... ces cartes permettent a la famille d'etre au courant des desirs du ... ment de psychologie, Universite d'Ottawa, Ontario. ... Psychologie clinique, Departement.
ls
Jan A. Walker, BA Patrick J. McGrath, PhD
The Role of Family Physicians in Organ Donation ORGAN TRANSPLANTATION is now a recommended and successful treatment for many fatal liver, kidney, and cardiac disorders1'2 and offers promising treatments for cystic fibrosis and diabetes.3 Psychosocial factors, however, have limited the availability of this technology. At present, there is a fundamental shortage of organs, with the need far outweighing the
supply.4 Approximately 3% of all deaths provide suitable organs for donation,4 and if 50% of the possible donor organs were donated, there would be sufficient organs for all potential transplant recipients.5 At present, less than 12% of potential donor organs are used for organ
transplant.3 This results in unnecessary death or substandard quality of life for many Canadians in need of transplants. The demand for organs for transplant is expected to become even greater as more and more patients are referred for transplantation without a comparable increase in donated organs. A simulation model of the organ procurement system recently predicted that, while higher survival rates may decrease demand for repeat transplants, demand for first-time transplants may necessitate increases of 50% to 300% over the current rate of donation to meet the overall
need.6 Shortage of donor organs is viewed as resulting from a problem in the asking for consent, not the giving of it.3 When families are approached by medical professionals for consent to donate a deceased loved one's organs, more than 80% agree.7-9 Family physicians are usually not directly involved in the identification and medical maintenance of potential donors, and their role in the donation process is often not considered. For example, a recent article in this journal, "Emergency Family Care Following a Child's Sudden Death,"10 did not make any mention of organ donation. This paper shall identify and discuss two ways that family physicians can help to overcome the shortage of cadaver organs for transplant. At different times in the transplant process, family physicians CAN. FAM. PHYSICIAN Vol. 36: JULY 1990
have unique opportunities because of research to increase agreement to pertheir established trust and familiarity form a requested behaviour.13 with patients. Fear of Imposing on Family Grief If family physicians are to support Support for Families in intensive care units, they families For families, confusion about death must realize they are not imposing on a has occurred with the advent of effec- family's grieving. Fear of "bothering" tive artificial cardiopulmonary support or "upsetting" a grieving family is idenfor persons with severe brain injuries. tified as a significant inhibiting factor A new class of patients has been created for many medical professionals in the by the recognition of a new standard initiation of organ donor requests.5 for determining death - "brain death." must realize that they are These individuals, although declared notPhysicians on a family, but are proimposing dead, do not resemble patients who die viding the family with an option that of cardiopulmonary failure. They often could help lessen their grief. For the appear as living, healthy individuals, overwhelming majority, donation eases with good colour, warm skin, and con- grief, provides meaning to an otherwise tinued digestion, metabolism, and elim- meaningless death, and leads to a sense ination.1 1 For family members, the imtheir loved one continues to live on, pression of continued life can create that in the case of children.14'15 particularly great confusion when asked to donate a Altruism, or "to help another child," is loved one's organs. most frequently reported encouragFamily physicians have a unique role the ing factor for parents intending to doat this time and should be present in in- nate their children's organs.16 tensive care units. In contrast to the attending neurologist or intensive care Assisting the Response to Death specialist who has medical expertise but Physicians and nurses are committed usually no established rapport with the to a fight for life; hence, death can be family, the family physician has both the perceived as defeat.17 When a patient is medical knowledge and knowledge of declared brain dead, the physician may the family. Family physicians are more frequently respond with grief and a likely to be trusted in discussion of or- sense of failure and guilt; a frequent regan donation than unfamiliar special- sponse to these emotions is to terminate ists. Many people identify their family the process as quickly as possible. 18 It is doctor as the person they would respect imperative for family physicians to and trust the most in a potential donor fight this understandable response to a situation.12 patient's brain death and realize that, This trust can have a twofold impact. through their support of the next of kin First, trust lessens anxiety for the family in intensive care units, they are often members and provides them with great- playing a vital role in saving and imer comfort than they might have had fac- proving the quality of life for many othing unfamiliar staff in an intensive care ers. Identification of this important unit. The family physician can explain function can help family physicians in the irreversibility of brain death and em- their response to the loss of a patient. phasize that the next of kin, by agreeing to donate the organs, is not playing God Concern over Refiusal Concern over family refusal to doand condemning the loved one to death. For example, the family physician can nate a loved one's organs is identified explain why the loved one is continuing as a significant barrier for some medical to produce urine or has a heartbeat on professionals in the transplant prothe cardiac monitor. Second, trust of cess.19 This concern must not inhibit and respect for the family physician family physicians' presence in intensive may play a significant part in a decision care units in potential donor situations, by the family to donate, as the presence as refusal is the exception rather than the of trust has been shown in social science rule.7-9 Attitude surveys have rein1235
forced this overwhelming support for donating a loved one's organs, with similar proportions of next of kin found in favour ofdonation (80% to 90%) in both the surveys and actual donor request situations.5'16'20 Of course, family physicians must realize that next of kin have the right to refuse donation and that this refusal should not be perceived as failure on the part of the physician.
