“Don’t you want to give? All right! But you don’t take either. People must be taught responsibility ”. What does Polish transplantology really look like?

Proven content

In Poland, three times too few organs are transplanted in relation to the needs. – We are still guerrilla, and this must be daily, long-term work for which we must pay well-trained people. But we also need to prepare the society, explain why consent to donate organs after possible death is so important, says Prof. Dariusz Patrzałek, transplant surgeon from Wrocław.

Dorota Przerwa, MedTvoiLokony: Some time ago prof. Tomasz Grodzki, thoracic surgeon and transplantologist, in an interview for Rzeczpospolita suggested that the number of transplants in Poland would increase if the National Health Fund paid more for organ donation. The low amounts provided for in the ordinance of the minister of health include the reluctance of hospitals to report donors.

Prof. Dariusz Patrzałek: Generally, in Poland, organs are harvested from people diagnosed with brain death. This has to be done in a very short time and with care to be absolutely sure that there is no mistake. Procedures have their own rhythm, precise times, what is done and when. A bit like an airplane pilot who has to perform a certain number of steps in order to take off. While the transplant procedures themselves, i.e. the procedure for transplanting a specific organ (liver, heart, lung), are on the verge of profitability, the donor hospital – that is, where there is a patient diagnosed with brain death, and where there is a donation – is underfunded. What does this imply? The hospital is not interested in making the donation.

I agree with prof. Grodzki, that the condition of transplantology in Poland, especially in this part of donation, is largely influenced by the underfunding of procedures, especially when it comes to the identification of potential donors and the diagnosis of brain death. When our community spoke about it, we were dismissed, explaining that there was no money. So if there is none, you have to accept that there will be no better results and please do not require it from us. But no one clearly wants to say that.

This is probably not the only reason for the bad situation?

This is the first element, but not the only one. Organ donation could also be done from a different group of donors, as is the case in other European countries. I mean from people who have had an irreversible cardiac arrest and have not been able to restore it. Of course, brain death is also part of this process, but we don’t diagnose it. We diagnose irreversible cardiac arrest. There is a procedure for that, there are rules for maybe 3 years, but a few other things are needed for it to play.

That is?

First of all, there must be an efficient medical transport system from the place where the cardiac arrest occurred, because it most often happens at home, on the street, in a shop, etc. An ambulance team arrives and undertakes resuscitation. If it is effective, the victim is taken to the hospital and there are usually cardiologists. But often on-site resuscitation is not effective. The ambulance team massages the patient and nothing happens, and this is, for example, a young man. What to do now? You cannot take this man in cardiac arrest to the hospital with a massage. It is impossible to massage in the ambulance, i.e. to maintain the function of this pump, which is the heart, because of safety. Because any sudden stop of the ambulance will be a disaster for the staff. The way out is a mechanical massage system. A special device is put on and this device massages the injured person. I believe that all ambulances should be equipped with such a device. Two years ago, I applied to the Marshal and the Voivode of the Lower Silesia Province to equip at least a few ambulances with such heart massage kits, but it did not help.

How would this translate to organ donation?

We can assure you that a person in cardiac arrest who cannot be resuscitated at the scene will end up in the hospital on this mechanical massage. She goes to the hemodynamic lab, is massaged all the time, and doctors check if the cardiac arrest is reversible. Some of the sick people can be re-circulated at this point, they are saved and this is pure profit. But some, despite all the haemodynamic treatments, cannot be helped, the matter is irreversible. But then you can prepare a procedure for organ donation after irreversible cardiac arrest by further massaging the person. And this is an added value, because we can save a large group of people using this procedure.

This procedure, of course, also requires tests, appointing a commission that will decide that the detention is irreversible, you need to talk to the family, check whether these organs are healthy, whether they are suitable for a possible transplant. The people in the emergency room are willing, but we can’t do anything without the machine.

In Poland, we only have 15 donors per million inhabitants. All our neighbors are better than us. Why?

It must be honestly said that the results of Polish transplantology are comparable to the world results in terms of patient survival or managing patients after transplantation for years. So if a transplant happens, everything is done to the highest standards. The problem, however, is the small number of effective donors. When we look at models of countries that have been successful in transplantation, and these include – apart from Spain, the world leader – Croatia (second in the world in terms of the number of transplants per population), our neighbors, the Czechs (in the top five), or even Belarusians (20 donors per million inhabitants), we can see that these countries have a well-organized system, decently financed, politicians everywhere have set certain priorities. In both the Czech Republic, Belarus and Croatia, changes began with the financing system. A kidney transplant in Croatia brings the hospital twice as much money as in Poland. The same is with organ donation. There is also an extensive educational issue there, not only of the health service, but of the whole society. Various churches help them.

We in Poland are still partisan. We have educated many transplant coordinators, who are key people in the process of organ donation, but these people are not fixed in hospitals, as is the case in Spain or Croatia. There, the coordinator is the right hand of the director of the hospital, who cares about transplants because he is held accountable for them. Our coordinators are people for whom this plot is a fraction of their daily work. Most often they are nurses or young doctors who have a lot of their duties.

Education is also failing?

