The Cost of Altruism: Patient Charges for Organ Donation After Traumatic Injury

摘要

OBJECTIVE: To determine the origin and extent of institutional charges incurred by lethally-injured patients while awaiting the diagnosis of brain death and organ procurement.DESIGN: Retrospective review.SETTING: Surgical Intensive Care Unit, Urban Tertiary Care Trauma Center.PATIENTS: 31 lethally-injured patients awaiting the diagnosis of brain death and subsequent organ procurement.INTERVENTIONS: None.MAIN OUTCOME MEASURES: Itemized hospital financial and medical records were reviewed. Length of stay and major medical complications were abstracted and charges calculated for three overlapping time periods : total hospital stay, lethal injury stay (period following documentation of a "lethal injury" until a second brain death exam was performed), and brain death stay (period between the first and second brain death exams).RESULTS: Multiple medical complications (3.2 +/- 0.2) and interventions occurred in all patients awaiting the diagnosis of brain death. The mean length of lethal injury stay was 19 +/- 2 hours; the mean length of brain death stay was 12 +/- 1 hours. As a result, significant (lethal injury stay - $20,902 +/- 1409 and brain death stay - $16,645 +/- 1223) hospital charges were accrued. Even though a "lethal injury" had been documented, and care was targeted solely at maintaining organ function, these charges were not subsidized by the local organ procurement organization (OPO).CONCLUSIONS: 1. Numerous medical complications are common in the traumatized patient awaiting the declaration of brain death. These require aggressive critical care interventions and management. 2. Significant hospital charges are accrued by patients for the care necessary prior to organ procurement. 3. OPOs must consider and enact reimbursement policy change to cover the cost of care before brain death is declared in all organ donors. INTRODUCTION More than 38,000 patients are currently awaiting organ transplantation.1 Nearly 2000 additional patients die each year while on organ transplantation waiting lists.2 A shortage of donor organs is primarily responsible for these staggering numbers. The altruistic spirit of donors and their families is cited as the major impetus for organ donation. In this regard, altruism is thought to bear little or no expense, and it is generally agreed that organ donation should add no financial burden to the family of an organ donor.3Attempts to increase referrals to organ procurement organizations (OPOs) by enacting required request laws have been undertaken, but have largely had little impact on organ donation rates.4 Once a potential organ donor is identified and referred to an OPO, actual organ procurement rates continue to be suboptimal.5,6 Failure to obtain consent from the next of kin remains the single largest cause of eligible organ procurement failure, with more than 40% of families refusing donation.5-7Once the family has consented, the multiple physiologic derangements which the potential organ donor manifests require aggressive, labor intensive management in order to maintain organ function until legal brain death is declared and procurement can be undertaken. One recent review suggests that the medical failures to organ procurement may be largely preventable with invasive hemodynamic monitoring, aggressive rewarming, and liberal transfusion therapy.7 This high level of care necessary to sustain potential organ donors until legal brain death is declared (and the OPO assumes financial responsibility for care) is expensive, and to date has not been itemized and reported as a part of the cost of the organ procurement process. We investigated the origin and extent of institutional charges incurred by lethally-injured patients while awaiting the medical and legal determination of brain death. MATERIALS AND METHODS With cooperation from the Delaware Valley Transplant Program (local OPO), traumatically injured organ and tissue donors cared for between 1991 and June 1995 at the University of Pennsylvania