Trauma and Transplant

Case Study: Trauma and Transplant

Cherry and Merry Richards were 12-year-old identical twin sisters. Tragically, on the way home from school, the car in which they were riding (driven by their mother) was hit by a car driven by a drunk driver. Cherry sustained severe trauma as a result of the motor vehicle crash, while Merry sustained only minor injuries. Cherry was hospitalized in the pediatric trauma unit for several weeks. She sustained kidney damage, and her kidneys shut down. She required dialysis treatments three times a week. She slowly began to recover, and it became clear that she would need to have dialysis for the rest of her life unless she received a kidney transplant. Cherry had a rare blood type, and Mr. and Mrs. Richards were told by the trauma team that it would probably be quite some time before a kidney became available. In the meantime, Cherry would continue dialysis three times a week, along with physical and occupational therapy. A dietician was part of Cherry’s interprofessional team to counsel the patient and family on dietary restrictions related to her renal (kidney) condition and dialysis. The plan was to eventually transfer Cherry to a pediatric rehabilitation hospital, where tutoring would begin so that she could keep up with her schoolwork.

Cherry and Merry were very close. Merry visited Cherry almost daily. She repeatedly expressed her wish to help Cherry in any way possible and couldn’t understand why this happened to her sister while she was spared. When she told this to Cherry’s nurse, the nurse consulted the team, and it was suggested that the girls receive psychiatric assessments. The Richards agreed, and after the assessment, the psychiatrist recommended individual counseling for each of the girls in combination with family counseling. A counseling social worker was brought into the team. Cherry told her they were waiting for a match before she could get a kidney. Together, the girls looked up information on the Internet and formed the idea that Merry would probably be a good match for a kidney. Merry said she would gladly give Cherry a kidney. The girls approached the parents with their idea, and the Richards’ agreed to discuss the idea with Cherry’s healthcare team. They approached the nephrologist (kidney specialist) with Merry’s offer to donate a kidney to her sister.

At this point in her care, Cherry’s team consisted of her family, trauma physician, nephrologist, primary nurse, dietician, social worker, psychologist, occupational therapist, physical therapist, and transplant nurse. The team met to discuss Cherry’s plan of care and progress, and the nephrologist presented the idea of having Merry donate a kidney. Several issues were discussed. First, Merry is a minor and cannot give legal consent, although her parents could give their consent. Some members of the team feel that this is acceptable, but others do not think that the parents are able to make an unbiased decision in this case. Merry will be left with only one kidney for the rest of her life, which she may later regret. Second, the surgical procedure presents a risk to Merry, with the only benefit being her contribution to her sister. Third, there is the chance that the kidney will be rejected anyway, which may cause psychological harm to both sisters and the parents. The team is faced with the difficult decision regarding whether to allow Merry to donate a kidney to Cherry, with the parents’ consent, after all members of the family are educated on the risks, benefits, and implications of the transplant and surgery.

Discussion Questions

1. Who is the center of care in this case? Whose best interests take precedence? Why?
2. Use a formal ethical decision-making process to work through this case. Determine at least two alternative solutions.
3. Role play with others as various members of the healthcare team, including the patient and family.
4. What solution by the team demonstrates acting with high ethical standards? Explain your answer and why this is the best ethical alternative.

1. The center of care in this case is Cherry, the 12-year-old twin sister who sustained severe trauma in a car accident, resulting in kidney damage and the need for a kidney transplant. Cherry’s best interests should take precedence as she is the patient in need of medical intervention and her health and well-being should be the primary concern. However, the well-being and best interests of Merry, the twin sister, are also important, as she is willing to donate a kidney, and her safety and psychological well-being should be considered as well.
2. Ethical Decision-Making Process: a. Alternative Solution 1: Allow Merry to Donate a Kidney with Parental Consent
   • Pros: This option respects Merry’s autonomy and her willingness to help her sister. It could potentially save Cherry’s life, improve her quality of life, and reduce her need for dialysis.
   • Cons: Merry is a minor, and there may be concerns about her ability to fully understand the risks and consequences of kidney donation. There are also potential long-term physical and psychological risks to Merry.

   b. Alternative Solution 2: Wait for a Deceased Donor Kidney for Cherry

   • Pros: This option eliminates the risks associated with live kidney donation by a minor. It ensures that both Cherry and Merry receive appropriate medical care without compromising Merry’s long-term health.
   • Cons: Waiting for a deceased donor kidney may take a long time, and Cherry would need to continue dialysis, which can have its own set of risks and challenges. There’s no guarantee of finding a suitable donor kidney in the near future.
3. Role Play:
   • In a role-play scenario, various members of the healthcare team, including the trauma physician, nephrologist, primary nurse, dietician, social worker, psychologist, occupational therapist, physical therapist, and transplant nurse, along with the patient and family, should engage in a discussion to share their perspectives on the situation. Each member should consider their professional ethics and responsibilities in the decision-making process.
4. The best ethical alternative would be to pursue Alternative Solution 2: Wait for a Deceased Donor Kidney for Cherry. This solution prioritizes the long-term well-being and rights of both Cherry and Merry while minimizing the risks associated with live kidney donation by a minor.

Explanation:

• Respecting the autonomy of a minor like Merry is important, but in this case, there are valid concerns about her ability to fully comprehend the risks and consequences of kidney donation. The team has a duty to protect Merry’s well-being.
• Waiting for a deceased donor kidney for Cherry is a more cautious approach that avoids potential harm to Merry and ensures that both sisters receive appropriate medical care. It also eliminates the need for the parents to make a difficult decision that may be influenced by their emotional attachment to both children.
• The team demonstrates acting with high ethical standards by prioritizing the well-being, safety, and rights of all individuals involved, including both Cherry and Merry, while taking into account the potential long-term physical and psychological risks. This approach aligns with the principle of beneficence, non-maleficence, and respect for autonomy in medical ethics. Additionally, the team should provide ongoing support, counseling, and education to both Cherry and Merry throughout the waiting period.