COVID-19: Time for progress in deceased organ donation

COVID-19: Time for progress in deceased organ donation
July 13, 2020 Center for Surgery and Public Health

COVID-19: Time for progress in deceased organ donation

by Manuel Castillo-Angeles, MD, MPH and Joel Adler, MD, MPH with policy contributions from Amanda Reich, PhD, MPH and Esther Moberg, MPH

Part of the CSPH Series “What Comes Next: the Impact of COVID-19 on Surgery”

The shortage of transplantable organs available for the ever-growing number of candidates on the transplant waiting list is a public health crisis in the United States. As of July 9, 2020, there were 110,059 candidates on the waiting list despite the record-breaking 39,719 organ transplants performed in 2019.

COVID-19 is severely impacting the entire transplant system. While much of the national attention has been turned towards transplant centers and who was safe to undergo an organ transplant with its attendant immunosuppression, relatively less attention has been given to the Organ Procurement Organizations (OPO), which are responsible for the conduct and recovery of deceased organs in the country.

Due to COVID-19, the entire process of deceased organ donation has been impacted in ways both expected and surprising. Not surprisingly, donor availability has been lower.  At its lowest, organ donation from deceased donors decreased by 37% during the initial Spring 2020 COVID-19 surge. This impact was felt differently across the country depending on the local incidence of COVID-19.  The practical explanation of this is an outgrowth of how different geographic areas handled the outbreak: stay at home and social distancing orders are associated with fewer traumatic deaths, and fewer hospital admissions for anoxic brain injury from stroke and cardiac arrest; all are the major avenues of organ donation.  The effects of differential exposure to risk factors compatible with organ donation have been palpable.

Another key aspect of the organ donation process that has also been markedly altered due to COVID-19: consent for organ donation. This process, mediated by the OPO, is usually conducted via in-person family meetings. OPOs have had to adapt to performing, often difficult, consent discussions over the phone or via videoconferencing systems. This consent process has been further complicated by social distancing, families may not have been able to see their loved ones in the intensive care units prior to having to make the decision to “donate,” or not. Further compounding the matter, staff filling in on ICU units who lack understanding of the organ donation process have negatively impacted the authorization rates for organ donation.  While there was already much ongoing work into different methods of consent, the limitations of COVID-19 have forced creative and innovative solutions that should be evaluated in the future as part of the standard of care.

Finally, the actual conduct of the donation operation is noticeably affected. The logistics of organ donation, when as many as seven different recovery teams could come to the operating room for a single donor, became more complex. With limitations on the use of personal protective equipment (PPE), travel bans on recovery teams from high prevalence areas, and the logistics of private air travel, the use of local recovery teams has become more common. Prior to COVID-19, most organs had been allocated to a wider geographic area, which forced longer travel times and increased risk to recovery teams. COVID-19 has accelerated the adoption of local recovery of deceased donor organs, which, pending further study on outcomes, is a promising trend in practice for the future, potentially decreasing time to transplant.

In both expected and unexpected ways, COVID-19 has tested the healthcare system. This has highlighted weaknesses in several domains, including the organ donation and recovery process. The original gap, the number of organs procured representing only a third of the possible donors, has been exacerbated by the pandemic. New and creative approaches have been taken to address the need of organ supply for this vulnerable group of patients, and many of these adaptations in practice will remain relevant post-pandemic.

TRANSFORMING POLICY & PRACTICE

Informal, temporary policies that have been utilized during the COVID-19 pandemic that warrant further future exploration and consideration for long-term adoption include:

Virtual Informed Consent Consultations. Although virtual informed consent consultations were in limited use prior to COVID-19, expansion and improvement of these services, including provider training, could improve donor rates. As more health services transition to virtual consultations, better strategies are required for fostering patient trust and satisfaction with this new service delivery mechanism.

Focus on Local. With the default for organ recovery transitioning to local teams, there is an opportunity and need to look at the patient outcomes of local versus national recovery and whether this practice should be maintained. There will also be a need to provide greater support for local recovery teams to ensure they are adequately resourced.