experience in organ donation in austria and vienna
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Experience in Organ Donation in Austria and Vienna. Ferdinand Mühlbacher Department of Surgery Visit to Kopenhagen 3.3.2010. Basic Structure of Austrian Transplant System. Center based System with little national authority. 3 Medical Universities with Transplant Programs for all Organs - PowerPoint PPT PresentationTRANSCRIPT
Experience in
Organ Donation in
Austria and Vienna
Ferdinand MühlbacherDepartment of Surgery
Visit to Kopenhagen3.3.2010
Basic Structure of Austrian Transplant System
InnsbruckGraz
ViennaLinz
• 3 Medical Universities with Transplant Programs for all Organs
• 2 Renal Transplant Program in non academic institutions (One City)
• 4 Donor Regions
• Donor regions and patient service regions match fairly well
Center based System with little national authority
# of Tx Centers/ Mill PopVs
Cadaveric Renal Transplantation
Transplantation Center
H
H
H
H
LabHLANeurologyEEGSurgLogisticTransport
Decentralized Donor Procurement
Manpower (fte)
Donors 2009
Regional
Coordinator
Center Coordinator
Off hour coordination
North 50 0,5 1 MDOn call doctors
on demand
East 76 1,0 2 MD+2 Secr.
West 36 0,5 3 NursesOn call doctors
on demand
South 50 0,5 2 Students
National 212 3 economists
17,5 fte
Budget (Federal Gonvernment)
€
Budget calculated for Organs 2 .460 .000
Budget effectuated for Organs 24D/M/Y
1.947.000
Returned to Fed. Gov. in 2007 513.000
Budget Expences %
Transport costs 26%
Coodination fee 8%
Brain death fee 6%
Man power 20%
Education 11%
Donor Hosp. reimbursement 29%
Potential of Organ Donors
Estimation between 20 und 80 Donors / Mio /Year• Schuster et al Öbig 1995:
– 85 potential d/mio/year realised 21only• Barber K et al Transplant Proc 2005 37:568
– Out of 22668 ICU death: 1387 (6%) brain death (23/mio/year?)
• Person N Lak 2005– Out of 3114 ICU death; 174 (5,6%)brain death
Critical Steps in Organ Donation
• 1. Donor detection
• 2. Viability / Safety
• 3. Donor management
• 4. Consent / Authorisation
• 5. Organ retrieval / Logistics
The „Donor Chain of Events“
Donor Age
0
25
50
75
100
125
0
25
50
75
100
125
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
≥6045-5930-4415-29<15
1998 - 2007
Achilles´s Heel of Organ Donation
Donor Detection
Enthusiasm
Information
Legislation
Infrastructure
Kooperation
“Singel Person effect”Trauma UnitLBK spender 1883-1990
0
2
4
6
8
10
12
1983- 1984- 1985- 1986- 1987- 1988- 1989- 1990-
Jahrgang
Spender
“Single Person effect”6 month periods
Regional Donor distribution
Inhabitants 2007 2008 2009
North 1.936.648 29,43 22,7 25,8
South 1.757.638 19,91 26,6 28,44
West 1.063.871 33,84 12,5 33,8
East 3.523.137 14,48 18,0 21,57
Austria 8,2 24,7 20,4 25,8
Authorisation
Explicit consent(Japan)
Pure presumed consent(Mandatory autopsy)
No statement available:Include next of kin in the decision making process
There is still an advantage to "presumed consent version", both for doctors and for next of kin
presumed non consentopt in
presumed consentopt out
"Since Henry VIII's time, the sole legal source for corpses for dissectionhad been the gallows - bodies of murderers handed over to the anatomists asa post-mortem punishment."(Introduction, xv)
UK Autopsy Tradition
Ruth Richardson: "Death, Dissection and the Destitute" (London, Routledge & Kegan Paul, 1987)
Gerard van Svieten
1700-1772
-
KAG § 25(1) and Wr. KAG §40(1)
Austrian Autopsy Law
Corpses of patients, who died in public hospitals have to undergo autopsy in case of
• Public health concerns
• Forensic matters and
• Public or scientific interest
Transplantationsgesetz ÖsterreichKAG §62a BGBL Nr. 273/182
(2) Die Entnahme darf erst durchgeführt werden, wenn ein zur selbständigen Berufsausübung berechtigter Arzt den eingetretenen Tod festgestellt hat. Dieser Arzt darf weder die Entnahme noch die Transplantation durchführen. Er darf an diesen Eingriffen auch sonst nicht beteiligt oder durch sie betroffen sein.(3) Die Entnahme darf nur in Krankenhäusern vorgenommen werden, die die Voraussetzungen des § 16 Abs.1 lit. A und c bis g erfüllen.(4) organe und Organteile Verstorbener dürfen nicht Gegenstand von Rechtsgeschäften sein, die auf Gewinn gerichtet sind.
Transplantationsgesetz Österreich
KAG §62b+c BGBL Nr. 273/182
§ 62b. Angaben über die Person von Spender bzw. Empfänger sind vom Auskunftsrecht gemäß § 11 Datenschutzgesetz, BGBl. Nr. 565/1978, ausgeommen.
