Death & transplants The sources of medical error
Lustig, Andrew
DEATH & TRANSPLANTS ANDREW LUSTIG The tragic case of Jesica Santillan Jesica Santillan was declared brain dead and removed from artificial life support on February 22, two days after receiving a...
...That may have been admirable, or prudent, or both, and it was certainly welcome...
...After being placed on the waiting list maintained by the United Network for Organ Sharing (UNOS), Jesica, with type-O blood, initially received organs from an incompatible type-A donor, which led to systemic life-threatening rejection...
...Nearly four years after the Institute of Medicine report, its earlier count of "statistical" deaths caused by medical mistakes is likely to be revised upward this spring...
...Right...
...More broadly, as Shankar Vedantam reported recently in the Washington Post, for more than a decade, American citizens have been "more likely to benefit from organs donated by noncitizens than the other way around...
...Many observers have questioned why Jesica received a second transplant...
...Indeed, immediately after the initial transplant error, the hospital changed its procedures to ensure "redundancy" in decision making...
...In response to such concerns, it should be noted that UNOS allows up to 5 percent of available organs to go to "nonresident aliens" each year...
...Commentators have also wondered whether Jesica, as a noncitizen, belonged on the waiting list at all...
...In Jesica's case, the charitable efforts of a local businessman provided sufficient funds for her to be placed on the waiting list...
...Jaggers's tragic error, and Jesica's death, are poignant and very visible examples of larger problems...
...There is a troubling lack of consistency or consensus among this country's 307 transplant centers on the question of which patients are likely to benefit from transplants...
...Despite the Institute of Medicine report, critics see little evidence of subsequent administrative or organizational reform...
...Individual centers, without further oversight, can assign patients to the highest medical urgency category on the national list...
...Many of those deaths result not from individual mistakes in judgment, but from inadequate record keeping and oversight, especially in the administration of drugs...
...Furthermore, with 101 patients of Jesica's blood type on the heart-lung transplant list waiting for a first transplant, and several thousand patients eligible for either a heart or a lung, informed speculation suggests that surely some of those individuals were more likely to benefit from a transplant than Jesica...
...Moreover, should her parents' uncertain immigration status now have any bearing on any litigation or settlement award...
...With a second transplant, the family held out hope for a "miracle," but Jesica's condition quickly deteriorated...
...Yet in succumbing to the tendency we have, in this litigious culture, to identify the individual at fault, we may miss the forest for the trees...
...Consequently, considerations of medical urgency and immediate need inevitably tend to trump other concerns...
...In a 1999 report, the Institute of Medicine estimated that "medical errors" cause between forty-four thousand and ninety-eight thousand deaths in the United States each year...
...everyone wonders how such an elementary error could have been made...
...In hindsight, six organs were transplanted unsuccessfully into a single patient...
...Much depends here on her prognosis at the time of the second procedure...
...The seventeen-year-old had been smuggled into the United States three years ago from Mexico in an effort to gain access to treatment for her restrictive cardiomyopathy, a condition that, since infancy, had progressively weakened her heart and lungs...
...Did an illegal immigrant "deserve" access to scarce medical resources...
...As a society, we tend to focus either narrowly or broadly...
...The key issue then becomes their ability to pay...
...Despite the startling features of Jesica's case, we should be mindful of the context within which it occurred...
...Given her subsequent rapid demise, that medical opinion seems questionable...
...Jesica's death, then, might be better viewed as not only the error of an individual physician, but also an institutional failure...
...On large matters of health-care reform and coverage, we tend to look to our state capitals or to Washington for systemic solutions...
...While Jesica's circumstances apparently did not qualify her for that status, transplant centers generally assume that patients are in the United States legally...
...Jesica's case has been the focus of great media scrutiny...
...James Jaggers, the transplant surgeon on call at Duke University Medical Center, accepted responsibility for the initial mistake...
...What is often ignored is the crucial mid-level role of health-care institutions, whose administrative and organizational decisions provide the bridgework between social entitlements and the care of individual patients...
...That trend is explained by the recent success of campaigns to encourage organ donation, especially among green-card holders...
...This aspect of Jesica's case reveals a point of contention within the transplant community...
...While Jesica suffered some brain damage after the initial transplant, the hospital ethics committee, in justifying the second operation, found such damage to be "potentially reversible...
...As to whether the Santillans' immigration status will affect any settlement, the final award, as a legal matter, may well be linked to judgments about customary living expenses in the country where the Santillans ultimately reside...
...DEATH & TRANSPLANTS ANDREW LUSTIG The tragic case of Jesica Santillan Jesica Santillan was declared brain dead and removed from artificial life support on February 22, two days after receiving a second heart-and-lung transplant...
...In a case like Jesica's, we want to assign blame...
...Clear protocols were not in place to reduce the likelihood that a single mistake or oversight might prove fatal...
...Surely, with the cool efficiency the public associates with high-technology medicine and with a highly coordinated system of organ procurement and distribution in place, such a mistake should never occur...
...While Jesica's second operation may be understandable as a compassionate response to the victim of an awful error, in light of the scarcity of organs, the second procedure may well have been unfair to others on the waiting list...
Vol. 130 • April 2003 • No. 7
