Episode Transcript
[00:00:04] Joe: Hello everybody. Welcome to this introduction to season three of the Great Ormond Street Paediatric Bioethics podcast. My name is Joe Brierley. I'm director of the Paediatric Bioethics Centre at Great Ormond Street Hospital. I'm the host of these pods. With this third season, we've attempted to focus a bit more on how clinical ethics support to childrens' medical teams, children and their parents has developed over time and focused a bit more on some of the legal issues and maybe practical issues in a more global sphere that people are thinking about in developing that support as paediatric medicine gets ever more complex. We also have some specific episodes focused at very hot, ethical topics such as organ donation and transplant in small infants, and I really hope you enjoy the season and please feedback. They're available wherever you get your podcast from, and we'll be releasing them every two weeks. Thanks everybody.
Hello everybody. We are delighted to have as our guest today Louise Kenny, who is a cardiothoracic transplant surgeon and we're going to focus on the area of paediatric cardiac heart transplant.
Morning Louise.
[00:01:20] Louise: Good morning. Thanks for having me. It's nice to come on and chat.
[00:01:23] Joe: I'm Joe Briley. I'm going to lead on this podcast. So Louise, we're going to start with a nice open question.
Everyone really interested in hearing about how you got into cardiothoracic transplant? Did you always want to be a heart surgeon?
[00:01:36] Louise: No, not at all. No. I started out not really knowing that I wanted to do medicine and I finished school and went off pottering about the world for a couple of years and I bumped into some doctors while I was abroad and thought that's a pretty cracking job.
And then came back and went to medical school and in house officer years I did a surgical job and said, I'm never going to do that. That's horrifying. And then I actually took a year working in Central America, I went to work in Guatemala for a year, and part of my job there was surgery. When you were on call, you were just the doctor on call and you did obstetrics and surgery and anesthesia and anything that came through the door.
And that's where I really got the hang of it and realised how it was a quick fix. I guess that was what I liked about it. And came back and did general surgical training first. I did a couple of years of that and as my first job, I did cardiac surgery as a must have been T1. And I survived it, I would say.
But I also really enjoyed the physiology and the surgery all mixed together, yeah. The thinking about it as you're operating.
[00:02:46] Joe: Yeah. I feel that's quite important.
[00:02:48] Louise: Yeah. I got to use my brain as well as my hands, and then I was really lucky, that first job I worked in at the Freeman Hospital where it is one of the big transplant centers in the UK and I was involved in transplant from day dot involved in the transplant ward rounds, involved in the preoperative planning. Went on some retrievals and I guess it grew from there. I went back into cardiac surgery the following year. Worked with a paediatric surgeon for a while during that period, and then that was really, that was where I've ended up. Yeah, there hasn't been a moment where I've thought, this is what I want to do. It is just always been, this is what I feel like I should be doing every time I've landed in something. It's felt like the right place to be. Yeah.
[00:03:34] Joe: Cool. I can imagine how working with Asif would inspire you, to be honest, but yeah, a great man. So that's interesting. So that combination of using your brain and your hands is very important I think. Something people see the surgical practical skills, but there's certainly an awful lot of physiology and complex medicine that surgeons have to know and do as a daily job, isn't it really?
It's not all about cutting, which sometimes people forget, I think.
[00:04:01] Louise: Yeah, I mean I, I would hate to generalise. I think our surgical specialty probably carries a slightly more cerebral input than others at times. So you find, particularly in the paediatric side, you find yourself coming off pump with cyanosis or all sorts of strange anatomy and you're coming off and you've got to try and work through what's going on.
There's a lot of puzzles to solve with what we do as well.
[00:04:27] Joe: Congenital heart disease, the physiology is one of the things that attracts you to it, but also is the big challenge as well, of course. When you started off, you suddenly thought, I want to do a one in two, I'm going to work really hard, that's for me. For a lady with a young family, if I'm allowed to use that term, that must be incredibly tough. Tell us about what that's like.
[00:04:45] Louise: It is tough. I suppose it was tough throughout my training. But there were always, and perhaps naively felt like there was light at the end of the tunnel.
And at some point you gain control over your own time. But of course, that never actually happens and you just become more and more involved. And I suppose, one of the parts of that is having a family balance that allows you to drop when you need to. And I have a, I can't be grateful enough to my partner Andy, and his support of what we do - most of our lives is based around, what's going on at the Freeman Hospital? So , it's pretty challenging. To get a break from work, we leave the country because that's about the only time that on a one in two, you don't end up being called in. We're a really good pair of colleagues. We look after each other. So even on days that we're not, one in two doesn't really mean one in two.
