Just as crops are harvested to nourish the living, Organs from the departed can restore life to others.
Organ donation is an ethically sensitive procedure. Special care must be taken to ensure all the ethical and legal regulations are followed. Not all hospitals are capable or allowed to do organ harvesting and/or transplants. Hospitals must comply with requirements such as operating rooms, ICU beds, etc mentioned clearly in the NOTTO, MoHFW and THOA regulations. (3) After fulfilling the regulations, hospitals have to pay a fee mentioned in regulations by NOTTO/SOTTO to get registered as transplant centre or Tissue banks. No fee is required to get registered as non-transplant Organ Retrieval Centres. Only these hospitals are legally allowed to carryout organ retrieval and organ transplants in India.
Live vs Deceased Organ Donation
Live Organ Donation
If a person who is alive and is voluntarily donating altruistically — it’s Live Organ Donation. Live organ donors can donate 1 kidney, part of liver, and rarely lobe of lung. There are strict regulations regarding live organ donation as there is a high risk of committing criminal offenses by coercion or trafficking people for organs. All the regulations are defined under THOA act 1994. (4)
Non-altruistic donations are rare and strictly scrutinised to prevent disguised commercial organ transplants.
Some of the requirements to qualify as a live organ donor are — donor should be older than 18 years, must be a close relative(children, siblings, parents, grandchild, grandparent) and non-related altruistic live organ donation should be approved by State Authorisation Committee, should donate it voluntarily and should not be coerced or forced to give consent for the donation(in family related cases, donors are emotionally coerced into giving consent for organ donation).
Living organ donation can be risky for the donors. The organ donors should follow up for the rest of their life after organ donation to monitor their health and related outcomes. The follow up is not legally required, but most hospital SOPs(standard operating procedure) do mandate follow up of live organ donors. The major risk is the risk of undergoing a surgery for retrieval of organs which directly puts the organ donor at risks associated with surgery. Living organ donors should properly assess their health conditions and reflect on their future goals before committing to donate organs as living organ donation can affect the quality of life of the donor. Most of the studies indicate normal to near-normal outcomes of quality of life in properly selected donors.
Living Donor Liver Transplant (LDLT) and Living Donor Kidney Transplant (LDKT) make up the majority of transplants in India.
Deceased Organ Donation
If the donation takes place in accordance with the dead donor rule — it’s Deceased Organ Donation.
Dead Donor Rule
Dead Donor Rule says,
“Organs can only be retrieved from a person who is legally and medically declared dead. Organ retrieval itself must not be the cause of death.”
Deceased organ donation can take place after brain death DBD(Donation after Brain Death) or circulatory death DCD(Donation after Circulatory death).
Dead Donor Rule is strictly followed to ensure patients receive the best care from treating physicians team and to comply with ethical and legal criteria for deceased organ donation.
Deceased donation is considered ethically optimal as it avoids harm to the donor. Donor is at ZERO risk from procedures of organ donation. Unlike living organ donation which comes with multiple risks and change in quality of life after donation, deceased organ donation does not affect donor in any way. The body of the donor is handled with dignity. Most of times, skin tissue of chest is harvested from below the level of clavicle and face is left untouched. In most of the cases cosmetic reconstruction is done to ensures the donor’s body looks almost similar before and after organ retrieval surgery.
India recognizes brain death legally under THOA. However, DCD is not yet widely implemented due to logistical and clinical challenges.
Chronology of Organ Donation from donor POV
In cases of deceased organ donation, the donor is actively managed to achieve management goals of organ donors. This includes management of vitals, electrolytes, pharmacological management, infection prevention, and lung protection strategies to protect lungs.
