Study Shows Coroners' Decisions Affect Transplant Rates
Eye donors whose deaths come under the jurisdiction of a coroner have a better chance at being transplanted, depending on the decisions made by the coroner. According to a new study by the Rocky Mountain Lions Eye Bank, if a coroner allows the recovery of donated corneas prior to performing an autopsy, the chances of the corneas being suitable for transplant are 15% higher and the time between death and the preservation of the corneas can be nearly 23% shorter.
"When we die, we stop producing tears," explained Robert Austin, the eye bank's manager of public and professional relations, "This allows the living tissue to start drying out and threatens the living cells that are so vital to the cornea's normal function." Coroners are charged with investigating deaths that happen under certain circumstances, as outlined by state law. Only the coroner may stop a donation from moving forward and then only if he or she feels that the recovery of the donated corneas will interfere with the ability to determine a cause and manner of death.
In practice, however, coroners cite reasons that vary widely, from the fact that the death is being investigated as a homocide to simply an administrative policy that requires a morning staff meeting to make decisions rather than giving the eye bank a decision right away outside of business hours. Still, other cases are denied without giving a reason to the eye bank. In 2018, the eye bank saw a 30% increase in the number of cornea donations that were denied by coroners. In nearly two-thirds of those cases, the coroner required the eye bank to wait until after the autopsy or until business hours when a decision would be made. In most cases, that effectively ruled out the possibility of cornea donation because of the tight time frames the eye bank has for cornea viability. In many cases, the coroner gave no reason for the denial of permission.
Yet, when it comes to evidence protection or the inability to determine a cause of death after cornea donation, experts say that there is little to fear. Dr. Samantha Wetzler, MD, is a medical examiner for the Commonwealth of Virginia and chair of the ad hoc committee on organ and tissue donation for the National Association of Medical Examiners (NAME). She points out that the cornea is unique among donated tissues. The cornea is not only transparent, but is the only tissue without a direct blood supply. "I cannot think of a situation in which releasing the corneas for donation would interfere with the determination of a cause and manner of death," she said. Wetzler also points to the position of NAME, which supports the release of all organs and tissues for transplantation in all cases under the jurisdiction of the coroner. Wetzler said that coroners are public health officials and the need for transplantable organs and tissues is a national public health need. "While there is definitely a role coroners play in the criminal investigation of deaths, that can be balanced with ensuring transplantable tissues get recovered and evaluated for transplant," she said. Indeed, several jurisdictions around the country have a stated goal of "zero denials," meaning the medical examiner makes every effort to release every eligible tisusse, every time. Most are successful because it is a collaborative effort between the coroner, forensic pathologists, the district attorney and the eye bank. While state law mandates that kind of cooperation, very few coroners in Colorado and Wyoming have signed written protocols.
For the Rocky Mountain Lions Eye Bank, the first goal is educating coroners and their staff that a cornea is not like any other donated tissue. In fact, when it comes to its status of living tissue with tight time constraints, a cornea is much more like an organ. "We also want to show coroners the successes," Austin said. "Our new study clearly shows that the decisions coroners make has a big impact on the suitability of donated corneas for transplant."
In fact, the study shows that transplant rates are the highest for corneas under a coroner's jurisdiction where the coroner allowed the recovery to occur prior to autopsy and prior to transporting the body to the coroner's facility. In these cases, the eye bank collects the fluid in the eye and seals it as evidence, which the coroner can use to help determine the time of death or test for drugs. The eye bank also performs a thorough eye exam, looking for sign of asphyxiation and other abnormalities. "There seems to be a misperception that all donated tissues can be lumped together when making desicions," Austin said. "Yet, corneas aren't like other tissues that are donated. Therefore, we are hoping coroners in our service area will begin to understand the impact they have on transplant rates as they consider each case."
The eye bank launches its campaign tomorrow at the Colorado Coroners Association annual conference.