Case Studies
Case studies showcase real-world applications of policies and innovations, offering insights into improving outcomes and efficiency. They enhance problem-solving skills, highlight best practices, and engage through storytelling for education and transparency.
Interest(s): , Donation after Circulatory Death (DCD), Donor Designation / First-Person Authorization (FPA), Family Care, Hospital Donation Process & Education, Legal and Regulatory
Organ(s): Eye, Heart, Intestine, Islet Cells, Kidney, Liver, Lung, Pancreas, Small Bowel, Tissue, Vascularized Composite Allograft (VCA)
Patient Group(s): Adult
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Contested First Person Authorization-BD
Christie
Ryan
, DNP,RN
, Director, Professional Services
, Center for Organ Recovery and Education
The Challenge
The decedent, a registered nurse and organ donor, had recently updated her driver’s license to affirm her decision to be an organ donor. Following her brain death pronouncement after an overdose, the OPO approached her husband regarding donation. He immediately objected, citing religious beliefs. His objections were rooted in the belief that his wife’s recent conversion to Islam, and their private conversations, superseded her documented legal decision to be a donor. He stated the organ donor designation was made before her religious conversion and claimed she had changed her wishes.
The husband presented multiple interpersonal and logistical challenges: he refused to speak with women, denied access to male staff he disapproved of, and escalated tensions by bringing in extended family and making threats. Despite her documented First-Person Authorization (FPA), the situation became ethically and operationally complex due to the husband’s persistent and escalating opposition.
The Approach
The OPO team began by respectfully explaining the legal authority of First-Person Authorization and how donation aligns with most major religious beliefs, including interpretations of the Quran that support organ donation. When the husband remained adamant, the team investigated further and confirmed the patient had recently renewed her license and again affirmed her donor status post-conversion.
With continued refusal and heightened tensions, the Professional Services Director (PSD) was dispatched to coordinate with hospital leadership and provide strategic support. A meeting was held involving the CEO, CMO, CNO, and hospital legal counsel to determine the best course of action. Legal review confirmed that honoring the FPA was supported by state gift law. The hospital and OPO collaboratively agreed to move forward with the donation.
A male attending physician, accompanied by hospital legal counsel, re-engaged the husband to outline the legal and ethical framework supporting the patient’s choice. Simultaneously, the hospital and OPO teams offered comprehensive support: engaging palliative care, ethics consultation, and involving other family members—who were supportive of donation.
Despite threats and family unrest initiated by the husband, the hospital and OPO teams remained aligned. Security and leadership maintained a safe and supportive environment for staff and other family members
The Results
In this case, the patient’s documented wishes were honored, and she became an organ donor. The hospital and OPO worked together to present a unified, consistent, and legally sound approach throughout the process. De-escalation strategies, including the involvement of palliative care and ethics consultations, helped create a more peaceful resolution during a challenging time. Ultimately, the patient’s husband came to accept that both the hospital and OPO were committed to respecting and carrying out his wife’s legal and ethical choice.
Insights & Lessons Learned
This case highlights the importance of a unified team response, where early and clear coordination between hospital leadership, legal, ethics, and the OPO proved critical when facing contested authorizations. Respectful yet firm communication was also essential, with consistent messaging delivered by carefully chosen messengers—in this instance, a male physician—to help navigate cultural or religious sensitivities. Documentation played a central role as well, with verification of the most recent donor designation serving to affirm legal authority and uphold ethical integrity. Anticipating family dynamics and preparing for possible escalations was equally important, and the early involvement of palliative care and ethics teams provided valuable support in managing distress for both the family and hospital staff. Throughout the process, legal and ethical clarity remained the foundation, as reinforcing that First-Person Authorization (FPA) is legally binding guided decision-making, even in the face of strong opposition.