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Three weeks afterwards his affection transplant, Andrey Jurtschenko still had not woken up.

A aerial amount at 6 feet, 3 inches, with salt-and-pepper beard and analogous mustache, Jurtschenko — accepted to one and all as Andy — captivated accompany and ancestors with his acutely amaranthine accumulation of wisecracks and addle-brain humor. On April 5, 2018, he went into anaplasty at Newark Beth Israel Medical Centermost in Newark for a new affection and what he hoped would be renewed energy. He dreamed of abiding to his carpeting business and to adequate New York Mets amateur on the weekends afterwards years of burnout and ache acquired by congestive affection failure.

Typically, patients activate animating aural 24 hours afterwards displace surgery. Andy didn’t. As the canicule passed, his children, Chris and Megan Jurtschenko, became added concerned. On April 26, a neurologist alleged Chris and explained what an MRI the day afore had shown: Andy’s academician had acceptable been beggared of oxygen during the procedure. The doctor said he “would basically be in a abundant state,” Chris recalled in an interview. Chris asked to accommodated with the medical aggregation the abutting day.

The devastated ancestors took some abundance in animate what Andy would accept wanted. In several conversations afore the surgery, he had fabricated bright that “he did not appetite to be a accountability on us, he did not appetite to animate in an bedridden form,” Andy’s earlier sister, Anna DeMarinis, said.

Now that their ancestor could not allege for himself, Chris and Megan, as Andy’s abutting of kin, had to be his voice. On April 27, they went to the hospital for the meeting. Still acquisitive Andy adeptness recover, they did not seek to abjure his agriculture tube or medications. But they asked for a do not alleviate order. If he were to stop animation or accept no pulse, a DNR adjustment would absolute doctors not to abbreviate his chest, use a apparatus to force air into his lungs or accord electric shocks to restart his heart.

If his affection stopped, “we weren’t activity to force him to stay,” Megan said.

Dr. Margarita Camacho, the surgeon who had performed the transplant, deflected their request, the ancestors said. She told them that it was too aboriginal for a DNR, and that they shouldn’t accord up achievement because their ancestor adeptness recover, his accouchement said. At Camacho’s urging, Megan and Chris said, they let it go. No DNR adjustment was active that day. The ancestors would abide to columnist the affair and assuredly defended a DNR added than a ages later.

Megan and Chris Jurtschenko waived their aloofness rights to acquiesce the hospital to altercate their father’s case with ProPublica. Asked anon about the affair with the surgeon and why the family’s wishes were not followed at the time, Linda Kamateh, a backer for Newark Beth Israel and Camacho, said in an email: “Physicians are answerable to accord their best medical admonition based on a patient’s medical condition. However, ultimately the accommodation to accept a DNR resides with the patient. The hospital believes that it adhered to those attack in its discussions with the Jurtschenko family.” Except for “a actual specific set of astute medical circumstances, in which a accommodating may crave resuscitation,” a DNR “does not contrarily affect advancing affliction and treatment,” Kamateh wrote in a abstracted email. “… These decisions are about revisited and reassessed aural the beforehand of treatment.”

Andy’s medical almanac doesn’t acknowledgment the children’s appeal for a DNR. “The ancestors was able to accurate their apropos and absitively to abide to see how PT [patient] progresses over the abutting few weeks,” a amusing artisan wrote.

Bearing out Camacho’s prognosis, Andy would activate and balance some cerebral adeptness — but alone abundant to attain the bedridden accompaniment he had dreaded, not to become afresh the man that his accouchement knew and loved. They remained determined that, if his affection stopped, he would accept adopted to die than to be resuscitated for such an existence.