sicians' offices can provide the donor cards and a useful background for initiation of this discussion. Physicians can obtain this material through the Pharmaceutical Manufacturers Association of Canada, 302-1111 Prince of Wales Dr., Ottawa, Ont. K2C 3T2.23
Conclusion
Family physicians, although not usually directly involved in the actual maintenance of donors or the surgery and imOngoing Promotion A survey of medical professionals in mediate postoperative care of transplant Ontario found that lack of awareness of recipients, must recognize the vital role a patient's wishes to donate can inhibit they can play in the transplantation proGreater involvement of family medical staff from initiating the dona- cess. is needed through their supphysicians tion process with the next of kin.21 Orof donor families in intensive care port gan donor cards provide a possible soluunits and their active promotion of ortion to this barrier to donation through on gan donation an ongoing basis. With providing physicians with information this involvement we can expect to come about a potential donor's wishes to do- much closer to achieving a transplant nate. Moreover, because the next of kin in need system whereby every Canadian ultimately make the decision to donate of an organ transplant receives one. e and not the actual donor,8 these cards provide the family with information about their loved one's wishes. This in- Acknowledgements formation can in turn aid families in Ms. Walker is supported by a Meditheir decision-making process. cal Research Council Studentship. Unfortunately, only 30% of Canadians carry a signed card.5 Campaigns Editor's Note: Ms. Walker is a to increase donor card signing can lead doctoral student in clinical psyto a substantial increase in donations, as chology, Department of Psycholfound recently in Great Britain, where a ogy, University of Ottawa, Ontarnet gain of 42% in donated organs was io. Dr. McGrath is Professor and produced by a six-month campaign proCoordinator of Clinical Psycholomoting donor cards.22 gy, Department of Psychology, Thus, it appears that an increase in the Dalhousie University, Halifax. numbers of cadaver organs for transRequests for reprints to: Ms. Jan plant would result if more Canadians Walker, Department of Psychology, Children's Hospital of Eastern carried signed donor cards. Family phyOntario, 401 Smyth Rd., Ottawa, sicians have the most regular, ongoing Ont. K1H 8L1 contact with patients. Further, their knowledge and opinions are respected and trusted by patients.12 Family physicians, then, have a second unique role in References increasing procurement of cadaver or- 1. Beveridge T. Clinical transplantation-overview. Prog Allergy 1986; gans through their active participation 38:269-92. donor card in promoting organ signing. During office visits with patients, physi- 2. Paradis KJG, Freese DK, Sharp HL. A perspective on liver transplantacians can bring up the subject of organ pediatric tion. Pediatr Clin North Am 1988; donation and encourage patients to sign 35(2):409-33. donor cards and discuss organ donation 3. Canadian Medical Association. CMA with family members. policy summary. Organ donation. Can Med Family discussion, and not just the Assoc J 1987; 136:752A. signed card, is essential because the deTE, Esquivel C, Gordon R, Todo cision to donate is the responsibility of 4.S. Starzl Pediatric liver transplantation. Transthe next of kin,8 as mentioned earlier. In plant Proc 1987; XIX(4):3230-5. a recent survey of parents' attitudes to- 5. Robinette MA, Stiller CR. Summary of ward donating their children's organs, task force findings. Transplant Proc 1985; family discussion was the best predictor XVII(6 suppl 3):3-16. of intention to donate.16 The organ do- 6. Ruth RJ, Wyszewianski L, Campbell nor promotion material provided by the DA. The future of kidney transplantation. Canadian Medical Association for phy- The effect of improvements in survival rate 1236
