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): , Brain Death / Death by Neurologic Criteria, Donation after Circulatory Death (DCD), Donor Designation / First-Person Authorization (FPA), Ethics, Family Care, Hospital Donation Process & Education, Legal and Regulatory, , Tissue Donation
Organ(s): Eye, Heart, Intestine, Islet Cells, Kidney, Liver, Lung, Pancreas, Small Bowel, Tissue
Patient Group(s): Adult
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Versiti Supports Families Through Complex Decisions Even Amid Legal Challenges
Bailey
Heiting
, MBA, BSN, RN, CPTC
, Manager of Organ Donation
, Versiti Organ and Tissue Donation
The Challenge
In 2019, Versiti encountered a challenging First Person Authorization (FPA) case involving a patient who had registered their decision to donate via Power of Attorney (POA) documentation. Initially, the legal next of kin expressed support for organ donation; however, shortly afterward, they reversed their position and opposed honoring the donor’s documented wishes. Despite multiple conversations and attempts to address the family’s concerns, opposition remained firm. At that time, Versiti did not have a formal, standardized process for managing FPA cases involving family opposition. Nevertheless, the team made concerted efforts to proceed, including leadership going on-site to support staff, and engaging in three days of discussions with the healthcare team, hospital C-suite leaders, Versiti leadership, and the family. Despite these efforts, the hospital ultimately chose to honor the family’s wishes rather than the donor’s legally documented intent. As a result, donation did not proceed.
The Approach
This case presented multiple complex challenges for Versiti and the hospital team. One significant challenge was the emotional toll on the healthcare team, who had cared for the patient over several days. As the organ procurement team continued to pursue First Person Authorization (FPA), some healthcare providers expressed frustration and internal conflict, feeling caught between the family’s wishes and the donor’s documented intent. Additionally, engaging with the family proved difficult, as emotions were high and they expressed concerns about potential legal repercussions if they continued to oppose donation. This was a new and sensitive dynamic that required careful navigation.
The situation also exposed organizational gaps. At the time, Versiti lacked a formalized process for managing FPA cases involving family opposition, which hindered coordination between the OPO and the hospital. There was also initial internal hesitation within Versiti to fully support Donation after Circulatory Death (DCD) in the context of FPA, particularly when dealing with opposition. This highlighted a need to revisit and clearly define how DCD and brain death cases should be approached under FPA scenarios.
Finally, the emotional burden on the on-site Versiti team was considerable. These highly charged situations place front-line staff in the center of emotionally intense reactions from both the family and healthcare providers. Ensuring team members had the necessary emotional support and resources became a clear priority during and after this case.
The Results
Following the case, Versiti conducted immediate debriefs with the care team, hospital staff, and internal organizational leadership. Through those discussions, there was a clear and collective realization that the organization should have moved forward in honoring the donor’s First Person Authorization (FPA). This acknowledgment became a catalyst for change. A dedicated work group was formed to develop a formal, collaborative process for managing future FPA opposition cases. This effort was seen as a positive and necessary step toward preventing similar breakdowns in the future.
From an internal standpoint, it was critical to engage leadership at all levels, particularly Versiti’s legal counsel. The legal team played a pivotal role in the process, becoming well-versed in state statutes and emerging as strong advocates for FPA cases. Their involvement was essential in shaping the new approach and empowering frontline teams through education. One standout effort was a “Legal Ask Me Anything” session designed to inform and support staff, helping them feel confident and capable of speaking to FPA with hospital partners underpinned by a clear legal foundation.
On the hospital side, the development of the new process required collaboration with C-suite leadership, legal, and risk management. These stakeholders had been deeply involved during the original case and were instrumental in the formation of a unified, forward-looking policy. Both organizations ultimately committed to supporting First Person Authorization across all applicable cases—including brain death and Donation after Circulatory Death (DCD). This alignment was formalized in the creation of a structured decision-making algorithm, ensuring consistency and mutual support moving forward. The algorithm includes notification of all stakeholders from both Versiti and the hospital, including clinical, legal, risk, administration, security, and public relations. The outcome of this case, while difficult, resulted in a transformative and collaborative approach to honoring donors’ legally documented decisions with integrity and confidence.
Insights & Lessons Learned
This case highlighted several key takeaways that have since informed how Versiti approaches FPA opposition. First and foremost was the importance of securing organizational and hospital support before cases arise. Attempting to resolve disagreements or escalate support in the heat of a live case—often occurring during weekends, holidays, or night shifts when key decision-makers may not be readily available—adds significant complexity. Early alignment ensures a united response when tensions, emotions, and risks are high, including concerns about legal action, media involvement, or safety. One of the most impactful changes stemming from this case was the clear organizational commitment that all brain death and DCD donors with First Person Authorization would be supported 100% of the time, without backtracking based on opposition.
Another critical takeaway was the engagement of legal counsel and the emotional support of on-site teams. Versiti’s legal team became deeply familiar with state statutes and now plays a key role in opposition cases, providing education and advocacy. Similarly, staffing protocols were updated to ensure leadership or the administrator on call (AOC) is physically present for any opposition case. This on-site support has been instrumental in helping frontline staff manage emotionally charged interactions and navigate complex dynamics with families and hospital teams.
Consistency across cases and health systems also emerged as an essential theme. To support this, Versiti created an FPA opposition algorithm—a structured phone tree and notification plan—to guide communication, escalation, and decision-making in real time. This approach was tailored to each health system, recognizing that internal roles and processes may vary. Rollout included collaboration with hospital development teams to secure buy-in, train staff, and foster clarity. Additionally, early conversations with families now emphasize the donor’s decision with confident, compassionate language to avoid inadvertently inviting opposition. Training staff with these clear talking points has helped mitigate confusion and reduce the likelihood of conflict from the outset.