their families."

Some doctors said they didn't want to be called in the middle of the night for the required brain death evaluation and are concerned about reimbursement for time spent discussing organ donation.

"The question of most physicians is: 'If I spend time talking to families, how do I code for that and how do I get paid?' " said Lainie Friedman Ross, MD, PhD, assistant professor in the Dept. of Pediatrics at the University of Chicago, during the meeting. "The reimbursement issue is very important."

There is also the question of when a physician's duty to save a life ends and when the time to save an organ for use by someone else begins. Many physicians lack training in recognizing medical futility. There are concerns about where organs go, particularly among some minority groups.

"There's a lack of trust in the health care profession among African-Americans, and they think the organs only go to white people, anyway," said Clive O. Callender, MD, director of the transplant center at Howard University Hospital in Washington, D.C. He has worked for the past 20 years to increase the pool of African-American donors.

A public health issue

Experts at the meeting said that more education and training was needed, but that a true solution may be to shift organ donation from an individual issue, which affects only a small number of people per year, to one of public health, where everyone is a potential donor and everyone is a potential recipient. This would move the issue to a higher position on the medical agenda.

"This is a low-incident event, and very low on the list for physicians," said Susan Marantz, MD, director of the Illinois Dept. of Public Health's Bureau of Medical Programs. "We need to approach it as a public health issue."

One the bigger challenges to increasing the pool of donors, however, is the lack of research into the process.

There have been studies into why some families grant consent, but there are none exploring why some families don't.

Another controversy is whether the physician who takes care of a patient should be the same one to approach the family regarding donation.

"The patient dies, and you turn around and talk about organ donation," said Allen W. Cortez, MD, a general and vascular surgeon with Santa Rosa Memorial Hospital in California. "The perception of the family may be that you did not do everything you could."

But there are also many who believe that a physician's role in organ donation is not at the time of death and should actually come much earlier in the process -- in the nonurgent setting in which patients are encouraged to sign donor cards and share end-of-life wishes with their families.

"Our goal should be to get the physician involved early in the game, not at the time of death, which is the worst time," said Dr. Callender. "The greatest need at the time of death is support and bereavement counseling. The best time to have the physician involved in education is long before any of this happens."

Experts concede, however, that being involved in organ donation may also not be appropriate for every physician.

"Some just aren't any good at it," said Robert A. Metzger, MD, a transplant nephrologist and chair of the organ availability committee at the United Network for Organ Sharing. "They have to be identified and learn to refer."