on the shortage of donated kidneys. Med Care 1987; 25(3):238-49. 7. Brady B. Does your hospital have an organ donation policy? Hosp Trustee 1986; 10(1):22-3. 8. Organ Donation, Department of National Health and Welfare and Canadian Medical Association. Organ donation services in hospitals-guidelines. Ottawa, Ont.: Department of NationalHealth and Welfare, 1987; catalogue no. H39-48/1987E. 9. Lutz S. Donation laws aimed at boosting supply of organs. Mod Healthcare 1988; 18(10):28. 10. Macnab AJ. Emergency family care following a child's sudden death. Can Fam Physician 1988; 34:2257-9. 11. Younger S, Allen M, Banlett E, et al. Psychosocial and ethical implications of organ retrieval. N Engl J Med 1985; 313(5):321-4. 12. WalkerJA. Attitudestowardpediatric organ donation: a survey [Thesis]. Ottawa, Ont.: Carleton University, 1988. 87 p. 13. Dillman D. Mail and telephone surveys. The total design method. New York: John Wiley & Sons, 1977. 14. Simmons RG, Fulton R, Fulton J. Effect of organ donation on families of brain dead patients. Read before the Pediatric Brain Death and Organ Retrieval Conference, University of Minnesota, 1987 March 28. 15. Batten HL, Prottas JM. Kind strangers: the families of organ donors. Health Aff (Millwood) 1987; 6(2):35-47. 16. Walker JA, McGrath PJ, MacDonald NE, Wells G, Petrusic W, Nolan B. Parental attitudes towards pediatric organ donation: a survey [Abstract]. Read before the International Congress on Ethics, Justice and Commerce in Transplantation: A Global Issue, Ottawa, Ont., 1989 Aug 22. 17. Sophie LR, Salloway JC, Sorock M, Volek P, Merkel FK. Intensive care nurses' perceptions of cadaver organ procurement. Heart Lung 1983; 12(3):261-7. 18. Stiller CR, Robinette MA, Reed RH. Transplantation in the 80's: a blueprint for success. Transplant Proc 1985; XVII(6
suppl 3):19-31. 19. Robinette MA, Marshall WJS, Arbus GS, et al. The donation process. Transplant Proc 1985; XVII(6 suppl 3):45-65. 20. The Gallup Organization, Inc. Attitudes and opinions of the American public toward kidney donation. New York: National Kidney Foundation, 1983. 21. Corlett S, ABT Associates of Canada. Public attitudes toward human organ donation. Transplant Proc 1985; XVII9(6 suppl 3):103-10. 22. Lewis A, Snell J. Increasing kidney transplantation in Britain: the importance of donor cards, public opinion and medical practice. Soc Sci Med 1986; 22(10):1075-80. 23. Anonymous. PMAC organ donor activity. Newsletter of the Canadian Coalition on Organ Donor Awareness 1989; 2(1):12. CAN. FAM. PHYSICIAN Vol. 36: JULY 199
---1
Jan A. Walker, BA Patrick J. McGrath, PhD
Le role des medecins de famille dans les dons d'organes L A TRANSPLANTATION d'organes est maintenant un traitement utile et recommande dans les affections hepatiques, renales et cardiaques irreversiblesl2 et s'avere prometteuse dans la fibrose kystique et le diabete.3 Les facteurs psychosociaux ont cependant limit6 la disponibilite de cette technologie. Actuellement, il y a une penurie d'organes, alors que les besoins depassent largement les disponibilites.4 Environ 3% de tous les deces constituent des sources d'organes propices aux dons,4 et si 50% des donneurs potentiels faisaient don de leurs organes, il y aurait suffisamment d'organes pour tous les receveurs en attente.5 Presentement, les organes de moins de 12% des donneurs potentiels sont utilises 'a des fins de transplantation.3 Cette rarete engendre le deces de nombreux Canadiens en attente d'une transplantation et en soumet d'autres a une qualite de vie
inferieure. On s'attend a une demande accrue d'organes pour fins de transplantation puisque de plus en plus de patients sont referes pour une demande en ce sens et que les dons d'organes ne suivent pas la meme courbe ascendante. Un modele simule d'un systeme d'acquisition d'organes a recemment predit que, meme si l'augmentation des taux de survie pourrait minimiser les demandes de retransplantation, les demandes pour une premiere transplantation necessiteront des augmentations de l'ordre de 50% a 300% des taux actuels de dons si l'on veut suffire a la demande.6 La penurie de donneurs d'organes serait attribuable a un probleme au niveau des demandes de consentement et non a celui de l'obtenir.3 Lorsque les familles sont approchees par les professionnels medicaux afin de consentir a donner les organes d'un etre cher decede, plus de 80% accepteront.7-9 Les medecins de famille ne sont habituellement pas impliques directement dans l'identification et le maintien medical des donneurs potentiels, et leur role dans le processus du don n'est souvent pas considere. Par exemple, un ar1238
ticle recemment publie dans cette revue, "Emergency Family Care Following a Child's Sudden Death,"'0 n'a fait aucune mention du don d'organes. Le present article vise donc a identifier et discuter deux moyens dont disposent les medecins de famille pour pallier a cette penurie d'organes pour fins de transplantation. A differentes etapes du processus de transplantation, les medecins de famille sont dans une position privilegiee a cause des liens de confiance bien etablis et la connaissance qu'ils ont de leurs patients.
