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Hospital, surgeon under fire after transplant death
Controversy has interrupted after an attempted organ transplant at a California hospital, with several groups investigating whether a doctor attempted to hasten a patient's death so that his organs could be harvested. The case already has prompted a clarification of national standards for transplant procedures, and criminal charges could be forthcoming.
At a meeting in Saint Louis, the board of the United Network for Organ Sharing (UNOS) said that all transplant hospitals must have policies preventing organ recovery teams from taking part in the care of a potential donor before a nontransplant doctor declares the patient dead. Members of the team are not allowed in the room when life support is withdrawn, according to the standards. Members of the board stated publicly that the clarification was prompted by the recent California case. (For details, go to the UNOS web site at www.unos.org and select the "newsroom" tab at the top of the page. Click on "view all press releases," then look for the press release from March 23, 2007.)
The case is unfolding in San Luis Obispo, CA, where a surgeon is accused of hastening the death of a donor who wasn't dying as quickly as expected. The case has prompted an investigation by the state medical board and may possibly lead to criminal charges. The attorney for the accused transplant surgeon says the doctor did nothing wrong during the case at Sierra Vista Regional Medical Center. Attorney M. Gerald Schwartzbach, JD, says Kaiser Permanente surgeon Hootan Roozrokh, MD, of San Francisco, did nothing to hasten the man's death.
The incident occurred on Feb. 3, 2006. Twenty-five-year old Ruben Navarro was on life support after being found unconscious at the residential care home where he lived. Navarro had a neurological disorder, and his mother agreed to donate his organs when it was clear he would not recover.
Navarro was taken into the operating room on a Friday evening and removed from life support, but he did not die immediately. According to the report of an investigation by the Centers for Medicare & Medicaid Services (CMS) obtained by the Los Angeles Times, a transplant surgeon ordered 100 mg of morphine and 40 mg of Ativan for Navarro.1 The surgeon is not mentioned by name, but several sources told the newspaper it was Roozrokh.
The report notes that Roozrokh was not authorized to care for patients or order drugs at the hospital, according to the hospital's own policies. When Navarro's heart did not stop, the surgeon reportedly ordered another 100 mg morphine and 40 mg Ativan, which the ICU nurse administered.
Navarro still did not die. After about 30 minutes off life support — the time limit set to ensure the viability of the organs — the process was ended. Navarro was returned to the intensive care unit, where he died early the following morning. His organs were not retrieved.
A Sierra Vista spokesman, Ron Yukelson, confirms that on the following Monday, operating room nursing staff alerted hospital administrators that Roozrokh violated hospital policy during the attempted donation when "he entered the operating room prior to the death of the patient and started giving orders." State law prohibits transplant doctors from directing the treatment of a potential organ donor until the attending physician declares the patient dead.
The hospital reported the incident to the state Department of Health Services, the state Medical Board, the county coroner and CMS. In response, CMS, the state medical board, the San Luis Obispo County Sheriff's Department, and the San Luis Obispo police began an investigation.
The doctor's attorney says the surgeon did not order any drugs administered to hasten the man's death. San Luis Obispo police announced recently that they completed an investigation and turned over the case to the district attorney's office. Prose-cutors are reviewing the case and will decide whether to press charges. The district attorney's office has declined to say how many people are being investigated and what the potential charges may be.
The case should raise serious questions for risk managers, says Skip Freedman, MD, an emergency physician and chief medical officer for AllMed Healthcare Management, an independent review organization serving insurance payers, providers, and claims managers nationwide. For starters, Freedman wonders if the hospital had an adequate peer review process to oversee physician credentialing and behavior.
"It is typical that a hospital asks physicians to do peer review on their friends, colleagues, and competitors, so I have to wonder how that played a role in this. And they also assert that the transplant doctor didn't even have staff privileges, so what is their internal policy for this kind of emergent procedure?" he says. "Do they have a policy for when a transplant surgeon comes in and needs privileges quickly? This all has to be lined up ahead of time."
The allegations in the case also raise questions about how quickly staff members reported their concerns about what happened during the procedure. If it's true that staff were slow to report their concerns, Freedman says that could signal a problem.
"There should be lines of confidential complaint within the hospital so that people can speak up with their concerns in a timely manner," he says. "What we don't know is whether that existed in the hospital, whether it had been used before, how people were treated when they used that system, or whether it existed but just wasn't well known to the staff."
1. "Police probe death in organ donation case." Los Angeles Times, Feb. 28, 2007. Accessed at www.latimes.com/news/local/la-me-transplant28feb28,0,2407719.story?coll=la-home-local.
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