Spain’s model organ donor system in jeopardy?

Madrid, Spain – Sonia Gallego, 30, was born with polycystic kidney disease. Since birth, she has had ongoing renal dialysis, and undergone three kidney transplants. Now, she is back on the waiting list and on stand-by to receive her fourth kidney.

“He [the kidney] can come when he wants, as long as he arrives all right and stays for many years,” says Sonia with a touch of humour. “That’s the most important thing”. 

Worldwide, there are one million patients just like Sonia waiting to receive a much needed heart, kidney, liver, lungs, or pancreas. According to the Global Observatory on Donation and Transplantation (associated with the World Health Organisation) just 100,000 transplants are carried out each year. Only one in 10 patients will receive a transplant.

Spanish transplant candidates are some of the most likely to receive an organ, since the country has the highest organ donation rate in the world: 35.1 donors per million.

But this achievement could be under threat as the financial crisis in the eurozone has been especially unkind to the healthcare budgets of Mediterranean countries.  

Ireland, Greece, and Portugal, the other EU-member recipients of EU and IMF bailouts, have seen significant drops in their organ donations rates since cuts were implemented. 

In the years just prior to the financial crisis, Portugal’s rate of organ donation ranked as one of the highest in the world. Over the past five years, however, it has dropped from 31 donors per million people in 2009, to 23.9 donors per million in 2012, bringing the country back to 2007 levels.

Despite the economic crisis, Spain has so far managed to retain its high number of organ transplants.

Social responsibility

Eurobarometer, a set of polls conducted by the European Commission, shows that 61 percent of Spaniards would be willing to donate an organ immediately after they die. When asked about donating the organ of a deceased family member, the percentage of affirmative answers was 59 percent. In contrast, only 55 percent of Europeans say they are willing to donate an organ immediately after death.

On the other hand, Sweden, Finland, and Denmark may top the rankings for organ donation awareness in Europe, but their actual donor rates are below 20 donors per million people.

“I wish it was a Spanish thing!” says Dr Rafael Matesanz, director and founder of Spain’s nationwide government-funded body, the National Transplant Organisation (ONT). “When the time comes [to consent to donate their loved ones’ organs,] 85 percent of Spaniards say ‘yes’. That 30 percent difference can be attributed to how the family is approached,” he says.

“We have to individualise each case,” explains Dr Francisco del Rio, an intensive care consultant and the transplant coordinator at the Clinico San Carlos Hospital in Madrid, regarding the critical conversation doctors conduct with family members who have recently lost a loved one.

“I cannot approach a Chinese patient and put my arm on his shoulder because that’s going to produce a rejection,” says Dr Del Rio. “On the other hand, with a Spaniard, my approach will be easier if I put my arm around his shoulder and look him in the eyes”.

In addition, experts say legislation that acknowledges the presumed consent of the deceased donor (although the family’s permission is compulsory), combined with highly qualified transplant coordinators who are permanently on call, have added to high levels of legitimate organ transplants.

“The key [to increasing the rate of organ donation] is to concentrate all efforts in the critical moments. It is important to have the right person at the right moment in the right place,” explains Dr. Matesanz.

The whole process is coordinated and overseen by the ONT, which ensures that organ donations are done without economic incentive and with transparency. It also guarantees that the organ goes to the patient most in need, regardless of financial means.

Austerity cuts

The budget cuts have not directly affected the National Transplant Organization, whose budget has remained steady throughout the crisis. But the cuts have had an indirect impact.

“The National Health System has lost 200.000 workers [since the crisis started],” says Dr Matesanz. In the past four years, the government has hardly hired any new doctors or nurses, and most of those who have retired haven’t been replaced. “The transplant coordination teams have not been properly replaced,” says Dr Matesanz.

“We have grown [in numbers of organs donated and transplanted] with less money and fewer staff. The system is very strong. We’ve made savings but we’ve also been able to better the results,” he explains. 

The ONT is responsible for giving the medical staff specialized training in transplant procedures. Dr Matesanz warns that the current austerity measures will take a toll in the medium to long run: “Intensive care consultants, heart and kidney consultants, and surgeons have not been replaced adequately”.

‘The most caring country in the world’

Doctors and experts are working to reduce the 15 percent family refusal rate. Much work is done in approaching families that come from cultural or religious background unfamiliar with posthumous organ donation. In 2012, 11 percent of organ donors in Spain were foreign nationals.

“Islam promotes organ donation,” says Dr Del Rio. “But many Muslims need to hear it from a religious leader – it’s like a delegated decision. So we bring in the imam. We have never had a problem”.

“We live in the most caring country in the world but there are still some families that refuse [consent],” says Emilio Bautista, 62, who received a heart transplant in 1999 and is currently the president of the Cardiac Transplant Recipient Federation (FETCO), a community of around 7,000 in Spain. “If we get over this handicap, there will be many more organs”.

The Spanish model could also benefit from increasing the harvesting of organs from cardiac failure – 90 percent of donated organs in Spain come from brain-dead donors – and training trauma and emergency physician to detect potential candidates.

In the case of a donor that is brain dead, doctors have up to 12 hours to act – from the minute the death is certified to the moment the last organ is extracted. In the case of a death due to cardiac failure, that time drops to six hours. The first hurdle is to seek the consent of the next-of-kin.

Despite of the growing need for organs, there remains a long way to go before strong donation protocols can be implemented around the world. For example, even the definition of death is not universal. “It’s complicated because of the different cultures and religions,” said Dr Matesanz. “Asia accounts for 60 percent of the world’s population but only four percent of the organs donated in world”.