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
- Who is the center of care in this case? Whose best interests take precedence? Why?
- Use a formal ethical decision-making process to work through this case. Determine at least two alternative solutions.
- Role play with others as various members of the healthcare team, including the patient and family.
- What solution by the team demonstrates acting with high ethical standards? Explain your answer and why this is the best ethical alternative.
- In this case, Cherry is the center of care as she is the patient who has sustained severe trauma, kidney damage, and is in need of a kidney transplant. However, the best interests of both Cherry and Merry should take precedence since they are twin sisters with a close bond, and Merry has expressed a strong desire to help her sister. The well-being of both sisters should be considered when making decisions.
- Formal Ethical Decision-Making Process: a. Alternative Solution 1: Allow Merry to Donate a Kidney
- Pros:
- Merry’s willingness to donate demonstrates a strong bond and love between the sisters.
- Cherry’s chances of receiving a compatible kidney increase, potentially improving her overall health and quality of life.
- This option respects the autonomy and wishes of both sisters.
- Cons:
- Merry is a minor, and her ability to provide informed consent is limited. Her parents would have to provide consent on her behalf.
- There are surgical risks involved for Merry, with no direct medical benefit to her.
- There is a risk of kidney rejection, which may have psychological consequences for both sisters and their parents.
b. Alternative Solution 2: Wait for a Matched Donor
- Pros:
- Waiting for a matched donor minimizes the surgical risks to Merry.
- There is no risk of kidney rejection if a matched donor is found.
- Merry can maintain her health without undergoing an unnecessary procedure.
- Cons:
- Cherry may have to continue with dialysis, which can be physically and emotionally taxing.
- There is uncertainty about how long it will take to find a suitable donor given Cherry’s rare blood type.
- Merry’s strong desire to help her sister may remain unfulfilled, potentially affecting her emotional well-being.
- Pros:
- Role play with healthcare team members:
- Trauma physician: Discusses the medical aspects and risks involved in the transplant.
- Nephrologist: Explains the importance of a kidney transplant for Cherry and the potential benefits of Merry donating.
- Primary nurse: Addresses the emotional and physical needs of Cherry and the potential impact of the transplant on her recovery.
- Social worker: Assists in facilitating family counseling and assessing the family dynamics.
- Psychologist: Provides individual counseling for Cherry and Merry to address their emotional concerns.
- Transplant nurse: Discusses the transplant procedure and its risks with the family.
- The ethical solution that demonstrates acting with high ethical standards is to carefully consider Alternative Solution 1, allowing Merry to donate a kidney, with the parents’ informed consent and after a thorough evaluation of the risks and benefits. This option respects the autonomy and wishes of both sisters, who have a strong emotional bond. To ensure ethical standards are met, the healthcare team should:
- Conduct a comprehensive assessment of Merry’s physical and emotional well-being.
- Ensure that the parents fully understand the risks and implications of the transplant and provide informed consent on behalf of Merry.
- Involve an independent ethics committee or consult with ethicists to ensure a balanced and unbiased decision.
- Continuously monitor and support the emotional and psychological well-being of both sisters and the family throughout the process.
- Be prepared to respect Merry’s decision if, after thorough counseling, she chooses not to donate her kidney.