HEALTHDeath of organ donor puts program on holdTransplant surgeons around the country are stepping back to try to prevent this tragedy from being repeated.By Victoria Stagg Elliott, amednews staff. April 8, 2002. Like most living organ donors, Mike Hurewitz, a New York man who in January donated part of his liver to his brother, went into the hospital healthy. But unlike most people in this select patient population, he didn't go home -- at all. His death has triggered significant introspection within the transplant community. Was Mount Sinai Hospital in New York City too aggressive about its living donor program? Was the donor medically suitable to undergo the surgery? Was he too old? Did he understand all the risks? Was this death unavoidable -- a statistical inevitability because of the high number of living donor transplants performed at the center? What is the acceptable level of risk when you perform surgery on a healthy person? These are the questions that medical ethicists, transplant surgeons and those involved in organ procurement are now asking.
10% of living donor liver transplants since 1988 were done at Mount Sinai.
"It's a sobering event," said Mark Fox, MD, PhD, director of the program on transplant ethics and policy at the University of Rochester Medical Center in New York. "Given that a high quality program had a tragic outcome like this, it really ought to make everyone stop and think." An ending under the microscopeMike Hurewitz is not the first living donor to suffer above and beyond the recovery period. But his case is getting a lot of attention for several reasons. Among them, the surgery was performed at one of the largest transplant centers in the country. Mount Sinai has performed 174 living donor liver transplants since 1988, more than 10% of the total performed nationwide during that time period. "The fact that somebody died isn't surprising given the statistics -- a living donor has a 2% to 3% risk of dying," said Lainie Friedman Ross, MD, PhD, assistant director of the MacLean Center for Clinical Medical Ethics at the University of Chicago. "What's upsetting is that it's not clear that the death was a necessary death." Mount Sinai won't be performing any more transplants, at least for the time being. The State of New York Dept. of Health has fined the facility $48,000 for deficiencies in Hurewitz's postoperative care and shut the program down for at least six months.
A living donor has a 2% to 3% risk of dying.
"Anyone who was going to do a transplant there has now got to look at their options," said Anne Paschke, spokeswoman for the United Network for Organ Sharing. "Can they afford to wait six months or do they need to go somewhere else?" Experts say that this is unlikely to have a significant impact on the number of transplants performed overall during the next few months. They expect Mount Sinai's patients to shift to other centers or postpone. Nationally, just two months after the event, transplant physicians say that their living donors are as committed as ever. "Those who volunteer for a liver donation are so strongly motivated," said Marwan Abouljoud, MD, head of the transplant surgery division at Henry Ford Hospital in Detroit. But physicians around the country are taking another look at their policies and procedures, particularly the consent process. They say Hurewitz's death helps drive home the message that living donation is not without risk. Despite great attention to the informed consent process, several studies have shown that, particularly for related donors, that message hasn't always sunk in. "People don't necessarily process informed consent the way that we lay it out," said Dr. Fox, who is also chair of the United Network for Organ Sharing's ethics committee. "Very often the information about risks is really not central to their concern. It's the fact that they have the opportunity to donate to someone important to them." Upping the anteAnd the risk-benefit equation is slightly trickier with liver donation than with kidneys. The risks for the donor are greater with a liver, but so are the stakes for the recipient. A nonfunctioning kidney means a lower quality of life because of dependence on dialysis. A nonfunctioning liver means death. "People are pretty comfortable with living donor kidney transplantation and the risks associated with that," said Dr. Fox. "But living donor liver transplantation ups the ante." Experts also say this incident adds weight to the push to provide a donor advocate. Some would prefer a whole team, but they say it is critical that at least one person be focused entirely on the donor without a conflict of interest related to the recipient. Meanwhile, the health department's investigation found no fault with Hurewitz's operation, only with the postsurgical care. Experts also say this is a reminder that the aftercare is as important, if not more so, than the procedure. "When we get patients who donate, we should treat them with silk gloves," said Dr. Abouljoud. "There is no excuse not to be all over a donor to make sure he's OK, because he did not need the operation. We should not forget that." And it adds even more questions to the debate about whether the increasing phenomenon of the Good Samaritan donor -- someone who gives a kidney or part of a liver to someone they may never even meet -- should be allowed to continue. Related donors, despite the physical risks, do get the benefit of helping their loved ones. The benefits to stranger donors is not quite as clear. "The experience at Mount Sinai should really give us pause," said Dr. Fox. "Within the context of families and other important relationships it makes sense for me to be willing to take on even a pretty substantial risk for my son or my wife. I don't know that we're at a point where the risk-benefit ratio justifies putting someone who doesn't have a vested interest in the recipient at risk." The journal Transplantation later this year will publish a paper authored by participants in the National Conference on the Nondirected Live Organ Donor addressing the ethical and practice consideration brought up by this issue. It will advocate caution and lay out a framework for institutions to deal with the growing number of people who are coming forward to offer a kidney, the more common situation. Good Samaritan donation of parts of liver is very rare. But those in the organ procurement industry say the death of a donor adds to their push for more people to become donors postmortem. "If we had more organ donors, surgeons would not have to resort to living organ donors," said Elaine Berg, executive director of the New York Organ Donor Network. "All we can do is the best we can to increase organ donation from deceased people. We've just got to all do better." ADDITIONAL INFORMATION:How it all went wrongJan. 10 - Mike Hurewitz, 57, undergoes surgery at New York's Mount Sinai Hospital to remove the right lobe of his liver to be donated to his brother, Adam Hurewitz, MD, 54.
Source: New York State Dept. of Health statement WeblinkNew York State Dept. of Health statement on the living donor death at Mount Sinai Hospital (http://www.health.state.ny.us/nysdoh/commish/2002/mtsinai.htm) Organ Procurement and Transplantation Network (http://www.optn.org/) United Network for Organ Sharing (http://www.unos.org/) Mount Sinai Hospital, New York (http://www.mountsinai.org/) American Society of Transplantation (http://www.a-s-t.org/) Abstract, "Consensus Statement on the Live Organ Donor," JAMA, Dec. 13, 2000 (vol. 284, issue 22) (http://jama.ama-assn.org/issues/v284n22/abs/jst00018.html) Copyright 2002 American Medical Association. All rights reserved.
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