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Opt-out organ donation; your body after death; what time of day to take blood pressure medication

Should opt-out organ donation be rolled out across the UK? What happens to the body after death? And a new trial investigates the best time of day to take blood pressure drugs.

More than 6500 people are currently on the national transplant waiting list, hoping for an organ to be donated which might save their lives. Many of them will wait for years and, sadly, hundreds will die before a suitable organ becomes available. The low supply of organs remains the main restriction on performing lifesaving transplant surgery. The British Medical Association believes that moving to an opt-out donation system - where people who die without expressing whether or not they wish to donate their organs will be presumed to be willing to donate - would increase donation rates and save lives. The system has been in place in Wales since December 2015 and now the BMA says it's time the rest of the UK followed the Welsh model. Dr Margaret McCartney discusses with Dr Phil Banfield, chair of the British Medical Association Welsh Council.

An area of medicine not often discussed on Inside Health is pathology. Mark visits the morgue at St Mary's Hospital in London to speak to pathologist Mike Osborn. What happens to your body after death? What is rigor mortis? And how much do crime dramas on TV get right?

Finally, what time of day should you be taking your blood pressure medication? Millions of people take drugs to control their blood pressure and reduce their risk of heart attacks and strokes. Most people will take their medications in the morning but with many heart attacks and strokes happening during nighttime hours, just when the medication might be wearing off, should we be considering evening dosing instead? A new online trial has enrolled 21,000 people and aims to find out what time of day is best to take blood pressure medications. Mark speaks to Dr Amy Rogers from the University of Dundee who is in charge of the trial.

Producer: Lorna Stewart.

Available now

28 minutes

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4

 

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE HEALTH

 

Programme 10.

 

TX:  08.03.17  1530-1600

 

PRESENTER:  MARK PORTER

 

PRODUCER:  LORNA STEWART

 

 

Porter

Hello. Coming up today:  Blood pressure pills – might millions of people across the UK be better off taking their medication in the evening rather than the morning?

 

Clip

We currently have 21,089 randomised participants across the whole of the UK.  We invited adults who are taking blood pressure medication once a day to sign up to the study and we think that in about three to four years’ time we should have a reasonably definitive answer of whether morning or evening blood pressure dosing is better at preventing heart attacks and strokes.

 

Porter

And a trip to the morgue – I discover that the life of pathologist isn’t quite as portrayed by the likes of Silent Witness and CSI, and dispel some of the myths about what happens to our bodies after we die.

 

But first transplants and calls for a UK wide change in the way we consent to our organs being used to help others.  In 2006 the British Medical Association proposed a move to an opt-out system where consent is assumed unless people actively say otherwise, instead of the then opt-in system where you have to sign up to be included on the Organ Donor Register.  In the decade since then, 6000 people – including 270 children – have died while waiting for a transplant, and lack of organ supply remains the main limiting factor in transplantation.

Ali Reynolds’ son Lee was just 21 when he was killed in a head on car crash.  A nightmare scenario for any parent.  And then came the question about organ donation, something Lee had never expressed an opinion about or discussed with his family.

 

Reynolds

On the Saturday evening which was six days after the accident they came and told us that they were going to try and bring Lee out of the induced coma.  We did just imagine that we’d go in on the Sunday morning and he’d be awake and sitting up moaning that he was starving hungry.  He was always starving hungry.  But sadly that wasn’t to be.  We were told at 10 o’clock on the Sunday morning, we were taken into a small office, and we were told that Lee was clinically brain steam dead.  And it was just the machines keeping him alive at that point.  It seemed within minutes we were introduced to a transplant coordinator and she very sensitively asked us if we’d ever considered organ donation or if it was something we’d ever talked about and to be truthful it wasn’t, the subject had never come up between Lee and myself.  We did agree and then the next question was what we would be prepared to donate.  I’m not sure why but I said anything but not Lee’s heart, for some reason whatever it was at that moment, I can’t put a finger on it, but I just said not his heart.  Which is a decision all these years later I have come to regret.  Two people had their eyesight restored because of Lee’s corneas.  His liver was donated to a lady who had only been given weeks to live, she lived a further two years.  And the gentleman that received Lee’s kidneys is still alive today.  We get a great source of comfort knowing that.  It is quite comforting to know that not only a part of him lives on but some other family have still got their dad or their granddad or their brother or sister or father or whatever, it’s lovely.

