The Ether Way

Cardiac Transplantation Following DCD Should Be An Oxymoron...

"Cardiac Transplantation following DCD should be an Oxymoron."    -Mike O'Connor.

No matter how cynical you get, it is impossible to keep up.         -Lilly Tomlin

As the saying goes, "you can't make this stuff up." This is in reference, of course, to the recent NEJOM article entitled Pediatric Heart Transplantation after Declaration of Cardiocirculatory Death. In this study, two infants had their hearts harvested following 75 seconds of asystole. The very first post of this blog was titled with a Thoreau quote; "Distrust any enterprise which requires new Clothes." That might be aptly rephrased in the present instance to "Distrust any behaviors which require new ethical language." Obviously, here, Donation after Cardiac Death would be a misnomer, since the heart is nothing like dead, so the designation has been quietly and not-so-subtly modified to cardio-circulatory death. This seems like a further slippery step along the path to a utilitarian transformation of the ethical calculus of donation. Initially, when Beecher et al advanced the definition of brain death, the inevitability of corporal death was a given. Then, in response to a shortage of organs, the line was moved to allow the hastening of death through Donation after cardiac death. Make no mistake, this new designation of cardio-circulatory death, and its ethical rationale represents a fundamental shift again, towards a paradigm of "relative" utility; the implicit argument is that the recipient can make better use of the organ than the donor. This all takes place under the cover of compact between the donor's guardian, the recipient, and the intermediary technicians (transplant surgeon, etc.)

The Inspections Will Continue Until the Quality Improves...

Not-so-long ago, on this continent, one of us was Chief of Staff at a local Columbia Hospital when the Joint Commission for Accreditation of Hospitals (JCAHO or here, JC) appeared for a scheduled survey. Surveys were a little different then; they were announced long in advance, and, if a hospital did exceptionally well, they would receive accreditation with commendation; sort of a gold star. RFI's (recommendation for Improvement) were called  "Type 1" recommendations, and were taken as show-stoppers by all parties, requiring follow-up to ensure correction/compliance. Enough Type 1s and you lost your accreditation, which meant financial ruin. At that time, the Columbia hospital chain owned over 300 hospitals, and had convinced the Joint Commission that their operating practices were so different from other hospitals that they needed their own dedicated surveyors. During the inspection at issue, the physician on that surveying team insisted on a type 1 recommendation based upon his sense that medical staff leadership was marginalized by administration (or some such- the actual wording was never shared with the clinicians). Subsequently, administration announced that this type 1 recommendation had been "rescinded" and that the hospital had received "Accreditation with Commendation." Rumor circulated that said physician was henceforth dis-invited from surveying Columbia hospitals...

The JC was once a consensus building organization that followed the lead of its subscribers and accomplished a great deal. When Congress conveyed "Shall Deem" authority for medicare certification upon the JC, it wrested control of the JC from it’s subscribers and transformed it into a regulatory limb of congress and CMS. While the JC is undeniably under the direction of honorable people, their efforts have become distorted by the politics of money and power which surround them. It's no secret around hospitals that practitioners see no connection between the Joint Commission process and quality of care. Indeed, every practitioner understands that some of the worst hospitals attain JC accreditation almost effortlessly, while some of the best struggle to maintain their certification. Historically, JC inspection was centered on physical plant and policy/procedure. Dreadful care was fine, as long as the policy and procedure manual was up to date and concordant with the most recent guidance. Joint Commission accreditation was, and is, a high stakes game, and unfavorable decisions are very likely to be contested in court (or with the threat of litigation). Consequently, JC regulatory activity has progressively focused on inspection activities that can withstand such litigation. This trajectory has relentlessly uncoupled Joint Commission inspection and accreditation from even a remote relationship to quality of clinical care.  High scores and necessary accreditation have become contingent upon putting up a temporary facade of strict compliance, which frequently obstructs, rather than enhances, care. For the past two decades, the closest thing to a Potemkin village in the American culture has been a hospital preparing for a JC survey.