Abstract Introduction Donation after circulatory death (DCD) is increasingly common, with 7,280 U.S. donors in 2024.1 While this growth expands transplant opportunities, it also complicates end-of-life care. When care shifts toward comfort, late identification of first-person authorization (FPA) can disrupt plans and distress families and providers. We describe a case when FPA was discovered hours before a planned palliative extubation, prompting a shift to DCD. Case Presentation A 63-year-old man with heart failure, asthma, and cocaine use disorder presented after cardiac arrest following toxic ingestion. Neuron-specific enolase peaked at 55.5 µg/L, and MRI showed diffuse anoxic brain injury. On hospital day 5, Neurology advised that meaningful recovery was unlikely, though he did not meet brain death criteria. The family shared that he valued independence and would decline long-term institutional care. Palliative extubation was planned for day 6 when relatives could be present. Hours before extubation, the organ procurement organization (OPO) identified him as a registered first-person donor, previously unknown to the family. The family consented to DCD, prompting re-escalation of care until extubation on day 9. After death, his liver and kidneys were procured. Discussion Late discovery of FPA after planned comfort-focused care in a DCD candidate exposed ethical ambiguity and required transparent communication through an unexpected shift in the patient’s final days. Although not unique to DCD, late identification is especially complex when donation requires premortem interventions that diverge from comfort-focused goals, creating moral distress among providers and families navigating competing demands. While FPA is legally binding, its implications before death and during transition to comfort care remain uncertain. For this family, like many others, donation was meaningful. However, when the expectation of a peaceful death surrounded by loved ones changes to accommodate invasive procedures, even well-intentioned care can feel misaligned. When families are unaware of donor registration, uncertainty may arise over whether a driver’s license opt-in demonstrates consent for interventions that alter dying or supersede other end-of-life preferences. This case prompted protocol revisions to improve timely donor identification. Further strategies may include embedding registry verification within the medical record and integrating donation discussions into advance care planning. Earlier, nuanced documentation of preferences, along with clearer FPA guidelines, could mitigate moral injury in critical care. As DCD expands, systems must bridge the space between donation logistics and how patients and families envision and experience dying. References 1. OPTN. Organ transplants exceeded 48,000 in 2024. Published online January 15, 2025. https://optn.transplant.hrsa.gov/news/organ-transplants-exceeded-48-000-in-2024-a-33-percent-increase-from-the-transplants-performed-in-2023/ This abstract is funded by: None
Vossler et al. (Fri,) studied this question.