Rejuvenating Ontario’s critical care
Organ, tissue donation specialist hopes to bring same successful program implemented in Spain to fruition at Ontario hospitals
BARBARA TURNBULL A Spanish kidney specialist who turned that country into a world leader in organ and tissue donation believes he can do the same for Ontario’s transplant program. Dr. Rafael Matesanz was in Toronto last week, learning about Ontario’s organ and tissue transplant system and sharing insights on how to improve it. He will prepare a blueprint report to help boost the province’s low rates of deceased donation and continue to advise as changes are implemented. A time frame has yet to be hammered out. “I really believe now that we are on the right path and that Ontario will become a beacon of organ donation within a short period of time,” says Dr. Gary Levy, who created the Multi-Organ Transplant Program at Toronto General Hospital. “We should be able to double and triple rates of deceased donation.”
Levy created a jam-packed, two-day itinerary for Matesanz with meetings with everyone from Health Minister Deb Matthews to transplant nurses, doctors and volunteers with Trillium Gift of Life Network, the provincial agency mandated with organ and tissue donation and transplant.
The trip was paid for by the hospital’s Birmingham Family Fund.
In an exclusive interview with the Star, Matesanz, 63, describes the Spanish Model as “the professionalization of organ donation.”
Right now in Ontario to get a transplant a hospital must contact Trillium when a potential donor is available. Matesanz’s model, based on compassion and understanding, has trained specialists at every hospital.
The premise is that organ shortage is the failure to accurately identify potential donors, obtain the consent and procure the organs.
“In many countries organ transplant is at the summit, but not much attention is paid to organ donation,” Matesanz says. “We want a very active system, where you can change the person from dealing with tragedy. “We are what we can say is proactive.” The model has four main components: A trained hospital coordination team. A transplant co-ordinator who obtains donation consent from the family and is switched out every three years to avoid burnout.
Aproactive referral method of possible donors to critical care units.
The referral to and management of potential donors in the ICU. The Spanish government addressed the donation issue in 1989, after a medical strike two years earlier sent rates plummeting 20 per cent. Matesanz was hired to improve the system. At the time, Spain had a rate of 14 donors per million citizens. About 1,000 kidney transplants a year were performed.
Matesanz began his work looking at his own hospital and noticed patterns.
“It was very dependent on the person who was on duty,” he says. “There were some of my colleagues who always got the organ and some who never got the organ. It was very person-dependent, not (donor) family-dependent.”
He realized the most successful colleagues were specially trained critical-care specialists.
“It was very clear for me we should establish professional transplant coordinators, who should be an intensivist,” Matesanz says. Physicians or nurses already working in the intensive care unit were ideal.
“We started with this philosophy and just in two or three years, we went from (being low) ranked in Europe to first in the world,” he says.
Spain now has a donor rate approaching 35 per million, and performs 2,600 kidney transplants a year. Many Ontarians wait up to 10 years for a kidney; in Spain the average wait is less than eight months.
Fewer than 1 per cent of donated organs in Spain come from live donors, whereas in Ontario last year 50 per cent of organ transplants were from live donors. Ontario’s deceased donor rate is less than 19 per million.
The Spanish transplant system operates under presumed consent, which means everyone is considered a donor unless they opt out, says Ronnie Gavsie, the CEO of TGLN. Many countries have that system in place, and there have been calls to adopt it here, she adds. While proponents believe that sways more families to agree to donate, Matesanz is adamant presumed consent bears no influence on donation rates, Gavsie says. It was introduced in Spain 10 years before Matesanz was hired. Success is largely about approach. “(The key is to) have a very good trained doctor, who can detect every potential donor and then approach the family,” says Matesanz. “At the end, the results are good.” Most countries in southern Europe have adopted principles of the Spanish Model, as has much of Latin America. Northern Europe is similar to Canada, which has a “wait and see what happens,” philosophy, dependent on a generosity, Matesanz says. “I’m sorry, but this is not (effective),” he says. In Britain 40 per cent of families who are approached to donate a loved one’s organs refuse, Matesanz says. But in a study of 200 cases of British tourists who suffered catastrophic accidents in Spain, fewer than 9 per cent refused. “So something different is happening,” he says. “It’s not putting pressure on the family. What we’re doing is learning the best approach. We analyzed and compared what methodologies have the most consent.” Gavsie believes Matesanz can be influential in improving the odds for the 1,500 Ontarians awaiting a lifesaving organ transplant. “He actually has the empirical proof, because they have tried various approaches and have found what works and what doesn’t,” she says. Letting the family speak, while the co-ordinator listens, turns out to be a crucial factor. “If you take the time, you get empathy with the family and finally, in many cases, it’s the family who offers you the organs,” Matesanz says. Organ donation is now widely viewed as an opportunity in Spain. “It’s not an obligation, it’s a right,” he says. Spaniards accept that organ and tissue donation benefits everyone, because anyone can find themselves on the waiting list at any time.
“It’s a source of national pride,” Matesanz says. “We are very proud to contribute to the system.”