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Archive for March, 2017

Ethics of Organ Donation from Prisoners on death row

Wednesday, March 29th, 2017

Organ Procurement and Transplantation Network

Dr David van der Poorten performs the transplant image www.newcures.info

Rationale for Deliberation

prison pic-5

As the scarcity of suitable organs for transplantation continues to grow, alternative sources for organs have been reported and others suggested. One such suggestion is to recover organs that would otherwise seem to go to waste, such as those from condemned prisoners. Reportedly the People’s Republic of China recovers organs from executed prisoners, and recent U.S. news reports have alleged that organ brokers operate in this country who arrange transplantation of the foreign prisoner’s organs. This discussion is not restricted to third world countries. In the United States, proposals of this type have come from prominent figures and bodies. While one proposal suggested that prisoners be given the option of donating organs upon their death, another suggests that condemned prisoners be offered the option of trading a kidney or their bone marrow in exchange for a commuted sentence of life in prison without parole.

While it is beyond the scope of the UNOS Ethics Committee to examine the moral and ethical issues encompassing the death penalty, it is worth noting that this topic is both ethically and judicially controversial. Acknowledgment should at least be made that the death penalty is rarely available or applied in most industrialized western nations, except for the United States. All western European countries, Canada, Mexico, Central and South American, with the exception of Chile, have abolished the death penalty. Recent U. S. data show an inequitable application of the death penalty with a significant evidence of racial bias particularly in the south. The data indicate that blacks are five times more likely to be sentenced to death than whites convicted of similar crimes and that the economically disadvantaged as well are more likely than the wealthy to receive the death penalty.

Any law or proposal that allows a person to trade an organ for a reduction in sentence, particularly a sentence from death to life in prison, raises numerous issues. Application of the death penalty is spasmodic and seemingly discriminatorily applied, which would suggest that these types of proposals would be coercive to particular classes of individuals–minorities and the poor. Would the reduction in sentence apply to the offer to donate, or would it only be honored if the act of donation took place? If the act of donation would exclusively qualify for the reduction in sentence, then the law or policy would discriminate against individuals found to be medically unsuitable to donate organs. Examples include:

  • those with common prison infections such as tuberculosis, HIV or hepatitis B
  • the prisoners with a single functioning kidney, or on dialysis, or with diabetes or other renal diseases

Were prisoners allowed to trade a kidney to mitigate a death sentence, it may affect the actual imposition of the death penalty. With greater publicity surrounding these types of proposals/laws, potential jurors could be influenced and ultimately impose the death penalty more often with a potential societal benefit in mind. Jurors might hope that the convicted persons would choose to trade their kidney for their life. This would present a gross inequity for those unable or unwilling to donate a kidney and who might otherwise have not received a death sentence.

The proposals that concern organ recovery from executed prisoners unveil another host of problems. One method of execution suggested is the act of organ donation itself. From a utilitarian standpoint this would make sense; the anesthetizing of the condemned and the recovery of organs in the usual manner would produce optimum organs for transplantation. However, the cross-clamping the aorta and the ensuing cardiectomy, followed by the disconnection of the ventilator, create an unacceptable situation for the organ recovery team. It clearly places the organ recovery team in the role of executioner. Many physician groups, including the American Medical Association, have prohibited physician participation in state executions on ethical grounds.

Issues of informed consent of potential donors as well as recipients need to be addressed. Obviously a person condemned to death cannot consider organ or bone marrow donation as a coercion-free option. Even a death row inmate should have the option of refusing an invasive surgical procedure–although unlikely, given the alternative. Correspondingly a person to be executed, or their next of kin/surrogate, should be able to make an informed decision regarding any donation options, including informed refusal if they so chose. Ultimately the potential organ/bone marrow recipient(s) should be informed that the source of the donation was a condemned prisoner, while maintaining the prisoner’s confidentiality. Individuals in opposition to the death penalty might object to accepting an organ from either an executed prisoner or a prisoner who traded their organ for their life.