 

Porter

Proponents of an opt-out system believe it makes difficult conversations, like the one the transplant coordinator had with the Reynolds family, easier, which in turn will increase the number of donor organs available.

 

Well, just over a year ago Wales became the first country in the UK to switch to the opt-out system, so called deemed consent.  So what difference has it made there?  Dr Phil Banfield is Chair of the BMA Welsh Council.

 

Banfield

In the first year we’ve seen 160 organs transplanted, 39 of those were from deemed consent, which is roughly about 25%.  We think probably what it’s done is it’s increased the ability to have difficult conversations with relatives.

 

Porter

Because that’s an important thing to point out with the opt-out is that the relatives would – I mean if something happened to me and my wife and family are there they will be consulted?

 

Banfield

Oh absolutely and the BMA was quite vociferous in trying to get safeguards in place to make sure that where an unregistered but known view of the potential donor surfaced after the event then that would be explained and clearly taken into account.  And I think that takes place whether you’re in an opt-in or opt-out system.  What the nurses report to us is that for Welsh patients that conversation has become much easier.

 

Porter

So what you’re saying is that sometimes it isn’t happening because it’s quite a difficult subject to raise with families but if there’s an opt-out situation that makes it a default conversation?

 

Banfield

It does.  I mean it changes the landscape in which you talk to relatives and it removes the default position that the relatives would start by saying no.  And for both systems the important thing to do is to consider the relatives, it’s a very difficult conversation and decision to make when you’re grieving for someone and it’s a better conversation to have while someone’s alive.

 

Porter

What happens if I’m visiting Wales, I don’t live very far away from Wales, and I’m involved in a car crash and I end up in a Welsh hospital for a long time and I’m a possible donor, who does this apply to?

 

Banfield

It only applies to people who are ordinarily resident in Wales and have been so for more than 12 months.  So there are other safeguards as well.  So if you’re Welsh and you have a tragic accident outside of Wales it doesn’t count, if you’re under 18, if you’re judged to not have mental capacity.  And of course it is still possible, and we would recommend, that you can positively express consent either in or out.  And the website, organdonationinwales.org, it’s incredibly easy to go through there and express not only your wishes but if you chose to be selective in what you may or may not want after your death that’s also able to be included.

 

Porter

Well listening in our Glasgow studio is Margaret McCartney.  Margaret, Scotland are currently in the middle of public consultation on this very issue but you have some concerns.

 

McCartney

I do, I completely support organ donation and I am a registered donor myself but I am completely against the idea of an opt-out policy for a number of reasons and I suppose at the end of the day it comes down to the word “donation”.  In my mind you only get to make a donation when it’s voluntary and as soon as something becomes mandated or expected that act of gift giving, in my mind at least, is lost.  And I know from speaking to people over many years how important that sense of gift giving is and I’m very concerned that we may lose that sense of altruism, somewhere in the ether here.  And as Phil was saying, families can veto the decision to donate, either when someone has opted out or opted in.  So really what you’ve got a law that isn’t really being enforced.  So we’ve now got a situation where 5% of the Welsh population have opted out of organ donation.  Now I think it’s good to make your views known, I think it’s good to tell your family and friends what you would like but I suspect that there are many people who’ve opted out because they didn’t trust the system that would presume consent.

 

Porter

Phil, based on the Welsh experience I mean there are a number of reasons why somebody might want to opt-out – personal beliefs, religious, cultural, whatever – and we’re not questioning any of those but do we have any evidence that some people are opting out because they’re scared that the system might be abused?

 

Banfield

No I don’t think we’ve any evidence for that at all, in fact the specialist nurses are reporting that the relatives that they’ve come across in Wales are ready for this kind of conversation because they’ve been part and have seen and involved in the really quite significant media campaign that the Chief Medical Officer and Welsh Government had in the run up to this becoming law.