If the phone rings we go in and help each other out. That's helpful. It also means when, the phone rings at home, we help each other out as well. So as colleagues we'll cover if there's something going on at home or someone's not, someone needs a bit more help. We're good to each other that way.
But yes, it's not an easy life. And the sacrifices are pretty big and not just by me, pretty big by my family around me.
[00:05:57] Joe: Yeah. I guess in my list of questions, I had a nice order plan, but I think it nicely brings us to, maybe tomorrow and how you think cardiothoracic units are going to be staffed because I guess, there's lots of considerations in medicine at the moment about how we keep young people in the profession and that old fashioned one in two, which some of us worked in all medical specialties, has gone. It's disappeared. And so for most of us consultants who work in bigger teams, transplant is almost not unique, butfrom the outside I can't imagine being on a one in two anymore. Certainly towards the later bits of your career. How are we going to attract new people into a specialty that either it needs to find a creative way of staffing itself or we're going to end up with people really struggling to comply with those rotors going forward.
I'm just interested in how you think maybe about your own job going forward, and then maybe the other things in transplant.
[00:06:56] Louise: I think it's the same as congenital heart surgery. I think they're not separate, in my life transplantation and congenital heart surgery is my job as a whole, but the two are very similar.
You can't train 10 people to be doing transplants, when we only do 28 year it's not possible. And actually, I wouldn't want to be doing less than I'm doing because of the outcomes and the skills, particularly as you get into the more complex end of the spectrum, which we certainly are with the kind of transplants that we're doing.
I think for transplant surgery, and I include in that for retrieval, especially as retrievals become more and more complex with technology and multi-organ and using perfusion devices, I think it has to remain a small, incredibly dedicated, committed group of people that do this. And it's not a job, it's not something that can be rostered.
It's not something that I, and I don't believe it can be, it's not something that you can say ‘It's my day off’. You've got to be a person that is so wholeheartedly committed to this, that you are willing to be a part of that. And as I suppose i'm not aging yet, so I do feel quite old some days when I'm exhausted.
But I can see my energy when there is a transplant, when there is a retrieval, when it's coming to a child that I know has been in the hospital for up to a number of years at times, that you pick up and you go, and I think the people around me, who do the same, I think we're the ones that will carry this through.
[00:08:27] Joe: Yeah.
[00:08:27] Louise: And the way that I see us staffing our service moving forward is identifying those individuals and building into the way that we train individuals and the way that we set up our teams, building up each other's lives in it. And like I said before, my colleague and I have definitely built into our lives the fact that I've got a younger child and he's got older children.
And we appreciate how that works for both of us in the times that we need off and the times that we have nativity plays and these sorts of things, and we cover each other. We make it work, but it has to come down to individuals. I can't imagine a way that a paediatric transplant rotor could ever be a rotor of
x number of people where you do one or two a year. It would just fall to pieces. Yeah.
[00:09:10] Joe: Yeah. Could, can absolutely see that. Because you just need the experience of the work, don't you? You have to do a minimum number to stay competent. So maybe we'll move on from the individual surgeon to teams, and I guess the two other big limitations I see again, more into my world in some ways, our ICU provision - always tough, particularly for elective work - but emergency work over winter encroaching on what you would try to do electively, it's a longstanding issue, but very acute in children's services and no more so than in cardiothoracics. And then the other thing is we will come on to thinking about devices and other stuff, but again, organ availability. The limitations I can see on your world are the availability of organs for transplant and staffing. So would you like to take staffing first, maybe Louise, how are we going to keep people working in ICU etc?
[00:10:00] Louise: I suspect it's the same all over the world, but the constant push and pull of, like you say, bringing elective cases in and taking care of the children in our immediate population that need to come through an intensive care unit in balance with bringing a child in heart failure in who will be on a Berlin Heart for several months with several trips to theater and uses a huge amount of staffing and resources and theater time and ICU time. It's always a difficult balance and I suspect that the more beds you build and the more space you build and the more staff you provide, you just grow to fill that, new capacity.
I don't think we'll ever have enough. I think it just continues to grow beyond what we are able to provide. And we've certainly felt that this winter with this surge of heart failure in children, even if we had an extra five beds, there'd be another five children that would come through after that, and we simply can't meet the demand.
