DOH Order Establishing PHILNo.for Organ Donation

Policy, purpose, and objectives

This Order sets policies and guidelines for the efficient and equitable sharing of organs from deceased donors.
PHILNOS is established to facilitate and oversee deceased-donor organ and tissue donation and transplantation nationwide.
This Order directs the initiation and maintenance of the Philippine Organ Donor and Recipient Registry System (PODRRS) to support the program.
This Order promotes deceased organ donation and implements mechanisms for coordination, referral, allocation, and procurement.

Scope and who must comply

This Order applies to all government and private hospitals and health facilities in the Philippines.
This Order applies to Organ Procurement Organizations (OPOs).
This Order applies to medical and allied medical practitioners involved in organ and tissue transplantation in the Philippines.
This Order covers organ and tissue donation and transplantation involving deceased donors.

Core definitions established

Brain Death (BD) is the irreversible cessation of all functions of the entire brain, including the brain stem.
Death (using the definition in RA 7170) is the irreversible cessation of circulatory and respiratory functions or the irreversible cessation of all functions of the entire brain, including the brain stem, determined in accordance with acceptable medical practice and diagnosed separately by the attending physician and another consulting physician who are appropriately qualified and suitably experienced.
Decedent means a deceased individual, including a still-born infant or fetus.
Donor Allocation Scoring System (DASS) is the national scoring system by which allocation of kidney grafts from deceased donors is based.
Graft is an organ removed from the body of an organ donor for transplantation into a recipient.
Hospital Transplant Candidate Waiting List is the database of potential organ recipients of a particular Transplant Center (TxC) administered by the Clinical Transplant Coordinator (CTC) of the hospital’s Transplant Program.
National Transplant Candidate Waiting List is the Philippine database of potential organ recipients registered from waiting lists of accredited TxCs.
Organ Procurement Organization (OPO) is a DOH-accredited non-profit organization (independent or hospital-based), composed primarily of transplant coordinators and transplant specialists, that identifies, evaluates, and maintains potential organ donors and retrieves organs.
Host OPO is the OPO responding to an organ donor call from a referring hospital.
Organ Transplant Candidate (OTC) is a patient with end-stage-organ-disease (ESOD) qualified to receive an organ graft.
Kidney Transplant Candidate (KTC) is an OTC with end-stage-renal-disease (ESRD) qualified to receive a kidney graft.
Liver Transplant Candidate (LTC) is an OTC with end-stage-liver-disease (ESLD), acute liver failure, or a specific metabolic disorder qualified to receive a liver graft.
PODRRS is the national computerized database containing organ transplant candidates, transplant recipients, and organ donors.
Potential Multiple Organ Donor (PMOD) is any patient who will imminently become brain dead or who currently meets criteria for brain death.
Referring Hospital (RH) is any hospital that identifies and refers potential deceased organ donors to PHILNOS.
Transplant Center (TxC) is a hospital with transplant facilities duly accredited by DOH.
Transplant Coordinator (TC) is a designated trained health care professional who is liaison among the donor hospital, retrieval and transplant team members in processing a potential organ donor.
Procurement Transplant Coordinator (PTC) is a TC who coordinates the donor’s evaluation, management, and recovery of organs and/or tissues for transplantation.
Clinical Transplant Coordinator (CTC) is a TC who coordinates the transplant candidate’s evaluation, management, and follow-up care.
Transplant Recipient (TR) is a patient who received an organ graft.

