'Donation after circulatory death'

HRSA's investigation, which was shared with the Times, focused on "donation after circulatory death," a practice becoming more common at some hospitals, Rosenthal reports.

Most organ donors are brain-dead, but in these cases, patients have some brain function but are on life support, are not expected to recover, and are often in a coma.

If family members agree to a donation, employees from a nonprofit organ procurement organization start testing the patient's organs and aligning transplant surgeons and recipients. Each state has at least one organ procurement organization, which often stations staff in hospitals to help manage donations.

Usually, the patient is taken to an operating room where hospital workers will withdraw life support and wait. Organs are only considered viable for donation if the patient dies within an hour or two. In those cases, the procurement organization's team will wait five more minutes and then start removing organs. There are strict rules in place that are supposed to make sure no retrieval begins before death or causes death, Rosenthal reports.

According to the Organ Procurement and Transplantation Network, which oversees the transplant system, officials recovered almost 20,000 organs nationwide through this type of donation last year, which was nearly double the amount in 2021.

What HRSA's investigation found

HRSA's investigation looked at around 350 cases in Kentucky over the past four years in which plans to remove organs were ultimately canceled. HRSA found that in 73 cases, officials should have considered canceling organ removal sooner as the patients had high or improving levels of consciousness.

While the surgeries didn't ultimately happen, the investigation said multiple patients showed signs of pain or distress while being prepared for the procedure. The majority of the patients did eventually die either hours or days later; however, some recovered enough to leave the hospital.

The investigation specifically criticized Kentucky Organ Donor Affiliates — now called Network for Hope following a merger — which was coordinating organ donations in the state.

Through its investigation, HRSA found that the organization's employees frequently pressured families to authorize donation, improperly took over cases from doctors, and tried to pressure hospital staff to remove life support and allow for surgery despite indications patients had growing awareness. Some employees also failed to recognize that hospital sedatives or illegal drugs could hide a patient's neurological condition, meaning they could be in better shape than they seemed.

The investigation was prompted by the case of Anthony Thomas Hoover II, a Kentucky man who had an overdose in 2021. He was unresponsive for two days before his family agreed to donate his organs.

Two former employees of the procurement organization spoke to the Times and said that higher-ups attempted to pressure the doctor to continue with the organ retrieval attempt. "If it had not been for that physician, we absolutely 1,000% would have moved forward," said one of the employees, Natasha Miller, who was present in the room. Three other former employees said they had seen similar cases.

The investigation didn't say whether there had been pressure on the doctors who treated Hoover.

In another example, in December 2022, a 50-year-old overdose victim started stirring less than an hour after they were removed from life support and began looking around. The organ retrieval attempt wasn't immediately ended nor was the patient given an explanation.

"The patient had no idea what was going on but was becoming more aware by the minute," records said.

After 40 more minutes, once the patient's organs no longer qualified for donation, the attempt was canceled, and the patient was moved to an intensive care unit. He later sat up and spoke with his family before he died three days later.

In total, the investigation flagged 103 cases as having "concerning features" and said problems were more likely to happen at rural hospitals. The investigation also noted that more than half of transplants arranged by Network for Hope were from circulatory-death patients, which is higher than the national average.

Network for Hope said it always follows the established rules and never removes organs until a hospital has declared a patient dead.

Following the investigation, federal regulators told the Organ Procurement and Transplantation Network that Network for Hope must implement several changes to its practices, including increasing training for its staff and conducting neurological assessments on potential organ donors every 12 hours.

Network for Hope said it had received a report about the investigation. "We will fully comply with all of their suggested recommendations," it said in a statement.