Everybody agrees that organ transplantation is the best and, often, the only treatment for patients with end-stage organ failure.1 Overall, it is also the least expensive treatment modality.2 However, no transplant is feasible without organs, and no organs can be made available without donation. Although living donors can sometimes contribute to the donor pool, there remains a shortage of organs. No organ donation and transplantation system can reach self-sufficiency without deceased donation.3
However, to the layperson and to many theoretically better informed interlocutors, deceased donation is synonymous with public sensitization.
Spain is a world leader in deceased organ donations.4 Prof. Matesanz, the father and creator of the Spanish model, did not attach a great importance to public sensitization.5 According to his experience, the deceased donation rate in Spain improved markedly without a significant change in the attitudes of the Spanish population.6 In the Spanish model, the improvement in the deceased donation rate was rather the result of an improvement in the in-hospital coordination network. Indeed, a quick review of the various steps in deceased organ procurement procedure will clearly reveal the important role of health professionals. Deceased organ donation rests on 4 essential pillars7: a favorable legislation, a solid infrastructure, well-trained health professionals, and a trusting supportive public.
In Lebanon, we were fortunate to have a valid legislation since 1983. Although it needed some amendments, the essentials were there. Deceased organ procurement in Lebanon was established with the financial and technical support of the Spanish Agency for International Development Cooperation (AECID) and the Donation and Transplantation Institute (DTI).8 In our initial approach to the problem, we were, naturally, influenced by the teachings of our Spanish tutors.
We started accordingly by establishing a solid basic infrastructure, adapted from the Spanish model. It consisted of a central office housing the national waiting list and the donor card registry. This office is under the control of the national coordinator. It is linked to an immunology laboratory developed initially with the devoted help of Prof. Masri. The central office is in continuous contact with all of the donating hospitals.
The next step was to form a knowledgeable team of health professionals to act as in-hospital coordinators. We carried on several specialized courses to this effect. Deceased organ procurement presented a series of challenges, and we decided to meet them one by one.
To improve donation and referrals, we adopted the Deceased Alert System.9 This system involves the timely referral of all patients presenting to the hospital with an advanced Glasgow coma scale. The neurological criteria of death have differed from one center to another and even from one neurologist to another in the same center. This diagnosis was regarded as a cumbersome chore that did not deserve to be performed so extensively. Based on the Lebanese law and the recommendations of the Lebanese Scientific Society of Neurology and Neurosurgery, NOD-Lb issued unified diagnostic criteria and supervised their implementation.10
Rather than losing precious time, in what was considered the futile management of a patient with no treatment options, it was so much easier to issue a DNR (Do Not Resuscitate) order. We decided to ban the DNR order and replace it by a unified algorithm for the management of the deceased donor.
To ensure the cooperation of the hospitals and their intensive care unit staff, we convinced the MOH (Ministry of Health) to include organ procurement in the accreditation criteria of the Lebanese hospitals,11 and planned regular audits to make sure that all the steps were being enacted.
At this stage, we felt that our mission had been accomplished, and we were looking forward to impressive results. These results were, however, below our expectations. Although all steps were followed, our coordinators were frustrated by a high rate of family refusals. We had not involved the public enough.
It was obvious that what was true for Spain did not fully apply to Lebanon. We have to sensitize the public as well. We had to build public trust and support. We decided, accordingly, to introduce the concept of deceased donation in the curriculum of medical and nursing faculties and to extend the program to involve complementary and secondary institutions.
In 2019, we provided our education material to the Center of Educational Research and Development to be reviewed and implemented. We also started, in parallel, educating trainers in charge of disseminating the culture of organ donation in Lebanese schools. We organized several national sensitizing campaigns,12 which included television and radio advertisements, billboards, and posters with the participation of donor’s families and well-known actors, singers, and journalists.
A problem remained: we needed to overcome the religious taboos that surrounded deceased donation. Religious officials were more than cooperative. Preliminary meetings in 2010 had emphasized their positive attitude. In 2016, the religious leaders insisted on underlining their unequivocal support of deceased donation by signing their donation cards in public. However, a significant portion of the public somehow did not get the message. In 2019, we revisited these religious leaders one by one to ask them to press their local officers to promote deceased donation through their Fridays or Sunday services.
In conclusion, it is obvious that there is a dual aspect to organ donation. Although it is clear that infrastructure, legislation, and education are necessary, they are not by themselves sufficient, and public support is also essential. A negative public attitude should never be used as an excuse. It has to be analyzed and clarified.
It had taken us years to get ready, and we felt that we had finally reached our goal and were dreaming of brilliant future achievements. Unfortunately, COVID-19, a disastrous economic crisis,13 and political unrest14 threatened to annihilate the efforts of all these years. But we decided not to give up! With the providential help and support of good friends such as Prof. Haberal, we will continue to fight.
Volume : 20
Issue : 3
Pages : 1 - 2
DOI : 10.6002/ect.MESOT2021.L9
From the National Organization for Organ and Tissue Donation and Transplantation (NOD-Lb), Baabda, Lebanon
Acknowledgements: The author has not received any funding or grants in support of the presented research or for the preparation of this work and has no declarations of potential conflicts of interest.
Corresponding author: Antoine Stephan, NOD-Lb, Habr & Khoury Bldg, 1st floor, Baabda, Lebanon
Phone: +961 5 760760, M: +961 3 532908
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