People across the United States have endured rushed or premature attempts to remove their organs. Some were gasping, crying or showing other signs of life.
Last spring at a small Alabama hospital, a team of transplant surgeons prepared to cut into Misty Hawkins. The clock was ticking. Her organs wouldn’t be usable for much longer.
Days earlier, she had been a vibrant 42-year-old with a playful sense of humor and a love for the Thunder Beach Motorcycle Rally. But after Ms. Hawkins choked while eating and fell into a coma, her mother decided to take her off life support and donate her organs. She was removed from a ventilator and, after 103 minutes, declared dead.
A surgeon made an incision in her chest and sawed through her breastbone.
That’s when the doctors discovered her heart was beating. She appeared to be breathing. They were slicing into Ms. Hawkins while she was alive.
Across the United States, an intricate system of hospitals, doctors and nonprofit donation coordinators carries out tens of thousands of lifesaving transplants each year. At every step, it relies on carefully calibrated protocols to protect both donors and recipients.
But in recent years, as the system has pushed to increase transplants, a growing number of patients have endured premature or bungled attempts to retrieve their organs. Though Ms. Hawkins’s case is an extreme example of what can go wrong, a New York Times examination revealed a pattern of rushed decision-making that has prioritized the need for more organs over the safety of potential donors.
In New Mexico, a woman was subjected to days of preparation for donation, even after her family said that she seemed to be regaining consciousness, which she eventually did. In Florida, a man cried and bit on his breathing tube but was still withdrawn from life support. In West Virginia, doctors were appalled when coordinators asked a paralyzed man coming off sedatives in an operating room for consent to remove his organs.
Stories like these have emerged as the transplant system has increasingly turned to a type of organ removal called donation after circulatory death. It accounted for a third of all donations last year: about 20,000 organs, triple the number from five years earlier.
Most donated organs in the United States come from people who are brain-dead — an irreversible state — and are kept on machines only to maintain their organs.
Circulatory death donation is different. These patients are on life support, often in a coma. Their prognoses are more of a medical judgment call.
They are alive, with some brain activity, but doctors have determined that they are near death and won’t recover. If relatives agree to donation, doctors withdraw life support and wait for the patient’s heart to stop. This has to happen within an hour or two for the organs to be considered viable. After the person is declared dead, surgeons go in.
The Times found that some organ procurement organizations — the nonprofits in each state that have federal contracts to coordinate transplants — are aggressively pursuing circulatory death donors and pushing families and doctors toward surgery. Hospitals are responsible for patients up to the moment of death, but some are allowing procurement organizations to influence treatment decisions.
Fifty-five medical workers in 19 states told The Times they had witnessed at least one disturbing case of donation after circulatory death.
Workers in several states said they had seen coordinators persuading hospital clinicians to administer morphine, propofol and other drugs to hasten the death of potential donors.
“I think these types of problems are happening much more than we know,” said Dr. Wade Smith, a longtime neurologist at the University of California, San Francisco, who frequently evaluates potential donors and has studied donation after circulatory death.
A recent federal investigation — prompted by the case of a Kentucky man whose organs were pursued even as he shook his head and drew his knees to his chest — found that the state’s procurement organization had ignored signs of increasing consciousness in 73 potential donors.
In interviews with health care workers, as well as a review of internal records, audio recordings and text messages, The Times confirmed 12 additional cases in nine states that troubled medical workers or were being investigated.
Most of these patients ultimately died, so it is impossible to know what they experienced. Doctors expressed worry that some patients might have recovered if given more time on life support. Other patients may have felt pain or emotional distress in the last hours of their lives.
The questions have taken on greater urgency as this type of donation has grown rapidly in the last five years, driven in part by federal pressure on procurement organizations to increase transplants. At the same time, the government has largely allowed the transplant system to police itself.
In interviews, leaders of the system said that donation after circulatory death was safe and critical to saving thousands of lives every year.
The Association of Organ Procurement Organizations, a trade group, said in a statement that potential donors receive the same quality of care as any other patient until a doctor declares them dead. Decisions about patient care and declarations of death “are the sole responsibilities of the hospital team,” the statement said.
