She kept muttering "I apologize to you 1,000 times," as she respectively marked permission on a form giving her consent to donate each part of her dying husband’s body. It was a day in May, 2021.
By then, her husband, Nguyen Thanh Thien, had been in critical condition at the to Ba Ria Hospital in Ba Ria – Vung Tau Province that borders Ho Chi Minh City for three days.
He suffered brain damage from a traffic accident, and doctors said there was no chance left to save him.
Su was then taken into the room where he lay to say goodbye.
Covering herself in a Covid-19 protective suit, Su, who is now 37, hugged her husband one last time amidst a tangle of tubes and wires. That was the last time she touched him physically.
Years ago, Su and her husband, who owned a noodle eatery, listened to a priest talking about "organ donation" when they went to church. They did not think much about it.
More than a week before that accident, they heard the term again from an elderly woman who dined at the eatery.
That woman told them about a young man in Ba Ria – Vung Tau whose family had just donated his organs to save others after he was declared brain-dead.
"If I could, I would donate everything," Thien told that woman.
At that time, Su did not pay much attention.
But as Thien was about to pass away, those memories resurfaced.
Other family members encouraged her. They said that could be his last wish.
She was hesitant. She feared it would cause him pain.
Then she thought about how a part of him could live on in someone else's body, and she knew it was the right thing to do.
When signing the consent form to give away his organs, she requested that her husband’s parts be given to poor patients and that the donation and transplantation process must be transparent and non-profit.
The information about Su’s family wishing to donate organs was quickly transferred from Ba Ria Hospital to the Organ Transplant Coordination Unit at Cho Ray Hospital in Ho Chi Minh City.
Immediately, an organ coordination and reception process involving about 200 personnel was activated.
A person in a brain-dead state like Thien can donate organs, potentially saving up to eight organ failure patients and more than 75 people in need of tissue, skin, or corneas. This becomes a precious source of life for thousands waiting for organ transplants.
A brain-dead donor can save up to eight patients. In contrast, a living donor can only donate on part or one organ at a time, if they are healthy enough.
But in Vietnam, the reluctance to donate organs from dead loved ones is limiting the availability of legal resources for life-saving transplants.
After the Law on Donation, Removal, and Transplantation of Human Tissues and Organs and Donation and Recovery of Cadavers took effect in 2006, organ donation from brain-dead donors was legalized.
The move recognizes the need to create a strategic supply to solve the organ shortage as the number of people needing transplants increases. However, it took four years after the law came into force for Vietnam to have its first brain-dead organ donation at Cho Ray Hospital in HCMC.
Until this day, families like Su and Thien remain in the minority.
In the total organ transplants performed over the past 31 years in Vietnam, brain-dead sources account for only 6%, with 157 cases. This rate is completely opposite to the global trend.
In 2022, the percentage of kidney and liver transplants from brain-dead donors worldwide accounted for 61% and 76%, respectively, according to the Global Observatory on Donation and Transplantation (GODT).
"The development of organ donation from brain-dead donors will be a 'natural weapon' against the illegal organ trade. Yet, over the years, this source of organs has been wasted," said Du Thi Ngoc Thu, head of Cho Ray's unit for coordinating human organ transplants.
She mentioned that every day, the hospital has three-five severe brain injury patients from traffic accidents beyond surgical help, and in most cases, their families ask to take their bodies home fully intact.
Very few families in those situations agree to donate the patients’ organs.
Barriers
The bottleneck causing Vietnam to lag in global brain-dead organ donation rates stems from the coordination process of donation and transplantation, according to experts. In developed countries, potential organ donors are often identified by doctors, while in Vietnam, it mostly depends on the voluntary will of the people.
The first "link" is identifying potential organ donors. The removal of tissue and organs is only allowed when a patient is declared brain-dead, a state of coma, cessation of breathing, irreversible loss of brain function, although the heart may still be beating.
Based on physiological developments, doctors can predict patients at risk of brain death as potential organ donors. Then, the information is transferred to the organ transplantation coordination unit to start the process of consulting and convincing the family once brain death is concluded.
The identification role must start from the units that receive emergency cases and offer neuro-intensive care. These units are where severe brain injuries cases are attended to.
But in reality, in Vietnam, most are doing the opposite, said Tran Thanh Linh, head of the ICU at Cho Ray Hospital.
"The medical team in departments with potential organ donors have not been proactive in notifying this type of patient to other units."
Most processes only start when the patient's family proactively expresses the wish to donate organs. From there, doctors report to the coordination unit, which is what happened in Thien's case.
According to the Vietnam Society of Organ Transplantation, if medical staff are poorly informed, fail to identify brain-dead individuals, and do not know resuscitation methods to maintain organ quality, it leads to the risk of losing potential donors.
Research by Antonio López-Navidad and colleagues at the Department of Organ and Tissue Procurement for Transplantation – Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Avinguda Sant Antoni María Claret in Spain – shows that about 20-47% of potential donors are never identified.
Some 17-30% are declined by doctors for applying stringent standards without consulting the transplant team, and 10-25% of potential donors experience cardiac arrest before organ retrieval.
And that's just the first barrier.
Even when the information of a potential donor reaches the coordination unit and their families agree, successful organ retrieval is not guaranteed.
In the process of receiving organs from deceased donors, the most urgent issue is time. Each organ has a different lifetime outside the body, ranging from four to 36 hours. This is the "tolerance threshold" for the lack of blood supply to the organs. If this period is missed, all efforts to regenerate life become worthless.
Doctor Tran Thanh Linh of Cho Ray Hospital said that during the process of receiving Thien’s donated organs, the highest priority was to protect the organs.
