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CF is a 23-year-old recent college graduate who is eagerly awaiting a job opportunity. In the interim, he has been working as a delivery driver to support himself and pay off his student loans. As the oldest of three siblings (ages 21 and 19), CF is known for his vibrant personality, love for the outdoors, and active lifestyle. He played on his college volleyball team and had a passion for dancing.

Tragically, CF was involved in a severe motor vehicle accident while on duty as a delivery driver. A driver ran a red light and collided with CF’s vehicle, resulting in significant trauma. Emergency Medical Technicians (EMTs) arrived on the scene to find CF in asystolic cardiac arrest. Due to the extensive damage to his vehicle, the fire department had to extricate him by cutting open the car doors, leading to a prolonged extrication process. CF experienced a total downtime of 45 minutes during which he was intubated on the scene to secure his airway.

CF was transported to the Emergency Department (ED), where the medical team stabilized him hemodynamically before transferring him to the Neurologic Critical Care Unit (NCCU). A head CT scan revealed a significant midline shift and severe traumatic brain injury (TBI). To prevent secondary brain injury, the NCCU team induced a coma, but after two weeks, when sedation was stopped, CF showed no purposeful movements or responses to stimuli. Neurological assessments indicated a very low level of brain activity, with imaging confirming extensive brain damage. He remains fully dependent on life-sustaining treatments, including mechanical ventilation and medications, with a grave prognosis for meaningful recovery.

The medical team, consisting of neurologists, neurosurgeons, and critical care specialists, have closely monitored his condition. After thorough evaluations, the medical team has concluded that Mr. CF’s neurological injuries are severe and irreversible. They have determined that further aggressive medical interventions, including life-sustaining treatments, would be unlikely to lead to any improvement in his condition. The clinicians feel that his injuries are incompatible with a meaningful quality of life. The medical team met with the family and initiated goals of care conversations, including the possibility of compassionate extubation as part of end-of-life care options.

At the meeting, a large family (including parents, grandparents, uncles, aunts, siblings, cousins, and friends) was present, with the parents serving as the legally authorized decision-makers. His family appears to understand the grave prognosis, and knowing the patient’s preferences, lifestyle, and values, they opt to withdraw life-sustaining treatments. They rely on their faith to make this decision, and they do not wish their loved one to be in pain or suffering. Per the Protocols, Infinite Legacy (IL), the organ procurement organization (OPO), is introduced to the family to discuss organ donation as an end-of-life option. The Family Services Coordinator (FSC) from IL meets with the family and approaches them for organ donation. The FSC discloses to the family that the patient was a designated donor as per his driver’s license and it serves as the first person authorization (FPA). It is further explained that it is the time for family to honor patient’s expressed wishes through FPA, and the OPO does not require any consent.

The family is in shock. His father feels it is his fault that he had influenced his son to say yes to the organ donation question at MVA and registered him as donor. The family’s reaction, their opposition to donation after circulatory death (DCD) stems from their understanding of organ donation occurring only after brain death. While they were generally supportive of organ donation, they assumed it would happen postmortem- meaning after a clear declaration of death, not while the patient is still being supported by life-sustaining treatments. This distinction has caused confusion and distress, especially as the family now faces the reality of organ donation while their loved one is still exhibiting bodily signs of life, such as breathing over the ventilator, pupillary movements, slight coughing, and withdrawal to pain. This raises profound religious and ethical dilemmas for the family, as they perceive their decision to withdraw life-sustaining treatments as potentially terminating life in order to give life to someone else. Furthermore, it forces them to question what true comfort, peace, and meaningful closure for their son would look like in this situation. They also believed that the patient’s designation would only take effect upon or after death and they feel that their legal rights have been undermined. Additionally, they are distraught with the fact that it might take 3 to 4 days for compassionate extubation to occur in an operating room with limited number of family members present. Moreover, the patient’s bodily functions will be supported during that time, and the family is petrified that this will prolong suffering of pain for the patient and family.

Learning Goals and Objectives

• Describe First Person Authorization (FPA) for organ donation
• Review the guidelines of the Uniform Anatomical Gift Act
• Discuss communication strategies used by organ procurement organizations to discuss organ donation with families
• Describe ways in which conflicts can be resolved when organ donation by FPA is being considered

Questions

1. What is First Person Authorization (FPA), and how does it apply in cases of Donation after Circulatory Death (DCD)? How does FPA influence the consent process and decision-making for organ donation in these cases?
2. What is the Uniform Anatomical Gift Act (UAGA), and how is it defined within the Maryland Statutes? How does this legislation guide the process of making anatomical gifts in Maryland?
3. What are the best practices for addressing family opposition to First Person Authorization (FPA) in DCD organ donation cases? How can healthcare teams effectively educate and support emotionally distraught families while also managing the moral distress experienced by the care team involved in these challenging scenarios?
4. How can medical teams effectively navigate and communicate with families who feel vulnerable or angry about a perceived loss of their decision-making rights, especially when organ procurement organizations are involved in complex situations? What strategies can be employed to address concerns about potential conflicts of interest while respecting both legal boundaries and family autonomy?
5. Is it morally, ethically, and legally permissible to administer medications, such as anticoagulants, to a potential Donation after Circulatory Death (DCD) donor prior to death? What are the requirements for Organ Procurement Organizations (OPOs) regarding formal consent for these medications, and how is ‘informed consent’ defined, obtained, and enforced in this context?
6. Do families have the right to rescind their decision to withdraw life-sustaining treatments after being informed about First Person Authorization (FPA) guidelines? What ethical challenges do Organ Procurement Organizations (OPOs) and care teams face if the family insists on pursuing tracheostomy, percutaneous endoscopic gastrostomy (PEG), or transferring the patient to long-term care or hospice?