[tt] Wesley J. Smith: Dead Enough?

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Wesley J. Smith: Dead Enough?
http://www.cbc-network.org/enewsletter/index_10_10_07.htm

A San Francisco surgeon named Hootan Roozrokh has been indicted for
attempting to hasten the death of Ruben Navarro in order to harvest
his organs. According to authorities, Roozrokh ordered unnecessary
doses of morphine and Ativan to be administered when Navarro didn't
die as expected after the removal of life support in an attempt to
hasten his death. When Navarro still didn't expire, the transplant
procedure was terminated. In a horrible scene, Navarro reportedly
died eight hours later frothing from the mouth and shivering.
The story made international headlines and raised a potent
question: How could such a horrible scene have happened in a modern
American hospital?
Answering this question requires a brief explanation of the arcane
procedures that govern cadaver organ procurement involving people
who die from irreversible cardiac/pulmonary arrest. For ease of
discussion, let's call this heart death.
Due to the growing organ shortage, in recent years transplant
centers have begun adopting protocols to govern heart death organ
procurement. Sometimes called the Pittsburgh Protocol, the
procedure permits the patient's treating medical team to withdraw
life support. Then, several minutes after the patient's heart
stops, a different medical team steps in and removes the organs.
The Pittsburgh Protocol is controversial: First, it permits organ
procurement from patients who might be capable of being
resuscitated. Second, it harvests organs from people who are not
brain dead. Finally, some worry that catastrophically ill patients
on life support could be treated more as organ farms rather than as
fully human beings. Of these, only the third seems to be cause for
significant concern.
Let's first examine the concern about procuring organs a few
minutes after the lungs stop breathing and the heart stops beating.
The crucial question here is irreversibility. Heart death in this
circumstance is considered irreversible precisely because no CPR
will be attempted and it is deemed nigh-on impossible for a
person's heart to restart spontaneously after several minutes
without beating. Moreover, after so much time without oxygen, the
brain has ceased all function and the now declared dead patient
will be totally unaware.
True, some critics say, but there is no doubt that a heart dead
patient's brain will contain living neurons when the organs are
removed. Yes, but so too do patients declared dead by neurological
criteria, as brain death is more accurately phrased. In fact, the
term brain dead is misleading in this regard precisely because it
implies that every cell in the cadaver's brain is dead, when the
term actually means that the whole brain and each of its
constituent parts have irreversibly ceased to function as a brain .
The concern that potential heart death donors like Navarro will be
treated as mere organ systems is supposed to be prevented by
iron-clad ethical rules. For example, medical decisions regarding
the patient are not to be made with an eye toward organ donation.
Of perhaps even greater importance, once the decision has been made
to withdraw life support and donate organs, the medical team in
charge of the organ procurement should have no contact with the
patient until after death.
All of these (and other) ethical rules appear to have been violated
in the Navarro botched organ donation. According to reporting in
the San Luis Obispo Tribune , based on interviews, unsealed court
documents, and the police report:
   * Before the transplant team arrived, Navarro's intensive care
  doctor wrote in his patient's chart and notified a transplant
  nurse that Navarro was not a good candidate for organ donation.
  If true, the donation protocol should never have proceeded.
   * Roozrokh, the primary organ procurement surgeon, took over
  Navarro's care before he was declared dead by a treating
  doctor, an especially egregious ethical violation.
   * When Navarro didn't go into cardiac arrest after removal of his
  respirator, the organ donation should have been called off.
  Instead, Roozrokh allegedly ordered the patient injected with
  drugs to make him die.

The Navarro case is our worst nightmare about organ
transplantation. To prevent erosion in the public's confidence,
steps need to be taken to ensure that the procurement system
operate ethically, consistently, and competently. One positive and
long overdue step toward that goal would be the establishment of
legally mandatory national standards to govern all organ
procurementwhether from heart dead or brain dead donors. Blithe
trust us assurances about the general safety, integrity, and
beneficence of organ transplant medicinetrue though they may beare
no longer good enough.

Award winning author Wesley J. Smith is a senior fellow at the
Discovery Institute, an attorney for the International Task Force
on Euthanasia and Assisted Suicide, and a special consultant to the
Center for Bioethics and Culture. His Web site is
http://www.wesleyjsmith.com .


San Luis Obispo County's: Witnesses offer new details in organ case 
http://www.sanluisobispo.com/news/local/v-print/story/109457.html
7.8.4

Sarah Arnquist

Witness accounts offer new details of Ruben Navarro's final hours
and how an attempt to recover his organs went wrong in the hands of
an inexperienced transplant team and unprepared staff at Sierra
Vista Regional Medical Center.

The witness statements to law enforcement were filed Monday in San
Luis Obispo County Superior Court when prosecutors charged San
Francisco transplant surgeon Hootan Roozrokh, 33, with three
felonies related to his alleged attempt last year to hasten
Navarro's death.

Roozrokh was arrested and was released on $10,000 bond. He is
expected to enter a plea on Aug. 14. His attorney has said Roozrokh
did nothing wrong and will defend himself.

The witness statements describe the Feb. 3, 2006, night when
Navarro, 25,was removed from life support and died eight hours
later. The witnesses were interviewed between March and August of
2006.

