GRAND JUNCTION, Colo. — It sounds like a horror sotry written for a Halloween movie.
First, a 31-year-old man shoots himself. When doctors find that his heart is still beating, they pronounce him brain dead and remove his organs.
Then, a coroner questions their decision and rules the death a “homicide” caused by organ removal.
The latest news is the scariest part of all, say some Catholics: Organ donation advocates want the Catholic coroner fired. They say the ruling would inhibit future organ donations.
But an independent report supports the coroner. It shows there was miscommunication and sloppy documentation during the process leading up to the pronouncement of death. The Oct. 20 report by Dr. James Kelly of the University of Colorado praised coroner Mark Young for his “alert and careful review of the medical records.”
Young's review found “discrepancies” between the documentation of events surrounding William Rardin's death and Young's “understanding of the procedures for determining brain death prior to organ donation,” the report said.
But Kelly, who is involved in clinical care, teaching and research at the University of Colorado School of Medicine, affirmed the brain-death ruling in Rardin's case.
The saga began in the early evening of Sept. 26, when Rardin, 31, sustained a gunshot wound which was apparently self-inflicted with a .22-caliber handgun. However, the coroner, after reviewing hospital records, declared Rardin a homicide victim, killed by the removal of his organs.
That set off a firestorm of protest from the Catholic hospital where Rardin was airlifted from a smaller hospital, and others. In an Oct. 12 press conference, the Montrose district attorney, Thomas Raynes, announced that a group — including physicians, organ-donation specialists and coroners — had reviewed the medical records and determined that Rardin's death caused by the gun-shot wound.
The Coroner Protocol Review Committee also concluded that St. Mary's Hospital in Grand Junction, which was founded by the Sisters of Charity of Leavenworth (Kan.), had followed accepted medical standards in determining Rardin as brain dead.
According to the report, the standard tests included apnea testing, which demonstrates the absence of breathing and lack of function of the brain stem, and clinical observations of the absence of brain-stem reflexes.
Officials from St. Mary's Hospital said they were pleased by the committee report and appalled by Young's “false allegations.”
“St. Mary's is asking the Montrose County coroner to publicly correct the death certificate to reflect the actual time of the pronouncement of brain death,” the Oct. 12 statement said. “We also recommend that Mr. Young work with the Donor Alliance to do everything in his power to repair the damage he has done to our state's organ-donor program.”
But Young, who has said he supports the organ- and tissue-donation program, said the report was “biased” and part of a campaign to discredit him because the committee included representatives from Donor Alliance, the organ-procurement organization that serves Colorado and Wyoming.
“It smells of a conflict-of-interest in the way the report was done,” Young said.
Young, who has been a para-medic for about 20 years and whose elected position requires him to determine the manner and cause of suspicious deaths, asked for an independent review of the case, including his actions, by an unaffiliated neurosurgeon.
In that report, Kelly said that after his interviews with doctors involved in the case, he concluded that the determination of brain death at St. Mary's Hospital was performed “in accordance with accepted medical standards.”
Rardin was first brought to Montrose Memorial Hospital, where a CT scan revealed “extensive brain damage from which he could not be expected to survive,” Kelly reported. “Since the severity of his injury was understood from the outset and his neurological status was irreversible, he was said to be ‘essentially brain dead’…with no further efforts to formally diagnose brain death at that time.
“He was not pronounced dead by either physician at the first hospital, even though a nurse's note indicates that he was,” Kelly said. “This may have been the result of a miscommunication at the time Mr. Rardin's care was handed off from one physician to the next at the change of shifts.”
Rardin's cardiopulmonary functions were stabilized and he was transferred to St. Mary's, the report said. There, a third physician examined him and found no signs of function in the entire brain, including the stem. The physician did not document his examination results, but Kelly said he found signs pointing to brain death, including the absence of pupillary responses to light, absence of gag reflex and absence of response to painful stimuli. An apnea test also showed no evidence of brain-stem function. He was pronounced dead at 11:45 p.m. on Sept. 26 but remained on a ventilator.
Six hours later, a fourth physician confirmed brain death using the same tests. But details of the examination also were not documented, Kelly said.
Seeking a Standard
On several occasions, the Vatican has affirmed that brain death is a legitimate standard to determine death, and that organ transplants, when done ethically, are acceptable. Pope John Paul II has said the Church teaches that vital organs can be removed only “from the body of someone who is certainly dead.” The question becomes how to determine death with certainty.
“The criterion adopted in more recent times for ascertaining the fact of death, namely the complete and irreversible cessation of all brain activity, if rigorously applied, does not seem to conflict with the essential elements of a sound anthropology,” the Holy Father said in an address to the International Congress on Transplants in 2000.
Young was concerned that different hospitals have different standards for determining brain death. In an Oct. 6 joint statement issued with Donor Alliance, he said his intent was to alert the medical community to his perception of differing and vague standards.
“The intent was not to concern the public about organ donation or the risk of donating organs,” he said in the statement. “What I want to come out of this is a defined standard. I plan to work with the right people to make that happen.”
Colorado defines legal death as the irreversible cessation of heart and lung functions or the cessation of all functions of the entire brain.
Diane Hochevar, president of the Colorado Right to Life Committee, said her group's position is that death occurs only when there is cessation of circulation, respiration and brain activity. She fears brain death being used as the criterion so organs can be harvested and costs contained. And she is concerned about what may happen if the state Legislature reviews and clarifies the brain-death issue.
“Few, if any, legislators would have the courage to seek a return to the three-part criteria,” Hochevar said. “Few legislators would be willing to say anything that appears to oppose organ donation or establish guidelines that make the procurement of organs more difficult. Many legislators will look at the cost-containment factor, and it would not surprise me if the standards were relaxed even further.”
Hochevar added that she is concerned that those who are dying are being reclassified in society's eyes. “They are not embraced as being part of those who are living,” she said. “They are just outside of that circle. The acceptance of the brain-death criterion as a definition of death was the prime factor that moved them outside of that circle.”
Father Tadeusz Pacholczyk, director of education at the National Catholic Bioethics Center, said it is possible that, by taking shortcuts and not doing the total number of tests required to determine brain death, physicians may conclude “too soon” that someone is brain dead when the person, in fact, is not.
“As the devaluation of human life occurs, as you decide that it's okay to expunge the life of human embryos for stem-cell research, as you decide it's okay to end the pregnancy for the convenience of the mother, as you decide at the end of life that providing care is very expensive, all of these kinds of factors do end up creating a momentum of their own, which then influences the way that people will view somebody who is in a situation that's less than ideal,” he said. “Then add to that the possible pressure for organ procurement. It's certainly more than a theoretical possibility that people will be tempted to cut corners.”
Carlos Briceño writes from Seminole, Florida.
- Oct. 31-Nov. 6, 2004