Examination of Witnesses (Questions 275
- 279)
THURSDAY 28 FEBRUARY 2008
Ms Jayne Fisher
Q275 Chairman: Ms Fisher,
you have had the benefit of listening to the previous witness,
which is helpful to us. We want to talk to you a bit about the
role of transplant co-ordinators. We have had some descriptions
of how that works here and how it works in other places. Would
you begin by explaining how the role of a donor transplant co-ordinator
is defined in the UK and how that role differs from those that
you have seen in other EU countries where donation is significantly
higher. What lessons can be learned form the transplant co-ordination
models used elsewhere in the EU where they do achieve those better
rates?
Ms Fisher: Perhaps I could first describe how
the donor co-ordination service works in the UK at present. Historically,
donor transplant co-ordinators have evolved from renal transplant
units. This goes back to the early days of transplantation when
really the only organs that were transplanted were kidneys. The
donor co-ordinators are based in renal and often liver units.
That means that we are based within usually a large teaching hospital
and we cover a large region. Most donor transplant co-ordinator
teams in the UK cover populations of between four to six million
people, so geographically we can often be a long way away from
the hospitals where potential donors are. At the moment, our role
is multifaceted, in that some of us work in what we would describe
as a dual role, so not only do we have responsibilities for potential
organ donors but we have a responsibility for a recipient workload
as well; that is, with the people who are waiting for a transplant
of some form or another—although it has to be added that
UK Transplant have addressed this over the last two to three years
and that role is diminishing rapidly. I believe, personally, that
it needs to be a completely separate role, so that either you
are a procurement co-ordinator or a recipient co-ordinator. The
donor co-ordinator in essence is the first point of contact for
the ICU when they identify that donor. This one person will be
on call, they will arrive at the hospital, if the family have
not been spoken to at that point we will then speak to the family,
discuss the option of donation, take a very detailed consent.
We will do an assessment of the donor, looking at their medial
background, their behaviour and their social history. We will
then advise the intensive care unit on donor management; that
is, as Dr Murphy alluded to, maintaining cardiovascular stability,
to ensure that we can honour the wishes of that person and their
family by retrieving as many organs as possible. We do all that,
and then, within UK Transplant we start the allocation of the
organs, set up a team of surgeons to come and retrieve the organs,
accompany the donor to theatre and then deal with the last offices
and the follow-up care with the family. That usually takes up
to 24 hours. That is one individual doing all of that. As an association
we would say that the present role is completely unsustainable
for health reasons, Working Time Directives, and other relevant
legislation therefore the role has to change. We always talk about
Spain because Spain is the ideal that we all want to achieve,
with those wonderful donation rates. In Spain, every intensive
care unit has a transplant co-ordinator employed on it. UK Transplant
have already looked at that option. Over the last two years we
have seen the introduction of in-house co-ordinators. They have
made a difference and the aim has been to get an in-house co-ordinator
in every large neurosurgical unit within the UK. I think that
has almost been achieved. In some areas they have had great success
and in some areas it has taken a bit longer to see that success
but I do believe that will happen. The other major difference
with the Spanish model and the UK model, as we stand at the moment,
is that the transplant co-ordinators in Spain are from a medical
background. Personally, I think most donor transplant co-ordinators
around the country would say, "I don't believe that because
that person is a medical professional makes any difference to
the consent rates". I do not believe every intensive care
unit needs a donor co-ordinator but you do need somebody who has
the knowledge and the information to speak to that family and
ensure that that family makes a truly informed consent. In the
UK at the moment there are many families where that does not happen,
where the families are not approached. A clinician makes a decision
that this person is unsuitable for donation with no reference
to a donor co-ordinator at all. Anecdotally, I have heard clinicians
say to me, "The family was so upset, we couldn't possibly
have asked about donation." The research has shown that asking
that question does not make any difference to these families.
They have already been told the worst outcome possible. The other
thing I have found while completing the potential donor audit—and
this has been reflected across the country with my colleagues—is
that, although we have an organ donor register and, yes, we know
that probably only 24% of the population are registered on that,
we still go to intensive care units and we find people who could
be potential donors who were registered on the organ donor register
and still an approach has not been made.
Chairman: Lord Kirkwood, this has gone
into your area.
Q276 Lord Kirkwood of Kirkhope:
I am very interested in that very comprehensive answer, but remember
we are lay people so we have to understand these things.
Ms Fisher: Sorry.
Q277 Lord Kirkwood of Kirkhope:
You have made a very clear case, and it certainly came through
in the taskforce report, that the 24-hour period after an event
that could potentially lead to transplantation event occurring
would involve a professional series of tasks that were really
impossible to do because you are being asked to do things simultaneously,
so one person can do this. I think you have just said that you
believe that looking to the experience from Spain we are moving
to a stage where every large neurosurgical unit would have someone
who was able to do that. Does that mean that we are only getting
to the stage where we are asking people to do the unsustainable
work? If every large neurosurgical unit has an in-house co-ordinator
are you saying that that means these in-house co-ordinators still
have this unsustainable task?
Ms Fisher: No,
Q278 Lord Kirkwood of Kirkhope:
Could you disaggregate that for us and then I have a further question.
Ms Fisher: The in-house co-ordinator's role
will be somebody who is in the hospital every day, effectively
working nine to five, so they will be on the hospital ward rounds,
they will be identifying people who could potentially be donors.
That person will have an on-call commitment, as it stands at the
moment. The difference will be that they will call on the regional
team and another transplant co-ordinator will come to the unit—so
there will be two: one with the family and one doing all the management,
so to speak, of the donor, and it is planned to have organ retrieval
teams working around the UK and they will then come to that hospital
at a certain point. Perhaps I could give you an example. You have
the in-house co-ordinator and she is on duty until five o'clock.
Her colleague, who is on call, comes to the hospital at one o'clock.
Q279 Lord Kirkwood of Kirkhope:
That colleague will be called what?
Ms Fisher: That colleague would also be a donor
transplant co-ordinator.
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