Soutien aupres des familles Dans l'esprit des familles, le maintien artificiel et efficace des fonctions cardiopulmonaires chez les personnes atteintes de lesions cerebrales severes a seme la confusion quant a la notion de d'ces. Une nouvelle categorie de patients a ete etablie par la reconnaissance d'un nouveau critere permettant de determiner le deces, soit " la mort cerebrale." Ces individus, meme lorsque declares morts, ne ressemblent pas aux patients qui meurent d'une defaillance cardiorespiratoire. Ils ont souvent l'air vivants, en bonne sante, leur peau a une bonne coloration, elle est chaude, et les fonctions digestives, metaboliques et intestinales se poursuivent.'I Pour les membres de la famille, l'impression que la vie se poursuit peut causer une grande confusion lorsqu'on leur demande de faire le don des organes de l'etre cher. Les medecins de famille ont un role tout a fait unique a jouer a cette etape-ci et devraient etre presents dans les unites de soins intensifs. A l'encontre du neurologue ou du specialiste des soins intensifs qui possede une expertise medicale mais n'a habituellement etabli aucun lien avec la famille, le medecin de famille possede a la fois les connaissances medicales et la connaissance de la famille. I1 est donc mieux place que ses collegues specialistes plutot etrangers a la famille pour avoir leur confiance au moment de discuter du don d'organes. Beaucoup de personnes identifient leur medecin de famille com-
me etant la personne en laquelle ils ont le plus de respect et le plus de confiance dans une situation de donneur potentiel.'2 Cette confiance peut avoir un double impact. D'abord, la confiance diminue l'anxiet6 des membres de la famille et leur apporte davantage de reconfort que n'aurait pu le faire le personnel de l'unite de soins intensifs qui leur est peu familier. Le medecin de famille peut expliquer l'irreversibilite du dec's cerebral et souligner que la famille consentante a donner les organes n'est pas en train de jouer a Dieu et de condamner l'etre cher a mourir. Par exemple, le medecin de famille peut expliquer pourquoi le patient continue d'uriner et d'avoir des pulsations cardiaques sur l'appareil de monitorage. Ensuite, la confiance et le respect envers le medecin de famille peuvent influencer grandement la decision de la famille a consentir au don d'organes, puisque la recherche en sciences sociales a demontre que la confiance favorise le consentement a accepter le comportement desire.'3
Crainte d'ajouter au chagrin de la famille Si les medecins de famille desirent intervenir comme soutien aupres des familles dans les unites de soins intensifs, ils doivent bien comprendre qu'ils n'ajoutent pas au chagrin de la famille. La crainte de "deranger" ou de "troubler davantage" une famille endeuillee est consideree comme un facteur qui inhibe considerablement la demande de dons d'organes chez plusieurs professionnels de la sante.5 Les medecins de famille doivent realiser qu'ils n'attristent pas davantage la famille mais leur offrent plutot une option qui pourrait contribuer a soulager leur douleur. Pour la plupart des gens, le don d'organes facilite le processus de deuil, donne un sens a un deces par ailleurs vide de sens et aussi le sentiment que l'etre cher continue de vivre, particulierement dans le cas des enfants.'4" 5 I1 est rapporte que l'altruisme, ou "le fait CAN. FAM. PHYSICIAN Vol. 36: JULY 1990
de venir en aide a un autre enfant", est le facteur le plus encourageant exprime par les parents qui choisissent de donner les organes de leur enfant.'6 Aide a' mieux reagir face au deces Les medecins et infirmieres sont impliques dans une bataille contre la mort; celle-ci est donc souvent per,ue comme une defaite.'7 Lorsque le cerveau d'un patient est d6clare mort, le medecin peut souvent avoir une reaction de deuil et un sentiment d'echec et de culpabilit6; un des moyens fr6quemment utilises pour contrer ces emotions est de terminer le processus le plus rapidement possible.'8 II est imperatif que les medecins de famille combattent cette reaction comprehensible face au deces c6rebral d'un patient et realisent que leur soutien aupres de la famille, a l'unite de soins intensifs, permet souvent de sauver des vies ou d'ameliorer la qualite de vie chez de nombreux autres. L'identification de cette importante fonction peut aider les medecins de famille a mieux reagir face a la perte