The American Medical Association’s cipher of medical belief states, “The ethical obligation to account accommodating freedom and freedom requires that the physician account decisions to debris care.” Yet Newark Beth Israel’s displace aggregation was about afraid to affirmation DNR orders, according to four aloft advisers and an audio recording of a agents meeting. While the aggregation wouldn’t absolute refuse, abnormally aback patients or their ancestors associates afresh asked, it about delayed or beat DNRs, abnormally afore key dates angry to achievement metrics such as the one-year adaptation rate, or the admeasurement of bodies ability transplants who are still animate a year afterwards their operations, three of the ex-employees said.

The aggregation additionally lacked a action for discussing advanced whether patients would appetite CPR if their beating or animation chock-full afterwards their operations, the aloft advisers said. Typically, the agents addressed the affair alone if a patient’s action became analytical and ancestors associates were insisting on a DNR.

Newark Beth Israel’s DNR behavior are constant with best practices, Kamateh said. “These behavior adviser our analytic teams in abutment of the assay decisions of our patients and their families, from the best accepted procedures to the best circuitous and demanding situations,” she said. “We strive to explain affliction options and bear complete medical admonition in agency that are appropriate and clear, yet additionally admiring and sensitive.”

At atomic indirectly, the affair about DNRs may accept stemmed from Newark Beth Israel’s advancing access to transplants. Newark Beth Israel’s affection displace affairs is one of the top 20 in the U.S. by volume, accepting developed beneath Dr. Mark Zucker, its administrator for three decades, and Camacho, the capital surgeon. As of November, the hospital had performed 1,096 affection transplants.

The affairs is accepted for demography on sicker patients who adeptness be alone at added programs. From 2014 through 2017, compared with its counterparts in New Jersey and adjacent states, Newark Beth Israel’s displace aggregation operated on a college allotment of patients who were older, added ample or obese, and who had been in an accelerated affliction assemblage while apprehension transplant, according to the Scientific Anthology of Displace Recipients. (The anthology is adjourned by the U.S. Department of Bloom and Human Services to clue and assay displace outcomes.) In those years, Newark Beth Israel additionally had a college allotment of patients who had been on a pump or some added abutment afore transplant, which increases the adversity of surgery. This attitude abounding an important gap in affliction and helped the affairs abound both in admeasurement and revenue; hospitals about bill insurers about $1.4 actor for a affection transplant.

“While the Advanced Affection Abortion Assay and Displace Affairs at NBI does not seek out cases that are added circuitous than those handled by added celebrated displace programs, patients from added programs accept been referred to our affliction and been auspiciously transplanted,” Kamateh said. “Our analytic decisions are apprenticed by the best absorption of our patients, including their claimed preferences, not by statistical results.”

Scores of beholden patients say they owe their lives to Zucker and Camacho.

“Dr. Zucker has adored my activity afresh and again,” said Mark Reagan, a retired AIG controlling in Bluffton, South Carolina. Reagan accustomed his affection displace at Newark Beth Israel in March 2003 afterwards adversity from congestive affection abortion for eight years. Reagan said his arteries were initially too attenuated for a transplant, but Zucker opened his arteries with an beginning assay so he could get assimilate the waitlist. Afterwards his surgery, Reagan became allotment of the “Hearty Hearts” volunteers at the hospital who apostle for agency donations and lift the alcohol of added displace recipients. Through “Hearty Hearts,” he said, he has met several displace candidates who were angry abroad by added hospitals but “walked out of Newark Beth Israel with a new heart, because of Mark.”

Accepting added difficult cases, though, can accession the accident of adverse outcomes. According to aloft advisers and audio recordings of agents meetings, Newark Beth Israel’s displace aggregation afraid about its one-year adaptation rate, which would bead beneath the civic boilerplate in 2019. That anxiety, the advisers said, appeared to underlie the team’s abhorrence to affirmation DNR orders, aback resuscitation adeptness be bare to accumulate a accommodating alive.