 

Porter

Let’s just be clear:  If somebody hasn’t opted out, they may not have given it proper consideration, their family may be against the idea, what would happen in that situation?

 

Banfield

The actual practical experience here is that no transplant surgeon or service would take an organ where the relatives are objecting.  It’s very easy and straightforward for relatives to let the transplant team know of an unregistered objection.

 

Porter

I suppose the big issue here is what we should be doing is getting everybody to think and talk about it and neither system really ensures that that’s happening at the moment, does it Margaret?

 

McCartney

Well in Spain, for example, which is often cited as a country which has got extremely high levels of organ donation, they had an opt-out system that didn’t seem to make much difference until they put in a really fantastic organisation of transplant coordinators within their health service which meant that, as Phil was saying, it became much easier to ask the question – if someone was dead would their family consent to them being an organ donor.  So I think the law is one thing but what actually happens on the ground is another.  I don’t think the figures so far would support a big jump in the amount of organ donations that have been made in Wales, particularly compared to other countries.  So I think there are better ways to do this and I think a better way to do it is actually provide the staff and infrastructure in our hospitals so that the question can become more routinely asked and donation can go ahead when it’s appropriate.

 

Porter

Phil, so far the figures in Wales, I mean they may indicate there’s been some change but you can’t be sure of that, is there lessons that we can learn from other countries elsewhere in the world that suggest this definitely does improve supply?

 

Banfield

Well I think these are promising results but inconclusive from the point of view that this could just be natural variation of course.  The WHO gives some figures for other countries with deemed consent.  So Austria, Belgium, Czechoslovakia, Finland, France etc., and they find that typically there’s a 25-30% higher rate of organ donation in these countries than in countries that have an opt-in system.  I think Margaret makes the really important point – is that the law by itself is not the thing that’s going to change practice.

 

Porter

Phil Banfield and Margaret McCartney. 

 

The public consultation in Scotland ends next week.  There are no plans for a change to an opt-out system yet in England.  And Northern Ireland rejected moves to do so last year.

 

Now to an area of medicine that rarely gets much coverage, at least not much outside the fictitious world of crime thrillers and TV dramas like CSI and Silent Witness, where its portrayal is often somewhat misleading.  Suffice to say that the real world of pathology and post-mortems isn’t quite as fast and furious, or as glamorous, as I discovered when I met up with Consultant Pathologist, Dr Mike Osborn, in the chilly morgue on the ground floor of St Mary’s Hospital in London.

 

Osborn

Well welcome to our mortuary.  At the moment we’re actually in the room that is the post-mortem room where post-mortems would be conducted and we would examine people who’d died to find out why they had died.

 

Porter

And it looks, if you don’t mind me saying, exactly like I’d expect it to look.  There are four ceramic tables here where you do the post-mortems presumably and at the end are the fridges, I presume, where the…

 

Osborn

That’s correct.

 

Porter

So where are these bodies coming from, how many have you got in there for starters?

 

Osborn

We’ve got 36 fridges, not all these people will be having post-mortems, about one or two of them will probably be expected to have a post-mortem at any one time.

 

Porter

And they’d be having a post-mortem because of what typically, it obviously varies, what sort of reasons might you be doing in a unit like this?

 

Osborn

Well there are two types of post-mortem really in this country.  The most common post-mortems are ones that are done for the coroner.  Anyone who died suddenly or unexpectedly that the country has an interest in looking into or finding out why they died.  So that’s one group.  And by far the largest group, about 95,000 cases a year in England and Wales.  About 1200 cases a year are done as consented hospital post-mortems and these are cases where somebody would have an illness, the doctors would know why that person has died, so for example they might have a cancer that the doctors knew about and were treating, the cancer couldn’t be treated and the person died but the doctors wanted to know some more information, so for example, where exactly had the cancer spread to, had the treatment they’d been given caused it to regress, how good was the treatment if it was a new treatment and so forth.

 

Porter

Most of our listeners’ perception of post-mortems and rooms like this will be from watching crime dramas, the forensic work, where you’re looking at somebody who’s been involved in an accident or may have been murdered.  How much of your work that you do here or is that done in a specialist unit?