PHILNOS structure, governance, and membership

PHILNOS is the national organization that facilitates and oversees deceased-donor organ donation and organ transplantation in the country, serving as the central coordinating body for deceased organ/tissue donation and transplantation activities.
PHILNOS replaces the National Human Organ Preservation Effort (NHOPE) established by AO No. 2008-0004.
PHILNOS functions through special organ procurement service units called Organ Procurement Organizations (OPOs) that must be DOH-accredited.
PHILNOS Program Manager heads PHILNOS and is appointed by the DOH Secretary.
PHILNOS is governed by an Executive Committee composed of:
- One (1) Program Manager
- One (1) Assistant Program Manager
- Committee Heads
- Three (3) Medical Advisers (Consultants)
- All Executive Committee members are appointed by the DOH Secretary.
The Executive Committee oversees PHILNOS day-to-day operations, handles membership concerns, and formulates and recommends policies to the Philippine Board for Organ Donation and Transplantation (PBODT).
PHILNOS includes an administrative staff comprising One (1) Administrative Officer, Four (4) Nurses as PHILNOS Transplant Coordinators, Three (3) IT specialists, and One (1) Utility Man.
PHILNOS has working committees with the following functions: Accreditation and Training, Ethics & Legal Affairs, Finance, Information and Advocacy, OPO, and Registry Committee (PODRRS).
An External Audit Committee conducts periodic review and audits of PHILNOS allocation procedures, submits reports to the PHILNOS Executive Committee, the Philippine Organ Donation and Transplantation Program (PODTP), the PBODT, and the DOH Secretary, and is appointed by the DOH Secretary upon PBODT recommendation with no conflict of interest.
Organizations may become PHILNOS members, including:
- OPOs (DOH-accredited)
- Transplant Centers (TxCs) (DOH-accredited)
- Medical Scientific Organizations (PMA-accredited)
- Patient Organizations/Support Groups (SEC registered)
- Histocompatibility Laboratories (DOH-accredited)
- Other groups relevant to the program
Representatives from the enumerated organizations may be tapped as members of PHILNOS working committees except for the External Audit Committee.

Regional OPO coverage and accreditation terms

Each region has its own designated OPO.
The National Capital Region (NCR), where transplant activity is concentrated, is divided into several areas of responsibility, and each area is serviced by a designated OPO.
OPOs must serve their designated areas of responsibility and any other regions assigned by the PHILNOS program manager on an annual basis.
Upon issuance of this Order, all existing memoranda of agreement between an OPO and a referring hospital or transplant center are terminated.
Existing OPOs are granted privileged accreditation for one year if minimum requirements are met (see Appendix B).
Existing OPOs then undergo review of performance and renewal of accreditation every 3 years.
Accreditation of new OPOs is initially for 1 year, with reaccreditation every 3 years.

Mandatory coordinators, referral, and registry

All tertiary hospitals and trauma centers must have a Procurement Transplant Coordinator (PTC) that works full-time or part-time to optimize identification and referral of potential deceased organ donors.
All TxCs must have a PTC.
All PTCs must be trained and duly certified by PHILNOS.
If a referring hospital lacks its own PTC, the PTC of the designated OPO is called.
All patients deemed to be brain dead or in a state of imminent brain death must be referred to the PTC for evaluation as a PMOD in all hospitals.
All transplant candidates must be enlisted according to established criteria per organ and must be registered in PODRRS through their respective TxCs.
All donor referrals must be registered in PODRRS, with required donor data provided by the Host OPO.
Donor evaluation, management, and procurement protocols—including organ acquisition fees—must be standardized by PHILNOS.
The organ acquisition fee includes:
- Brain death assessment and certification costs
- Donor evaluation costs
- Donor management costs
- Organ recovery and delivery costs
- Professional fees of specialists involved
- OPO administrative costs
Funeral assistance to the family of the deceased is optional.
Policies and guidelines for non-renal solid organ donation and transplantation must be developed.

