Hospital Case Study if the First Requirement

Hospital Case Study

If the first requirement of any successful case study is a detailed and analytical examination of the situation, the emotional component of so called "high stakes" issues can make this requirement difficult, indeed. The simple fact, however, is in order to find good solutions and policies regarding the problem presented in the case study, one must apply the three main questions of "situation," "remedy/s," and "method/s." Although this may seem difficult in some situations, the emotional component must not be considered.

A good example of this fact occurs in the examination of an unfortunate case involving the botched heart/lung transplant of a 16-year-old girl, much like the recent incident at Duke Hospital. In this case, a young girl died as a result of receiving miss-matched organs. Unfortunately, in this case, all of the supposed safeguards of the system, imposed to assure that proper blood typing of both donor and organ recipient are compatible failed. As a result, the young girl was not only transplanted with incompatible organs, but, due the significant downturn in her health following the procedure, doctors failed to obtain another set of matched organs with the speed necessary to possibly save her life.

Because it is believed that certain ethical questions contributed to the slow decision to re-transplant, it has been decided that the hospital ethics committee consider the main ethical questions involved -- both to ease the pressure on physicians and staff in the case of a similar situation, as well as to reassure potential patients that all measures will be taken to assure a successful outcome.

In order to achieve the above goals, the committee must identify the ethical questions at hand. After much deliberation, the conclusion was made that the two main questions are -- 1 / Should assumptions concerning the likelihood of survival post-op impact the decision to grant a second set of organs should the first ones fail for any reason? And 2 / If a medical mistake be found to be directly responsible for patient deterioration, as well as responsible for the immediate need for a second set of organs influence the decision to quickly obtain (if available) those organs?

When one considers the first question regarding the eligibility of patients for transplant in the case of failing health has been debated extensively in the medical and ethical community. Of course, this debate is based on the unfortunate fact that there are many who desperately need organs for their continued survival, while there are simply not enough organ supplies to go around. Consider, for example, the following:

There is a huge gap between the number of people who need an organ transplant and the number of organs available. Each year, 3,000 U.S. patients die while waiting for a transplant -- and another 100,000 people die before they can even be put on the transplant list. There are some ways to narrow this gap -- but they raise both ethical and practical problems (DeNoon, 2000).

Based on facts such as these, it has been put forward by some that the important decision regarding just who gets a new organ should be based on the likelihood of survival post-transplant. However, the ethical implications of this position present some real problems.

Presently, there are several criteria affecting the level of one's placement on transplant lists. Of course, the most obvious determining factor is that a patient be determined to be in desperate need for the organ -- that is, without the rapid procurement (in some cases, depending on the organ involved, this may be just a few days or hours (Keen, 2001)) of the needed organ, the patient will die.

Although there are presently more than one "list" on which patients are placed for organ donation, the organization known as the UNOS, or the United Network for Organ Sharing is charged with producing and maintaining those lists. According to this agency, the method by which patients are assigned organs involves assigning those in the most urgent need the most appropriate organ for their needs, taking into consideration issues of blood type, as well as the size and condition of the organ (Keen).

Interestingly, however, there are times when other factors in addition to "urgent need" come into the frame. For, although UNOS expressly claims that organ decisions are made irregardless of age, sex, race, lifestyle, finances, religion, or personal affiliation (Keen), there are times when a patients overall health situation is taken into account as a liability.

When any organ becomes available for transplant, those who are highest on the list are given precedence if at all possible (CTDN). Further, as stated above, the number one criteria determining one's placement is the current status of one's health dependent on the failing organ. However, it is important to understand that health status as a result of other, non-organ related issues may place otherwise qualified candidates at a distinct disadvantage. Over the years examples of these factors have included health issues such as HIV and AIDS infection, Hepatitis C infections, and lifestyle issues such as drug use or alcoholism.

Interestingly, even if the UNOS lists do not place any emphasis on these factors, it is worth noting that several transplant hospitals do, placing an entire other level on the ethical debate. One example of this, of course, is the infamous position of the nations Veteran Administration hospitals on the issue of transplantation of AIDS patients, whom they refuse to serve at all (Chibbaro, 2004). Even more troubling is the habit of refusing to perform transplant surgeries on anyone who is unable to pay for the procedure -- making obtaining transplants largely within the reach of the middle and upper classes (DeLong, 1998).

Perhaps what is most important in this case, however, is the hospital's ability to comply with the legal and ethical requirements of the United States Government under the Department of Health and Human Services. Not only does this help to ensure the transplant program of the hospital, itself, but it also protects other programs dependent on the hospital's ability to comply with national transplant guidelines (most notably, Medicare). In fact, the government has, in an effort to reduce such ethical quandaries, has developed an eligibility plan upon which Medicare funded hospitals are required to be bound. In short it requires:

Decision to transplant, and placement on donor lists should be decided only on patient need.

This need is based on likelihood of death without transplant.

Age, lifestyle and cause of disease must not be considered (DeLong).