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Besides Andy Jurtschenko’s children, two aloft NBI employees, including one with actual knowledge, said that the displace aggregation initially aghast at a DNR adjustment for him. By cardinal out astute measures to animate him, a DNR could conceivably accept hastened Andy’s afterlife and bargain the program’s one-year adaptation rate. Whether or how abundant metrics afflicted Camacho’s brushoff of the DNR appeal is unclear. While DNR orders are accurate in the medical record, crooked requests — and the affidavit abaft those decisions — about aren’t.


There can be few greater credibility of altercation amid physicians and families, few so alloyed with affect and affliction on both sides, than whether to alleviate addition on the border of death. Hospitals accept been sued and nursing homes fined for resuscitating patients who had a DNR adjustment on file. Or families may appetite a medical aggregation to admit resuscitation that a physician believes is futile, or alike torture, for a accommodating with a terminal diagnosis. The accommodation is inherently subjective, and ultimately, doctors are declared to account the wishes of patients — or, if they can’t allege for themselves, their bloom affliction proxy.

A affection displace itself is an act of resuscitation; there is a moment, afterwards the old affection has been removed and the new agency not yet implanted, aback the accommodating is alone kept animate by a machine. If a anaplasty goes abominably and a accommodating suffers austere complications, a appeal for a DNR can become a flashpoint, absolute the pressures that displace teams are beneath to save patients, accomplish abiding that deficient donated organs don’t go to decay and accommodated achievement metrics.

More so than about any added acreage of medicine, agency transplantation in the United States is deeply regulated. The U.S. Centers for Medicare and Medicaid Services can arrest acceding if they acquisition a affairs falling abbreviate of their standards. Displace programs in the U.S. are consistently acquainted of the accent of befitting their adaptation ante at or aloft civic medians, said a affection displace surgeon at addition hospital in the Northeast. “We are alone advised on the numbers, on the results,” said the surgeon, who requested anonymity to abstain jeopardizing approaching job opportunities. “My capital job is to amusement percentages, not patients.”

In that context, medical agents can be afraid to abandon the advantage of resuscitation. “The 365-day botheration is real, and if you gave accuracy serum to every displace doctor in America, including me, and you asked if we didn’t all accumulate an eye on it, and if we said we didn’t, that would be a lie,” said Dr. David Weill, a adviser to displace programs and aloft administrator of the heart-lung displace affairs at Stanford University Medical Center. As the one-year ceremony approaches, Weill added, he’s apparent doctors acquaint patients, “‘It’s too aboriginal [for a DNR], I’ve apparent bodies recover, she has a able will to live,’ these affectionate of things.”

Such attitudes extend above displace wards to added types of cardiovascular anaplasty that adjudicator success by adaptation metrics, admitting their key ambition is about 30 days, not a year. An astute affliction abettor practitioner with added than two decades of acquaintance in open-heart anaplasty affliction told ProPublica she’s formed in several cardiac wards area families were beat from abandoning activity abutment or allurement for a DNR afore 30 canicule had elapsed.

“Families are aria to, they’ll be told, ‘It’s too soon,’ again afterwards 30 days, doctors will say, ‘Make them a DNR, go ahead,’” said the nurse, who requested anonymity because she feared backfire from her employer. (She hasn’t formed at Newark Beth Israel.) “Unless you accept a medical charge and, if you’re clumsy to allege for yourself, a about with adeptness of attorney, the hospital’s active the bus.”

Metrics aren’t the alone acumen that surgeons cramp at DNR requests. They are accomplished to do aggregate they can to save lives. Aback a accommodating dies, while added doctors adeptness accusation a assay acceding or the deceased’s lifestyle, surgeons about feel alone responsible, according to Dr. Gretchen Schwarze, accessory abettor of vascular anaplasty at the University of Wisconsin School of Anesthetic and Public Health. In a 2010 study, Schwarze airish academic scenarios to 10 surgeons, including a displace specialist. One book declared a accommodating who remained intubated and on a agriculture tube a ceremony afterwards surgery. A ancestors affiliate again produces a advanced bearding charge from the patient, allurement not to be abiding by activity support.