I don't know how we staff it moving forward. It has to be on all fronts. It has to be that we employ the technology, we invest in the staff, we invest in the training. We give people back what they give to us. If I go to any single part of the process. If I go to the retrieval surgeons, if I go to the ICU nurses, everybody feels just a little bit undervalued and a little bit like they're being asked to do more than they can do on a day-to-day basis.
And there's small things that we can do to alleviate that and the small things we can do to retain staff, but overall it's building a service that allows us, to utilise the technology to increase organ donation, to increase how we can get children through at the other end. Yeah,
[00:11:40] Joe: I think that's a brilliant point.
You're heading towards, in some ways kindness to our own staff and that little saying ‘thank you’ and just little things that make our lives worth, carrying on and wanting to do this job. I think how we treat each other is super important, but maybe onto the ultimate finite issue is the availability of organs of transplants. And we'll touch on Berlin Hearts and the concern that hasn't really led to increases in transplants because it was never the rate limiting step really. So the UK doesn't have a great organ donation track record in paediatrics. I know because I've been working on that for some time and we've really not managed to increase the number of organs being donated for lots of reasons. But I think there are lots of things that we can do to maybe look at that. But any thoughts as a transplant surgeon on that?
[00:12:30] Louise: Yeah, I suppose, one of the things that's happened is we've got really good at keeping children alive while they wait for a heart and that is a wonderful thing, of course, but it also means that there are more and more children who are sitting in hospital going to school, doing their lessons.
Sitting in the playroom, going out on adventures, waiting for a heart and their families move across the country to be with us. As they live in shared flats with other families waiting for heart, they go into complete financial ruin and family meltdown in order to achieve what they want, which is their child to have a heart transplant.
And while we've got really good at keeping those children alive, you're right, we haven't got really good at finding hearts for them. We have a limited number of hearts each year. We have, at any one time between 40 to 50 children waiting for a heart. And the majority of those children will be at least half, will be waiting in hospital, in crisis.
And at the same time, we get offered 15 to 20 hearts a year. And so the maths isn't difficult to work out. We have a 25% mortality on the waiting list. Which at the moment is unavoidable. The way out of it is to increase organ donation. And I know your work has focused hugely on increasing organ donation historically and present.
And I suppose my big mission in the last couple of years has been to increase the number of hearts from the number of donors, which we are already retrieving organs from. And in the UK, in the last 10 years there have been 200 children who've become specifically DCD donors, DCD being circulatory death donors, and only 16 of those children have donated their hearts.
That's a huge number of children whose families have gone through this tragedy and who have chosen to donate their child's organs, livers, kidneys, lungs, and we have not been able to retrieve their hearts. And there's lots of limitations on why we haven't been able to retrieve their hearts and some of them would not have been heart donors, but there are many children in that group where if we had the technology, if we'd had the logistics, we would've been able to retrieve those hearts. And that's my big, waking and sleeping and dreaming, mission at the moment is to set that up and get that up and running.
[00:14:55] Joe: But maybe we'll go further on that. So I wonder, the one thing that's worth focusing on, I think for people who aren't involved in this area of medicine, to me it was always shocking how well the children on the Berlin Heart are, and you described they're going to school, their only restriction is they're stuck in a hospital attached to a pump, but other than that, they have a really good quality of life. It's quite astonishing to see that. And the ability of the nursing teams and their parents and families to provide that for them always leaves me in awe.
I think it's fantastic. But as you say, ultimately isn't an ends to the means of heart transplant. And the challenge is the organs available are, we are not increasing the consent rates. That's for sure. So your work, just to clarify, is about increasing donation of hearts from children who were already DCD donors, particularly in the young side.
Yeah, the smaller size patients. Yeah. Which haven't been machines available for until fairly recently. Would you explain that a bit more, louise?
[00:15:55] Louise: Yeah, so for the last 10 years we've been retrieving adult DCD hearts and the difference with a heart from a DCD donor is that the heart has undergone and because the heart has arrested, which is how we have come to deceased donation. The heart by that very nature, has undergone an ischemic event. And we can't just take it out and put it into an icebox. It has to be reperfused. It needs oxygen in order to recover from that. And we've always used a device, which runs the heart at a warm temperature and allows the heart to beat, and that's very common practice.
Now, 30% of adult heart transplants come from DCD donors using that particular type of technology. Now, it's always been very limited. We try to take that technology down into smaller children, but unfortunately the pressures involved and the cannulation involved, it doesn't work for children's hearts.