d'un patient. Preoccupation face a un refus Une certaine preoccupation face au refus de la famille 'a faire le don des organes de l'etre cher est identifiee comme 'tant une barriere importante au processus de transplantation chez de nombreux professionnels de la sant6.'9 Cette preoccupation ne doit cependant pas inhiber la presence des medecins de famille dans les unit6s de soins intensifs avec les donneurs potentiels, les cas de refus etant l'exception plut6t que la regle.7-9 Des enquetes effectuees sur les attitudes ont renforce ce soutien extremement rejouissant qui favorise les dons d'organes, affichant des proportions semblables pour ce qui est des proches parents qui sont en faveur du don (80% a 90%) tant au niveau des enqutes que des situations ou les gens acceptent effectivement de faire le don.S5"6'20 Bien sur, les medecins de famille doivent comprendre que les proches parents ont le droit de refuser le don d'organes et que ce refus ne doit pas etre perqu comme un echec de la part du medecin.
Poursuivre cette incitation Une enquete effectuee aupres des medecins ontariens a revele que le fait de ne pas connai^tre les volontes du patient en ce qui a trait au don d'organes peut empecher le personnel medical d'initier le processus de demande aupres de la famille immediate.2' Les CAN. FAM. PHYSICIAN Vol. 36: JULY 1990
cartes de don d'organes permettent d'eviter ce probleme en renseignant les medecins sur les volontes du donneur potentiel. De plus, puisque la famille immendiate doit ultimement prendre la decision de faire le don et non le donateur lui-meme,8 ces cartes permettent a la famille d'etre au courant des desirs du patient. Ces renseignements peuvent aussi aider les familles dans le processus d6cisionnel. Malheureusement, seulement 30% des Canadiens portent sur eux une carte de don d'organes diument signee.5 En Grande-Bretagne, les campagnes afin d'inciter les gens a signer leur carte de don d'organes ont porte fruit et entraine une augmentation substantielle des dons; en effet, les dons d'organes ont augmente de 42% suite a une campagne qui a dure SiX moiS.22 I1 semble donc que, si davantage de Canadiens portaient leur carte signee, il s'ensuivrait une augmentation du nombre d'organes propices 'a la transplantation. Ce sont les medecins de famille qui sont le plus souvent en contact avec les patients. De plus, leurs connaissances et opinions sont respectees par leurs patients. 12 Ainsi, par leur participation active a promouvoir la signature des cartes de don d'organes, les medecins ont donc un deuxieme role important ajouer pour favoriser la constitution de banques d'organes. Profitant des visites des patients au bureau, les medecins peuvent soulever le sujet du don d'organes et encourager les patients a signer leur carte, et discuter aussi du don d'organes avec les membres de la famille. La discussion avec la famille, et non seulement la signature des cartes, est essentielle parce que la decision du don d'organes est la responsabilite de la famille immediate8, tel que mentionne precedemment. Dans une etude recente portant sur les attitudes des parents face au don d'organes de leurs enfants, la discussion avec la famille fut le meilleur element permettant de predire l'intention de faire le don. 16 Le materiel de promotion sur les dons d'organes offert par l'Association medicale canadienne et mis a la disposition des patients dans les bureaux de medecins comprend des cartes de don et des renseignements utiles pour initier la discussion sur ce sujet. Les medecins peuvent obtenir ce materiel par le biais de l'Association canadienne de l'industrie du medicament, 320-1111 Prince of Wales Dnive, Ottawa, Ont. K2C 3T223
Conclusion Les medecins de famille, meme s'ils ne sont habituellement pas impliques directement dans le maintien des listes de donneurs ou dans l'intervention chirurgicale et les soins postoperatoires immediats chez ceux qui sont l'objet de transplantations, doivent etre conscients du role vital qu'ils peuventjouer dans le processus de transplantation. Les medecins de famille doivent s'impliquer davantage, par leur soutien aux familles des donneurs dans les unites de soins intensifs et par la promotion active du don d'organes sur une base continue. Cette implication permettra de structurer un systeme de transplantation et assurera a tout Canadien ayant besoin d'une transplantation d'organe d'y U avoir acces.
