Organ donation is the donation of biological tissue or an organ of the human body from a living or dead person to a living recipient in need of a transplantation. Transplantable organs and tissues are removed in a surgical procedure following a determination, based on the donor's medical and social history, of which are suitable for transplantation.

Organ Transplantation has been one of the greatest advances of modern science that has resulted in many patients getting a renewed lease of life. It was included in the top five miracles of the last century. Transplantation would not be possible but for organ donation. Organs can be donated by a living person, after natural death and after “Brain Death” Brain death is a relatively new concept of death that was recognized in Paris in 1959.

The Government of India recognized this as a legal form of death in 1994 and passed an Act called the “Transplantation of Human Organs (THO) Act”. This legislation was also enacted to streamline the activities of living transplants, especially kidneys. Since this act was passed it has been possible to undertake multi-organ transplant activity from brain dead donors in India. After natural death, only a few tissues can be donated (like cornea, bone, skin and blood vessels) whereas after brain death almost all organs and tissues can be donated including critical organs such as kidneys, heart, liver and lungs.

What is brain death?

Brain death usually happens when there is internal hemorrhage and the expanding hematoma cuts off the blood supply to vital sections of the brain thus starving it of oxygen and glucose an leading to death. Bleeding can happen due to a spontaneous rupture of an aneurysmal artery within the brain or more commonly due to a severe head injury that occurs in a road traffic accident. The diagnosis of this condition is clinical and most doctors in intensive care units are familiar with the condition. As we all know the brain is the master conductor that directly or indirectly controls the functioning of the body and once it dies everything is lost. Normally in death as we understand it, the heart comes to a stop first and the brain cells die within a few minutes due to lack of blood circulation but in brain death the reverse takes place.

A patient who is brain dead is in an irreversible state and is totally dependent on ventilators and has a constant need for medications to keep their heart and circulation functioning. This condition was first recognized in an ICU in Paris and was called coma de passé.

Brain death and Organ donation

Brain death is a very tragic situation and mostly results from a road traffic accident involving a young person. The only positive outcome can be organ donation before the machines are switched off. A post-mortem may be required if the patient is involved in a road traffic accident and this entails removal and examination of body parts. The relatives may in this situation consider organ donation. The emotional upheaval of death is most difficult to overcome and accepting the notion of organ donation by the relatives can be very difficult. However, if the body is to be buried and cremated, some of the organs can be donated to give critically ill organ failure patients a second chance in life.

Brain death versus cardiac death 

Cardiac or circulatory death is what most lay people think of when they think about the definition of death. It's typically seen when the heart has stopped beating or is beating too irregularly to sustain life. The heart's main function is to pump blood through the lungs for oxygenation and then out to the rest of the body. When the heart stops contracting, tissues are deprived of oxygen and become ischemic. Cardiac arrest causes a generalized lack of perfusion to all organs, anaerobic metabolism, and global cellular death.

Although cardiac arrest may be reversed with the rapid initiation of CPR and ACLS, most instances aren't reversible. If a perfusable rhythm isn't restored quickly, the risk of permanent damage increases. The sooner circulation is restored the better the patient outcome. After 3 to 5 minutes, brain cells start to die and this damage is irreversible.

Brain death, on the other hand, is the cessation of all brain activity, including all of the activity in the brain stem. It's generally caused by blunt head trauma from accidents, falls, or crush injuries; thrombotic or hemorrhagic stroke, especially when the infarct causes brain herniation; or an anoxic injury that causes the death of brain cells that don't regenerate. Any injury that causes brain death injures the entire brain and its function. Sometimes brain injury is seen in combination with cardiac arrest, which may be the underlying cause of brain death.

Brain death is often confused with a coma or a persistent vegetative state, but they differ greatly. Patients in a coma or persistent vegetative state may have limited brain function, but some areas of the brain still remain intact. These patients often have intact reflexes, take spontaneous breaths, and may respond to stimuli even when higher cognitive functioning is absent. In brain death, there's no function in the brain at all; patients have no respiratory function, no spontaneous movements, and all reflexes are absent. Because the brain doesn’t control the heart, a patient receiving artificial ventilation may continue to have a heartbeat.

Consent Process

Consent is an important aspect of any surgical procedure. In India, we follow what is called ‘Informed Consent’ – where consent is taken from the patient or the next of kin for any operative procedure. Consent is another fundamental principle in the process of organ donation.

1. Required request or Opt-in System

Both in the United States as well as the United Kingdom, a required request is compulsory. While making a request to the family, the entire process of organ donation and transplantation should be explained to the family. The Transplant Coordinator should do this.

In the “Opt-in” system, to express consent, the donor can express consent to donate organs after death during their lifetime or any of the relatives of the donor can give their consent to donate the organs after the death of such person, if they are the ‘next of kin.’

