To the Editor:
There are considerable differences regarding transplantation among various countries. Unfortunately, Greece is at the bottom of the list of western European countries regarding the number of organs transplanted per population (1). This is in direct contrast to the fact that the country is on the top of the list of western European countries regarding the number of motor vehicle accidents (1). Furthermore, organ transplantation is approved and supported by the government, the medical profession, public and private organizations, media, and the Greek Orthodox Christian religion and church. In Greece, the National Organization for Transplantation is in charge of operating a centralized nationwide system of transplantation that is responsible for various practical aspects of organ procurement and allocation (center driven system). The public authorities have made considerable efforts during the last years to help increase the organ procurement. A specific important effort has been the vote and the implementation of the law for giving the opportunity to each citizen to consent in becoming a potential organ donor during several instances, including the general election day. However, so far Greece has informed consent for organ donation.
Although the appropriate health services infrastructure to support transplantation programs is available and transplantation programs for heart, kidneys, liver, skin and cornea function successfully in the country, there is a shortage of organ donation that inhibits the further growth of transplantation programs. The first successful transplantation took place in Greece in 1968 (kidneys), in 1969 (kidneys and pancreas) and in 1990 (heart and liver). We report our experience from the donation by brain death program in Henry Dunant hospital, a tertiary medical center in Athens, Greece.
Out of 7850 adult patients (70.6% males), of mean (± SD) age 63.4 (±14.8) years, admitted to the general intensive care unit (ICU) of our hospital from January 01, 2001 to June 15, 2005 with a mean (± SD) ICU stay 3.7 (± 8.1) days, 538 patients (6.9%) died during the ICU stay. Fifty-four of 73 (74%) patients with documented brain death diagnosis (positive tests) were potential organ donors. We asked for organ donation the close relatives of 48 (89%) of these patients. Organs were taken for transplantation from 24 (50%) patients. Organs procured and tissues were kidneys (46), liver (13), heart (7), lungs (4), pancreas (1), cornea (31), skin (9) and bone (1). Donor conversion rate per ICU beds was higher in our hospital compared to the rest of the ICUs in the country (24/24 vs. 248/520 donors/ICU beds, p = 0.01).
We considered several factors in our attempt to identify the ingredients for the success of our donation by brain death program. We concluded that the main reason for the better donor conversion rate in our hospital compared with other Greek hospitals lies in the efforts of the ICU staff. The medical, nursing and administrative ICU staff having special training was inspired to become dedicated to the idea of organ transplantation. They work hard to explain to the relatives of potential donors the exact meaning of brain death in order to overcome their considerable reluctance to accept the idea of brain death, a problem that is common in several countries (2–5). The method that the staff employs in discussing donation with potential donor's families is based on their firm belief for the merit and the paramount importance of organ transplantation. This maybe the main difference between this center and other hospitals leading to higher conversion rate for informed consent in our hospital. The director of the ICU (and in his absence one of the two deputy directors of the ICU) performs in person the request for organ donation after the documented brain death diagnosis. Intensivists perform the tests in all patients with possible brain death in order to document brain death. Following this documentation, they try to persuade the family of the potential donor to sign the informed consent after a full explanation of the meaning of brain death. They also emphasize the problem of organ shortage resulting in death of patients with terminal disease who are in the transplantation lists as well as the beneficial consequences of transplantation in life or quality of life in this group of patients. Greek people have the culture to donate organs for transplantation, but some of them do not fully accept the meaning of brain death. There are substantial differences between relatives of consented and non-consented donors in culture, philanthropy and realism. People having religious fanaticism or belonging in religious dogma, e.g. Jehovah's witnesses usually hesitate to donate organs. In addition, the relatives of younger patients (less than 25-years-old) with brain death usually have more difficulties to donate organs. In Greece, a small percentage (less than 20%) of citizens and residents has decided and signed an informed consent regarding their will to donate organs when brain death occurs. The characteristics of our non-profit private hospital and the population it serves did not seem to explain the observed differences. In Greece, the intensivists are always the requestors for consent from the relatives of patient with documented brain death. There is no conflict of interest in Greek intensivists for this important issue.