Remerciements Mme Walker recoit l'appui du Medical Research Council Studentship.
Note de la redaction: Mme Walker est etudiante au niveau du doctorat en psychologie clinique, Departement de psychologie, Universite d'Ottawa, Ontario. Le Dr McGrath est professeur et coordonnateur de Psychologie clinique, Departement de psychologie, Universite Dalhousie, Halifax. Veuillez adresser vos demandes de tires-a-part a: Mme Jan Walker, Departement de psychologie, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ont. K1H 8L1
References 1. Beveridge T. Clinical transplantation-overview. Prog Allergy 1986; 38:269-92. 2. Paradis KJG, Freese DK, Sharp HL. A pediatric perspective on liver transplantation. Pediatr Clin North Am 1988; 35(2):409-33. 3. Association medicale canadienne. Resumd de la politique de l'AMC. Don d'organes. JAss mid can 1987; 136:752A. 4. Starzl TE, Esquivel C, Gordon R, Todo S. Pediatric liver transplantation. Transplant Proc 1987; XIX(4):3230-5. 5. Robinette MA, Stiller CR. Summary of task force findings. Transplant Proc 1985; XVII,6(3):3-16. 6. Ruth RJ, Wyszewianski L, Campbell DA. The future of kidney transplantation. The effect of improvements in survival rate on the shortage of donated kidneys. Med Care 1987; 25(3):238-49. 7. Brady B. Does your hospital have an organ donation policy ? Hosp Trustee 1986;
Jan/Fev:22-3. 1239
8. Sante et Bien-etre social Canada. Organ and tissue donation services in hospitals-guidelines. Ottawa, Ont.: Services et approvisionnements, 1987; catalogue no. H39-48/1987E.
(pentoxifylline)
9. Lutz S. Donation laws aimed at boosting supply of organs. Mod Healthcare mars 1988; 4:28.
DOSAGE * It may take up to two months to obtain full results. * Once the patient has experienced improvement, the subsequent maintenance dosage may be adjusted to twice daily, depending upon response.
Pharmacologcal Classflcation Vasoactive agent
Indications Symptomatic treatmentof patients with chronic occlusive peripheral vascular disorders of the extremities. In such patients Trental may give relief of signs and symptoms of impaired blood flow,suchasintermittentclaudicationortrophic ulcers.
ContraIndications In patients with acute myocardial infarction, patients with severe coronary artery disease when, in the physician's judgement, myocardial stimulation might prove harmful, patients with hemorrhage, patients who have previouslyexhibited intolerance to pentoxifylline or other xanthines such as caffeine, theophylline and theobromine, patients with peptic ulcers or recent history thereof. Warnings The use of this drug is not recommended in patients with marked impairment of kidney or
tensiveagents. Patients receiving theseagents require blood pressure monitoring and possibly a dose reducton of the antihypertensive agents. Combined use with other xanthines or with sympathomimetics may cause excessive CNS stimulation. Nodataareavailableonthepossible interactionofTrentalanderythromycin. However concurrent administration of erythromycin and theophylline has resuited in significantoebvation of serum thophyllineleveis w toxic reactions. In patients treated with hypoglycemic agents, a moderateadjusbentinthedoseoftheseagents may be required when Trental is prescribed. There have been reports of bleeding and/or prolonged prothrombin time in patients treated with Trental with and without anticoagulants or platelet aggregation inhibitors. Patients on warfarin should have more frequent monitoring of prothrombin time, while patients with other risk factors ompicated by hemorhage (e.g. recent surgery)should have periodicexaminationsfor signs of bleeding, including hematocrit and hemoglobin.