 

Osborn

I personally don’t do any forensic post-mortems, I’m not a forensic pathologist, that’s a sub-specialty, there are about 38 forensic pathologists in the whole country.  But no there are really no specialist forensic units.

 

Porter

Let’s talk about the process of death and what actually happens to our bodies once we die, how quickly does that begin?

 

Osborn

People are made up of lots of different types of cells and different types of cells all die at different times.  So, for example, the brain cells will die within three to seven minutes without oxygen.  Whereas some other cells, for example muscle cells and skin cells, they can last for much, much longer – 12 hours, 24 hours – so that’s really because the death of a cell depends on the metabolic activity, so the cells in the brain are very, very delicate cells so they die much quicker than the tougher sort of cells in your skin and so forth.

 

Porter

By the time you get to the person, let’s say it’s 48 hours later, what sort of changes have already occurred in the body?

 

Osborn

The changes that occur in the body depend very much on the ambient temperature and the environment that the body is kept in.  So I mean there’s documented cases in Texas in America where people have died in their car, it’s been bright sunshine, and they have decomposed within 24/48 hours, so what would take a week or two in Britain is accelerated because of the heat.  Similarly if you go to places like Canada or Russia people can die and stay absolutely unchanged for months on end, if it’s the winter, I mean you’ve got mammoths that are pulled out of the Siberian Tundra that are a 100,000 years old.  So you know it all depends on the environment you’re in.  The first changes you see are some green discolouration at the front of the abdomen, at the front of the tummy…

 

Porter

And that’s caused by?

 

Osborn

The thing that really causes the decomposition is the bacteria in your gut.  So your gut is a tube that starts at your mouth and finishes at your bottom and is basically full of bacteria and these bacteria are kept within the tube by all of the cellular mechanisms that depend on you being alive to work.  So the minute you stop working the gut becomes much more permeable to bacteria, they can move through the gut, they can move into the other organs and that’s what you see.  So the first place is the tummy.  And then they spread around the body.  The blood vessels, usually in the upper limbs, become more obvious, that’s because bacteria get into the blood, they breakdown the components of the blood, so that would happen within sort of two to four days.  And then gradually that would progress through the rest of the body, you would then have blister formation on the skin, the skin would start to slip away, the hair would start to slip away.  And after sort of four or five days virtually the whole body would really be green and the skin would be shedding and the process of decomposition would be very much on its way.

 

Porter

And is it those bacteria that are responsible for that characteristic smell of death?  I mean not everybody’s smelt it but they will have heard it described as sort of the sickly sweet almost smell of death.

 

Osborn

A decomposed body does smell very characteristic and it’s quite a potent smell.  It is a sickly sweet smell with the emphasis being on the sickly bit.  Yes it’s the breakdown products, it’s the bacteria doing that.  There’s gases being given off, that’s the smell that you get.

 

Porter

Since we mentioned that we were visiting you I’ve had numerous emails from listeners, so I’d like to run some of these past you.  Let’s start with the first one:

 

Does your hair and do your nails keep growing after you die?

 

Osborn

No they do not.  But what does happen is that your skin on your head and on your face and on your fingers can shrink back because it loses water, it dehydrates so what that does is you – where you may have been clean-shaven before, had a small amount of stubble because it shrinks back, it becomes more obvious. 

 

Porter

Another possible myth here, what about noises post-mortem, do corpses ever make noises?

 

Osborn

Somebody who has been dead for a week in a fridge waiting for a post-mortem doesn’t make noise.  The only exception to that would be if the body is moved and some of the air came out of one of the lungs there might be a vague noise.  But that’s just like if you were moving an inanimate object around your garage – a wardrobe – and the door moved or something.  No they really don’t make noises.

 

Porter

A number of people have asked me to find out what rigor mortis is – to get you to explain what rigor mortis is.

