Government Orders on Organ Donation and Transplantation From Tamil Nadu Health Department

Dr.Sumana Navin, Editor, Indian Transplant Newsletter, MOHAN Foundation, Chennai, Hyderbad, India Since Jan 2008 the health department along with representatives ofvarious hospitals and NGOs in the field of transplantation has madecertain regulations to help facilitate the deceased donor programme inthe state. It has clearly laid out procedures on declaratrion of braindeath and enlarged the panel of members who can certify brain death.The important areas that it has addressed includes the following 

I. BRAIN DEATH DECLARATIONG.O. No. 6. dated 08.01.2008

Declaration of brain death made mandatory in Government Medical CollegeHospitals in Chennai  Compulsory includes - Government GeneralHospital, Government Stanley Hospital, and Government Kilpauk MedicalCollege Hospital (inclusive of Government Royapettah Hospital).

II. PROCEDURE FOR DECLARATION OF BRAIN DEATH

G.O. No. 75 dated 03.03.2008

Form 8 of the THO Act to be utilised

Two medical exams with minimum interval of six hours.

Team of four doctors to certify brain death
a) Doctor No.1
RMP in charge of hospital  Head of Institution, RMO, ARMO, Duty RMO.
b) Doctor No. 2 
RMP from panel approved by Appropriate Authority - panel of names shallbe sent by the Dean/Medical Superintendent/Medical Director to theAppropriate Authority namely the Director of Medical and Rural HealthServices.
Each hospital may determine its own procedure for this duty.
c) Doctor No.3
Neurologist/Neurosurgeon from panel approved by the Appropriate Authority
d) Doctor No.4
R.M.P. treating the patient.

The 1st and 2nd Medical examination to be conducted by category 2 and 3 doctors.

Same procedure applicable to private hospitals

The Director of Medical Education and the Director of Medical and Rural Health
Services to periodically organise awareness workshops


III. AUTHORISATION COMMITTEE - ADDITIONAL RESPONSIBILITIES 

G.O. No. 175 dated 6.6.2008

Living unrelated organ donation  screening of donors onus rests with AC

Recommend to the appropriate authority to file a criminal case whenfalse records are submitted by donor or prospective recipient 

Permitted to refer doubtful cases to the police or revenue department for further enquiry. 

All sittings to be videographed.

Permit a change in the hospital chosen by the recipient for transplant surgery. 

Clearances and rejections to be uploaded on the website on the same day on which sitting is held 

Give recognition (certification) to counseling institutes in the State to provide additional counseling support to live donors. 

Process any form of paired donor exchange between near relatives to ensure that the arrangement is genuine.

IV. PROCEDURE TO BE ADOPTED FOR CADAVER TRANSPLANT BY THE GOVERNMENTAND PRIVATE HOSPITALS APPROVED FOR ORGAN TRANSPLANT BY THE APPROPRIATEAUTHORITY 

G.O.No.287 dated 05.09.2008

1. Hospitals to upload waiting list of prospective cadaver organ recipients through an online form to a computer database
2. Maintained by the Transplant Coordinator of the Government General Hospital,
   Chennai. (Convenor, Cadaver Transplant Program, Tamil Nadu)
3. NGOs to assist in maintaining database
4. Database will maintain prioritization lists for
1. each hospital
2. for all Government hospitals combined
3. for all private hospitals combined and
4. for Government plus private hospitals combined
Each hospital will have its own waiting list for each organ, which will include the date of registration.
An individual can be registered through only one hospital at a giventime. Original date of registration will continue to apply even withhospital change
5. Organs will be shared in the following manner:
1. A multi organ recipient takes precedence over all others on the regular waiting list.
2. Potential liver recipients
1. URGENT
- Hepatic Artery Thrombosis following a liver transplant.
- Primary Non function of a graft
- Fulminant hepatic failure.
These conditions do not require a waiting time on the list.

