MANY HOSPITALS UNREADY FOR CHANGE TO LAW ON ORGAN TRANSPLANTS FROM BRAIN-DEAD CHILDREN
Source: Mainichi Daily News
Just 36.8 percent of medical institutions that the Ministry of Health, Labor and Welfare has recognized as able to provide organs donated by brain-dead children will be equipped to handle such donations when they become legal later this month, a Mainichi survey has found.
A revision to the Organ Transplant Law that comes into effect on July 17 will make it legal for organs from brain-dead children under the age of 15 to be donated. However, medical institutions have complained that the field of emergency medicine which handles brain deaths is too busy for them to cope with organ transplants. It has also been pointed out that some doctors are hesitant to receive organs from children. The situation highlights the fact that the medical field in Japan is lagging behind the legal revisions.
At Japanese Red Cross Okayama Hospital in the city of Okayama, doctors and nurses in the hospital's intensive care unit hurriedly make their way around the beds of patients who are attached to tubes and other equipment.
"It's hard enough determining brain death in adult patients, and to respond to children as well is too much of a burden," says Takeshi Mikane, head of the hospital's emergency and critical care center. Even after the law is revised, the hospital reportedly has no plans to handle organ donations from children.
Each year the hospital receives over 40,000 people seeking emergency care, and it is not uncommon for the intensive care unit to be full.
Since the current organ transplant laws were adopted in 1997, the hospital has not provided any organs from brain-dead patients, but it conducts simulations once a year. It takes 45 hours for the donation of organs from a patient who is judged to be brain dead to be completed, and during this time there is no option but to halt the daily activities of the emergency division. In the case of a child under the age of 6, the period between the two decisions that are made in determining brain death is increased to 24 hours or more -- four times the current period -- and so the process takes 18 hours longer.
The wishes of the patient's family also play a part in the process.
"Most families want us to do all we can up until the person's heart stops beating. We put a full effort into treatment, even if we aren't getting enough sleep," Mikane says. "Our mission is to save the lives of patients, and if we can't save them then we are defeated. We want to be understanding of people's wishes for organ transplants, but we can't go ahead with them if it means going as far as to sacrifice day-to-day emergency diagnosis and treatment."
One pediatric hospital in eastern Japan that will be allowed to provide organs from brain-dead children has already decided that it will not be doing so as of July 17. Some pediatricians who have established longstanding relationships with patients and their families reportedly say it is emotionally difficult to confirm the wishes of parents when it comes to organ donations from brain-dead children. Furthermore, children have a strong ability to regain consciousness, and there are cases when their hearts keep beating for years even though they are thought to be brain dead, making the process of judging them to be brain dead difficult, medical workers say.
"As a result of discussions, about half of our doctors thought that we should cooperate in transplants, but everyone is troubled by the issue, so we can't go ahead with it," the director of the hospital said.
Many of the medical institutions designated to handle the transplants are hubs of emergency medical treatment and advanced medicine known to face a doctor shortage and harsh working conditions.
Sadao Suga, the vice director of Tokyo Dental College's Ichikawa General Hospital, says the hospital has provided organs from two brain-dead people. At the hospital there are three full-time neurosurgical doctors who are involved in determining whether a patient is brain-dead, and they have only two or three days off a month.
"All core hospitals in regional areas are worn out," Suga says. "There are also concerns about the medical difficulty of determining brain death in children." For the time being, the hospital does not intend to provide organs from children who are brain-dead.
A major pillar of the revision to the Organ Transplant Law is that it will become possible to supply organs with the consent of the patient's family even if the wishes of the person themselves remain unclear. However both the dental college hospital and Japanese Red Cross Okayama Hospital have no plans to voluntarily provide explanations about organ donations from brain-dead children, and unless they are approached by families, they will continue to respond only to patients aged 15 or over who have expressed their intention to donate organs on a donor card.
Satoshi Teraoka, president of the Japan Society for Transplantation, says that reform of Japan's emergency medical treatment system is a pressing issue.
"In order to further treatment involving transplants, we urgently need to improve the emergency medical treatment system," he said. "We also need to make efforts to provide explanations to each medical institution and enlighten the public."