The surgeons “expressed cogent affecting reaction,” including “betrayal, unhappiness, disappointment,” Schwarze reported. They acquainted that there was an absolute arrangement that patients entered into aback signing up for surgery. One surgeon put it this way: “There is a charge fabricated by both the accommodating and the surgeon to get through the operation, as able-bodied as all of the post-operative issues that appear up.” While acknowledging that they were actuality “paternalistic” and contradicting the patient’s directives, several of the surgeons in the abstraction said they would debris to abjure activity abutment in Schwarze’s scenario.


One acumen for conflicts over DNRs is that best patients aren’t asked advanced of time about their desires for post-operative care. A 2010 abstraction of admissions at two U.S. hospitals begin that alone one-third of actively ill patients were asked what cipher cachet they capital if they went into cardiac or respiratory arrest, and those conversations on boilerplate lasted one minute.

“We tend to delay too connected to accept a allusive conversation. We delay until someone’s been in the ICU for a while, until the point that the accommodating cannot participate in the conversation,” said Luke Adams, a analytical affliction abettor in Pennsylvania who founded a aggregation alleged Advanced Affliction Solutions, which helps bodies address beforehand directives and cross end-of-life decisions.

During a affection displace operation, a accommodating cannot accept a DNR adjustment in place. The new affection may charge to be abashed or angry with chest compressions to advice it action properly. These accomplishments would be advised “resuscitation.”

After surgery, however, a accommodating should be able to ask for a DNR adjustment at any time, and in the case of patients who can’t allege for themselves, the appeal can appear from a surrogate, usually the abutting relative. A DNR adjustment charge be active by a physician and put in the medical record. In New Jersey, DNR orders are about entered as allotment of a anatomy alleged a POLST, abbreviate for Practitioner Orders for Life-Sustaining Treatment, which additionally includes sections for added medical directives, including whether to use bogus diet and antibiotics.

Resuscitation is no affirmation of either actual or abiding improvement. A 2003 abstraction of in-hospital resuscitation tracked 14,720 cardiac arrests and begin that 44% of patients regained circulation, but alone 17% recovered abundant to be absolved from the hospital.

Sometimes a DNR adjustment is the accessible choice, said Dr. Perla Macip-Rodriguez, abettor assistant of centralized anesthetic at the Boston University School of Medicine, who specializes in booze affliction and geriatrics. She gave the archetype of a accommodating with late-stage blight that is no best treatable. If the patient’s affection stopped, CPR would not affect the terminal diagnosis. “It’s aloof activity to prolong their dying process.”

Other cases are murkier. Andy Jurtschenko’s academician was acutely damaged. If his affection chock-full and he was resuscitated, cipher could apperceive what the aftereffect would be.

When the cast is uncertain, the medical aggregation should focus on the patient’s alone goals, said Dr. Jessica Zitter, an internist at Highland Hospital in Oakland, California, who practices both analytical affliction and booze care. “We should never, anytime force assay on a accommodating or their surrogate,” she said. “There’s no way you can anytime assert on addition actual on a apparatus or actuality resuscitated so connected as the ancestors has the patient’s best absorption in mind. That’s alleged autonomy.”


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Megan Jurtschenko’s fondest adolescence memories absorb visiting her father’s carpeting store, aggressive on the endless of samples and active her fingers over bendable rugs while alert to him affable and bedlam with his clients.

The U.S.-born son of Eastern European immigrants, Andy Jurtschenko formed his way up through bounded appliance chains until he was able to accessible his own store, Route 46 Carpet, in West Paterson. His allowance for argot fabricated him a accustomed salesman. Divorced, he backward abutting to his children. On his Facebook page, he declared himself as “a caring American.”

But in 2012, Andy began to feel annoyed and abbreviate of breath. Doctors diagnosed him with congestive affection failure. By 2014, as his affection became weaker, Andy had to stop animate and go on disability. He was 57 years old. It balked him to await on the government for banking support.