2. STANDARD
- Patients on the standard list have to be registered for more than 24
hours to be listed in this category.
The Liver is to be allotted to participating hospitals in turn.
Note: Patients on the urgent list supersede the standard list
and the hospital misses its regular turn on the rota.
3. Potential heart recipients
1. URGENT:
1. Patients with Left Ventricular Assist Device (LVAD).
2. Followed by patients with Intraaortic Balloon Pump
   (IABP)
2. STANDARD: Sick, but stable patients waiting at home for a
   heart transplant.
   A Heart is to be allotted to participating hospitals in turn.
4. Likewise for lungs, prioritization would be made according to the
   urgency of transplant and allotted to participating hospitals in turn.
5. For kidneys no out of turn allocation would be permitted and the
   sharing criteria in the following para shall be followed.
6. Sharing of Organs for waitlisted recipients, retrieved from cadaver
   donors in Government Institutions:
1. First priority to the list of the Government Hospital where the
deceased donor is located, for liver, heart and one kidney. The other kidney
would be allocated to the general pool in the priority sequence as listed below.
2. Combined Government Hospitals list
3. Combined Private Hospitals list
4. Government Hospitals outside the State(in order to maximize organ utilization)
5. Private Hospitals outside the State
6. Fforeign national registered in a Government or Private hospital within and then outside state.
7. Sharing of Organs for waitlisted recipients retrieved from cadaver
   donors in Private Hospitals, which are transplant centers.
1. First priority to the list within the Private Hospital where the
   deceased donor is located, for liver, heart and one kidney. The other kidney
   would be allocated to the general pool in the priority sequence as listed below.
2. combined list of Government and Private Hospitals.
3. Government / private hospitals outside the state
4. Foreign national registered in Government or private hospital within and then outside the state
8. Whenever a deceased donor becomes available in a hospital, the
   concerned hospital shall contact the Transplant Coordinator or a member of
   his team at the Government General Hospital, Chennai who will then make
   allocations based on the above. MOHAN Foundation and National Network for
   Organ Sharing, (NNOS), NGOs promoting organ transplantation may assist
   the Transplant Coordinator.
9. Advisory committee will work on 
   1. establishing formats and procedures for recipient listing, organ
      allocation and transfer
   2. coordination between hospitals where donor / recipient are
      located
   3. Forming a coordinating body that would be
      institutionalized and fine-tuning identification criteria to
      determine the beneficiaries-
   4. Proposing policy initiatives from time to time.
   5. Monitor working of the cadaver organ
      transplantation program,
10. Advisory committee shall be headed by the Secretary, Health or
    his nominee as Chairman and the committee shall consist of:
1. Secretary, Health or his nominee-Chairman
2. Convenor, Cadaver Organ Transplant Program,
   Tamil Nadu (i.e Transplant Co-ordinator,
   Government General Hospital, Chennai.)
3. Director of Medical Education or preventative
4. Director of Medical and Rural Health Services or representative
5.  Transplant team member, Government Stanley Hospital, Chennai
6.  Transplant team member, Kilpauk Medical College Hospital,
   Chennai.
7. Transplant team member, Government General Hospital. Chennai.
8. One senior police officer of DIG rank or above as nominated by the
   Director General of Police, Chennai.
9. Member from MOHAN Foundation, Chennai.
10.  Member from National Network for Organ Sharing, (NNOS)
    Chennai.
11.  One transplant team member from three different hospitals that
    currently have largest cadaver donation experience.

V. RESPONSIBILITIES OF TRANSPLANT CENTRE HOSPITALS 
G.O.No.288 dated 05.09.2008

Transplant surgery records for a minimum period of ten years.

Availability of a counseling department with trained personnel. Assist in pre- and post-operative counseling.

Designate in-house person as Transplant coordinator.
Coordinates matters relating to organ transplant on behalf of the hospital.

Media publicity not to be sought earlier than the date of discharge of recipients. 
Positive aspects of organ donation may be highlighted to promote the cause of organ donation.

Details of the recipient and ethics of the medical profession not to be compromised.

Approximate cost of a transplant surgery to be displayed on website ofhospital and the website designated for this purpose by the HealthDepartment.

VI. NON-TRANSPLANT CENTERS - CRITERIA FOR NON-TRANSPLANT CENTERS TO RETRIEVE ORGANS FROM BRAIN DEAD PERSONS
G.O. NO.289 DATED:05.09.2008

All hospitals in the state that have a minimum of 25 beds along withOperation Theatre and Intensive Care Unit to be registered as NonTransplant Organ Retrieval Centres (NTORCs)

Permitted to certify brain death and organ retrieval for therapeuticpurposes, but not permitted to perform actual transplantation of humanorgans

Procedures stipulated in the government orders for certifying brain death as per the
Transplantation of Human Organs Act will apply for brain death certification in NTORCs as well

Can take assistance from any transplant centre hospital registered withthe Appropriate Authority for maintaining brain dead person until organretrieval

Whenever a brain death occurs in an NTORC and the deceased person'sfamily consents to organ donation, the NTORC should contact theTransplant Coordinator, at Government General Hospital, Chennai fororgan allocation as per norms.

VII. CONVENOR, CADAVER TRANSPLANTPROGRAMME, TAMIL NADU
G.O. NO.296 DATED: 16.09.2008

Convenor - Dr.J.Amalorpavanathan, Reader in Vascular Surgery, MadrasMedical College and Vascular Surgeon, Government General Hospital,Chennai

Central responsibility for co-ordinating all activities relating to cadaver transplant programme in the state

Design and maintain a computerised waitlist of all potential organ recipients from participating hospitals

Responsible for organ allocation as per guidelines

Seek status reports from all the participating hospitals on brain deathoccurrences and on transplant activities during each month and theiroutcomes. Send consolidated report to Government.

Report violations to Advisory Committee and forward their recommendations to the Government

Convene meeting of the Advisory Committee once in two months or as needed

Coordinate with Advisory Committee on awareness generation, knowledge development and motivation programmes