改正臓器移植法：１７日施行 小児脳死に対応、３６％－－毎日新聞アンケート
＜分析＞
◇提供病院「救急現場にしわ寄せ」「成人より判定困難」－－全国３４８施設アンケート
１５歳未満の小児からの脳死臓器提供が可能になる改正臓器移植法が、１７日に全面施行される。渡航移植に頼ってきた小児の国内での移植を実現する制度改正と期待されるが、厚生労働省が臓器提供に対応できると認めた全国の医療機関のうち、施行時に小児からの提供に対応できるのは３６・８％にとどまることが、毎日新聞の調査で判明した。現場からは「脳死患者が発生する救急医療の現場は多忙すぎて対応不能」「小児からの提供に疑問を持つ医師もいる」などの声が上がり、法改正に追いつかない医療現場の実態が浮き彫りになった。【藤野基文、永山悦子】
「成人の脳死判定だけでも大変なのに、小児まで対応するのは負担が大きすぎる」。岡山赤十字病院（岡山市）の集中治療室（ＩＣＵ）。さまざまなチューブや機器につながれた患者のベッドの間を、医師や看護師が慌ただしく動き回る中、同病院の實金（みかね）健・救命救急センター長はそう話した。同病院は改正法施行後も小児の臓器提供をする予定はない。
同病院には、年間４万人以上の救急患者が来院する。ＩＣＵが、すべて埋まることも珍しくない。同病院は９７年の現行法施行以降、脳死臓器提供の経験はないが、年１度、シミュレーションを実施している。成人の脳死判定から臓器提供終了まで４５時間前後かかり、その間、救急部門の日常業務をストップするしかない。６歳未満の小児の場合、２回の脳死判定の間隔を現在の４倍に当たる２４時間以上空けるため、さらに１８時間も長くなる。
「ほとんどの家族は心臓が止まるまで何とかしてくれと考えている。我々は寝る時間がなくても、全力で治療にあたる。患者の救命が使命であり、救えなければ敗北だ。臓器提供の意思は拾い上げたいが、普通の救急診療を犠牲にしてまでは踏み込めない」と、實金氏は心境を明かした。
法改正で提供可能な医療機関として新たに認められた東日本のある小児病院は、１７日時点では対応しないことを決めた。治療のため患者や家族と付き合いが長い小児科医の中には「親に意思確認するのは心情的に難しい」と話す人がいるという。また、小児は蘇生力が強く、脳死状態と思われても何年も心臓が動き続ける例もあるなど、脳死判定の難しさが指摘されている。「話し合いの結果、移植に協力すべきだと考える医師は約半数いた。だが皆が悩んでいるので、踏み切れない」と男性院長は話す。
臓器提供を担う医療機関の多くは医師不足や過酷な勤務実態が指摘される高度医療、救急医療の拠点病院だ。
東京歯科大市川総合病院（千葉県市川市）の菅貞郎副院長は、脳死臓器提供を２回経験したことがある。院内で脳死判定にかかわる脳神経外科の常勤医は３人、休みは月２～３日しかない。「地域の中核病院はどこも疲弊している。小児の脳死判定が医学的に難しいことも気にかかる」として当面、小児の提供に対応しない。
本人の意思が不明でも家族の同意で脳死臓器提供を可能にしたことも改正法の大きな柱だが、同病院も岡山赤十字病院も、施設側から臓器提供の説明をする予定はない。家族から相談がなければ、従来通り、意思表示カードで提供意思を示した１５歳以上の患者にのみ対応する予定だ。
日本移植学会の寺岡慧理事長は「移植医療を広げるためには、救急医療体制の改善も急務だ。各医療機関への説明や、一般への啓発に努めたい」と話す。
◇「虐待見抜けぬ」の声も
調査は、厚生労働省が臓器提供への対応を認め、昨年４月時点で名称を公表している大学病院▽救命救急センター▽日本救急医学会などが認定する医療機関計３２２施設と、改正法施行後に加わる小児専門病院の一部計２６施設の計３４８施設を対象に５月下旬から実施。２２９施設（回答率６５・８％）から回答があった。
臓器提供への対応について、「成人と小児の両方に対応する」と答えた施設が３５・０％、「小児のみ」が１・８％で、小児に対応する施設は計３６・８％。「成人のみ」と答えた施設は４８・９％だった。「成人のみ」と回答した施設に理由を聞いたところ（複数回答可）、「対応する体制が整備されていない」が６２・４％、「（小児臓器提供の要件である虐待を受けた児童から提供させない）虐待防止体制が整備できない」が４０・４％、「小児の脳死判定は医学的に難しい」との答えも２２・９％あった。
本人意思が不明の場合、提供に同意する家族の割合は、「３割程度」から「ほとんどない」との予想が、小児の８５・２％、成人の７４・４％を占め、改正法による提供の大幅増に否定的な見方が目立った。
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