Consider the effect that such a policy/law could have on organ donation overall. The number of potential organs recovered from condemned prisoners would be small. The conceivable stigma that would be attached to organ donation from its coupling with execution could lead to decreases in donation rates. This may especially be true within certain minority groups. Any notion that particular groups of people were receiving increased numbers of death sentences to provide organs for the rest of society would clearly make it difficult to attempt to obtain consent for altruistic donation from these groups.

Conclusion

The UNOS Ethics Committee has raised a small number of the many issues regarding organ donation from condemned prisoners. The Committee opposes any strategy or proposed statute regarding organ donation from condemned prisoners until all of the potential ethical concerns have been satisfactorily addressed.

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Henry Sapiecha

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Most cancers are caused by DNA replication errors, landmark study reveals

Friday, March 24th, 2017

Halfway through her HSC, Rachel Woolley suffered exhaustion and a stiff neck.

“All my friends were tired, but it got to the point where I couldn’t get up the stairs,” Ms Woolley said.

Rachel Woolley at home in Sydney. She is a candidate for a bachelor of music at UNSW and is recovering from Hodgkin lymphoma image www.newcures.info

Rachel was diagnosed with Hodgkin lymphoma, a cancer of the lymphatic system.

“It was just completely random,” Ms Woolley said.

“You certainly go through a ‘why me?’ phase. What had I done?” she said.

Now 19, Ms Woolley is studying for her bachelor of music at the University of NSW. Despite the cancer then coming back last year, she was given the all-clear again in January.

What triggered Ms Woolley’s cancer is not known, but a landmark study published on Friday shows that about two-thirds of all cancers are caused by random errors made during normal cell division.

“Our research has broken the paradigm that most cancers are environmental or inherited,” said Assistant Professor Cristian Tomasetti of the Johns Hopkins University school of medicine.

His study with Bert Vogelstein, published in Science, evaluated cancer occurrence in 69 countries, including Australia, covering 4.8 billion people.

Professor Vogelstein said: “Most of the time random mutations during cell division don’t do any harm. That’s good luck.

“Occasionally they occur in a cancer-driver gene. That’s bad luck.”

The study reviewed 32 types of cancer and found that about 66 per cent of cancer mutations result from random DNA copying errors, 29 per cent can be attributed to lifestyle or environmental factors and the remaining 5 per cent are inherited.

Comparative rates of cancer by heredity, random and environmental causes. Most cancers are caused by random errors in DNA replication during cell division. ScienceTomasetti image www.newcures.info

Comparative rates of cancer by heredity, random and environmental causes. Most cancers are caused by random errors in DNA replication during cell division. Photo: Science/Tomasetti

“Detecting cancers earlier can save lives regardless of what caused the mutation,” Assistant Professor Tomasetti and Professor Vogelstein said in a statement. “More research to find better ways to detect cancers earlier is urgently needed.”

The researchers are at pains to say that a cancer is very rarely caused by a single error in cell division, but is often a cumulative process, which is why cancers are more common in older people.

Professor David Thomas is head of the Garvan Institute’s cancer division and director of the Kinghorn Cancer Centre.

“The first Vogelstein study in 2015 was important and heretical. Here they have got a much larger data set that expands to the entire globe.

“I’m not surprised at the ratios of random errors to environmentally-induced mutations and hereditary causes. They seem about right.”

However, Professor Thomas said that in his view some of the assumptions made in the modelling “are very rubbery”, and there will be strong debate about the paper.

Despite his reservations, Professor Thomas said the paper is important: “I do think the broad balance is accurate.”

The overall balance also matches the expectations of Professor Sanchia Aranda, chief executive of the Cancer Council.

“We already know that about one-third of cancers are preventable,” she said. “Very few cancers are truly inherited.”

Professor Thomas said just because most cancers are caused by random mutation, it doesn’t mean environmental factors don’t play a role.

“Even if the bulk of mutations are random, a cell needs to get to the final step to become malignant. Environment and heredity play a role here,” he said.

Assistant Professor Tomasetti said: “Cancer rates vary widely by organ. If you look at lung cancer the concentration is in the environmental component.

“However, with brain cancers, bone cancers or childhood cancers the concentration is in the random component.

“That means virtually all the cancerous mutations are caused by simple mistakes caused by every cell when it divides.”

Is this any comfort to Ms Woolley?

