Hospitals Forced to Make ‘Anguished Decision’ on Transplants; Insufficient ICUs, Staff Cited as Key Issue in Survey

Yomiuri Shimbun file photo
The University of Tokyo Hospital in Bunkyo Ward, Tokyo

A recent survey of Japan’s three major hospitals revealed specific reasons why some organ transplants from brain-dead donors ultimately did not take place. Brain-dead donors are still scarce in this nation, and efforts must be accelerated to prevent the trasnplant system from being overwhelmed, given the increase in organ donations that is expected in the future.

On May 4, in the latter part of the Golden Week holiday period, operations to transplant a heart and a liver from a brain-dead donor were performed at the University of Tokyo Hospital. The hospital was also asked to perform a lung transplant but declined, citing in-house regulations that allow a maximum of only two transplant operations a day.

Because transplants are an emergency procedure and take a long time, the hospital gathers many staff for such operations. In some cases, scheduled operations are postponed to secure operating rooms for organ transplants. According to the hospital, the number of transplant operations they perform has to be limited, in order to maintain a balance between organ transplants and other medical services.

Since the beginning of this year, the University of Tokyo Hospital has performed 33 transplants of hearts, lungs and livers from brain-dead donors. This accounts for one-fourth of all the organ transplants across the country.

Regarding the decision to sometimes decline to perform a transplant, Kazuhiko Fukatsu, the head of the hospital’s Surgical Center, said with a serious expression, “Of course, we want to save patients waiting for organ transplants, but we have to make an anguished decision in some cases.”

Lower than U.S., S. Korea

According to the survey conducted by the Japan Society for Transplantation (JST) on the University of Tokyo Hospital, Kyoto University Hospital and Tohoku University Hospital, the three facilities declined to transplant a total of 62 organs in 2023.

Asked why, and with multiple answers allowed, the most cited cause was a “lack of vacancies in intensive-care units.” Twenty transplants were declined for that reason.

After organ transplants, patients are treated in an ICU to manage their ventilators and administer drugs to prevent rejection of the donated organs. ICUs are also used for other patients who underwent surgeries for injury, stroke, cancer and other medical conditions.

According to statistics from the Organization for Economic Cooperation and Development, the number of intensive care beds per 100,000 population stood at 14.4 in Japan in 2023, which is lower than the United States at 21.2, South Korea at 17.1, and even the average of OECD member states at 16.9.

Yasuhiro Kuroda, the chair of the Executive Board of the Japanese Society of Intensive Care Medicine, said: “ICU beds at university hospitals are almost always full and securing sufficient ICU staff is difficult. With the added factor of their financial situation, hospitals do not have the luxury of keeping ICU beds open just in case.”

Norihisa Shigemura, a professor at the U.S.-based Temple University who has performed lung transplants for over 15 years in the United States, said: “In the United States, even if their ICU beds are fully occupied, hospitals try to perform organ transplants by transferring patients with milder conditions to other beds.

“Unlike the United States, the culture and system of prioritizing organ transplants are not well established in Japan. This might lead many Japanese hospitals to give up on organ transplants.”

In the JST survey, a lack of staff such as transplant doctors, anesthesiologists and nurses for transplant operations was another common reason for declining to perform organ transplants.

Tomoaki Imamura, a professor of medical policy at Nara Medical University, said: “The government needs to closely examine why these university hospitals had to decline to perform organ transplants and check on such matters as whether there are enough ICUs. It should at least discuss financial assistance for hospitals where transplant operations are concentrated, to help them increase the number of beds and staff.”

Work-style reform

Doctors involved in transplant operations have to work long hours. The work-style reform that was implemented in April to cap overtime for doctors has also prompted concern that it could result in more transplants being declined due to a shortage of doctors.

Transplant doctors not only perform operations but also visit donor facilities with brain-dead donors, recover organs from them and transport the organs to their own facilities.

To reduce the burden on these doctors, the JST introduced in 2017 a mutual support system among medical institutions. Transplant doctors at donor facilities or nearby medical institutions recover organs from donors on behalf of doctors at transplant facilities. The Japan Organ Transplant Network also launched an initiative in 2019 to allow organ transportation to be outsourced to private companies.

In principle, patients on the organ transplant waiting list usually undergo the operation at pre-registered facilities when their turn comes.

“The overall number of organ donations in Japan is increasing. It’s necessary to establish a system under which, if a medical facility declines to perform a transplant operation, the patientcan undergo the operation somewhere else,” said Takashi Kenmochi, a professor at the organ transplantation department of Fujita Health University Hospital in Aichi Prefecture.