The association said it was misguided to focus on a small number of cases with bad outcomes. “These stories paint a frightening, inaccurate and unbalanced view of our system,” it said.
Several groups representing hospitals didn’t respond to requests for comment. The U.S. Department of Health and Human Services, whose agencies oversee hospitals and procurement organizations, said in a statement that it was improving patient protections.
Dr. Robert Cannon, a transplant surgeon at the University of Alabama at Birmingham, said he believed the system was hesitant to confront safety lapses during circulatory death donations, out of fear that people would stop donating.
“I don’t know the scope of the problem. I don’t know that anybody does,” he said. “That’s the scary thing.”
A Beating Heart
Ms. Hawkins, who had a lifelong cognitive disability, lived with her mother and stepfather in Midland City, Ala. She loved movies and dancing around the living room to Alan Jackson songs. She insisted on celebrating her birthday for the entire month of August.
She was eating lunch at home on May 21, 2024, when she choked on a peanut butter and jelly sandwich. Her stepfather called 911, and doctors at Flowers Hospital in nearby Dothan removed the obstruction, but her brain suffered oxygen deprivation that left her comatose on a ventilator, records show.
Her mother, Faye Johnson, raced to the hospital from her job at a car dealership. Doctors said Ms. Hawkins would never again breathe on her own and gave her mother 72 hours to decide whether to move her to a nursing home or withdraw life support. Ms. Johnson did not want her daughter to suffer. She asked about organ donation, she said, because she wanted some good to come of the tragedy.
Alabama’s procurement organization, Legacy of Hope, coordinated the donation. It ran tests, chose recipients and arranged for an outside company, TransMedics, to send surgeons to remove the organs.
Ms. Hawkins was wheeled to an operating room. Her family said a final goodbye.
Flowers Hospital is a Level III trauma center, meaning it lacks some of the capabilities of larger institutions. It rarely handles circulatory death donation, data shows. Ms. Hawkins was one of just three attempts last year.
In the operating room, a hospital doctor took Ms. Hawkins off the ventilator and gave her drugs for comfort. The doctor declared her dead 103 minutes later, near the outer limit of organ viability.
The surgeons entered the room. They began operating after a five-minute waiting period. All circulatory death donations require a waiting period to ensure the heart does not restart.
Almost immediately, they saw Ms. Hawkins’s heart moving. Records reviewed by The Times characterized the movement differently: Legacy of Hope called it “reanimation,” as did Flowers, which also said the heart “fluttered.” An H.H.S. review of the case said the heart was beating strongly enough to pump blood through the body.
Records from the procurement organization also noted “subsequent gasping respirations,” a type of breathing.
The surgeons stopped and left the room. Another doctor sewed up Ms. Hawkins. It is unclear if she was given any anesthetic. Twelve minutes later, she was again declared dead.
Ms. Johnson was on her way home when she received a call from Legacy of Hope. A coordinator said her daughter’s organs had not been used, but did not tell her what had happened. Nor did Flowers. Ms. Johnson learned the details from The Times more than a year later.
Five doctors with expertise in critical care who independently reviewed Ms. Hawkins’s records at The Times’s request said it was all but impossible that her heart restarted after the waiting period. Research has found that when people are taken off life support, their hearts do not restart on their own after five minutes.
The doctors said they were particularly struck by indications that Ms. Hawkins was breathing, which meant she had at least minimal brain activity. They each said the declaration of death was very likely premature.
“I highly doubt that proper procedures were followed, because if they’re followed correctly, this could not happen,” said Dr. Robert Truog, a Harvard University bioethicist who serves on a transplant system working group on circulatory death donation.
In a statement, Flowers Hospital said it had correctly followed its protocols. “Misty Hawkins was declared deceased by a very experienced and highly reputable member of our medical staff, and that happened only after five minutes with no cardiopulmonary function or vital signs,” it said.
