Further reforms called for after transplant case

December 24, 2008

Further reforms called for after transplant case

The Associated Press
12/19/2008

LOS ANGELES�The case of a transplant doctor acquitted of speeding a patient’s death to harvest his organs led to new national guidelines, but the jury and a medical ethicist say more work must be done to prevent problems during the procedures.

Dr. Hootan Roozrokh was cleared by a jury Thursday in San Luis Obispo in what is believed to be the first such criminal case in the U.S.

The case involving patient Ruben Navarro led to national organ transplant reforms involving the fast-growing procedure known as donation after cardiac death.

Unlike brain-death donation, in which organs are recovered only after doctors determine that a donor’s brain has stopped working, cardiac-death donation requires withdrawal of life support.

Once the heart has stopped, the patient is declared dead, and organs can be removed. However, some experts say organs are viable only if they can be harvested within 30 minutes after life support is ended.

Bioethicist Arthur Caplan of the University of Pennsylvania said the new rules should help doctors and nurses who don’t routinely do transplants understand their roles in preparing a person for cardiac-death donation.

But he pointed out there is still no standard for the amount of time that should pass before a person is declared dead.

“You’ve got to have clear-cut specifics with the details filled in to secure people’s trust,” he said.

The jury also said the Roozrokh case identified important
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issues that need to be resolved.

“Refining the nationwide protocol of DCD organ procurements will be an important part of Ruben’s legacy and for that we pay him our respect and owe him our thanks,” the jury said in a note read in court while the verdict was delivered.

Cardiac-death donors now make up an estimated 10 percent of all deceased donors.

Roozrokh, 34, was accused of prescribing too much medication to Navarro, 26, when he died in February 2006 at Sierra Vista Regional Medical Center. He had a debilitating neurological disease and was in a coma after a heart attack.

An operating room nurse testified that she was ignored when she questioned the amount of drugs given to Navarro.

The attending physician, Dr. Laura Lubarsky, told jurors she did not realize she was in charge that night, and that the transplant coordinator had told her that she was only to observe and to declare death when it occurred.

Roozrokh testified in his own defense that hospital staff and the transplant coordinator abdicated their duty to take care of Navarro. He said that left him no choice but to order the use of painkillers to ensure Navarro would not suffer when being withdrawn from life support.

As it turned out. Navarro’s organs were never harvested because he died hours after the machine was turned off.

The United Network for Organ Sharing, which manages the nation’s transplant system, developed uniform rules last summer for cardiac-death donation. Before that, the effort depended on individual hospitals or groups.

The case “caused us to redouble our efforts to make sure that what we are doing is in the best interest of the potential donor and meets the standard of the public’s trust,” said Joel Newman, a UNOS spokesman.

Under the guidelines, doctors choose a suitable candidate for organ donation and receive consent from relatives. Next, life support is withdrawn and there is a waiting time before a potential donor is declared dead. The transplant team is not allowed to care for the patient before declaration of death.

Bryan Stewart, a spokesman for OneLegacy, an organ procurement agency in Southern California, said the group has long had strong rules in place for donation after cardiac death.

“No system is immune to human action,” he said. ‘As much as we set up these protocols, we’re also relying on human judgment.”

Other experts contend the division of roles between a transplant surgeon and the doctor who declares death has always been clear.

“I would suggest that this case underscores an important separation of those that are providing end-of-life care from those that are involved in the recovery of organs after the declaration of death,” said Dr. Francis Delmonico, transplant surgeon at Massachusetts General Hospital.

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