Kidney candidate enlistment and waiting-list rules

Enlistment of a Kidney Transplant Candidate (KTC) for a deceased donor graft is done in the TxC of choice of the patient.
A KTC must be at least near-ESRD calculated as creatinine clearance < 20ml/min for diabetic nephropathy/pre-emptive transplants, or must have ESRD calculated as creatinine clearance <15ml./min for non-diabetic chronic kidney disease at the time of enlistment.
KTC enlistment must be done in person at the TxC of choice.
Only Filipino KTCs may be enlisted in a Hospital Transplant Candidate Waiting List of any accredited TxC in the Philippines.
KTC registration requires submission of all requirements and payment of the registration fee.
After enlistment in the Hospital Transplant Candidate Waiting List, the TxC forwards the patient names and required documents to PHILNOS for enlistment in the National Transplant Candidate Waiting List.
KTCs are initially listed as INACTIVE until approved by PHILNOS.
After review and approval, KTC status changes to ACTIVE.
Once ACTIVE, fresh serum samples from the KTC must be stored:
- Every month, and
- Whenever sensitizing events occur (including blood transfusion, pregnancy, failed allograft),
- At PHILNOS reference laboratories for cross-matching use.
Each KTC may be enlisted in only one (1) Hospital Transplant Candidate Waiting List, which must be in their TxC of choice.
If a KTC transfers enlistment to another TxC, the Transplant Coordinator (TC) must immediately report the change to PHILNOS.
If a KTC resides in an inaccessible area (e.g., no telephone or internet coverage, living in an island), the KTC must provide a contact person for communication with the CTC on a 24/7 basis; the contact person must be able to communicate or be reached anytime.
Only ACTIVE patients in the National Transplant Candidate Waiting List are eligible to receive offers of deceased organs.
If, at the time a graft is offered, the KTC is found medically unsuitable or financially incapable, the KTC is temporarily considered INACTIVE.
A KTC INACTIVE status can be reactivated once the medical or financial problem is resolved, and the original enrollment date is retained.
If a KTC is out of the country for a certain period, the KTC must inform their CTC, who must transmit the information to PHILNOS so the patient status becomes INACTIVE during physical absence from the country.
As soon as the patient returns to the Philippines, the patient must inform their CTC for status updating in the National Transplant Candidate Waiting List.
If a KTC goes abroad and fails to inform the CTC and is offered a deceased donor graft, the patient is automatically delisted.
A delisted patient must register again with the Hospital Transplant Candidate Waiting List, resetting the date of enrollment in the National Transplant Candidate Waiting List.

PMOD identification, referral, and evaluation process

Any patient found in the Emergency Room (ER), or in the Pediatric or Adult Intensive Care Unit (ICU) of a RH or TxC who is deemed brain dead or imminently brain dead must be referred as a PMOD to the PTC of the RH.
If the RH has no in-house PTC, the designated OPO must send its PTC to assess and evaluate the PMOD.
The PTC must assess the PMOD’s eligibility and perform complete clinical evaluation that includes:
- Consultation with the primary Attending Physician (AP) and nurse-in-charge
- Review of medical records
- Review of laboratory and diagnostic examination results
- Physical examination of the patient
- Exclusion of contraindications to organ donation
The PTC must record findings in a checklist incorporated in the patient’s chart and indicate whether the PMOD is eligible or not.
Pregnancy situations require arranging obstetrical consultation to ensure fetal well-being takes precedence over organ donation.
Medico-legal cases must be referred to the Medico-Legal Officer of the RH and/or the National Bureau of Investigation/local police.
When a patient is determined to be a PMOD, the AP and/or Intensivist must explain the current medical status and prognosis to the legal next-of-kin or family.
The PTC must offer the legal next-of-kin or family the opportunity of the gift of life, including the option of organ donation.
If the family agrees, the PTC must facilitate BD certification.
If the family opts out, the decision is recorded in the patient’s chart and further organ donation efforts are aborted.
The PTC must alert the Host OPO of PMOD identification if not already done.
Brain death determination must use physicians with skills and experience in neurological assessment, based on existing guidelines including Philippine Neurological Association (PNA) and Canada Practice Guidelines for the Diagnosis of Brain Death.
The AP must refer the PMOD to another physician, or call on two (2) other qualified physicians, to assess brain death.
Brain death requires confirmation by a second evaluation by the same two (2) physicians after an interval of at least two (2) hours.
If findings remain unchanged and brain death is confirmed, a Declaration of Brain Death Form must be signed by the two (2) physicians.
The Death Certificate must be signed by the AP, recording the date and time of death; the time of death is when the patient is initially declared brain dead.
The PTC and AP must inform the family that brain death has been confirmed.
No member of the transplant team or Host OPO may participate in the determination of brain death of the PMOD.
Securing family consent for organ donation is the sole responsibility of the PTC after BD certificate issuance.
Consent for organ donation must be obtained from the legal next-of-kin in this order of priority (RA 7170):
- Legal spouse
- Son or daughter of legal age
- Either parent
- Brother or sister of legal age
- Guardian over the deceased person at the time of death
The Consent for Organ Donation form must be signed by the legal next-of-kin.
Consent remains required even if the decedent has a living legacy (e.g., organ donation card or will).
After consent is obtained, the PTC must inform PHILNOS of PMOD availability and provide all available clinical data to PHILNOS.