The hospital declined to comment on the improbability of a heart restarting after five minutes or on the procurement organization’s
records saying Ms. Hawkins was breathing.
TransMedics said in a statement that its surgeons “immediately stopped the procedure once they saw that the donor’s heart was beating” and notified Legacy of Hope. The procurement organization declined to comment on the case.
A contractor working for H.H.S. investigated and found “no deficiencies” at the hospital or procurement organization, according to letters reviewed by The Times. H.H.S. declined to provide further details.
Ms. Johnson said she was still struggling to understand the loss of her daughter and desperately hoped she had not suffered during surgery. More than a year later, she still speaks to her every day. Her daughter’s bedroom remains as it was when she was alive.
“I just wish I knew what really happened,” she said.
Rushing Donations
Circulatory death donation used to be largely forbidden. That began to change in the 1990s, when a dying patient asked the University of Pittsburgh Medical Center to remove her life support and donate her organs. The hospital honored her wishes, then spent two years creating guidelines for future cases. Use of the practice gradually spread.
Procurement organizations attributed the procedure’s recent growth to technological advances. Dozens of employees at the organizations said it was largely because of government pressure.
Citing the number of Americans waiting for organs, H.H.S. said in 2020 that it would begin grading procurement organizations on how many transplants they arranged. The department has threatened to end its contracts with groups performing below average, starting next year. Many have raised their numbers by pursuing more circulatory death donors.
Employees said some organizations had blown past safeguards, potentially rushing the process. For instance, coordinators are not supposed to approach a patient’s relatives until the family has decided to withdraw life support, but workers said that rule was frequently violated.
After relatives agree, it can take several days to prepare for organ retrieval. During this time, the hospital is supposed to keep treating the patient, including looking for signs of recovery.
In reality, said 16 workers at hospitals in a dozen states, once patients are approved for donation, hospitals sometimes put them in the care of young residents or fellows who tend to defer to procurement organizations.
Dr. Alejandro Rabinstein, chair of hospital neurology at the Mayo Clinic, said medical workers sometimes lacked the experience to tell whether a patient’s movements were a sign of recovery or meaningless reflexes. “Training can be a real issue, especially in smaller hospitals,” he said.
The federal investigation noted that Kentucky’s procurement organization often failed to recognize that illegal drugs or hospital-administered sedatives could make patients seem less neurologically healthy than they were.
Recent research also has called into question longstanding assumptions about human consciousness.
A study published last year in The New England Journal of Medicine reported that 25 percent of patients who were thought to be unresponsive actually might have awareness, even if they couldn’t communicate. Another study, although small, found that when doctors predicted in the first 72 hours that a patient would not recover from a traumatic brain injury, they were frequently wrong.
Still, circulatory death donation has come to be widely accepted as crucial to reducing the national organ shortage. Dr. Joseph Scalea, a transplant surgeon at the Medical University of South Carolina, called it “one of the most impactful innovations in accessing more organs for patients in need.”
More than 100,000 people are waiting for an organ in the United States, and many won’t receive one. Recently, the system has set transplant records largely because of circulatory death donation, data shows. Organs from these patients were transplanted into 43,500 people from 2020 through last year.
‘What a Disaster’
Health care workers across the country recounted cases that haunted them.
Bryany Duff, a surgical technician in Colorado, said one patient, a middle-aged woman, was crying and looking around. But doctors sedated her and removed her from a ventilator, according to Ms. Duff and a former colleague.
The patient did not die in time to donate organs but did so hours later. “I felt like if she had been given more time on the ventilator, she could have pulled through,” Ms. Duff said. “I felt like I was part of killing someone.”
Afterward, Ms. Duff quit her job and temporarily left the field. “It really messed with me for a long time,” she said. “It still does.”
In Miami in 2023, a potential donor who had broken his neck began crying and biting on his breathing tube, which a procurement organization worker said he interpreted as him not wanting to die. But clinicians sedated the patient, withdrew life support, waited for death and removed the organs, according to the worker and a colleague he told at the time.