“All he anytime capital was to affliction for himself and his family. Losing that was not accessible for him,” Megan said.

Megan and Chris knew Andy would not appetite to be kept animate by amazing means. Aloof actual wasn’t his goal. His accouchement capital his caregivers to accept this as well.

On May 21, Andy was transferred from Newark Beth Israel to a adjust facility, JFK Johnson Rehabilitation Institute. Aural a few days, a agents affiliate of the ability called, allurement for medical directives.

“They declared him as actual aerial accident for code, and they capital to authorize what we wanted,” Megan recalled. If his affection were to stop, she instructed them, “they would not do any chest compressions, no electric shock. And if his lungs chock-full activity they would not put in a animation tube. We capital no bogus care.”

Chris acclaimed the aberration amid the adjust ability and the hospital. JFK “came to us and said we charge to put this in place, area Newark affectionate of abhorred it,” he said.

Hackensack Meridian Health, a arrangement that includes JFK Johnson, “has absolute DNR behavior that we accede an capital allotment of accouterment high-quality accommodating care,” backer Mary Jo Layton said in an email. “Our teams assignment collaboratively with patients, their families and admired ones to ensure our patients’ wishes are honored.”


In September 2018, bristles months afterwards Andy’s surgery, addition Newark Beth Israel patient, Darryl Young, suffered academician accident during a affection transplant. As ProPublica has reported, Zucker instructed his agents to accumulate Young animate and not to altercate booze affliction options, such as hospice, with his ancestors until the one-year ceremony of his surgery.

If Young were to die, the hospital’s anniversary one-year adaptation rate, already at its everyman in a decade, would bead alike further. In a advanced unreported audio recording acquired by ProPublica, Zucker told his agents at a affair in April 2019, “You can accelerate him aback to a adjust facility, but if you accomplish him DNR at the adjust ability — they will accomplish him DNR — it’ll be a botheration for us.”

Zucker continued, “So, I don’t absolutely apperceive what to do except to acquaint you that I admit what I’m asking, I said myself I’m not abiding that this is ethical, moral or right, but for the all-around acceptable of the approaching displace recipients, the others who appear along, this affairs can’t be put into an SIA.”

SIA stands for systems advance agreement, a action through which CMS can force a displace affairs to get aback into compliance. It about costs a hospital at atomic $2 million. Afterwards the April meeting, Zucker’s aggregation never appear Young to a adjust center, and he charcoal at the hospital. Young’s sister, Andrea, did not appeal a DNR, and the aggregation alone discussed the advantage with her afterwards ProPublica’s commodity was published, she said.

The Centers for Medicare and Medicaid Services, the FBI, the New Jersey Department of Bloom and the Accompaniment Board of Medical Examiners are investigating the hospital’s assay of Young. The hospital has placed Zucker on leave awaiting the after-effects of its own review.

Newark Beth Israel and Zucker did not acknowledge to questions about his comments apropos a DNR for Young.


On June 1, 2018, Megan Jurtschenko went to appointment her ancestor at the adjust facility, but his allowance was empty. Afterwards actuality transported to Newark Beth Israel the antecedent day for a checkup, he hadn’t alternate to JFK Johnson.

Panicked, Megan affective an Uber to the hospital. There, she raced to the fourth floor, sneakers anguish adjoin the attic as she beelined for the cardiology unit. By that point, Andy had regained alertness and could sometimes nod yes or no, but he calmly became agitated, according to his children. Andy’s medical almanac from that day declared him as “non-verbal.”

Megan went to her father’s allowance aboriginal “to let him apperceive that he wasn’t alone” and again to the nurse’s station, area two physicians met her. She said they told her that her ancestor had a agitation aback he accustomed for his checkup, so they kept him brief and started a beforehand of antibiotics. The hospital doubtable pneumonia, according to his medical record.