Although, as a Medicare hospital, we are required to operate under the HHS guidelines, there remains the underlying ethical issue that not only gave rise to the above rules, but also perhaps led to the delay of the second transplant in the patient in question. For this reason it is important to consider these issues.

It is simple human nature, given the horrible organ shortage that questions regarding the future utility of the transplant be in the background of any organ allocation. After all, who does not take pause at the idea of a frequently hospitalized race-car driver, for example, being given a kidney transplant over a child who is perhaps only a small degree healthier? So, too, does one naturally wonder at the years of life expectancy in a seventy-year-old patient compared to one who is only eighteen. It seems that taking such details into consideration should be natural. Why, then does HHS refuse to do this?

Like many issues of ethics, transplant issues are often more complex than first thought. After all, if hospitals and transplant list administrators are allowed to differentiate based on the projected utility of the organ, based on time, quality of life, lifestyle, etc., there opens a window for not only grievous abuses of the system, but also a national transplant program in which no centralized decision can be made. In this reality, important life and death decisions would come to be based on subjective criteria, often based on the personal beliefs of a few. The repercussions of this could be devastating.

Given, however, that the first issue is resolved, and it is decided that the hospital will comply with HHS rules regarding transplantation eligibility, physicians must be instructed as to the acceptability of using more than one set of organs during an individual transplant procedure.

Talk to any transplant physician, and he or she will tell you that one of the greatest dangers for any transplant patient is known as "primary non-function." In simple terms, this means that once the new organ or organs are "hooked up," it simply fails to function. Unfortunately, when this event occurs, the usual outcome is death. However, there are instances when a transplant team have been able to swiftly acquire a second organ or set or organs in sufficient time to save the patient. Should this be any different in the case of medical-induced non-function, or even projected non-function?

There was little question after it was discovered that the wrong blood-type organs were implanted in the subject patient that non-function and death would be the near-future result of the surgery, and that another set of organs were vital to the patient's survival. However, in this instance, the second set of organs were not immediately sought.

Although grevous medical errors such as the one that occurred in this case are hardly uncommon, in this case, the error was compounded by the failure to seek (as opposed to failure to obtain) replacement organs quickly (Mitchel, 2004). However, it is also possible to consider another angle on the problem.

Because the medical team had reason to believe that the patient would have significant reduced likelihood of survival, as well as a questionable quality of life following a second transplantation, all indicator point to value judgments on the part of the hospital transplant team, causing them significant pause concerning the ethics of pursuing another set of organs for their patient. Clearly, the issue of organ scarcity was paramount in the delay of treatment.

However, had the transplant team been thoroughly briefed on hospital policy regarding responsibility as defined by the governmental standards concerning transplant eligibility, they would have known that their fundamental responsibility was to the preservation of the patient, not the supply of organs for more promising candidates. The simple fact was that they realized their error, the patient was compromised but not dead, and as such they were charged with finding every means at their disposal to save her. The sad fact, here, is that the patient required an additional set of organs, yet they were not actively and quickly sought. Further, the reality that if the case were different, and organs were not scarce, would have resulted in her immediate re-transplantation indicate that the value/ethical judgment was an inappropriate factor in this case. The simple fact is that under hospital policy, the physicians were not qualified to act in the interest of the organ program over the interest of their patient. Not only did she obviously still present a dire need for matched organs, but her condition indicated certain death without them. By not aggressively pursuing their acquisition, the team, in effect, gave up. Further, because the team failed to do this based on their inappropriate (based on governmental rules) consideration of future organ utility, they put the continued health of the transplant unit in extreme jeopardy.

The fact is, the patient, under governmental criteria, was clearly eligible for a second set of organs. The decision to delay was inappropriate and tragic. Not only should this serve as an example of the difficult nature of transplant ethics, but it should also serve as a springboard for an educational campaign aimed to assure that this issue will never arise again.

Although the issue of organ scarcity is necessarily an emotional one for all involved, there remains the salient truth that the physician's responsibility is to the patient before him or her (MCPM). To consider the greater issue of organ supply and utility over the immediate need of the patient on the table is a gross violation of this responsibility.

What should be done, then, to help future transplant teams avoid similar errors? First and foremost, the initial typing error must never again occur. Indeed, its very occurrence raises extreme doubt as to the safety of typing procedures nationwide. Therefore, an aggressive study of an appropriate typing procedure should be immediately implemented, developed, and applied.

Second, while it cannot be denied that there is a shortage of organs available for transplant, to place responsibility for this issue in the hands of hospital doctors and staff is a dangerous practice. The current wisdom clearly errs on the physician's responsibility to his or her immediate patient. To allow other ethical issues to arise necessarily violates patient trust. Further, in this case, the ethical decision presumably (if not overtly) violated HHS criteria as well.

Here, implementing an educational campaign concerning the ethical responsibilities of transplant team members will be entirely dependent on a clear and open example of communication (CSU). If the team is not aware of a clear and defined protocol for situations like the one presented here, there is simply a greater chance that they will rely on personal subjective judgment. To allow this is to invite error.