In West Virginia, doctors were taken aback after Benjamin Parsons, a 27-year-old man paralyzed in a car accident, was brought to an operating room and asked to consent to donating his organs as he was coming off sedatives.
Communicating through blinks, he indicated that he did not give permission. Still, coordinators initially wanted to move forward, according to text messages and interviews.
Mr. Parsons’ brother Andrew told The Times that the family had authorized the donation and believed his brother had blinked his agreement several times in the hours before the procedure, when sedation had been dialed down. He changed his mind in the operating room, said Andrew Parsons, who added that the procurement organization had been compassionate.
In a text exchange that day, doctors involved in the case said that without a full neurological exam under no sedation, it was unclear whether Mr. Parsons was lucid enough to consent. “What a disaster and handled COMPLETELY inappropriately,” one doctor wrote. Mr. Parsons chose to go off life support two days later and died without donating. A transplant system oversight committee has been investigating the case.
The procurement organizations for Miami and that part of West Virginia declined to discuss the cases, citing privacy laws. The Colorado group did not respond to requests for comment.
The Times spoke with workers who described other cases in North Dakota, Pennsylvania, Texas and Washington.
For years, the transplant system, the Organ Procurement and Transplantation Network, has largely governed itself. Its oversight committee reviews complaints but has rarely acted against the hospitals and 55 procurement organizations that make up its membership, The Times has reported.
The federal government increased oversight after an explosive House committee hearing last September.
The hearing was about the general performance of the transplant system, but was upended by testimony about the Kentucky man, who awoke just as he was about to be removed from life support in 2021. The man, Anthony Thomas Hoover, is still alive. He has neurological injuries and cannot recount what he experienced.
An investigation by the transplant system found “no major issues.” But an H.H.S. agency conducted its own inquiry and identified widespread problems, The Times has reported. The department directed the Kentucky procurement organization to perform regular neurological tests on potential donors and ordered transplant officials to develop a way for clinicians to pause donations when they believe patients are improving.
The department is examining other cases, records show. But it has not disclosed any of its investigations or findings. The House committee has scheduled another hearing for Tuesday.
Mr. Hoover’s story shocked many people, but it sounded familiar to Danella Gallegos.
In 2022, when she was 38 and homeless, Ms. Gallegos was hospitalized and went into a coma. Doctors at Presbyterian Hospital in Albuquerque told her family she would never recover.
Her relatives agreed to donation, but as preparations began, they saw tears in her eyes. Their concerns were dismissed, according to interviews with the family and eight hospital workers. Donation coordinators said the tears were a reflex. (Tears can be an involuntary response to irritants.)
On the day of the planned donation, Ms. Gallegos was taken to a pre-surgery room, where her two sisters held her hands. A doctor arrived to withdraw life support. Then a sister announced she had seen Ms. Gallegos move. The doctor asked her to blink her eyes, and she complied. The room erupted in gasps.
Still, hospital workers said, the procurement organization wanted to move forward. A coordinator said it was just reflexes and suggested morphine to reduce movements. The hospital refused. Instead, workers brought her back to her room, and she made a full recovery.
Two years later, after hearing about Mr. Hoover, Ms. Gallegos filed a complaint with H.H.S., which opened an investigation.
Presbyterian made the treatment decisions, but hospital workers said they faced pressure from the procurement organization, New Mexico Donor Services.
“All they care about is getting organs,” said Neva Williams, a veteran intensive care nurse at the hospital. “They’re so aggressive. It’s sickening.”
In a statement, Donor Services said that it does not interfere with medical decision-making and that hospitals are in charge of patient care. Presbyterian noted that Donor Services was responsible for managing all aspects of the donation process but said it was reviewing Ms. Gallegos’s case.
Ms. Gallegos said in a recent interview she did not remember much about what had happened in the hospital. She recalled feeling fear but not pain.
“I feel so fortunate, obviously,” she said, “but it’s also crazy to think how close things came to ending differently.”
—-New York Times
Read by Brian Rosenthal
Mark Hansen contributed reporting. Susan C. Beachy contributed research. Audio produced by Adrienne Hurst.
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