When Disaster Strikes: Donor Deaths Are Treated With Intense Scrutiny, but Broader Sharing of Information to Benefit All Living Donors Should Be Implemented

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To the Editor: The American Society of Transplant Surgeons (ASTS) Council and the American Society of Transplantation (AST) Board agree with the premises outlined by Ratner and Sandoval (1) that rapid, accurate and confidential dissemination of information regarding ‘lessons learned’ when a severe adverse event occurs in a living organ donor could make living donation safer without a punitive intent. We agree that ‘lessons learned from any donor death are not adequately communicated to other programs’. However, the authors failed to recognize that a system is in place in the United States to conduct systematic reviews performed routinely to identify correctable causes, administered by the very organization they proposed to operate their recommended National Donor Death Task Force. In July, 2006, the Membership and Professional Standards Committee (MPSC) of the United Network of Organ Sharing (UNOS) and the Organ Procurement and Transplantation Network established a policy to provide immediate, peer-reviewed analysis of living donor deaths in solid organ transplantation. Policy 12.8.4 Submission of Living Donor Death and Organ Failure Data stipulates that transplant programs must report all living donor deaths and failure of living donor's native organ function for 2 years from the date of donation to the UNet Patient Safety System. When these rare events occur, an immediate conference call and electronic communication occur with the UNOS/OPTN staff, representatives from HRSA and the Chair and Vice Chair of the MPSC. Each case is initially evaluated to see if a Category A violation is indicated, representing an immediate risk of ongoing patient safety, and a subcommittee of peers reviews the case details to present to the entire MPSC for further peer review at the next face-to-face meeting. In many cases, programs place themselves on voluntary hold from further living donor transplants until a full review takes place and patient safety can be reassured. Missing from this process is the ability for public dissemination of the pertinent findings given the protections inherent in the peer review process. Any efforts to reduce living donor morbidity and mortality are to be applauded and pursued. Unfortunately, there will always be some risk. In the past when use of the hemostatic clip for living donor nephrectomy (2) was associated with higher risk of post operative bleeding and led to three donor deaths, the ASTS and UNOS developed an ‘alert notification’ to transplant centers to disseminate the manufacturer's warning effectively. Information dissemination, such as with the National Transportation and Safety Board, is an excellent way to prevent similar adverse events in other centers, to reduce low frequency, high impact events and to improve donor safety. However, keeping this activity free of legal discovery and confidential to centers and families would require high level governmental authority, a process currently being evaluated by UNOS/OPTN. It is important to recognize that there is a difference between rapid dissemination of lessons learned to improve patient safety and the regulatory oversight commissioned to UNOS/OPTN that makes transplant centers accountable for their actions and for any performance issues that occur. The latter is protected legally under peer review. These separate issues both have a place in how the transplant community handles these events. Finally, the fund proposed by Ratner and Sandoval (1) to pay bereaved donor families is not in alignment with all other medical and surgical procedures done with full informed consent and is therefore not supported at this time. Risks of living organ donation are known and accepted. If payments are accepted for living donor deaths, how can we not provide funds for other adverse medical events? Where do we draw the line? That being said, however, it must be acknowledged that a living donor receives no medical benefit from organ donation surgery and therefore the concept cannot be dismissed without further careful discussion of the many pros and cons involved. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.