§ 62c. Wer dem § 62a zuwiderhandelt, begeht, sofern nicht eine gerichtlich strafbara Tat vorliegt, eine Verwaltungsübertretung und ist mit Geldstrafe bis 30.000,- ATS zu bestrafen.
Transplantationsgesetz Österreich
KAG §62a BGBL Nr. 273/182
§ 62a (1) es ist zulässig, Verstorbenen einzelne Organe oder Organteile zu entnehmen, um durch deren
Transplantation das Leben eines anderen Menschen zu retten oder dessen Gesundheit wiederherzustellen. Die
Entnahme ist unzulässig, wenn den Ärzten eine Erklärung vorliegt, mit der der Verstorbene oder, vor
dessen Tod, sein gesetzlicher Vertreter eine Organspende ausdrücklich abgelehnt hat. Die Entnahme darf nicht zu einer die Pietät verletzenden Verunstaltung
der Leiche führen.
Essentials of Austrian TX Law
• Removal of organs from deseased persons allowed– For the purpose transplantation– No personal objection (presumed consent)– Death certified by licensed independent doctor– In public hospitals only– No commercial interest allowed– Piety has to be respected
What is not regulated in Austrian TX Law
• Living Donation
• Organ Allocation
Advantages of Presumed Consent Regulation
• Long tradition in Austria (Autopsy law)
• Personal - not family- decision
• Balances public vs personal interests
• No written decision by relatives necessary
• In favour of transplantation
% Agreement
1. Forensic Criteria: 100Cold, Stiff,Spots, Fermentation
2. Clinical Criteria:Unconscious, No Breathing, No Heart Beat,
3. Brain Death Criteria: 96 / 92 *)No Brainstem Function +Flat EEG
Death Criteria
*) Wamser et al. Transplant.proc. 1992
Controversy About Brain Death
Very dangerous!!
Brain Death vs Brain Stem Death
Pragmatic solution:
„Irreversible loss of all intracranial functions“
Allocation
Basic requirements for Organ allocation
TransparencyEgalitarian Principle -- Utilitarian Principle
Simple
Trust
Leiden
6666
3737
44
3939
2525
3838
ET transplant programsET transplant programs
Total population: 120 Mill.
Allocation:XCOMB (ET)Points Weight Maximum
HLA - A,B,DR Missmatch 100 4 400
Missmatch Probability 100 1 100
Waiting Time 100 2 200
Distance: Donor-Recipient Center
100 3 300
National Balances 100 2 200
1989-2009
Donor- und Transplant-Frequencies in Austria
Deseased Donor Frequencies in Europa*)
Transplant Newsletter Vol 9:1 2008 Council of Europe *)Donors per mill population
Country Inhab 2001 2002 2003 2004 2005 2006 2007 2008 2009
Spain 44,7 32,5 33,7 33,8 34,6 35,1 33,8 34,6 34,8
Austria 8,2 23,7 24,3 23,9 22,6 24,8 25,2 24,7 20,4 25,8
Belgium 10 21,6 21,7 24,8 21,8 20,0 27,1 29,8 25,5
Portugal 10 20,2 21,7 19,0 22,2 19,0 20,1 26,1 26,7
France 60 17,8 20,0 18,3 21,0 22,2 23,2 24,8
Czech.R. 10,3 16,7 18,6 20,5 20,3 18,8 21,1 19,2
Swiss 7 13,2 10,4 13,2 12,6 12,1 10,7 10,7 11,8
Italy 57,7 17,1 18,1 18,5 21,1 20,9 21,7 20,5 21,2
GB 62,9 13,1 13,0 12,1 13,8 10,7 12,9 13,2 13,4
Germany 83 13,1 12.2 13,8 13,0 14,1 15,3 16,5 14,6
Greece 4,5 5,9 8,1 6,5 6,0 8,1 7,1 5,8 8,9
Slovenia 2,0 11,5 17,5 14,0 18,0 10,2 15,0 11,4 19,5
Renal Transplantation in AKH Vienna1965 - 2009
Efficiency of RT in ESRD 49%
48% 48% 49% 50% 50%
49% 48% 48% 46% 45% 46% 45% 46% 45% 44% 45% 44% 40% 37% 35%
51%52%52%51%50% 50%51%52%52%54%55%54%55%54%55%56%55%56%60%63%65%
Ethical Issues in Transplant Legislation
- Cadaveric Source for Transplant Organs- Brain Death Criteria /Determination- Safety / Quality Control- Authorisation- Allocation- Live Donation- Non Profit Rule- Logistics
1.Paar 2.Paar
Empfänger 58 m B 56 m A
Spender 54 w A 36 w B
„Über Kreuz Transplantation“
„Domino“ Transplantation
Empfänger 27 m B
Spender 53 w AB
ET-Spenderpool
Lokale Warteliste
LRD vs LURD vs CAD
Terasaki P. et al: NEJM 333:6, 333-6, 1995
•a) dead upon arrival •b) unsuccessful resuscitation
•c) awaiting cardiac arrest•d) circulatory arrest after brain death confirmation
NHBD Categories (Maastricht)
Targets of Promotion
• >>> ICU Personnel (Communication Courses)
• >> Medical staff at large (Lectures, meetings, Courses, „Medical lay journals“
• > Public. (Donation days, „Media culture“-Information)
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