State awaits decision on
organ-sharing policy

By Helen Altonn
Star-Bulletin

A proposed new national system of distributing donated human organs could seriously affect Hawaii patients, depending on the guidelines, Hawaii organ and transplant officials say.

For now, "It's still up in the air," said Robyn Kaufman, Organ Donor Center of Hawaii director.

Donna Shalala, secretary of Health and Human Services, and congressional members have agreed on a new organ-sharing regulation that has been debated and disputed since she proposed a change early last year.

But how it's going to work hasn't been determined.

"I don't even know if I understand it yet," said Donna Pacheco, heart and liver transplant coordinator at St. Francis Medical Center. "It is so ambiguous."

The nonprofit United Network for Organ Sharing, which coordinates organ distribution, must draft a plan to meet Shalala's goal of broadening the distribution of life-saving human organs and giving the sickest patients first priority.

"It's a challenge to UNOS to define what that means," Kaufman said.

"Sickest" has a lot of definitions, Pacheco said.

Transplant specialists have argued that giving organs to patients with the most urgent need may result in organs being wasted on patients not healthy enough to survive the transplant.

Controversial rule

Kaufman said she believes the Department of Health and Human Services is going ahead with the rule it put into effect last year. It was so controversial that Congress put a moratorium on it, which expired at the end of October.

She said UNOS was given 120 days after the regulation takes effect to propose a detailed policy for broader sharing, starting with livers. It is to come up with a similar policy in a year for other organs, she said.

One of the most controversial features of the regulation, she said, is that it gives Shalala's department more oversight over the entire transplant network, including organ allocations. If Shalala doesn't like the policy proposed by UNOS, which is expected within a couple of months, she can issue her own.

Kaufman said UNOS "saw the handwriting on the wall" and started a new regional liver-distribution policy in July, which it may decide to continue. Livers are offered first to the most critical patients in the area where they are donated. If no one is qualified for them, they go to the sickest patients in the region rather than to a less acute patient in the local area.

While there is uncertainty about the new policy, Kaufman said, "My feeling is due to the foresight of the transplant program here, which said a year ago we should start looking at shifting regions, Hawaii is in good shape."

Earlier change works well

She said the network's new liver-sharing policy has worked "just fine" for Hawaii because it has changed regions in the organ-sharing network.

Under UNOS, the states are divided into 11 regions. Hawaii was in Region Five, sharing organs with California, Nevada, Utah, New Mexico and Arizona, which have larger populations and greater demands for organ transplants.

The Transplant Institute and the Organ Donor Center a year ago asked UNOS to shift Hawaii into Region Six, with more compatible Pacific Northwest states, including Washington, Oregon, Idaho, Alaska and Montana.

The shift occurred in August, and Hawaii already has benefited with offers of organs from the Northwest, "which we didn't get from Region Five," Kaufman said.

She said the change is much better for Hawaii because of direct flights to the Pacific Northwest and comparable transplant programs and populations within the region.

"There will be more reciprocity. ... In a region with similar size and philosophy, we feel Hawaii is in good shape to maximize organs," she said. "But bottom line, we need more organs."

Uncertainty looms

Pacheco said Hawaii might not be hurt by the new regulation if distances are limited for sharing. But if the new policy supercedes regional sharing and says livers should go to every critical patient, she said, "it could eat up every liver in Hawaii."

"It's hard to figure out how it's really going to affect us," she added.

There's already a severe shortage of organs, particularly for patients in Hawaii's minority populations.

Figures change daily, but at last count, Pacheco said, about 180 residents were waiting for kidneys, 23 for livers and three for hearts. "We did six kidneys this week," she said.

Shalala has argued that the old organ-sharing system wasn't fair because of wide variations in waiting times from region to region.

Her proposal in February last year to revamp the system ignited a fight between small and large transplant centers. Small centers protested that they would lose organs to big city hospitals. Congress put a moratorium on the rule and asked the Institute of Medicine in the National Academy of Sciences to look at the organ-sharing system.

The institute looked only at livers, the scarcest organ. It recommended wider sharing in July, but not as widespread as Shalala proposed.