“One perspective is ‘At least I didn’t do anything wrong’,” she said. “But you still feel ‘Why me?'”

Professor Thomas said that while the study was important it won’t change clinical practice.

“The fundamental advice we give as clinicians about how to manage and look out for cancer are not affected by this study.

“People should still try to minimise and manage their exposure to environmental or inherited risk factors.”

While the study won’t immediately impact clinical practice it could assist in the management of the psychological impacts of cancer.

Dr Pandora Patterson is general manager of research at CanTeen, the charity that supports young people living with cancer.

“People digest information in different ways, so it could be helpful to know ‘This is not my fault, it’s just random’,” she said.

Ms Woolley is a member of CanTeen. “By talking to people who have been through all this you can learn stuff that the doctors don’t tell you,” she said.

“It’s such a relief not feeling you’re on your own. You can just sit around with people talking about life – people just get you.”

Her message is that while going through treatment is “very shitty”, things can get better. “It’s really important to stay positive and look forward to the future.”

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Henry Sapiecha

A Vision Into the Post-Apocalyptic Future of Antimicrobial Resistance

Sunday, March 19th, 2017

medications-pills-floating-in-black-space image www.newcures.info

About 4 million years ago, a cave was forming in the Delaware Basin of what is now Carlsbad Caverns National Park in New Mexico. From that time on, Lechuguilla Cave remained untouched by humans or animals until its discovery in 1986—an isolated, pristine primeval ecosystem.

When the bacteria found on the walls of Lechuguilla were analyzed, many of the microbes were determined not only to have resistance to natural antibiotics like penicillin, but also to synthetic antibiotics that did not exist on earth until the second half of the twentieth century. As infectious disease specialist Brad Spellberg put it in the New England Journal of Medicine, “These results underscore a critical reality: antibiotic resistance already exists, widely disseminated in nature, to drugs we have not yet invented.”

The origin story of antibiotics is well known, almost mythic, and antibiotics, along with the other basic public health measures, have had a dramatic impact on the quality and longevity of our modern life. When ordinary people called penicillin and sulfa drugs miraculous, they were not exaggerating. These discoveries ushered in the age of antibiotics, and medical science assumed a lifesaving capability previously unknown.

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Note that we use the word discoveries rather than inventions. Antibiotics were around many millions of years before we were. Since the beginning of time, microbes have been competing with other microbes for nutrients and a place to call home. Under this evolutionary stress, beneficial mutations occurred in the “lucky” and successful ones that resulted in the production of chemicals—antibiotics—to inhibit other species of microbes from thriving and reproducing, while not compromising their own survival. Antibiotics are, in fact, a natural resource—or perhaps more accurately, a natural phenomenon—that can be cherished or squandered like any other gift of nature, such as clean and adequate supplies of water and clean air.

Equally natural, as Lechuguilla Cave reminds us, is the phenomenon of antibiotic resistance. Microbes move in the direction of resistance in order to survive. And that movement, increasingly, threatens our survival.

With each passing year, we lose a percentage of our antibiotic firepower. In a very real sense, we confront the possibility of revisiting the Dark Age where many infections we now consider routine could cause severe illness, when pneumonia or a stomach bug could be a death sentence, when a leading cause of mortality in the United States was tuberculosis.

The Review on Antimicrobial Resistance (AMR) determined that, left unchecked, in the next 35 years antimicrobial resistance could kill 300,000,000 people worldwide and stunt global economic output by $100 trillion. There are no other diseases we currently know of except pandemic influenza that could make that claim. In fact, if the current trend is not altered, antimicrobial resistance could become the world’s single greatest killer, surpassing heart disease or cancer.

In some parts of the United States, about 40 percent of the strains of Streptococcus pneumonia, which the legendary nineteenth and early twentieth century physician Sir William Osler called “the captain of the men of death,” are now resistant to penicillin. And the economic incentives for pharmaceutical companies to develop new antibiotics are not much brighter than those for developing new vaccines. Like vaccines, they are used only occasionally, not every day; they have to compete with older, extremely cheap generic versions manufactured overseas; and to remain effective, their use has to be restricted rather than promoted.