Consent
In case of live organ donation, the patient’s voluntary consent which is active and ongoing — meaning the donor can opt out of organ donation at any stage of organ donation— is taken. In case of registered deceased organ donor, a thorough counselling session by transplant coordinator with the family is done to introduce organ donation and help in the grieving process and take consent of family for organ donation. In India, organ donation consent is opt-in type, meaning donors have to register as organ donors to be considered for organ donation. The final say on consent for organ donation lies with family and/or next-of-kin. If family refuses the consent, organ donation cannot take place. This is why its important to discuss about organ donation with family and next-of-kin before getting registered as organ donation in India.
In countries like Spain, its opt-out type —meaning the consent for organ donation is presumed to be given unless they opt-out as donors.
The final decision of consent lies with the family. If family or next-of-kin don’t give consent for organ donation in India, the organ donation cannot take place.
Medical tests
After the consent is taken, in cases of DBD, controlled DCD and live organ donation, patient is tested for organ viability and compatibility through various scans, blood tests and urine tests. Thorough history of the patient is taken to rule out risks such as malignancies. There is no age limit for organ donation.
In cases of uncontrolled DCD, organ retrieval is done as soon as possible due to time constraint and warm ischemic time. Limited tests are done in the operation theatre simultaneously with the organ retrieval surgery.
Family time
In deceased organ donation(both DCD and DBD), prior to treatment withdrawal and/or organ harvest operation, family is allowed to spend time with the donor.
Forensics clearance
In some countries, for suspicious causes of death a forensic pathology report should be given prior to organ retrieval operation. In India, Medicolegal cases need a mandatory forensics Post Mortem(PM) clearance before Organ Retrieval Operation to ensure evidence is not tampered with during the procedure.
Organ retrieval operation
The consent form clearly mentions which organs and tissues are being donated by the donor and accepted by the family. Only the organs mentioned in the consent form are harvested.
All organs and tissues of a donor are NOT harvested. Only the organs and tissues mentioned in the consent form are harvested.
Organ retrieval operation takes place according to the regulations set by different countries. The organ retrieval operation is often done simultaneously with organ transplant operation.
Organ retrieval operation is done in proper sterile setting and the deceased organ donor is treated with dignity and proper medical procedure is followed. The surgeons follow sterile procedures, use standard incisions for organ retrieval and suture the incisions. During the operation, organs(Heart, Lungs, Liver, Pancreas, Small bowel, Kidneys) and tissues(Cornea, Skin, Blood vessels, Heart valves, Bones, Tendons) are retrieved. The skin on face and chest are not harvested to preserve the appearance of the donor. The donor is wrapped in bandage and treated with dignity in the operating theatre.
In India, Hospitals manage everything related to organ harvesting, and organ transplantation while complying with regulations set by NOTTO/SOTTO under THOA. Tissue banks in India are registered separately and work to procure and store tissues like corneas, bones and tendons. Police and Traffic personnel coordinate with hospitals in the transport and logistics of organs from one hospital to the another through green corridors.
In USA, almost everything from organ procurement, family counselling, consent, logistics and transplant are managed by independent non-profit Organ Procurement Organisations. This reduces burden on hospitals and helps speed up the procedure of organ transplants.
Final rites
The donor is handed over to the family and assist with the transition from hospital to the final rites.
Cold vs Warm Ischemic Time
Organs in our bodies are functional under ideal conditions of PH, O2 Concentration, electrolytes, temperature, etc. When organs are removed from our body, they are prone to ischemic damage as their blood supply and consequentially oxygen supply are cut off. Organs are preserved in preservation fluids similar to plasma/ interstitial fluid at 4oC. This cold temperature slows down cell metabolism and delays apoptosis and necrosis.
Warm Ischemic Time
Warm ischemic time(WIT) is the time from cut off of blood supply during organ retrieval to perfusing and/or cooling organ with the preservation fluid at 4oC. This is the time when organs suffer most of the damage. WIT is a critical factor in DCD.
Cold Ischemic Time
Cold ischemic time(CIT) is the time organs can remain viable in the cold preservative fluid. The time before which organ transplantation should take place.
