By Rob Stein
Washington Post Staff Writer
Thursday, September 13, 2007
After a long fight with a degenerative disease, Ruben Navarro appeared close to death. So the hospital caring for him alerted the local transplant network, which rushed a team to the medical center to try to salvage the 25-year-old's organs.
But as Navarro hung on, tension mounted in the operating room of Sierra Vista Regional Medical Center in San Luis Obispo, Calif. With time slipping away, one of the transplant surgeons ordered repeated doses of the narcotic morphine and the sedative Ativan, jokingly calling the drugs "candy," according to police reports. Navarro eventually died, but too late for his organs to be useful.
Horrified nurses complained, prompting multiple investigations. In July, prosecutors charged Hootan Roozrokh with trying to hasten Navarro's death, marking the first time a surgeon has faced criminal charges in a transplant case.
No one thinks the Navarro case is typical, but it comes as transplant advocates are becoming increasingly aggressive in their efforts to procure hearts, livers, kidneys and other organs in the hope of saving more of the thousands of desperate Americans who die languishing on waiting lists. For some doctors, nurses and medical ethicists, it represents their worst fear -- the extreme end of a spectrum of practices that have been raising alarm in hospital wards, emergency rooms and intensive care units around the country.
"This is what we've been worrying about," said Michael A. DeVita, a University of Pittsburgh critical care specialist. "If you promote organ donation too much, people lose sight that it's a dying patient there. It's not just a source of organs. It's a person."
Organ-donation agencies condemn the Navarro case and argue that they walk a careful line between advocating effectively for those who need transplants and violating ethical boundaries meticulously calibrated to protect dying patients and their families.
"That case appears absolutely to be a case of a transplant recovery surgeon crossing a very clear line that should never be crossed," said Thomas Mone, president of the Association of Organ Procurement Organizations. "Our job is to recover organs and save lives. But we have to do that sensitively, honestly and fairly, keeping the interests of the donors and families in mind. There's often a fine line there, but we make sure we never cross it."
Even the critics agree that most organ-donation advocates are acutely sensitive to ethical concerns, help save many lives and enable families to find solace in their losses. But they worry that disturbing lapses may be increasingly common.
"The greatest fear the public has when it comes to organ donation is their loved one will not receive aggressive treatment and will wind up having their death hastened because of the zeal people have to get organs," said Arthur Caplan, a University of Pennsylvania bioethicist. "You create a tremendous fear on the part of the public whenever any crossing of that line takes place."
The more aggressive drive for organ donations grew out of a federal campaign known as the Breakthrough Collaborative, which the Department of Health and Human Services launched in 2003. The project was designed to boost the number of organs retrieved by the nation's 58 organ-procurement organizations, or OPOs. These private, nonprofit government-authorized entities deploy nurses, social workers and other specialists to identify potential donors, obtain consent from families, and work with doctors and nurses to recover as many organs as possible.
"We launched this initiative because the waiting list was getting longer and longer," said Ginny McBride of the Health Resources and Services Administration. "The bottom-line goal is to save more lives."
Since the campaign began, doctors, nurses and others say they have noticed a clear change.
"The demand for organs is very intense, and the organ-procurement organizations have become much more aggressive about supplying it," said David Crippen, who heads neurocritical care at the University of Pittsburgh Medical Center. "I worry that some of the changes in the logistics of organ procurement could compromise public trust."
Most hospitals now have detailed criteria that automatically trigger a call to the local OPO within the first hour after a potential donor is identified. Hospitals also regularly get reports rating their performance. The campaign has increased the number of organ donations, but some doctors and nurses say the shift has been accompanied by a discomfiting rise in both subtle and overt pressure.
"I personally am very supportive of organ donation. But people I work with sometimes feel they are too pushy," said Mary Henman, an intensive care nurse at Meriter Hospital in Madison, Wis., stressing that she was not speaking on behalf of the hospital. "I think their enthusiasm for their ultimate goal kind of causes them to sometimes lose sight of the fact that the general public has some qualms about organ donation."
At Emanuel Medical Center in Turlock, Calif., neurologist Narges Pazouki said an OPO representative pressed her this summer to declare a patient brain-dead before the appropriate tests had been done.
"I told them, 'It's too soon for you to be involved. Let us do our job,' " Pazouki said.
