How do I discuss organ donation and assess eligibility (brain‑death or circulatory‑death criteria) for an adult terminally ill patient with advanced heart failure, metastatic cancer, or severe neurologic injury while keeping end‑of‑life care decisions separate?

Discussing Organ Donation and Assessing Eligibility in Terminally Ill Adults

Always discuss withdrawal of life-sustaining treatment and end-of-life care decisions with the patient or family first, and only after they have accepted the futility of continued support and inevitability of death should you introduce organ donation as a separate conversation. 1, 2

Critical Sequencing: The Governing Principle

The American Thoracic Society, Society of Critical Care Medicine, and International Society for Heart and Lung Transplantation establish a clear hierarchy: discussions about withdrawing or limiting life-sustaining therapy must occur before any mention of organ donation. 1 This separation is required in 89% of pediatric hospital policies and should be adopted universally. 1

Why This Sequence Matters

• Decoupling these conversations is not just ethical—it actually improves consent rates while maintaining integrity of the end-of-life care process. 2
• Families must first fully accept that death is inevitable before they can meaningfully consider donation options. 2
• Introducing donation prematurely creates the perception that the medical team is prioritizing organ procurement over the patient's care, which damages trust and reduces consent. 2

Step 1: Initiate End-of-Life Discussions Early

Begin frank, open discussions about prognosis and the high likelihood of death at the time of ICU or ED admission—not when withdrawal is being considered. 2

Key Communication Points

• Use a shared decision-making model that avoids both paternalism and placing the entire burden on families during extreme stress. 2
• For patients with advanced heart failure, metastatic cancer, or severe neurologic injury, address realistic outcomes and treatment limitations early in the hospital course. 2
• Ensure families understand the futility of continued organ support before any other discussions occur. 2

Step 2: Notify the Organ Procurement Organization (OPO) Early

Contact the OPO within 1 hour of identifying an impending death or decision to withdraw life-sustaining therapy. 1

Why Early Notification Is Essential

• Early OPO notification increases time to evaluate medical suitability for donation and improves consent quality. 1
• This allows the OPO and hospital team to collaboratively develop a family communication plan on a case-by-case basis. 1
• Critical caveat: Early OPO notification does NOT mean early family discussion—the family conversation about donation still occurs only after end-of-life decisions are finalized. 1

Step 3: Assess Eligibility Criteria

Brain Death (Donation After Brain Death - DBD)

For patients meeting neurological criteria for death:

• Brain-dead donors are legally deceased and require no family consent beyond what the patient documented (first-person consent). 1
• However, families still require consent for withdrawal of life-sustaining therapy even when first-person consent exists. 1
• Only discuss donation after brain death has been confirmed using standardized, auditable criteria. 2

Donation After Circulatory Death (DCD)

For patients who do not meet brain death criteria but have catastrophic injuries:

Eligibility considerations for DCD:

• Patient must have a decision to withdraw life support that is independent of donation considerations. 1
• Death must be expected to occur within a timeframe compatible with organ viability (typically within 90 minutes of withdrawal). 3
• Patient must be in an ICU setting with capability to provide expert palliative care during withdrawal. 1

Absolute contraindications to consider:

• Active malignancy with high metastatic potential (metastatic cancer patients are generally excluded). 1
• Severe infections that could transmit to recipients. 1
• Prolonged warm ischemia time anticipated. 1

Step 4: The Organ Donation Discussion

Only after the family has accepted the decision to withdraw life support should donation be introduced as a separate topic. 1, 2

Who Should Lead This Discussion

• Either an OPO representative or a hospital "designated requestor" who has completed OPO-approved training must obtain consent. 1
• These individuals must clearly disclose their organizational affiliation and role in the donation process. 1
• The transplant team should never be involved in brain death determination or withdrawal decisions—this represents a conflict of interest. 4

Essential Information to Provide Families

For DCD specifically, families must understand:

• Death may occur quickly after treatment withdrawal, leaving limited time with their loved one if donation proceeds. 2
• Conversely, if death does not occur within the required timeframe (typically 90 minutes), organ donation may not be possible, though tissue donation may remain an option. 2, 3
• Cannulation and perfusion procedures will occur after death is certified. 2
• Death certification requires: absence of cardiac output and respiration, lack of response to supraorbital pressure, absence of pupillary and corneal reflexes, confirmed after a minimum standoff time of 2-5 minutes. 1, 2
• No interventions to facilitate donation (such as heparin administration) occur until after death is certified. 2
• They can withdraw consent at any stage without providing a reason. 2
• The coroner may refuse permission, and transplantation may not be possible even after organ retrieval. 2

Honoring First-Person Consent

If the patient documented first-person consent (DMV registry, online registry, durable power of attorney, living will, or advance directive):

• Legally, surrogates cannot override the patient's documented decision to donate under the Uniform Anatomical Gift Act. 1
• However, family consent for withdrawal of life-sustaining therapy is still required even when first-person consent exists. 1
• Frame the conversation around a default assumption of donation when first-person consent is documented. 1
• If families persistently disagree, facilitate discussions between OPO representatives and surrogates, but recognize that DCD may not be possible if families refuse required ante mortem interventions or refuse to withdraw care at a time/location compatible with donation. 1

Step 5: Location and Timing of Withdrawal

For DCD, withdrawal of life support preferably occurs in the operating room to minimize warm ischemia time, which significantly impacts outcomes. 1

Process Details

• Graft and patient survival are better when life support is withdrawn in the operating room rather than the ICU. 1
• Each hour of cold ischemia increases risk of graft failure by 6% in DCD liver transplantation. 1
• Critical requirement: Operating room personnel involved in organ recovery must not be present during withdrawal of life support. 1
• Families must have as much time as needed to say goodbye before withdrawal begins. 1
• After death is declared, a mandatory standoff time of at least 2 minutes (not more than 5 minutes per local policy) confirms irreversibility of circulatory death before organ recovery begins. 1

Step 6: Palliative Care Integration

Those caring for potential DCD donors must demonstrate core competencies in palliative care. 1

Required Competencies

• Ability to communicate openly with families, ICU team members, and OPO staff. 1
• Skill in withdrawing life-sustaining therapies quickly without precipitating distress. 1, 2
• Expertise in managing symptoms of pain, anxiety, and breathlessness. 1
• Capacity to provide emotional and spiritual support for bereaving families. 1
• Consider involving palliative care specialists as part of the end-of-life care team to improve quality of care. 2, 3

If Death Does Not Occur Within Expected Timeframe

• If the patient survives longer than the timeframe compatible with donation (typically 90 minutes), organ recovery is aborted. 1, 3
• The patient is transferred back to the ICU with continued palliative care provided. 1, 3
• Families must be prepared in advance for this possibility to prevent emotional distress. 1

Common Pitfalls to Avoid

• Never discuss organ donation before families accept the inevitability of death—this is ethically problematic and reduces consent rates. 2
• Never allow the transplant team involvement in brain death determination or withdrawal decisions. 4
• Do not delay initial prognostic discussions until withdrawal is being considered; start at admission. 2
• Treatment withdrawal protocols must not differ when organ donation is being considered—the dying patient's dignity and comfort remain paramount. 2
• Do not proceed with DCD if the institution lacks adequate physical and personnel resources to provide expert palliative care. 1
• Avoid situations where ICU clinicians lack continuous supervision during withdrawal; DCDD should only occur when supervision is available. 1

Special Considerations by Patient Population

Advanced Heart Failure

• These patients may be suitable for DCD if withdrawal of mechanical circulatory support is planned. 1
• Ensure hemodynamic instability is expected to lead to death within the required timeframe. 1

Metastatic Cancer

• Generally excluded from solid organ donation due to risk of transmitting malignancy to recipients. 1
• Tissue donation may still be possible in select cases. 2
• Consult OPO early to determine if any organs/tissues are suitable given the specific cancer type and extent. 1

Severe Neurologic Injury

• Assess whether brain death criteria will be met (DBD pathway) or if withdrawal without brain death is planned (DCD pathway). 1, 2
• For DCD candidates, donor age, body mass index, and anticipated ischemia times significantly impact outcomes and should factor into suitability assessment. 1