As an environment, we have tried many times to do various actions, but without the support of the state, it will not work. In the 90s, we developed quite dynamically in Lower Silesia, but then we were helped by pharmaceutical companies. They put quite a lot of money into training doctors and nurses, and the effect was excellent. In Lower Silesia, in the Opole region, we had 25-30 donors per million inhabitants. The West Pomeranian region sometimes reached 40 donors, which is the border that the Spaniards have today. We wanted to continue doing it, but with the state money, and it was over.

Politicians and society must ask themselves what is most important to us. Since health security is very high in the hierarchy of values, let us rely on it, let us not save. Hardly anyone talks about it, but we spend less than 5 percent on health protection. GDP. We are in the tail of Europe. The minimum expenditure on health care is 8-9 percent. GDP. Otherwise nothing will change.

The Church helps?

When we come to the church hierarchs, some talk to us, but when it comes to concrete things, everything blurs. The point is to give a sermon on this subject at least once a year, prepared by a priest and a transplantologist. There are individual priests who help us, but these are raisins. Most are either indifferent or average negative. On the other hand, there is a very small but flashy group, akin to the church, that works in quite the opposite direction. They say there is no brain death, that it can be cured. It’s a small group, but their voice spoils our work. Several years of building awareness are wasted.

Do you see any solution?

The staff in hospitals is reduced to below the minimum risk and thus the doctor “is”, for example, in two places at the same time. There is no strength for this – most often an anesthesiologist in the intensive care unit – to be able to diagnose brain death, when he has 5,6 other postoperative patients in a serious condition. It is known what gradation it will have. He will deal first with those he can save, and whoever suspects brain death will come last.

Therefore, in hospitals there must be dedicated people only for organ donation, they must work in a good system. Because the motivation has to be not only financial. These people must feel that they have behind them, that their activities are supported. The person who deals with the donation in the hospital must have the prerogative of various activities, to view all patients in the hospital, regardless of whether the head of the hospital likes it or not. Because she works in the interest of society.

In Poland, we only have 2-4 percent. family transplants, while in Scandinavia or the USA it is 40 percent.

Because here people think that they are entitled to them. They can get an organ from the deceased, so why should they donate theirs. Our love for loved ones turns out to be declarative. That is why it is so important to work with families and loved ones. There must be media broadcasts on this subject, it should be talked about in school. I have had a few occasions to talk about transplants at school, but how many activities can I do as an active doctor? There must be a group of educated educators here who will travel to these schools on a regular basis.

A few things. First, there is a distrust of health services and doctors in particular. Secondly, it has already undermined almost all authorities. Added to this is the lack of knowledge, sensational media. And we do not know what our deceased relative’s position on the donation was, because we do not talk to our relatives about such sad topics.

But how do you talk about organ donation to someone who has just lost a loved one?

Honestly, accessible, at the right level of reception, in the right environment. The conversation should be conducted in stages and both parties should be prepared for it.

And if I consent to the removal of my organs after possible death, do I have to submit any document stating this, or is it enough that I did not object?

The principle of tacit consent occurs in two variants. The first variant is consistent presumed soft – this is the case in Poland and most countries in Europe. What does it mean? That there is a Central Register of Objections (CRS) located at the Poltransparta. If someone does not want their organs harvested, they make an appropriate declaration and send it by post.

So I did not object, so I gave my consent?

This is implicit consent. Every time we diagnose brain death or irreversible cardiac arrest, when it comes to deceased donors, because we are talking about such donors, we must check in the CRS whether a person with such a social security number, surname, place of residence and parents’ names has objected. Most often – in 99 percent. – we receive information that she did not object. But that doesn’t mean we can donate organs. There are three options for objection. The first is the one in the CRS, the second is a written declaration of will. The legislator did not say on what medium it should be written, it may even be on a napkin. This napkin can be brought by the family and it is also a document. As physicians who deal with a potential donor, we have no way of questioning whether this is real. The family brings this statement, says “he wrote it yesterday, before the accident”, we have to respect that. We are finishing the procedure, there is no organ harvesting. A third option is for two witnesses to certify that the deceased has objected. Nobody can prove otherwise.

What if I write a declaration that I consent to the donation of my organs?

Such a statement is only auxiliary. Because the family comes and says, “but she opposed” and we must respect that. Interestingly, when I started working in the 90s, the number of opposition to collection was about 10 percent. in our region. Now there are more refusals – about 15 percent.

There is implicit hard consent in Austria. Each citizen may record his objection to organ donation in the Central Register of Objections. But if he doesn’t, his organs can be harvested after death. He did not object, so he agreed. No person other than the person concerned has the right to vote.

I believe that in Poland there should also be implicit hard consent. Everyone has the right to object to being a donor, there is no doubt about that, but there should also be an additional educational and fair option: if you do not want to donate after your eventual death, you also take the right to be a recipient of organs from deceased donors. . You don’t want to give? All right! But you don’t take either. People must be taught responsibility, there must be reciprocity and balance. In an educated society that knows that doctors act in accordance with the law, professional ethics, and obey the rules, such a decision should be made consciously. But society must be carefully educated.