The responsibility continues to lie with the intensive care department. Brain-dead patients, with rapidly progressing conditions, if not resuscitated in time to optimize the donation source, their organ function could deteriorate quickly and may become unusable.
"That means missing the opportunity to save the lives of many patients waiting for a transplant," Linh explained.
Receiving the news of Thien’s organ donation, Linh and his team from Cho Ray Hospital immediately went to Ba Ria Hospital that morning.
At 5:30 p.m., doctors officially announced the patient was brain-dead. The organ retrieval was scheduled to take place the next morning.
However, Thien's kidneys showed signs of damage. Infections appeared in the body, and if prolonged until morning, it would be difficult to preserve the organs. The plan had to change, and the organ retrieval needed to be carried out that night.
At 10:30 p.m., the surgery began.
At 00:09 a.m., an ambulance carrying his heart left Ba Ria Hospital.
At 01:04 a.m., the team arrived at Cho Ray Hospital. The organs were transferred directly to the operating room.
Two hours later, Thien's heart beat again in the recipient's chest.
Everything took place in just over eight hours, requiring the smooth and urgent cooperation of more than 200 people - both doctors and patients. However, not every such race to preserve donated organs goes as expected.
"More than 20% of potential organ donors cannot donate organs because the resuscitation phase fails," Linh said, citing statistics from an international study.
He said the current issue is the limited number of resuscitation doctors trained in organ protection. In southern Vietnam, besides Cho Ray Hospital, very few healthcare facilities have medical staff with this experience.
With over 30 years of experience in organ transplantation, doctor Thu of Cho Ray Hospital stated that although there are nearly 80,000 people who have registered on their own to donate their organs in case they are declared brain-dead, the receipt of donated tissues and organs has remained modest.
"The key issue in developing the source of deceased donations is the resuscitation phase. The core reason comes from the lack of coordination between the stages: from identifying potential donors, then the resuscitation and preservation of tissue and/or organs, and then finally approaching and convincing the family to agree," she said.
The Ministry of Health currently does not have national regulations and guidelines for hospitals nationwide on the process of connecting those stages. The role still depends a lot on the National Coordinating Center for Human Organ Transplantation, with three affiliated units at Viet Duc Hospital (Hanoi), the Central Hospital of Hue, and Cho Ray Hospital.
In reality, the responsibility of resuscitation doctors is heavy. They must detect and notify the coordination unit when there is a brain-dead case, explain frequently and in detail everything to the patient's family, and at the same time, prevent the organs from being damaged during the process of convincing the family.
The "extra" costs in the organ donation and transplantation process also inadvertently become barriers, making hospitals hesitant to promote organ donation.
The process of carrying out an organ protection resuscitation can cost up to hundreds of millions of dong (VND100 million = US$4,000), but it is not covered by the state budget.
This number does not include other expenses, such as: organ transportation, overtime allowances for the medical staff involved.
Meanwhile, investing in organ transplantation can bring many times more benefits compared to maintaining treatment for organ failure patients.
A 2019 study by doctor Thu showed that health insurance costs for a kidney transplant patient are three-five times lower than the two other treatment methods of dialysis and peritoneal dialysis.
This is also similar for other end-stage diseases like liver and heart failure, although the difference rate may not be the same.
"That means, if the state pays for organ transplantation, it is still more beneficial than having to pay health insurance for a chronic patient for life," she said.
A kidney transplant costs VND15.2 billion (US$600,000), of which the patient pays 1.8 billion and the rest covered by health insurance. For dyalysis, the patient will have to pay VND4.1 billion, out of the total cost of VND57.5 billion.
Moreover, transplant patients often resume normal lives, take care of their families, and contribute to the socio-economic development, instead of requiring additional care from their family members and become a burden.
From there, social welfare increases, and the state can save money.
This is one reason so many countries have invested a lot of money to develop the program of tissue - organ transplantation from brain-dead donors, Thu explained.
The day of Thien's funeral was also the date that all of his donated organs had finally been successfully transplanted, reborn in the bodies of new recipients.
When doctors from Cho Ray Hospital came to the family home to pay tribute, they informed Su and her four children that their husband and father had revived the lives of four different people on the brink of death.
Su cried.
The remorse for "having caused him pain" gradually eased.
For her and the children, Thien is still present somewhere, in the parts of the body he gave away.
She wished to meet the person who received her husband's heart, but the information is confidential to protect the rights and interest of everyone involved.
Now and then, she texts the doctors at Cho Ray only to learn about the health of the recipients, as a way to hear news about her late husband.
"Just knowing they are healthy makes me happy because that is how to keep what remains of him alive," she said.
In their rented house, she reserved the most honored place for the commendation certificate and thank-you letter from Cho Ray Hospital and the Provincial People's Committee of Ba Ria – Vung Tau for the family's noble deed.
Su said, although her husband's departure was sudden, it left her children a lifelong role model on how to be a decent human being.
Ever since her husband's death, the family of five relies on Su's street-side noodle eatery.
The income has been just enough to scrape together rent and school fees for the two youngest children.
The eldest, Tri, 15, had dropped out of school one year after his father's death to work, "giving the opportunity to my siblings."
The next born, named Bao, now wants to become a doctor. At 12, he can now explain to others the whole process of donating organs to "keep others alive."
"I want to be like him [his father] when I grow up, donating my organs to save people," the boy said.
Story by May Trinh, Le Phuong, Le Nga
Graphics by Khanh Hoang, Thanh Ha, Dang Hieu
Photos by Phung Tien