Donor management, allocation mechanics, and matching

Donor management in the ICU or ER must commence after consent for organ donation is obtained.
A donor management physician of the RH/TxC must attend to the PMOD until organ procurement time, or the designated OPO physician must attend if no such physician is available.
The donor management physician is responsible for hemodynamic stability and maintenance of the PMOD.
After consent is obtained, the PTC must facilitate completion of the medical evaluation/work-up of the PMOD and request initial laboratory tests.
The PTC must analyze test results to determine if the PMOD remains qualified as a multiple organ donor; if not qualified, further organ donation efforts are aborted.
If qualified, the PTC alerts PHILNOS.
Completion tests and examinations include HLA typing.
Once HLA typing is obtained, the PTC informs PHILNOS and the donor allocation process starts using PODRRS.
Donor allocation rules include geographical location, ABO compatibility, and the DASS for kidney transplantation.
ABO compatibility rule includes preferential allocation:
- Blood Type “O” donors are preferentially allocated to Blood Type “O” recipients before allocation to other blood types.
- Donors of other blood types are allocated to identical or compatible recipients equally.
PHILNOS TC runs the match in PODRRS, draws:
- The top 10 KTCs in the host OPO’s areas of responsibility/region, and
- The top 10 KTCs in the national list,
- As potential organ recipients.
A full house match or zero antigen mismatch takes priority regardless of the potential recipient’s geographic location.
If no zero mismatched KTC exists, DASS determines kidney graft allocation:
- If PMOD is from a region other than NCR: one kidney graft goes to a KTC within the region and the other goes to the national list.
- If PMOD is from NCR: one graft goes to a KTC within the areas of responsibility of origin and the other goes to a KTC on the national list.
- If the top-ranked KTC has a negative tissue cross-match but refuses for any reason, the organ is offered to succeeding KTCs until placed.
- If after the 10th KTC there is still no suitable candidate, PHILNOS draws the next 10 potential recipients from the National Transplant Candidate Waiting List.
- If transport of the second kidney graft to a matched national-list KTC is inconvenient and threatens graft quality due to prolonged ischemia time, the second graft may be allocated to another recipient within the region of donor origin.
PHILNOS must alert other tissue procurement agencies or tissue banks of PMOD availability, including:
- Sta. Lucia International Eye Bank of Manila (SLIEB)
- Bone Banks
- Skin Banks
- Vessel Banks

Kidney DASS scoring system and limits

DASS for kidney transplantation uses 5 criteria:
- Number of HLA mismatches
- Panel Reactive Antibodies
- Date of enrollment
- Recipient age
- Previous kidney donor
The DASS assigns the following points:
- Number of HLA mismatches
  - 0 DR mismatch, any B: 4
  - 1 DR mismatch, any B: 2
- Panel reactive antibodies
  - >50%: 4
  - >50%: 2
- Date of enrollment
  - >3 years: 4
  - >2 and <3 years: 3
  - >1 and <2 years: 2
  - <1 year: 1
- Recipient age
  - <18 years: 2
  - 19–65 years: 1
- Previous kidney donor
  - 15
DASS provides that categories corresponding to the greatest graft survival advantage receive the highest points.
Kidney grafts with zero HLA mismatches are preferentially allocated to that recipient without using DASS.
In the absence of a zero-mismatch waitlisted KTC, DASS ranks candidates from highest to lowest points.
A cross-match negative, highly sensitized patient (defined as PRA >50% on either Class I or Class II PRA) receives point advantage based on the highest historical or current PRA.
Enrollment date and time refers to when the KTC considered ACTIVE in the National Transplant Candidate Waiting List; priority goes to the longest ACTIVE period.
Recipient age point advantage prioritizes:
- <18 years, then 18–65, then >65
Previous kidney donors who developed ESRD receive a point advantage to allow immediate transplant.
Donor age cut-off for kidney grafts is 55 years old, but expanded criteria donors >55 years old may be allowed as exceptions.
Expanded criteria donors >55 years old are preferentially allocated to recipients aged 56 to 65 years old.
The maximum number of points that can be given is twenty-nine (29).
The KTC with the highest DASS points is offered the kidney graft first; refusal results in offers to the next candidate until accepted.
For equally ranked patients, ties are broken:
- First by waiting time, prioritizing the oldest date of enrollment in months and days.
- If still equally ranked, by age, prioritizing the youngest recipient age in days.
PHILNOS may recommend review and revision of DASS to PBODT when appropriate.