As it is, according to the CDC, each year in the United States at least 2,000,000 people become infected with antibiotic-resistant bacteria and at least 23,000 people die as a direct result of these infections. More people die each year in this country from MRSA (methicillin-resistant Staphylococcus aureus, often picked up in hospitals) than from AIDS.

If we can’t—or don’t—stop the march of resistance and come out into the sunlight, what will a post-antibiotic era look like? What will it actually mean to return to the darkness of the cave?

Without effective and nontoxic antibiotics to control infection, any surgery becomes inherently dangerous, so all but the most critical, lifesaving procedures therefore would be complex risk-benefit decisions. You’d have a hard time doing open-heart surgery, organ transplants, or joint replacements, and there would be no more in vitro fertilization. Caesarian delivery would be far more risky. Cancer chemotherapy would take a giant step backwards, as would neonatal and regular intensive care. For that matter, no one would go into a hospital unless they absolutely had to because of all the germs on floors and other surfaces and floating around in the air. Rheumatic fever would have lifelong consequences. TB sanitaria could be back in business. You could just about do a post-apocalyptic sci-fi movie on the subject.

To understand why antibiotic resistance is rapidly increasing and what we need to do to avert this bleak future and reduce its impact, we have to understand the Big Picture of how it happens, where it happens, and how it’s driven by use in humans and animals.

Human Use

Think of an American couple, both of who work fulltime. One day, their 4-year-old son wakes up crying with an earache. Either mom or dad takes the child to the pediatrician, who has probably seen a raft of these earaches lately and is pretty sure it’s a viral infection. There is no effective antiviral drug available to treat the ear infection. Using an antibiotic in this situation only exposes other bacteria that the child may be carrying to the drug and increases the likelihood that an antibiotic resistant strain of bacteria will win the evolutionary lottery. But the parent knows that unless the child has been given a prescription for something, the daycare center isn’t going to take him and neither partner can take off from work. It doesn’t seem like a big deal to write an antibiotic prescription to solve this couple’s dilemma, even if the odds the antibiotic is really called for are minute.

While the majority of people understand that antibiotics are overprescribed and therefore subject to mounting resistance, they think the resistance applies to them, rather than the microbes. They believe that if they take too many antibiotics – whatever that unknown number might be—they will become resistant to the agents, so if they are promoting a risk factor, it is only for themselves rather than for the entire community.

Doctors, of course, understand the real risk. Are they culpable to the charge of over- and inappropriately prescribing antibiotics? In too many cases, the answer is Yes.

Why do doctors overprescribe? Is it about covering their backsides in this litigious society? Is it a lack of awareness of the problem? According to Brad Spellberg, “The majority of the problem really revolves around fear. It’s not any more complicated than that. It’s brain stem level, sub-telencephalonic, not-conscious-thought fear of being wrong. Because we don’t know what our patients have when they’re first in front of us. We really cannot distinguish viral from bacterial infections. We just can’t.”

Spellberg cited a case, one he heard at an infectious disease conference he attended. A 25-year-old woman came into the urgent care facility of a prominent health care network complaining of fever, sore throat, headache, runny nose and malaise. These are the symptoms of a classic viral syndrome and the facility followed exactly the proper procedure. They didn’t prescribe an antibiotic, but instead told her to go home, rest, keep herself hydrated, maybe have some chicken soup, and they would call her in three days to make sure she was all right.

She came back a week later in septic shock and died soon after.

“It turns out she had Lemierre’s disease,” says Spellberg. “It clotted her jugular vein from a bacterial infection that spread from her throat to her bloodstream. This is about a one-in-10,000 event; it’s pretty darn rare. But it’s a complication of an antecedent viral infection, and it’s a known complication. So this patient, ironically, would have benefitted from receiving inappropriate antibiotics. How many times do you think doctors need to have those things happen before they start giving antibiotics to every person who walks in the door?”

As much difficulty as we’re having controlling antibiotic resistance in the First World, for the rest, we believe the situation to be a whole lot worse.

