Measuring out medicine (book excerpt: The Surgeons: Life and Death in a Top Heart Center)
December 2nd, 2007 Posted by: Dr. Cox
While the match is made by a computer, the decision whether someone actually gets on a list, and his medical urgency classification, is made by local transplant committees. At Columbia-Presbyterian, the adult transplant coordinating committee meets every Friday morning, chaired jointly by Yoshifumi Naka [MD, PhD], the transplant surgery program director and Donna Mancini [MD], a professor of medicine and director of the Center for Advanced Cardiac Care, who oversees transplant cardiology. There are usually about 30 people around the table — transplant cardiologists, social workers, psychiatrists, infection specialists, neurologists, surgeons, transplant nurses and others. Most of the cardiologists are from Mancini’s section, but very occasionally an outside cardiologist may attend as well, to help advocate a listing for one of his patients.
Committee meetings open with a review of the current waiting list, followed by an intense case review of recent transplants. Few patients are ever the focus of so much concentrated medical brainpower. Transplant X has an intestinal infection: is that resolving itself or are we overdoing the immunosuppressants? Transplant Y is refusing to get out of bed: is she depressed? The psychiatrists will follow up. Here are Transplant Z’s blood chemistries, and last week’s trends: what does the group think? The lavishness of the resources partly reflects the value of the sunk investment. It’s not just money — although at $200,000 to $300,000 per patient, transplants are stunningly expensive. The “most precious resource of all,” in Naka’s words, is the donated heart, which is quite literally priceless. An early death of a transplant patient is therefore uniquely tragic — not only has a patient died, but a rare gift has been wasted, a donor’s good intentions flouted, and another patient who might have been more suitable may now die as well.