The Living Donor Who Wants to Back Out
A 34-year-old man, Mr. K, is cleared as a living kidney donor for his older sister. Workup is complete and surgery is scheduled in 10 days. During a routine pre-op call he tells the nurse, 'Honestly, I'm only doing this because my mother will never forgive me if I don't. I don't want to. But I can't say that to my family.' He asks the nurse not to tell anyone, saying it would 'blow up the family.' His sister's dialysis access is failing and she is symptomatic. The nurse is unsure what confidentiality applies to a donor evaluation.
1. What are the nurse's obligations regarding the patient's request for secrecy, and what is the correct immediate action?
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Core principle: Living donation must be voluntary and free of coercion. A donor who is donating to avoid family conflict is not giving valid informed consent, and proceeding risks psychological harm and resentment.
On confidentiality: The donor is the nurse's patient. His disclosures are protected, but the request to 'tell no one' cannot bind the team when it bears directly on the validity of consent for an imminent operation. The correct path is not to promise silence, and not to broadcast to the family.
Immediate action:
- Tell Mr. K honestly that this information must go to the transplant team because it affects whether he can consent - but that it will be shared only with those who need it (donor advocate, surgeon, coordinator), not his family.
- Escalate to the independent living donor advocate (ILDA), whose role exists precisely to protect the donor's interests separately from the recipient's.
- Pause the scheduled surgery pending a confidential donor reassessment.
Do not: proceed because the recipient is deteriorating, or disclose to the mother/sister.
2. The family pressures the team, saying the sister 'will die' without the kidney. How should the team respond, and how is the recipient protected?
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Response to family: The team should not debate the donor's private reasons. A neutral statement works: 'We are completing final donor safety checks; surgery may be rescheduled.' Recipient urgency is a real clinical fact but it is not a reason to override donor voluntariness. A coerced donation is not a rescue; it is a harm to one patient to benefit another without valid consent.
Protecting the recipient:
- Reactivate/expedite her on the deceased-donor list; address access and symptoms.
- Explore whether another donor exists.
- If she is unstable, pursue urgent medical management of access failure.
Protecting the donor: Offer a face-saving 'medical disqualification' if he wishes - a legitimate way to preserve family relationships without lying to the team. Document that consent was withdrawn voluntarily. The ILDA and psychosocial team should follow up afterward.