In many of these countries, antibiotics are sold right over the counter just like aspirin and nasal spray; you don’t even need a doctor’s prescription. While we in the public health community would certainly like to see a complete cessation of antibiotic use without a prescription, how do we tell sick people in developing countries that they first have to see a doctor, when there may be no more than one or two physicians for thousands of individuals, and even if they could find one, they couldn’t afford the visit in the first place? Taking an action in a vacuum, such as banning over-the-counter sales without improving infrastructure, simply isn’t viable.

We also have to understand the inordinate burden antibiotic resistance places on the world’s poor. Current effective antibiotics now out of patent may cost only pennies a dose. When those are no longer useful, new compounds will cost many dollars a dose – far more than the poor can afford.

Many of the antibiotic compounds in the developing world are produced in loosely or unregulated manufacturing facilities, where there is no way to gauge quality control. And millions of poor people are living in tightly packed urban slums with inadequate hygiene and sanitary conditions, which generate both more disease and more opportunity for microbes to share resistance characteristics with each other.

Animal use—for food and pets

All of the world’s use of antibiotics for humans is a relatively small percentage of total use. The US, Canada and Europe use about 30 percent of our antibiotics on humans. The rest we use on animals—specifically, animals we kill for food or companion animals and pets.

We produce our food animals in very large numbers and raise them densely packed together, whether we’re talking about chicken and turkey operations, cattle and swine feedlots, or industrial fish farms. While these animals are less likely to catch infectious diseases when large production operations use high levels of biosecurity—the practice of limiting the ways that disease-causing germs can contact the animals—when these germs do get introduced their spread is rapid and extensive. So we use antibiotics to treat the resulting infections. But we also use them to prevent infections in the first place, or to control them by dosing healthy animals so they don’t catch anything from the sick ones. And then we use them to enhance growth.

For decades we have given food-production animals repeated doses of certain antibiotics to make them grow bigger and fatter, producing more meat per animal. This practice is known as growth promotion. The FDA has implemented a voluntary plan with the agriculture industry to phase out the use of certain antibiotics for growth promotion. The European Union banned this use in 1969, though they still use antibiotics for infection prophylaxis, control, and treatment. The AMR found mounting evidence that the use of antibiotics for growth promotion may only provide very modest benefits to farmers in the high-income counties, usually less than 5 percent additional growth.

How does use of this affect us? The AMR team reviewed 280 published, peer-reviewed research articles that address the use of antibiotics in food production. Of these, 72 percent found evidence of a link between antibiotic use in animals and antibiotic resistance in humans. Only 5 percent, found no link between antibiotic use in animals and human infections.

Certain enlightened nations like Sweden, Denmark, and the Netherlands have limited agricultural use and set up comprehensive surveillance systems to determine the rates of antibiotic resistance in human and animal disease-causing germs. Jaap Waganaar, Professor of Clinical Infectiology at Utrecht University, points out that while the Netherlands has traditionally had the lowest rate of antibiotic use for humans in the European Union, as a major agricultural exporter, it was the highest on the animal side. To combat this, the health ministry set prospective standards to be met year by year, mandating full and transparent reporting by the industry. Antibiotics for animal use must be prescribed by certified veterinarians. And for the most powerful antimicrobial agents, there must be confirmation that there is no reasonable alternative to their use.

Most other nations have not attempted to institute such progressive practices. As the developing world has adopted our “meat-centric” diet, they have also adopted our agribusiness formula for producing that meat, making heavy use of antibiotics for animal growth.

We see another frightening example of the mess we’re in China, with the use of colistin, an absolute last-ditch antibiotic for bacteria that react to nothing else. It was isolated in Japan in 1949 and then developed in the 1950s, but not used unless absolutely necessary because of potential kidney damage. They don’t use it for people in China, but are using it in agriculture—thousands of tons a year. Likewise, in Vietnam it is only approved for animal use, but physicians obtain it from veterinarians for their human patients.

Colistin is used for people, though, in much of the rest of the world, including India. As other antibiotics with fewer harmful side effects have become resistant, colistin is about the only agent still effective against certain bloodstream infections in newborn infants. In early 2015, as reported by Bloomberg, physicians treating two babies with life-threatening bloodstream infections at King Edward Memorial Hospital in Pune, India, found that the bacteria were resistant to colistin. One of the babies died.