They become very edematous and they don't work and we haven't had good outcomes using Normothermic technology for smaller children. And a number of years ago, people started to look at Hyperthermic technology, which is where instead of running the heart warm and beating, you run the heart cool, and in diastolic arrest.
And that means that the oxygen demand is very low. The heart isn't beating. You don't need high pressure, you don't need coronary profusion. At the same degree. And you can run these hearts at very low pressure, cold perfusion, and that's perfect for a child's heart. That's really lovely for perfusing a child's heart to allow it to recover from an ischemic event.
We started using this particular device in DBD hearts and the first child DBD Heart was transported in Australia using this device. And we've now done a couple of DBD hearts at the Freeman Hospital using this device, which are hearts that we otherwise wouldn't have been able to retrieve because they have come from far away and this device has allowed us to perfuse those hearts for several hours longer and travel further to retrieve hearts. In terms of DCD, it was quite a big leap of faith to go from, retrieving A DBD heart, which beating before you take out to a DCD heart to putting it onto this device, where the next time that you see the heart functioning is once you've implanted it into the recipients. And actually that's taken quite a lot of work to navigate people's conceptions around you. With the Normothermic device, which we call OCS, you can see the heart beating and that's very reassuring.
With the ex vivo, which is the hyperthermic device you can't see the heart beating, so you have to trust in your preoperative echo, your understanding of the cardiac function, your understanding of warm ischemia, the retrieval process itself, the perfusion process. You have to trust in the process of recovery that we know from animal studies and we know from having now done this in humans and in children, but there's a leap of faith that's required. I call it educated faith that is required.
The first DCDs were done by Philip Rager in Belgium.
And those were adults. They've actually done one adolescent child over there and they think it's set up slightly different over there with the way that withdrawal occurs and more ischemia and such things. Each country has their own legislation around what we can and can't do in DCD particularly.
We earlier this year, we also received compassionate permission from MHRA, from the regulatory body here in the UK to go ahead with a DCD retrieval and transplant for a young child. And that's the first small child, DCD transplant that's been done using hypothermic technology. And that child has gone home with a lovely, well-functioning heart and gone back to a lovely, well-functioning life now.
So that's good.
We in many ways have proved that this technology works, that we can apply this technology to DCD hearts. We've also used this technology in really small donors now down to infants. And that really opens up to me that we found the solution here. So we've retrieved a heart from a very small DBD donor and we've retrieved a heart from a small child, DCD donor, and we put that together and suddenly we're in a position where we can be retrieving DCD hearts from even the smallest age group of children.
And we've never been able to do that. We've never retrieved a heart from anybody under the age of eight via a DCD donor, despite the fact that there have been over 70 DCD donors in those age groups. So now suddenly we're in a position that we perhaps can start to do that. And I hope estimating based historically, that should bring somewhere between five to 10 more hearts a year for the UK alone.
[00:20:43] Joe: And although that sounds a small number, it's a huge percentage increase in the number of transplants. And for this group, the small group, they haven't been able to. The other thing that's probably worth talking about is the original DCD heart recipients. Some received hearts from children, but most were from young adults.
So I think, this is that small children need hearts from small children. There's no way you can change the size matching. So I think that's super important. I guess just to maybe come to end this area. My colleagues in Spain use NRP and I think that's quite interesting. So Normothermic Regional Perfusion, two types, abdominal, thoracoabdominal, and obviously for a heart transplant, thoracoabdominal is what would be used.
They have reported that in small, infant donors and I know there are the kind of restrictions in the UK you touched on about different legislation, although it's not really law, it's clinical practice. But I guess the question is, I think NRP is used in abdominal retrieval in the uk. I don't think it's used in thoracoabdominal and it's certainly not used in children that I'm aware of, but I don’t know, I'm not fully all over that. But I wonder in Spain, they really see the advantage of that because again, organs are perfused in situ and can assess them. And the other thing they talk about, which is I think super important, is it takes that pressure on the surgeons of time. The patient's body is stabilised, therefore, the surgeon can go and look at the organs and make a decision rather than have to rush over at, whatever time it is. And it seems just such a straightforward, sensible thing. But there are ethical concerns and people are worried about cerebral perfusion. And I wonder what your thoughts are about that. Have you had any discussions about using that in there?
[00:22:28] Louise: I guess so, just to answer your question, first of all, so TA-NRP is not used in the UK at all currently.
There is a trial which it was used, again, I'll use the word historically. And it was stopped because of ethical concerns. Because of the concern regarding cerebral perfusion. And just in the last couple of months, a trial has started in the UK looking at TA-NRP which is perfusion of the whole body, so all organs with monitoring of cerebral perfusion.