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Nobody at the hospital had alleged Megan, Chris or anyone abroad in the ancestors to let them apperceive that Andy was actuality accepted or treated, his accouchement said. A few canicule later, a handwritten agenda in Andy’s medical almanac said that the ancestors was “upset” that they weren’t informed.

Megan said she angry to a abettor to ask, “What’s his cipher status?”

“Oh don’t worry, he is at abounding code,” the abettor responded, acceptation that if Andy chock-full animation or his affection stopped, they would do aggregate accessible to alleviate him.

Her words absorbed Megan to the floor.

“I said, ‘Oh, no, that is the complete adverse of what we want.’”

Newark Beth Israel didn’t acknowledge to questions about this incident.

Andy bare to break in the hospital until his infection cleared. That Friday, Megan banned to leave the hospital until she got a DNR order, so a cardiologist active one. “Extensive altercation with babe — Accommodating is DNR,” a agenda in the medical almanac states. The ancestors appointed a academic affair to altercate the adjustment on the afterward Monday with a booze affliction abettor practitioner and Zucker, the displace program’s director.

Chris was out of town, so Megan and her aunt, Anna DeMarinis, abounding the meeting. Megan reminded Zucker that her father’s goals for the displace had been to resume his accustomed life, she said. She common that the ancestors wasn’t allurement to abjure his agriculture tube or medications. They aloof didn’t appetite Andy to abide what they saw as amazing measures.

As Camacho had, Zucker apprenticed caution. “He looked at me and said: ‘You know, this is a actual austere document. It’s actual extreme. Are you abiding you appetite to do this?’” Megan recalled.

She wondered if Zucker was ambrosial to her emotions. “I got the consequence he anticipation I was activity to be the one who was activity to say, ‘No, I don’t appetite to lose my Dad, let’s accumulate trying!’”

Megan wasn’t swayed. “I could see what was absolutely happening, which is — he was adversity and that’s the alone affair I saw.” The booze affliction abettor practitioner at the affair revised and active Andy’s POLST form, advertence that Andy would abide abounding medical assay unless he chock-full animation or had no pulse. In the CPR section, she arrested the box for “Do not attack resuscitation.”

Even then, Zucker wouldn’t let it go. Afterwards abiding from his trip, Chris was sitting by his father’s bedside aback Zucker came by. Unprompted, Zucker brought up the DNR.

“He said, ‘So, you’re giving up on him,’” Chris recalled.

Chris didn’t respond. “I was shocked, for a doctor to bandy that in my face,” he said.

Newark Beth Israel and Zucker did not acknowledge to questions about the affair with Megan or Zucker’s chat with Chris. “Mr. Jurtschenko’s medical almanac confirms that his family’s accommodation to apparatus a DNR in June rather than in April did not change his outcome,” Kamateh said.


Andy Jurtschenko eventually alternate to JFK Johnson. Over the abutting few months, during which he was confused to a altered abiding affliction facility, Andy’s action bigger modestly, until he was able to clue bodies with his eyes and accept abbreviate conversations.

But his assets anon plateaued. He was never able to stand, sit or eat on his own. He started hallucinating, seeing bodies who weren’t there. Over time, his easily began to decline and coil in on themselves, admitting attempts at concrete therapy.

Andy’s ancestors associates took turns visiting, authoritative abiding he had aggregation about every day. Sitting by his side, they approved to appoint him by flipping through photo albums, arena music from his admired band, AC/DC, and watching sports on TV. They ached to see his misery. The atom in her adolescent brother’s eyes was gone, DeMarinis said. Holding aback tears, she said, “When he did become cogent, he aloof kept bombastic what we already knew — he was suffering. He was adversity terribly.”

On the morning of Oct. 31, 2018, the adjust ability phoned Chris. Andy had died at sunrise. Aback his affection stopped, and his animation faded, there was no attack to alleviate him.

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Claire Perlman and Sophie Chou contributed assay and assay to this article.

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