“If we lose colistin, we have nothing,” stated Umesh Vaidya, head of the hospital’s neonatal intensive care unit. “It’s an extreme, extreme worry for us.” Some hospitals in India are already finding that 10 to 15 percent of the bacterial strains they test are colistin-resistant.

What is worse, some bacteria can share independent little hunks of DNA, called plasmids, with each other. And on one such plasmid, Chinese researchers found a gene known as mcr-1 that conferred colistin resistance. More recently, they have detected NDM-1—for New Delhi metallo-beta-lactamase—an enzyme that protects bacteria against an important class of antibiotics called carbapenems, used mainly in hospitals against already multidrug-resistant bugs.

Recently, colistin-resistant E. coli, made itself know in the United States—in the urine of a 49-year-old woman in Pennsylvania. When an article documenting this unhappy development appeared shortly after in Antimicrobial Agents and Chemotherapy, a journal of the American Society for Microbiology, CDC’s Tom Frieden said, “It basically shows us that the end of the road isn’t very far away for antibiotics—that we may be in a situation where we have patients in our intensive-care units, or patients getting urinary tract infections for which we do not have antibiotics.”

Many of the largest chicken-growing concerns in India, including ones that supply meat for the nation’s McDonald’s and KFC outlets, use one of several antibiotic cocktails that combine colistin with such other vital antibiotics as ciprofloxacin (Cipro), levofloxacin, neomycin and doxycycline. According to an article by Ms. Pearson and Ganesh Nagarajan, “Interviews with farmers indicated that the drugs, permitted for veterinary use in India, were sometimes viewed as vitamins and feed supplements, and were used to stave off disease—a practice linked to the emergence of antibiotic-resistant bacteria.”

“The combination of colistin and ciprofloxacin is just stupidity on a scale that defines all imagination,” commented Timothy Walsh, Professor of Medical Microbiology at Cardiff University in Wales.

What are the implications of all of this? The end result could very well be untreatable bacterial infections going directly into the world food supply. This would be the ultimate Frankenstein scenario.

Excerpted from Deadliest Enemy: Our War Against Killer Germs, Copyright © 2017 by Michael T. Osterholm and Mark Olshaker. Used with permission of Little, Brown and Company, New York. All rights reserved.

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Henry Sapiecha

Just Hours after this photo was taken, she tragically died

Sunday, March 19th, 2017

Gabrielle Marsh died hours after this photo was taken. She was celebrating her upcoming 20th birthday at home with friends when she suffered a catastrophic brain bleed image www.newcures.info

Gabrielle Marsh died hours after this photo was taken. She was celebrating her upcoming 20th birthday at home with friends when she suffered a catastrophic brain bleed

IT WAS supposed to be a fun night with her friends celebrating her 20th birthday – and when Gabrielle Marsh started to get a headache, no one suspected she would be dead hours later.

Photos of the night show the young Auckland woman raising a toast with her best friends, showing off the platter of food she’d thoughtfully planned and created for the night.

Two hours after those photos were taken Gabby, as she was known, was lying on the floor of her home in agony, her mother Kathryn at her side and an ambulance on its way.

Later that night as Gabby lay hooked up to life support machines Auckland City Hospital staff delivered the heartbreaking news to her family – she had suffered a brain haemorrhage and was unlikely to survive.

The next day a decision was made. Gabby was to be taken off life support – but not until her organs had been donated.

And on Monday March 6, on her 20th birthday, after her family had said their goodbyes, Gabby was taken to surgery.

“The woman at the hospital called me and said it was all done, and the donation was taking place as we speak,” Kathryn Marsh told the NZ Herald.

“Gabby loved doing things for other people, and that was her biggest, most amazing gift.”

Gabby’s organs saved the lives of at least six people; her kidney, pancreas, lungs, liver and heart valves were all successfully donated.

“Of course, more than anything, we would love to have her here, but that’s not to be,” said Kathryn.

“But if anything good can come out of it, if she has helped people, then that’s comforting.”

Gabby was the eldest of three children and is survived by Jacob, 18 and 16-year-old Victoria.

