Potential organ donor was wrongly declared brain-dead
Pastor Dale Morgan
Potential organ donor was wrongly declared brain-dead*
The error raises concerns about the medical care of those who have
promised their organs for transplants.
By Charles Ornstein and Tracy Weber, Times Staff Writers
April 13, 2007
A man whose family agreed to donate his organs for transplant upon his
death was wrongly declared brain-dead by two doctors at a Fresno
hospital, records and interviews show.
Only after the man's 26-year-old daughter and a nurse became suspicious
was a third doctor, a neurosurgeon, brought in. He determined that John
Foster, 47, was not brain-dead, a condition that would have cleared the
way for his organs to be removed, records of the Feb. 21 incident show.
"It kind of blew my mind," said the daughter, Melanie Sanchez, "like
they were waiting like vultures, waiting for someone to die so they
could scoop them up."
Foster, who had suffered a brain hemorrhage, died 11 days later at
Community Regional Medical Center in Fresno. By then, Sanchez said, his
organs were not viable for donation.
The apparent close call is the second in recent months to raise
questions about whether, amid a national organ shortage, doctors might
be compromising the care of prospective donors. Law enforcement
authorities in San Luis Obispo County are investigating whether a
transplant surgeon tried to hasten the death of a 26-year-old patient
last year by ordering high volumes of pain medication.
Contacted Wednesday, Community Medical Center's spokesman John Zelezny
characterized Foster's case as "unusual" and said it "wouldn't surprise
me" if the medical staff launched an internal review.
"This hasn't fully played out yet," he said. National experts said they
believe that it is uncommon for a patient to be declared brain-dead
incorrectly. But the ramifications are great, they said, both for the
potential donors and for the integrity of the organ donation process.
"It is one of those things that is pretty spooky when it happens," said
Dr. Michael A. Williams, chairman of the ethics committee of the
American Academy of Neurology. "It's a rare, but high-stakes, error."
Said Dr. David J. Powner, a professor of neurosurgery and internal
medicine at the University of Texas Health Science Center at Houston:
"It only takes one or two of those situations to really sour the public
and sour those upon whom we depend so much for donation."
Brain death means that a person has suffered a total and irreversible
loss of brain function. The patient is comatose, cannot breathe without
support and lacks reflexes. It often is determined by a mixture of
physical examination and clinical tests, and meets the legal standard
for death.
There are no national criteria for declaring brain death, but California
law requires that two physicians independently verify the condition and
that those physicians not have any role in procuring the patient's
organs. Organs cannot be retrieved until a patient is declared legally dead.
Foster, an auto mechanic, collapsed Feb. 18 and was diagnosed with an
inoperable Pontine bleed, a catastrophic hemorrhage in his brain stem
with almost no hope of recovery.
Hours later, hospital personnel alerted the California Transplant Donor
Network — the organ procurement group for much of Central and Northern
California — that he was a potential candidate for organ donation. Such
notification is routine.
After Sanchez agreed to donate, she said, she got calls "at least twice
a day" from the organ group, saying: "We have to get the body parts in a
certain time. Your dad can be a life-saver to someone else. How is he
doing today? Did he go up or down?"
In the afternoon of Feb. 21, it seemed the end had arrived for Foster.
First, one doctor declared him brain-dead, according to confidential
internal records kept by the organ group and reviewed by The Times.
Then, a couple hours later, a second doctor, an emergency physician,
shined a light on his pupils and agreed. With two such declarations,
Foster was legally dead under California law.
Sanchez said she was concerned because the second doctor seemed in a rush.
3rd opinion sought
After the exam, Sanchez recalled, "he just came in and threw the paper
on my dad's legs and said, 'We got two signatures. We're pulling the
plug,' He said, 'That's hospital policy.' "
She said she demanded a third opinion.
About the same time, a nursing supervisor asked the family to leave the
room and did her own examination, the organ group's records show. Foster
displayed a strong gag and cough reflex and slightly moved his head, all
inconsistent with brain death. She shared her concerns with physicians.
The third doctor, neurosurgeon Mukesh Misra, determined that Foster was
not brain-dead and supported Sanchez's decision not to remove her father
from life support, records show.
Misra declined to comment on his colleagues' actions, but said, "I know
what I did was right."
Dr. Robert Grazier, the second physician who declared Foster brain-dead,
acknowledged that he performed a brief examination. "I examined the
patient and I confirmed the first doctor's findings that were recorded.
That was about it," Grazier said.
"My involvement in it was pretty minimal," he said.
The Fresno hospital's policy does not specify how long a physician must
spend examining a patient nor what tests the doctor should order. It
only says that the doctor must write his findings in the patient's chart.
Williams, the ethics expert, said he sets aside 30 to 45 minutes to
perform a brain-death examination or confirmation exam. Told of notes in
Foster's record, he said, "If the documentation is correct, they should
never ever have considered the possibility of brain death for that
patient…. It's not even close."
Phyllis Weber, executive director of the California Transplant Donor
Network, said the donation would not have proceeded anyway because her
organ procurement staff also had concerns about whether the patient was
brain-dead.
"They do a careful examination, and if there's any questions, the
process gets halted then until their questions are resolved," Weber
said. "The public should be really grateful that that happens."
If her staff had concerns, however, they were not reflected in the
confidential case notes kept by the donor network.
She said she was sorry to hear that Sanchez felt pressured. Other family
members told The Times that they did not feel coerced, although the
ultimate decision was Sanchez's.
"It's certainly not ever our position to pressure families to make this
decision," Weber said. "We have people who are very trained, have a
great deal of experience, and we give families a lot of time."