They tried to hire new surgeons. They crafted a marketing campaign to attract new patients. They begged regulators for more time. They sidelined people who complained and looked past doctors' egos and what Hoefs described as their "peculiar behaviors." They hung on by persuading two doctors from UC San Diego to work part-time.
All the while, they kept adding patients to the waiting list -- until this week.
In pulling the program's certification Thursday, the U.S. Centers for Medicare and Medicaid Services said that not enough transplants were being performed to maintain proficiency. The few patients who received new livers were dying at an unacceptable rate.
Dr. Ralph Cygan, UCI Medical Center's chief executive, insisted that the university placed the patients' best interests first. But he acknowledged that he would have acted differently had he known the problems would take so long to fix. "I would have insisted that we would have closed the program until we were in a better position," he said.
But now, families of patients who died are left to wonder whether those lives might have been saved.
Audrey Degenhardt said her husband, Geoffrey, had been told that the greatest obstacle to his receiving a transplant was a lack of donated livers in Southern California.
Still, she said, "he was so optimistic. He always thought he was going to get one."
Geoffrey Degenhardt, a warehouse manager who had hepatitis C, never left home without the pager the hospital had given him.
The pager never beeped. He died April 3, 2004, at the age of 51.
"Maybe it's a good thing he's not here to see this," Audrey Degenhardt said. "How insane is that, to turn down livers? How many people have died because of them not having a doctor on duty?"
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When UCI Medical Center opened its liver transplant program in 1993, the campus saw it as having great potential.
The surgery was becoming increasingly common, and Orange County was an ideal market, with a large population of patients with hepatitis C, a leading cause of liver failure.
At first, the program was run as a satellite to the UCLA liver transplant program, with Dr. David Imagawa in charge. Surgeons performed 105 transplants in the first seven years, surpassing the federal minimum of 12 per year.
In early 2000, the program had three full-time surgeons. But one soon left, and the following year, Imagawa suffered a heart attack. He returned to work but stopped performing transplants.