And I hope that will answer some questions for people who are concerned about cerebral perfusion. There's lots of good points to TA-NRP as you say, it's a really physiological way of re-perfusing the organs. You have time, you can reperfuse, you can see the organ in situ, you can see the heart beating. You can measure lactates; you can measure gases. You can measure perfusion pressures. You can see the heart functioning as though it was a DBD heart. And actually that's a very reassuring thing to be able to do. Also there's good evidence that it shows the number of organs that we're able to retrieve from a donor via TA-NRP in countries that do that is much higher.
We managed to retrieve more organs from a single donor than we do using direct procurement and ex-situ technologies. And that's because the simplicity of TA-NRP is the surgeon opens and puts the child onto ECMO and then everything is perfused. There's not multiple teams trying to reperfuse their individual areas of what they need to be reperfused.
It's the most simple answer. And I do see it in the future. It's not something I've ever done, and it's not something that I'm an expert in. The ethical issues with it related to diagnosis of death and cerebral perfusion and sentience. That's all well discussed in this. And it's all currently up in the air. It's big at the moment. For me, there is a certain discomfort that I have as a, and I guess it comes from not just as a heart surgeon, but from who I am as a human. There's a certain discomfort for me that I've never quite been able to pin down, and there's something about restarting perfusion within that child that, that sits a little uncomfortably with me.
And I don't quite know why, because it is exactly the same as a DBD donor. And I'm certainly not in any way against TA-NRP, but there is something that sits a little bit uncomfortably and I wonder often if it's because, it's not unfamiliar for me in my day-to-day job to open a child's chest and put them onto ECMO to resuscitate them.
And there is a moment where you've got that child onto ECMO where you take a breath and you think, phew, we might get out of this. That I might be able to tell these parents that this child is going to survive. And so when I think about TA-NRP, it's almost there's an error sound in my head.
It's something that doesn't quite sit well with me, but then I am very interested to see more data coming out of Spain and out of America, who, who've just started to do TA-NRP with the ex vivo hypothermic perfusion and also this study here in the UK and I am very interested to hear and learn, and understand and grow my own thoughts about that and my own discomfort. That's something that I'm looking forward to hearing more about. Yeah.
[00:25:58] Joe: Yeah. And thanks for sharing that. I completely can understand your thoughts. Just to, to reassure people, the data from Spain is very reassuring about the lack of any cerebral perfusion or any cerebral activation. There is good data coming out, but as you say, it's just one of these kind of, a rubicon if you like, to cross, if you like.
[00:26:16] Louise: But I suppose we have probably crossed this feeling many times if you think back through transplantation, people must have been horrified at the start of any of this.
And then slowly we come around to thinking that there is good that comes from bad and so you step forward into the next realm of what you're doing and you think maybe we can try something that would make this better. And you step forward again. And each time you come up against these ethical issues or discomforts or whatever, and you navigate around them.
And some of them we probably haven't overcome and some of them we certainly have overcome to get to where we are.
[00:26:51] Joe: Nicely put, I went to an anniversary about the IVF, kind of, startup, in the UK and it is very much similar. Something that was very concerning in ancient historical times, which I of course remember is now so normal and standard in our society that it's what's the biggie?
So things change and you can argue about whether that slippery slope or, evolution of society, which is probably outside our remit today, maybe. But back to our remit today, you've talked about the future and just to finish off, there are two hot topics in medicine, but very much kind of being discussed in transplant at the moment.
And one is the use of AI, artificial intelligence, which is this nebulous, wonderful thing that's either going to solve all our problems or end humanity. I can never work out which of those, somewhere between the two, I think. And the second is xeno transplant, which it probably is more practically likely to revolutionise what you do. Although AI could do that too. So I wonder what your thoughts are about those two hot topics.
[00:27:51] Louise: Tell me what you mean by AI.
[00:27:52] Joe: No, that's almost it, isn't it? It's this kind of, what does it mean? Is it AI, artificial intelligence, to match organs better?
You go to meetings and people say AI is coming in, and it's okay. The only thing I've seen about it in my world, Louise, is some very smart tech, which will tell people if the nasogastric tube's gone the wrong way on an x-ray because humans aren't as good at doing it as machines are.
And actually, in all seriousness, there's another major alert come out in the ICU community because that gets missed and people are fed in the lungs and people die. It's a really important thing. And it sounds very straightforward when you are sitting outside medicine going of course you can see if the tube's in the wrong place.
