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. In this case, Cherry is the center of care, as she is the patient who is facing a life-threatening medical condition. Her best interests should take precedence because the primary goal of healthcare is to provide the best possible care and outcomes for the patient. However, the well-being and rights of all family members, including Merry, must also be considered.
2. Formal Ethical Decision-Making Process:a. Identify the Problem: The problem is whether to allow Merry to donate a kidney to Cherry, with the parents’ consent, given the potential risks, benefits, and implications of the transplant and surgery.

   b. Gather Information:

   • Assess Cherry’s medical condition and her need for a kidney transplant.
   • Evaluate Merry’s physical and emotional readiness to donate a kidney.
   • Consider the legal and ethical aspects of a minor donating an organ.
   • Assess the parents’ capacity to make an unbiased decision.
   • Evaluate the potential risks and benefits for both Cherry and Merry.
   • Explore alternatives to kidney donation, such as waiting for a suitable donor.

   c. Identify Stakeholders:

   • Cherry
   • Merry
   • Parents
   • Healthcare team
   • Social worker
   • Psychologist
   • Ethicist

   d. Explore Alternatives: Alternative 1: Proceed with the kidney donation, with the parents’ consent, after thorough education and assessment of risks and benefits. Alternative 2: Explore other potential kidney donors, including extended family or the organ transplant waiting list, while continuing Cherry’s dialysis treatment.

   e. Make a Decision: The decision should involve a consensus among the healthcare team, taking into consideration the best interests of Cherry, the ethical principles of beneficence (doing what is best for the patient), autonomy (respecting the patient’s and Merry’s choices), and non-maleficence (avoiding harm). The decision should also ensure that Merry’s consent is not coerced and that the parents understand the risks and benefits.

   f. Implement the Decision: If the decision is to proceed with kidney donation, ensure that all necessary steps are taken, including obtaining informed consent from the parents, assessing Merry’s medical and emotional readiness, and providing appropriate counseling and support.

   g. Evaluate the Decision: Continuously monitor the progress and well-being of both Cherry and Merry. Assess whether the decision made leads to positive outcomes and make adjustments if necessary.

3. Role Play: In a role-play scenario, various healthcare team members can take on different roles to discuss the case, ensuring that all perspectives are considered:
   • Cherry (patient)
   • Merry (sister)
   • Parents
   • Trauma physician
   • Nephrologist
   • Primary nurse
   • Social worker
   • Psychologist
   • Ethicist
   • Transplant nurse
4. The solution that demonstrates acting with high ethical standards is one that prioritizes the best interests and autonomy of both Cherry and Merry, while also considering the potential risks and benefits. This involves:
   • Ensuring that Merry’s consent is not coerced and that she fully understands the implications of kidney donation.
   • Providing comprehensive education and counseling to the parents, Cherry, and Merry about the risks, benefits, and alternatives.
   • Continuously assessing Merry’s physical and emotional readiness for donation.
   • Making the final decision based on a consensus among the healthcare team members, taking into account the ethical principles of beneficence, autonomy, and non-maleficence.
   • Ensuring ongoing support and follow-up care for both Cherry and Merry, regardless of the decision made.

This approach respects the autonomy and well-being of all involved parties while prioritizing the best possible outcome for Cherry’s medical condition.