Her death was the second tragedy for her family, her father Shayne died just 17 months ago after a long illness.

“It’s still not really sunken in, it was so sudden,” Kathryn said.

“Shayne was sick for 14 months and we all had time to get used to the idea, but with Gabby it was the complete opposite. It’s left us all a bit shell-shocked.”

Gabby was born and raised in Auckland, attending Mount Albert Grammar School before enrolling at Auckland University.

She was about to start her third year of a double degree in commerce and law when she died.

“She was a really good sister, she was kind, generous and she was like a second mum to me,” Jacob said.

Her family described her as extremely thoughtful and loving, adventurous, caring, a “rock star academic” and a young woman motivated and driven with a lot of energy.

“She had a killer smile that came easy and often,” her aunt Michelle Cliffe said.

Kathryn said she didn’t know where to begin when asked what was special about her eldest child.

“She just made people feel at ease and she was easy to be around. There was something special about Gabby,” she said.

After Shayne died, Gabby was a “phenomenal help” to Kathryn, stepping up to do her share of cooking, cleaning and helping with her siblings.

“She just got stuff done, she was pragmatic, hard working and so organised,” Michelle said.

The day Gabby died she woke early and went for a walk with Kathryn – something they did most days together.

Then the pair went to Newmarket shopping and Gabby helped her mother choose a new swimsuit for an extended family holiday to Fiji in April.

The family ate lunch together and Gabby went to watch her boyfriend Bradley play softball before returning home to prepare for her party.

She didn’t drink alcohol, but prepared pina colada cocktails for her three best friends, making a rum-free version for herself.

The girls had planned to go out in the city that night; Gabby loved old music so wanted to go dancing at Irish bar Danny Doolans.

Bradley was going to pick them up and drive them to town.

Then, Gabby started to complain about having a headache.

“It was getting worse and worse,” Kathryn said.

“She just wanted to lie down. Her friends left, they told her it was okay, that they would celebrate with her another time and they called Bradley to tell him.”

After the girls left, Gabby started throwing up and became agitated and slurring her words.

Kathryn suspected a severe migraine, and called an ambulance.

As the paramedics arrived – and Bradley – Gabby lost consciousness.

She never woke up.

Doctors have told her family they believe she had a arteriovenous malformation (AVM), a tangle of abnormal blood vessels connecting arteries and veins in the brain.

It is likely she was born with the condition and there was nothing her family could have done to detect or prevent her death.

“She was healthy, she exercised, she didn’t drink,” said Kathryn, shaking her head.

“The specialist said it was like a ticking time bomb,” Jacob added.

The family said the decision to donate Gabby’s organs was easy; they knew it was what she wanted as she specified it on her licence, and she was a generous young woman.

“She had such a bright future in front of her and I would have just loved to see her future unfold,” Kathryn said.

“We said goodbye to her and we knew that she was then going off to theatre – that she was the one giving the gifts on her birthday.

“She’s given life to more than six people on her birthday, that is her legacy.”

Jacob was brimming with pride over his sister’s final gift.

“It’s like she is living on in other people,” he said.

The Marsh family urged people to openly discuss organ donation with loved ones and make their wishes known.

They hoped to one day meet some of the people that Gabby’s organs helped.

The Gabby Marsh Scholarship

Gabby’s university friends have started a Givealittle page to fund a scholarship in her name, with the support of her family.

“Gabby was passionate, fun loving and kind. She smiled easily and often. She was selfless, considerate and generous.

She was someone who impacted everyone she met,” her friends said.

“Gabby changed the lives of so many around her, and we dream for her character and kindness to continue changing the life of others.

“To honour her academic ability, her exceptional character and her future cut tragically short, the Gabby Marsh Scholarship will be established and offered annually to enable a young school leaver demonstrating exceptional character and service to fulfil their dream of studying commerce at the University of Auckland.”

More than $20,000 has been donated so far.

To donate or read more, click here.

Thanks to the generosity of 503 deceased organ donors and their families a record 1,447 Australians were given a second chance at life in 2016. There were an additional 267 living donors, including 44 under the Australian Kidney Exchange Program.

To register on the Australian Organ Donor Register, click here.

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Henry Sapiecha