It's not always easy when you have four quadrant infiltrates on an x-ray. So I think maybe assisting us in what we do is maybe where I think AI might have a role, but maybe we'll go to xeno, which might be an easy one for you to start.
[00:28:47] Louise: What you made me think of with AI is the hyperthermic device that I talked about, ex vivo, the French surgeons recently retrieve a heart in, I think it was French Polynesia, and flew across the Atlantic
[00:28:59] Joe: Nouvelle-Calédonie
[00:29:01] Louise: Yeah, 13 hours on a commercial flight, I believe, strapped the seatbelt in the cabin. And that's been applauded as this device, if we can perfuse a heart for 13 hours safely, and actually in animal studies, we've perfused these hearts up to 24 plus hours.
That opens up transplantation globally, isn't it? We have donors here in the UK who we offer out to Europe because we don't have a suitable recipient. And suddenly if you can open up transplantation globally, then that changes perhaps the profile of every child waiting on the transplant list in the world.
It does open up another enormous problem, which is retrieving organs from places that don't have a transplant program and heading into other countries to retrieve organs. That's a really ugly can of worms if you think about it in a different way. But it's something that AI is probably pitched to address at some point, I would've thought being able to match in a much bigger space.
[00:29:59] Joe: I guess in some ways it's, the law of the countries the law of the country, and if the organs have been donated, they've been donated. That's my simplistic view. Whether you morally as a surgeon, for instance, have to worry about them being donated, following euthanasia, for instance. People have talked about that, and there's this kind of a, are you having to consider how that works. And of course, if there's something that's really immoral in something you really worry about, then you have the option of not doing that. But then you have a patient waiting for an organ who may die, as you said. So these are tough areas. So let's move to the simple topic of xenotransplantation.
Any thoughts about that?
[00:30:37] Louise: Yeah, xenotransplantation. So it, I guess again, it's definitely not my area of expertise. Something that is coming, isn't it? We engineer so much now in tissue and we engineer so much on a molecular level to allow things to be accepted that it, I can see that it is in the future that we are able to molecularly engineer, the Baboon heart to be able to be received by a human.
There's one recently been done in America and it was actually retrieved in the, they used hyperthermic perfusion to protect that heart during the time it was traveling. I'm not sure. Again, it's something that sits a bit uncomfortably, but I don’t know why it does.
[00:31:16] Joe: There's an a kind of an ‘ick’ factor, which is doesn't ethically stand any rigorous analysis, but it's something about, ‘I don't like this 'cause it's something about my upbringing says it's not right’.
[00:31:29] Louise: Yeah, absolutely.
[00:31:30] Joe: But actually when you rationally consider it, maybe it's not quite as worrying.
Yeah. But anyway, that's probably enough of your time. You probably have to go and do important stuff. But thank you so much for taking the time to speak to us today.
[00:31:41] Louise: You're very welcome.
[00:31:41] Joe: This has been an ELPAT podcast and also part of the Great Ormond Street Paediatric Bioethics podcast series as well. So we'll duplicate it for both things. Louise Kenny, Cardiac Transplant Surgeon, pushing the boundaries in a really good way. Is that allowed to be said?
[00:31:58] Louise: Yeah I'll allow that.
[00:32:00] Joe: It’s so important because children, children are dying and you have to change that.
[00:32:02] Louise: They are.
[00:32:03] Joe: It's important.
[00:32:04] Louise: This, it's always been the solution to me. There are children and just, I'm sorry you were trying to finish, but just there are children dying of heart failure.
[00:32:12] Joe: Yes.
[00:32:12] Louise: And there are children dying in the UK who are becoming organ donors, who aren't donating their hearts. And to me it's always been that those two families are able, in many ways to help each other out. There's something really special about donating the heart.
And if you speak to families who have, and you speak to, there's a wonderful BBC Radio 4 for recording called ‘The Boy Who Gave His Heart Away’, which is a wonderful thing to listen to if you ever question donation and question whether that is something that helps families beyond tragedy. And those families are in a position to be able to help the families who are waiting for a heart. So to me, that equation has always matched up. It's always been very simple. And so whatever we can do to facilitate that for both sides is important to me.
[00:32:57] Joe: Absolutely. And I think we'll leave it that the true heroes of transplant to the families who donate.
I absolutely agree with that.
Lovely Louise, thank you so much. Take care everybody.
[00:33:06] Louise: Bye. Thanks Joe. Have a good day.
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