 

Osborn

Rigor mortis is the stiffening of the body after somebody dies.  And basically your muscles have got a chemical in them that lets them work, it’s an energy related chemical called ATP.  But obviously once you die you can no longer make that.  After a period of time when all of that is exhausted in the body the muscles become locked in a certain position.  It would start sort of two to four hours afterwards, would be the very earliest you’d see it.  It happens in all the muscles simultaneously but in some muscles it’s more obvious than others, so it’s more obvious first of all in the small muscles, particularly around the jaw, so you’d find it difficult to open somebody’s mouth and around the fingers.  And then progressively over a period of time, sort of six to eight to 12 hours, you wouldn’t be able to move any of the joints, the muscles would become very stiff.  And then what happens is as the body decomposes, so the muscle starts to break down, the muscle no longer stays rigid and that would happen after about 30 hours, the body then becomes flaccid and moveable again.

 

Porter

Couple of forensic questions now.  The first one is looking at the time of death – how do people estimate when someone might have died?

 

Osborn

Telling what time somebody died is infamous for being extremely difficult.  And the most common way of doing it and the one that is usual is temperature of the body.  What is very clear is that it is not an exact science, so you will get a window of usually at least sort of 12-14 hours at the very best that they may have died in and it’s always may have.  What you do not get is what you see on crime films where they died at 27 minutes past six on Thursday – absolutely definitely, that doesn’t happen.

 

Porter

What about evidence that a body’s been moved after the person has died?  I’m thinking about changes in the skin, this is another thing you often see in the crime dramas.

 

Osborn

Basically when you die your heart stops pumping, so all the blood in your body then – it becomes dependent on gravity, so it will move to the places that are the lowest in the body.  And those areas will become pink because they’re full of blood.  So if someone dies and they lay on their back for 12 hours they’ll go red on their back, you then move them and lay them on the front, the back will still be red.  So in your crime dramas that’s what they’re talking about.  But again it’s probably over played.

 

Porter

What is it about this sort of work that you enjoy because it’s an unusual field to work in?

 

Osborn

Pathology’s interesting because at the end of the day it’s the ultimate arbiter, to be honest.  There’s lots of people who can get towards the diagnosis but usually – in most things – most things like cancer and inflammatory diseases and things like that it’s the pathologist who gives the answer – it is cancer and it isn’t cancer, whatever any of the others may point towards.  And as far as post-mortems go it’s quite a good specialty because you get to interact with all the other specialities, so you really get to put together all of the medicine you’ve ever learnt really.

 

Porter

Dr Mike Osborn extolling the virtues of a career in pathology, of which post-mortems form just a small part.  As anyone who has seen Silent Witness knows, pathologists actually spend most of their time running around interviewing witnesses and chasing suspects.  Or not.  If you want to know the facts about a career in pathology there are some useful links on our website.

 

One in three adults in the UK have higher than ideal blood pressure and most of those on treatment need at least two medicines to try and control it, normally once a day in the morning.  But is that the best time to take the drugs for maximum benefit?

 

High blood pressure can lead to a number of problems but it is the three-fold increase in the risk or stroke and heart attack that is most worrying.  And given that the peak time to have a stroke or heart attack is early in the morning, an hour or two before most people take their pills, it has been suggested that taking them in the evening may offer more protection.  But does it?

 

A question Dr Amy Rogers, clinical research fellow at the University of Dundee, hopes to answer definitively.

 

Rogers

When you measure your blood pressure in the doctor’s surgery you get two numbers – the systolic and diastolic blood pressure – and people often think well that’s my blood pressure.  But actually if you measure people over 24 hours you can see that the blood pressure changes throughout the day, it tends to increase during the day and then fall in the late evening, when people go to bed, and it reaches its lowest point in the middle of the night.  And we’ve known for a long time that people are far more likely to have a heart attack, for instance, in the very early hours of the morning.  And it may be that that relationship is because of the change in the blood pressure.

 

Porter

Of course that’s also the very time that the tablet that they took the preceding morning is likely to be wearing off or have worn off.

 

Rogers

Exactly, yeah, so if somebody’s taken a medication say 8 o’clock one morning, shortly before 8 o’clock the next morning they’ll be at their lowest level of effectiveness before they take the next dose. 

 

Porter

Why is it then that we routinely give pills first thing – I mean if it’s once daily medicine it’s normally taken first thing in the morning?

