Saints Cosmas and Damian, Fra Angelico, 1438 [not blue]
|The Patient and his Mother||Sierra Vista Regional Medical Center||California Transplant Donor Network|
25 year old severely-disabled male with adrenoleukodystrophy, celebral palsy, and a seizure disorder
Jan 29, 2006
Reuben found unconscious, admitted to Sierra Vista Hospital placed on life support (presumably respirator), determined to be comatose without hope of recovery (never diagnosed as brain dead). Mother, Rosa Navarro, agrees to Organ Donation after Cardiac Death.
[N.B. Neither critical care nurse Dianna Stevens, nor ICU attending physician Dr. Laura Lubarsky familiar with protocols for Organ Donation after Cardiac Death
ATTEMPTED ORGAN DONATION
AFTER CARDIAC DEATH
Feb. 23, 2006
Transplant nurse Carla Albright arrives first,
examines chart and patient, orders Sierra Vista nurse Dianna Stephens to
administer 20 mg morphine in ICU. No evidence of distress
Patient moved to operating room where life support removed.
Over one hour an additional 180 mg morphine and 80 mg Ativan administered by Nurse Stevens on orders from Dr. Roozrokh.
At one point Dr. Roozrokh ordered betadine infusion via :feeding" (NG? gastrostomy?) tube.
“I was like a technician,” said Lubarsky, who was one of at least half a dozen medical personnel in the room. “I deferred to the experts who were there, who were presumably following protocol.”
Roozrokh took Navarro’s pulse and suggested that electronic monitors may have been showing “pulseless electronic activity” -an indication that the patient had died. But, she said, she saw Navarro’s heart beating in his thin, uncovered chest and heard it when she examined him.
Patient returned to ICU where expired after approx. seven hours. Organs were not harvested.
Sierra Vista Medical Center settles civil complaint with Ms. Navarro for $250,000. Medical Center not listed in current civil complaint.
Feb. 22, 2008
Initial hearing in criminal case against Dr. Roozrokh:
“The central issue of this case is the mistreatment of a developmentally disabled, dependent adult in an attempt to hasten the person’s death for organ transplantation,”
District Attorney notes that this is the first such criminal case against a transplant doctor in the United States
initially charged with:
 dependent adult abuse,
 unlawful prescribing of a drug [prescribing a controlled substance without a legitimate medical need] and
 administering a harmful substance — Betadine.
April 2, 2008
Criminal charges against Dr. Roozrokh reduced to one felony count of abuse of an adult.
The Jury Trial is taking place at this time.
for the DYING:
RESPECT for the DEAD
PROFESSIONAL CONFLICT of INTEREST
Transplant surgeon and Attending physician
Mother acting as Surrogate
AUTHORITY over PATIENT
Who is attending physician? When does Role change
Protocols should be clear and followed
All members of team caring for dying patient should feel comfortable with protocols, especially attending physician and those who will accompany the patient to the O.R.
All should accept that this approach may occasionally waste the time of the transplant team and especially transplant surgeon
This Webpage was created for a workshop held at Saint Andrew's Abbey, Valyermo, California in 1990