Organ Logistics and Green Corridors
Not all hospitals are authorised to perform both organ harvesting and organ transplantation. It’s important to manage logistics and transplant of organs from hospital certified as only organ harvesting centres — they can only retrieve organs from donors when transferring patients to higher tier hospitals is not viable— to organ transplant hospitals.
Green Corridors, first developed in 2013 in Chennai are now used nationwide. Certain routes are certified as green corridors serve as traffic free routes during the transport of organs from one hospital to the other. The transport is coordinated and assisted by the police and traffic departments to ensure traffic free and fast transport of organs as quickly as possible.
Green Corridors have significantly reduced organ ischemic time in cities like Hyderabad, Mumbai, and Delhi.
SWOT analysis of Organ Donation in India
How organ transplantation works in India? TL;DR version
India has a national Organ and Tissue Transplant programme run by NOTTO(National Organ and Tissue Transplant Organisation). (1)
This programme operates at three levels. National(NOTTO), Regional(ROTTO) and State(SOTTO) levels.
Jeevandaan (Telangana state's SOTTO programme) is the most successful programme. Telangana recorded highest number of cadaveric organ donations when compared with the national average and other states. (2)
The protocol of how the Telangana's Jeevandaan operates can be referred in the attached link. (3)
The legal legislation that dictates the legalities of transplantation is the THOA 1994 (Transplantation of Human Organs and Tissues Act). The act was amended several times to put a clear transparent protocol in place to prevent organ trafficking and other illegal activities. (4)
NOTTO released SOP(Standard Operative Procedure) for each Organ retrieval. (7)
India recognises brain death and cadaveric organ and tissue donation of both brain dead and cardiac death donors. The guidelines to managing brain death patients pre organ donation are provided by MoHFW and NOTTO. (8)
In Indian transplantation landscape, living donor transplants make up about 84% while deceased donor transplants make up only 16% (according to the data of the MOHFW NOTTO report year 2023). (6) The reasons stated (by public surveys/polls but not formally quantified by scientific studies) are lack of public awareness about the deceased organ donation and families presume they have to pay for organ donation operation. Steps are being taken to tackle these challenges with awareness programmes at district level. (5)
As per NOTTO (2023), approx. 15,000 organ transplants were performed in India, but estimated demand exceeds 200,000 annually. (6)
Green corridors development started in the year 2013 to ensure traffic free routes between hospitals for logistics of organ transport from harvesting centres to organ transplant centres.
How to register as an organ donor in India?
Enter your Aadhar number to login.
Enter your details and your next-of-kin details — mentioned as emergency contact.
Select the organs and tissues you want to donate.
Click submit.
You will receive a organ donor registration certificate as a confirmation of your registration.
If you needed an organ transplant would you have one? If so, please help others.
Register as an organ donor here https://notto.abdm.gov.in/register
Now we are familiar with the technicalities of organ donation. Lets move on to discuss the Ethical Concerns related to Organ Donation in coming up article of this 3 article series, “Why it took me a month to get registered as a Deceased Organ Donor?”
AI Disclosure
This article series is the original work of the author. AI tools such as ChatGPT were used only to identify and correct factual inaccuracies.
Postscript
This article is for educational purpose only. This is an effort to raise awareness about organ donation and the potential of 1 organ donation in saving 7 lives and improving quality of life of many more. Do not take this decision impulsively. Discuss about organ donation with your family and friends before registering yourself as an organ donor.
References and Resources
National Organ and Tissue Transplant Organisation | NOTTO
Jeevandan portal | Jeevandan
Jeevandan Transplantation Guidelines of Telangana state | DMETelangana
The Transplantation of Human Organs and Tissues Act, 1994 | IndiaCode
NOTTO organ donation statistics information | NOTTO
Data of Organ Donation and Transplantation 2013-2023 | MohfwReport
Standard Operative Procedure | MoHFW
Management of the brain dead organ donor in the operation theatre (OT) | MoHFW
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