The Transplantation of Human Organs (THO) Act recognizes a person in lawful possession of the body, as the authority to give consent for organ donation of the deceased.

2. Presumed consent or Opt-out System

Countries following presumed consent law include Belgium, Austria, Finland, France, Norway, Spain and Singapore. The success of presumed consent law in these countries has been quite dramatic and to a large extent overcome the shortage of organs.

In the “opt-out” system or presumed consent system, the state assumes that consent for organ donation has been given by the deceased. Only if the deceased has expressed to the state that he or she does not wish to donate an exception is made. An exception is also made in case of minors. Doing away with the on-the-spot consent process means that organs can be retrieved without delay to save many lives. This type of consent is also called Implied consent.

Types of donation 

1. Living Donor Organ Donation

Living donation happens when someone voluntarily donates an organ or part of an organ to a person in need. With the transplant waiting list increasing and the shortage of organs for transplant available, patients in dire need of a life-saving procedure can be aided through living donation. Living donation allows more patients to be moved off of the waiting list, thus increasing the existing organ supply.

A person during his life can donate one kidney (the other kidney is capable of maintaining the body functions adequately for the donor), a portion of the pancreas (half of the pancreas is adequate for sustaining pancreatic functions) and a part of the liver (the segments of the liver will regenerate after a period of time in both recipient and donor). 

Different types of Living donation

Living Near Related Donors: Only immediate blood relations are accepted usually as donor’s viz., parents, siblings, children, grandparents and grandchildren (THOA Rules 2014). Spouse is also accepted as a living donor in the category of near relative and is permitted to be a donor.

Living Non- near relative Donors: are other than the near relatives of the recipient or patient. They can donate only for the reason of affection and attachment towards the recipient or for any other particular reason.

SWAP Donors: In those cases where the living near-relative donor is incompatible with the recipient, provision for swapping of donors between two such pairs exists, when the donor of the first pair matches with the second recipient and the donor of the second pair matches with the first recipient this is permissible only for near relatives as donors. For example, if there were two donor/recipient sets, A and B, Donor A’s organ would go to Recipient B, while Donor B’s organ would go to Recipient A. When multiple donor/recipient pairs are used, this type of matching is called a Paired Organ Exchange. 

2. Deceased Donor Organ Donation

Deceased donation takes place when organs become available for transplantation after someone has died. Donations can take place after brain death or after cardiac death.

Donation after brain death – donation may only be considered after the person has been declared dead. Organs such as the heart, liver, kidneys and pancreas have the best chance of successful transplantation when they have a constant supply of blood and oxygen. A ventilator supplies the necessary oxygen to those organs, enabling them to keep functioning and allowing a window of time for the coordination of the donation process.

Donation after cardiac death – When someone dies after diagnosis of cardiac death, they can only donate tissues for transplantation, as most tissues do not require a constant blood supply to be successfully transplanted. More people will die as a result of cardiac death than brain death. Tissues, which can possibly be donated, are corneas, heart valves, bone and skin.

Myths regarding organ donation

One of the reasons for the donor shortage in the country is the many myths and misconceptions clouding the topic, particularly among those who have not personally encountered transplant recipients or family members of donors. Rumors, myths and misunderstandings about organ donation and transplantation are widespread.

Recent advances in medicine and surgery have undoubtedly served to create awareness amongst the masses that many more lives can be saved by organ transplants, but there is a severe shortage of donors.  There is a crying need to remove the myths and misconceptions associated with organ donations by the living, as much as by those who are dead (known as deceased donations).  Since the sustenance of organ transplants cannot succeed without the majority participation and support of the community, it is important to explore all the avenues and remove the stumbling blocks so that budding donors feel at ease when making a decision to donate.

Some of the myths listed below have a corresponding reality check that we need to be aware of:

Myth: Organ transplantation is still in the experimental phase of surgery and is possible only in the highly developed Western countries

Reality: Organ transplantation involves surgery to remove a diseased organ and replace it with a healthy one. The person who donates the organ is called a “donor” and the patient who receives it is a “recipient”. Transplantation has become one of the most remarkable success stories in the history of medical science. Almost every organ, except the brain, can now be transplanted with very high success rates. It is no more experimental, but an accepted method of treatment of organ failure all over the world.

Myth:  Organ donation is not necessary in India

Reality: Unofficial statistics from India indicate that there are nearly 300 deaths every day due to the failure of organs. That is more than one lac deaths per year. Of the 9.5 million deaths in India every year, at least one lac are believed to be potential donors; however, less than 100 actually become donors. The remaining nearly 99,900 are lost. At an average of five organs per donor that could have been transplanted, almost 5 lac organs are burnt or buried. Organ donation after death is one simple act that does not hurt anyone. There are many people who could use our organs after death.