The following details are included in the San Luis Obispo police
report that The Tribune received Friday.

o Before the transplant team arrived at Sierra Vista, Navarro's
intensive care doctor wrote in his patient's chart and notified a
transplant nurse that Navarro was not a good candidate for organ
donation because he would not die in the short time frame necessary
for donation.

o Only two of the 11 people caring for Navarro that night had
experience with the specialized donation procedure to be used in
his case. And each had done it only once.

o Three physicians reviewed Navarro's medical charts and determined
the doses of narcotics given to Navarro were excessive and given to
hasten his death.

o From his arrival at the hospital, Roozrokh took over Navarro's
care when he should not have seen him before he was declared dead
by a Sierra Vista doctor.

Poor candidate

Navarro was dying of a rare degenerative disease and had suffered
irreversible brain damage before being taken to the hospital Jan,
29, 2006. He weighed only 80 pounds.

The following details are taken from the police report:

Dr. Erik Shultz, who attended to Navarro in the days leading up to
his death, told investigators that Navarro wouldn't have felt pain
when his breathing tube was removed so the substantial amounts of
painkillers given to him wouldn't be necessary.

Shultz also said he knew Navarro would not die immediately after
being removed from a ventilator, or breathing machine, because he
had already tried it days prior for a few minutes and Navarro
continued to breathe, making him a poor organ donor candidate.

The California Transplant Donor Network coordinated the organ
recovery process. Transplant surgeons Roozrokh, and Arturo Martinez
came from San Francisco to recover the organs.

Phyllis Weber, the network's chief executive officer, told
investigators that Martinez had never done a donation after cardiac
death, the kind used in Navarro's case, and planned to observe
Roozrokh, who had done one.

The network's transplant nurse, Carla Albright, traveled to Sierra
Vista early Feb. 3 to coordinate the organ recovery. Albright had
seen one donation after cardiac death.

All the Sierra Vista employees who witnessed the events in the
operating room told investigators they were not familiar with the
specialized donation procedure used in this case. Because Navarro
was not brain dead, he could only be a donor after his heart
stopped.

Prepping for donation

According to Albright's account, Roozrokh and Martinez's arrival on
Feb.3 was delayed because their plane couldn't land in the fog.
Once they did get to the hospital around 10:30 p.m., they examined
Navarro in the ICU.

Roozrokh asked Albright if she would be giving pain medications in
the operating room, and she told him that would be a conflict of
interest so it would be intensive care unit nurse Diana Stevens'
job. The transplant team was not supposed to care for Navarro until
after his doctor, Laura Lubarsky, declared his death, under state
law.

Stevens told investigators Roozrokh told her while they were in the
ICU to bring morphine and Ativan, a sedative, with her to the
operating room. They brought Navarro to the operating room at 11:20
p.m.

The surgeons and operating room nurse and technician prepped
Navarro for the organ recovery. Operating room technician Celeste
Tracy told investigators she saw Roozrokh put a Betadine and saline
solution into Navarro's feeding tube to sterilize his organs.

At that point, Lubarsky, the doctor on call, arrived at the
hospital from home, Albright told investigators. Albright said she
had to explain to Lubarsky why she had to be there to declare death
and why the surgeons couldn't do it.

In the operating room

Navarro's organs had to be recovered within 30 to 60 minutes after
his breathing tube was removed to remain viable for transplant.

Martinez and Roozrokh should have left the operating room after
prepping Navarro, but didn't, Albright said.

After Navarro's breathing tube was removed, Roozrokh ordered ICU
nurse Stevens to give the patient 50 milligrams of morphine and 20
milligrams of Ativan intravenously, Albright said.

Lubarsky didn't object to the order, Albright said.A few minutes
later, Roozrokh repeated the same medication order. Albright said
at that point, it was Lubarsky's role as the attending physician to
order medications, and Lubarksy said "whatever they want."

Navarro's heart rate and blood pressure dropped again, Albright
told investigators, and then there was a discussion about declaring
death. Albright said Roozrokh thought he had no pulse and could
begin operating, but Albright disagreed.

Albright said she asked Lubarsky to listen for a pulse. Lubarsky
placed her stethoscope on Navarro's chest and said he had a pulse,
Albright said. After the conversation about a pulse, Roozrokh asked
nurse Stevens to get more medicine. Lubarsky again deferred to the
surgeons, Albright said.

The Tribune did not contact Lubarsky on Friday. Her attorney has
said she was cleared of any wrongdoing by the state medical board.

Stevens called the nursing supervisor who asked nurse Suzanne
McDougal to get the medicine. McDougal told investigators she went
to three areas of the hospital to collect the morphine and Ativan
vials for the operating room. She said she had never brought that
much medication to the operating room before.

Stevens said she was giving the medicine because she didn't want
Navarro to be in pain.

In total, Stevens said she gave Navarro 220 milligrams of morphine
and 80 milligrams of Ativan before the transplant was called off
because Navarro did not die.

Operating nurse Jennifer Endsley told investigators the events in
the operating room that night disturbed her. She said she
questioned more than once why nurse Stevens was giving Navarro
medications, but was ignored.

After Navarro's organs were deemed unfit for donation, Endsley said
the transplant team left, leaving her and Tracy to clean up.
Navarro was "frothing from the mouth and shivering," she said.

All the witnesses say Martinez said little in the operating room
and gave no orders. Nor did he question Roozrokh.

Sierra Vista has said it tightened its organ donation policies and
given staff more training.