Organ acceptance and time limits

Each OPO must have a uniform set of criteria defining acceptable deceased donors or organs for that OPO and its served transplant programs.
Renal transplant programs must submit their minimum renal acceptance criteria annually to PHILNOS.
PHILNOS must not offer renal organs to a TxC that fail to meet the submitted minimum renal acceptance criteria.
Renal acceptance criteria do not apply to zero antigen mismatched kidney offers.
A TxC may inform PHILNOS of criteria for acceptance of non-renal organs allocated through PHILNOS.
PHILNOS must not offer non-renal organs to that TxC if the organs fail to meet the TxC’s informed acceptance criteria.
A CTC (or designee) must access donor information in PODRRS within one hour of receiving the initial organ offer notification.
If PODRRS is not accessed within one hour, the offer is considered refused.
After accessing donor information, the TxC has one hour to communicate acceptance or refusal.
If one hour elapses without a response, the offer is considered refused and PHILNOS offers the organ to the next KTC in priority.
All communication and exchange of information between the PHILNOS TC and the CTC must be properly documented.
Final organ acceptance remains the prerogative of the transplant nephrologist or transplant surgeon responsible for the KTC’s care.
If an organ is declined for a KTC, the reason must be recorded on the appropriate form and submitted promptly.
Even after acceptance is confirmed by the receiving TxC, final placement depends on tissue crossmatching results.

Procurement and transplant rules

Neither the AP of the decedent at the time of death nor the physician who determines and certifies the decedent’s death may participate in the operative procedure for removing or transplanting an organ.
If the PMOD is stable, organ procurement may be delayed until tissue crossmatching results of potential recipients are known.
Otherwise, the organ retrieval team is informed and procurement is scheduled.
The Host OPO’s surgical team performs organ procurement either in the RH if possible or in another hospital where the PMOD is transported if necessary.
If the RH is also a TxC and an organ retrieval team is available, the RH may perform organ retrieval.
If a non-renal organ is to be recovered, the operation is performed by the non-renal organ retrieval team.
If grafts are not yet placed after procurement, grafts remain in the custody of the Host OPO until placement.
The OPO coordinates transport of grafts to the receiving TxC once placement occurs.
Organ transplantation is performed at the TxC of choice of the KTC and is performed by the transplant team of choice of the KTC.

Financial responsibilities for organ acquisition and care

Hospital expenses of the PMOD not related to organ acquisition (i.e., prior to obtaining consent) are for the account of the PMOD or the PMOD’s next-of-kin.
Charges related to organ acquisition (from time of BD certification until transport of organs to the TxC) are for the account of the Host OPO.
Regardless of graft placement, the Host OPO must settle bills pertaining to organ acquisition in the referring hospital on immediate basis.
If organs are placed, the Host OPO is reimbursed by recipient(s) through appropriate sources of funds, such as personal account, PhilHealth, private insurance, PCSO, and others.
If organs procured are not placed, the Host OPO is not reimbursed for expenses incurred from the organ acquisition process.

Postmortem care and performance reporting

Postmortem care is provided for the decedent by the hospital where procurement was performed.
The Host OPO and PTC assist in providing postmortem care.
If necessary, assistance for funeral arrangements is provided by the Host OPO.
The PHILNOS Program Manager must prepare and submit monthly performance reports to PODTP, PBODT, and the Secretary of Health.
Each OPO must submit to PHILNOS every 1st week of the month the list of PMOD referred to them in the previous month.
Each TxC must submit to PHILNOS every 1st week of the month the list of new patients transplanted with deceased donor grafts in the previous month.
Each PTC must submit to PHILNOS on a quarterly basis during 1st week of April, July, October, and January the list of PMOD referred in the previous 3 months (regardless of outcome).

Repeal and effectivity

Section VIII requires amendment and/or repeal of all existing issuances inconsistent with the provisions of DOH Administrative Order No. 2010-0019.
Section IX states the Order takes effect 15 days after publication in a newspaper of general circulation.