Myth: Apart from being an altruistic act, my family or I have nothing to gain from organ donation

Reality: That, as a matter of fact, is not true. From the existing data, the glaring reality remains that during our life span, each one of us has more chance of requiring an organ transplant than being a donor! So in case you ever have the misfortune of being afflicted with an organ failure your life then would depend on an organ donor. Thus, in simple terms, the more organ donors there are, the more your chance are!

Myth: I have always understood that when an individual dies, the heart stops beating. Since my loved one’s heart is beating, he is still alive.

Reality: The heart has its own pacemaker independent of the brain. As long as it has oxygen, it continues to beat. The heart could actually be removed from the body, placed in a saline solution, given oxygen, and still continue to beat for a few minutes! This is like a lizard’s tail, which can continue to wriggle even after it is cut off. But remember, this is only for a short time. Eventually, the heart will stop, despite being on maximum life support machines.

Myth: My religion discourages organ donation:

Reality: There are 22 major religions in the world, none of which discourages organ donation. Being a very noble act by which one human can provide life to another most religions support organ donation.

Myth: If I agree to donate my organs, the hospital staff won’t work hard to save my life

Reality: When you go to the hospital for treatment, doctors focus on saving your life – not somebody else’s. You’ll be seen by a doctor whose specialty most closely matches your particular emergency. The doctor in charge of your care has nothing to do with transplantation.

Myth: I’m under the age of 18. I’m too young to make this decision.

Reality: That’s true, in a legal sense. But your parents can authorize this decision. You can express to your parents your wish to donate, and your parents can give their consent knowing that it’s what you wanted. Children, too, are in need of organ transplants, and they usually need organs smaller than those an adult can provide.

Myth: I’m too old to donate. Nobody would want my organs.

Reality: There’s no defined cut-off age for donating organs. Organs have been successfully transplanted from donors in their 70s and 80s. The decision to use your organs is based on strict medical criteria, not age.

Myth: When you're waiting for a transplant, you’re financial or celebrity status is as important as your medical status.

Reality: When you are on the transplant waiting list for a donor organ, what really counts is the severity of your illness, time spent waiting, blood type, and other important medical information. Your income and social status have no bearing when determining how organs are allocated

Myth: If you agree to donate your organs, your family will be charged for the costs.

Reality: There is no cost to the donor's family for organ and tissue donation. Funeral costs remain the responsibility of the family.

Myth: Your history of medical illness means your organs or tissues are unfit for donation.

Reality: Even if you have a history of medical illness including such diseases as diabetes, hypertension and even cancer, your ability to donate organs or tissues will be determined at the time of death. So, if organ donation is important to you, make your wishes known and rest assured that the medical professionals will review your medical and social history to determine suitability.

Myth: “I am an organ recipient, can I be a donor?”

Reality: Organ recipients may not be tissue donors due to the immunosuppressive drugs that are administered. The medical team decides the eligibility of donating healthy organs.

Myth: “If I register to donate my eyes only, will they take any other healthy organs as well?”

Reality: You may specify which organs you want to be donated. Your wishes will be complied with.

Myth: Organ/ tissue removal affects cremation/ burial arrangements or disfigures the body

Reality: Removing organs or tissues will not interfere with customary funeral or burial arrangements. The appearance of the body is not altered.  A highly skilled surgical transplant team removes the organs and tissues which can be transplanted in other patients.  Surgeons stitch up the body carefully, hence no disfigurement occurs.  The body can be viewed as in any case of death and funeral arrangements need not be delayed.

Myth: If I donate my organs it will cause delays to my funeral arrangements

Reality: Yes there is a possibility. However, given the altruistic nature of the donation, families usually accept this and take it as part of the process of donation.

Myth: It is enough if I have a donor card

Reality: No. Just having a donor card is not enough. You need to carry it at all times and also inform your relatives about your wishes so that they honor your want at the moment of truth.

Myth: Once I become an organ donor I can never change my mind

Reality: You always have the option to change your mind. You can withdraw your registration, tear up your organ donor card and let your family know that you have changed your mind.

Pledging your organs

Being an organ donor can make a big difference, and not just one person. By donating your organs after you die, you can save or improve as many as 50 lives. And many families say that knowing their loved one helped save other lives and helped them cope with their loss.

Signing a donor card is the first step to pledging one's organs. The Donor Card enables people to express their wish to become an organ donor. It is like making a will. By signing the 'Donor Card' one has agreed to organ donation. It is extremely important to discuss the decision with one’s family or next of kin because, in case of an emergency or untoward incident, the family will be the first to be contacted. Only after seeking their permission can the doctors go ahead with retrieving the organs.

In the past when the families have not been aware and needed to be counseled on the wishes of their deceased relative, a lot of precious time was lost and sometimes the opportunity to donate was gone.  In Organ donation, time is of prime importance. It is essential for the organs or tissues to be removed as soon as possible after the event of death, or else they become unusable.