A young boy needs a heart transplant but doesn't seem to want it, and his treatment causes Burke and Yang to have philosophical differences. Meanwhile, when the interns rally to help Alex prepare to re-take his exam, Meredith has to remind Izzie of the true spirit of the Christmas holiday; and despite a reconciliation with his wife, Derek isn't in a festive mood.
David finally embraces his demons. Brenda delivers early and fights Nate's negativity. Margaret is impressed to see Olivier's nurturing side. Rico and Vanessa celebrate an investment. Claire's departure reveals what's to come for those she loves and herself.
Ruth is delighted when her sister Sarah visits but she brings bad news with her. David and Keith begin experiencing difficulties on how to discipline their new foster children. Elsewhere, Nate muses on the loss of his first love and Vanessa hires a nanny.
When David attempts to make a bid on a crematorium, Federico refuses and pushes for another employee. Brenda receives information from her doctor & Nate begins attending Quaker services with Maggie, to the chagrin of Brenda. Meanwhile, Ruth sees her ex-boyfriend Hiram.
Nate's funeral divides the family. David deals with being left in charge of the family business, while Keith makes an embarrassing discovery on the job. At the same time, Brenda is challenged by Nate and makes a painful decision about what to do with Maya.