In patients with digestive side effects, antacids liverfunctions.Patientswithlesssevereimpair- may be administered with Trental. In a comment of these organs should be closely moni- parative bioavailability study, no interference toredduringTrentaltherapyandtheymayrequire with absorption of Trental by antacids was
lower doses.
observed.
Pediatric use: not recommended in patients below the age of 18, as safety and effectiveness have not been established in this age group.
Adverse Reactions The most frequent effects reported with Trental (pentoxifylline) are nausea (14%), vomiting (3.4%), dizzinessAightheadedness (9.4%),. headache (4.9%).
Precautions Caution should be exercised in patients with low or labile blood pressure. In such patients any dose increase should be done gradually. Should be used with caution in elderly patients as peak plasma levels of pentoxifylline and its metabolites are moderately higher in this age group.
Dosage and Administration The recommended starting dosage of Trental (pentoxifylline) is 400 mg twice dailyaftermeals. Theusualmaintenancedoseis400mgtwiceor three times daily. A maximum dose of 400 mg three times daily should not be exceeded. It maytake uptotwo months toobtain full results. Trental 400 mg tablets must be swallowed
10. Macnab AJ. Emergency family care following a child's sudden death. Medfam can 1988; 34:2257-9. 11. Younger S, Allen M, Banlett E, et al. Psychosocial and ethical implications of organ retrieval. N Engl J Med 1985; 313(5):321-4. 12. WalkerJA. Attitudestowardpediatric organ donation: a survey [These]. Ottawa, Ont.: Universite Carleton 1988; 87 p. 13. Dillman D.Mail and telephone surveys. The total design method. New York: John Wiley & Sons, 1977. 14. Simmons RG, Fulton R, Fulton J. Effect of organ donation on families of brain dead patients. Read before the Pediatric Brain Death and Organ Retrieval Conference, University of Mennesota, 28 mars 1987. 15. Batten HL, Prottas JM. Kind strangers: the families of organ donors. Health Aff (Millwood) 1987; 6(2):35-47. 16. Walker JA, McGrath PJ, MacDonald NE, Wells G, Petrusic W, Nolan B. Parental attitudes towards pediatric organ donation: a survey [Abstract]. Read before the International Congress on Ethics, Justice and Commerce in Transplantation: A Global Issue, Ottawa, Ont., 22 aoiut 1989. 17. Sophie LR, Salloway JC, Sorock M, Volek P, Merkel FK. Intensive care nurses' perceptions of cadaver organ procurement. Heart Lung 1983; 12(3):261-7.
18. Stiller CR, Robinette MA, Reed RH. Transplantation in the 80's: a blueprint for success. Transplant Proc 1985; XVII,6(3): 19-3 1.
19. Robinette MA, Marshall WJS, Arbus GS, et al. The donation process. Transplant Proc 1985; XVII,6(3):45-65. Trental is not recommended for women who are, or may become, pregnant unlss the ex- whole. pected benefits for the mother outweigh the 20. The Gallup Organisation, Inc. Attitudes potential risk to the fetus. The use of Trental in Supply and opinions of the American public toward nursing mothers is not recommended as its Trental is available as 400 mg, pink, oblong, donation. New York: National kidney safety under this condition has not been es- sugar-coated, sustained-relasetabets, packed Kidney Foundation, 1983. in Unit-Pack boxes of 60 blister-packed tablets, tablished. and bottles of 500. 21. Corlett S,ABT Associates of Canada. Drug Interactions -Public attitudes toward human organ donaTrental may potentiate the action of antihyper- Product Monograph available on request tion. Transplant Proc 1985; XVII, 6(3): 103-10. 22. Lewis A, Snell J. Increasing kidney transplantation in Britain: the importance of donor cards, public opinion and medical practice. Soc Sci Med 1986; 22(10): 1075-80.
2368/9010/E Hoechst Canada Inc., Mobntreal H4R 1R66
II3 .Hoechst and®z, Reg. Trademarks of Hoechst AG, G3erma,iy (West)
1240
ch st kI H oe
23. Anonyme. PMAC organ donor activity. Newsletter of the Canadian Coalition on Organ Donor Awareness, Fev 1989; 2:1. CAN. FAM. PHYSICIAN Vol. 36: JULY 1990