 

Rogers

I think it’s just because it’s what we’ve always done.  It’s kind of assumed that daily medications will be taken in the morning.  No one’s ever really tested it to see whether that’s the right thing to do with a whole variety of medications.  I think often we, as doctors, assume that patients won’t remember to take their medications if we ask them to take it at different times and we think that everyone will find it easier to fit into their routine at that time of day.  But we actually don’t have any evidence to base that on.

 

Porter

What does the evidence tell us about altering the timings of taking blood pressure tablets, what’s the impact on stroke and heart attack?

 

Rogers

We don’t know for sure whether the timing makes a big difference to whether you have a heart attack or stroke.  We know that people with high blood pressure are at an increased risk of heart attack and stroke and we know that if you treat that high blood pressure with medications you can reduce that risk of somebody having a heart attack and a stroke.  We also know, as I mentioned before, that the blood pressure varies throughout 24 hours and from looking at studies using these 24 hour blood pressure measurements we know that people whose blood pressure doesn’t dip like it should do at night-time are at an even higher risk of heart attack and stroke even if they’re being treated with medication.  So it’s been suggested that maybe it’s the dip at night-time that’s important and if you could try and encourage the blood pressure to dip further at night-time by giving the medication just before bed, so that it’s maximally effective at that time, that that might further reduce the risk of heart attack and stroke.  But apart from one study that was conducted in Spain and published in 2011 no one’s actually been able to show any effect of that.

 

Porter

Now you’re hoping to put that right at your unit, can you tell us what you’re doing?

 

Rogers

Yeah, so at the University of Dundee we have a study ongoing at the moment and we currently have 21,089 randomised participants across the whole of the UK.  We invited adults who are taking blood pressure medication once a day to sign up to the study and we randomise people to taking all their blood pressure medication either in the morning or in the evening and then we follow these people up.  And we think that in about three to four years’ time we should have a reasonably definitive answer of whether morning or evening blood pressure dosing is better at preventing heart attacks and strokes.

 

Porter

And to be clear you’re not actually looking at what’s happening to their blood pressure over the 24 hours, you’re looking in terms of outcomes – so whether they have stroke or heart attacks?

 

Rogers

That’s right.  The main outcome of this study is whether the intervention – the dosing time – makes a difference to your risk of having a heart attack or a stroke.

 

Porter

What might be the downside of shifting tablets to the evening?  I mean the most obvious one from my perspective as a GP is that we have quite a few elderly patients who are taking these medicines and you can imagine them getting up in the middle of the night, when their blood pressure’s low anyway, it would be even lower on treatment and they’re going to fall.

 

Rogers

Absolutely, that’s certainly a concern and that’s one question that we want to answer with this study.  There are a number of other possible problems.  It has been suggested that dipping too low at night might be bad in terms of heart failure or even in terms of cognitive function and the possibility of it worsening the development of dementia.  And again that’s another thing that we’re looking at in this study.

 

Porter

I don’t know what’s happening in Dundee but over the last year or two in my area, I practise in Gloucestershire in South West England, there’s definitely more people coming out of hospital having had their medicines changed to evening dosage, so there seems to be some awareness already in the UK about this, is that your experience too?

 

Rogers

Yes, I think the Spanish study, that I mentioned earlier, it made quite an impact on the medical community when it was first publicised.

 

Porter

The results of the Spanish study were pretty dramatic…

 

Rogers

They were.

 

Porter

… but one of the problems has always been that everyone says well they were almost too good to be true.

 

Rogers

Yeah I think that’s correct.  They reported a 64% lower chance of having a heart attack or stroke in the evening dosing part of their study versus a…

 

Porter

Which is huge isn’t it.

 

Rogers

Yeah, it’s a huge difference.  It was done in just one – one location in Spain by one team and had relatively small numbers.  So I don’t think the results were really significant enough to persuade all doctors to change their practice.

 

Porter

Well Amy we’d love to have you back when the results are in.

 

Rogers

I’d love to come back, thank you.

 

Porter

Dr Amy Rogers and there is a link to her time study, as well as the Spanish one, on our website.

 

Just time to tell you about next week when I travel to Gloucester to meet the team behind a new pathway to help people with irritable bowel syndrome (IBS) using dietary manipulation rather than drugs.

 

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