In many hospitals, organ network representatives now routinely comb through patients' records looking for potential donors.
"It's like they're vultures flying around the hospitals hovering over beds waiting for them to die so they can grab the organs," said Michael Grodin, a Boston University bioethicist. "That's the impression you get sometimes."
In some cases, OPO representatives request tests, such as HIV screening, of a patient without obtaining family members' consent, or ask doctors to administer blood pressure drugs or other medication to keep a possible donor's organs viable until their suitability can be determined and the family consent can be obtained.
"I worry about the care of the dying patient being dictated by the potential for organ donation," said DeVita, the Pittsburgh specialist. "By and large, I think OPOs are working hard to make sure that when organ donation can appropriately occur it does occur, which is important. But they have to be careful not to step over that line and get involved in the management of dying patients."
Organ-procurement advocates argue that nothing is done that would harm a potential donor, and that any testing is aimed at saving families from agonizing about a donation only to find out that their loved one was not eligible.
"It can save a lot of time and effort on everyone's part, and save the family from the disappointment of being offered an opportunity and not have that opportunity come to fruition," said Eric Grossman, the New York Organ Donor Network's medical director.
Critics also worry about how OPO representatives interact with families reeling from the impending death of a loved one. Some representatives delay identifying their role, either initially letting families assume they are part of the hospital staff or being vague, saying only that they are "end-of-life" or "grief" counselors.
"In some places, the organ-procurement folks will actually go into the room and meet the family and wear scrubs that are the same color as the hospital personnel and allow themselves to be experienced by the family as being members of the hospital staff," said Daniel O. Dugan, a bioethicist who advises hospitals in California and Illinois. "They will introduce themselves and build a kind of rapport when actually their whole agenda is organ procurement."
Some OPOs say their representatives always identify themselves immediately, but others acknowledge that practices vary.
"There is great debate on that topic," said Mone, who heads the OneLegacy OPO in Southern California. "Sometimes simply mentioning it will send a family into shock. It may not be appropriate to put that stress on a family at that time."
Once they have made their role clear, many organ procurers use what some consider a high-pressure pitch. In what is known as the "dual advocacy" approach, OPO representatives are increasingly trained to try to persuade families to consent by describing dying patients desperate for organs. They also take a "presumptive" approach that assumes the family would want to donate.
"They can definitely get overzealous at times," said Eric Gluck, director of critical care services at the Swedish Covenant Hospital in Chicago. "I have seen these guys come in and almost browbeat families into submission to get them to donate organs."
Some say the newly aggressive stance makes them especially uneasy because it comes amid a campaign to rewrite state laws governing organ donation to give OPOs more power. In addition, they note, organ donor advocates have been pushing a controversial practice known as " donation after cardiac death," which involves patients who have not been declared brain-dead but are being kept alive with a respirator.
That was the case with Navarro. Severely disabled, he was put on a respirator after being taken to the hospital on Jan. 29, 2006, from a nursing home, where he had been found without a pulse. When doctors told his mother, Rosa, that there was no hope, she agreed to allow him to become a donor.
But she was shocked when she heard what happened next. Her son's heart kept beating even though his ventilator had been removed and the multiple doses of drugs had been administered. Roozrokh also allegedly administered through a feeding tube in Navarro's stomach an antiseptic normally used to sterilize a donor only after death. The doctors eventually gave up and wheeled him back to his room, reportedly as he frothed at the mouth and shivered.
The transplant surgeon's attorney, M. Gerald Schwartzbach, defended Roozrokh in a written statement, denying that he did anything to hasten Navarro's death and calling the charges part of a "witch hunt." Roozrokh pleaded not guilty yesterday to two of the three felony counts he faces.
Officials at the California Transplant Donor Network declined to comment. But Phyllis Weber, who headed the organization, said the actions violated the group's policies.
In an e-mail forwarded by her attorney, Rosa Navarro said: "I hope by this case that the doctors and the hospital and the organ transplant network learn that they need to treat people with dignity." She is suing the hospital, the doctors and the organ network, among others. "This type of thing should never happen to anyone else or their loved ones again."
Previous articles on new state laws governing organ donations and "donation after cardiac death" are available atwww.washingtonpost.com/science.