Shock, Sepsis & Multisystem · Topic 14 of 14

Organ & Tissue Donation

Professional role · organ & tissue donation

Organ & Tissue Donation

Refer every death and imminent death to the OPO, ideally within an hour and before withdrawal; the OPO, not the bedside team, decides suitability.

Key numbers

Call the OPO within 1 hour≤ 1 h, before withdrawal

DCD: 5-minute observation after arrest5-min observation

Donor targets: MAP ≥ 60, urine 1–3 mL/kg/hMAP ≥ 60 mmHg

01 · The ruleRefer every death and imminent death

CMS Conditions of Participation (42 CFR 482.45) require hospitals to notify their organ procurement organization (OPO) in a timely manner of every death and imminent death; the OPO, not the bedside team, determines medical suitability.

02 · FirstCall the OPO within 1 hour

Notify the OPO as soon as possible, ideally within 1 hour, after death or an imminent-death trigger — and always before withdrawing any life-sustaining therapy.

03 · Defined byDCD: 5-minute observation after arrest

In donation after circulatory death, death is declared only after a mandatory 5-minute period of continuous observation of complete circulatory arrest with no autoresuscitation; no recovery or perfusion begins before then.

The rules

Know these

Only OPO or designated requestor asks family must knowThe family is asked about donation only by an OPO representative or a designated requestor who completed an OPO-approved course, with sensitivity to the family's beliefs — not by untrained treating clinicians.

Withdrawal and death declaration stay independent must knowThe patient's own team and family decide on withdrawal of life support, and the team declares death — independent of the OPO and transplant teams, who play no part in comfort care or pronouncement.

A registered donor's gift is legally bindingUnder the Revised Uniform Anatomical Gift Act, a donor-registry or driver's-license designation is a valid anatomical gift that no one else may amend or revoke; families decide only when the patient left no decision.

Hospitals also partner with tissue and eye banksHospitals must also have agreements with at least one tissue bank and one eye bank, and the family is told of the option to donate organs, tissues or eyes — or to decline.

Diagnosis & monitoring

Work-up

Brain death is legal deathDonation after brain death requires death by neurologic criteria — coma, absent brainstem reflexes and a positive apnea test; time of death is when the final apnea-test blood gas meets criteria (see Brain Death Determination).

Donor targets: MAP ≥ 60, urine 1–3 mL/kg/hBrain-dead donor goals: MAP ≥ 60 mmHg, urine output 1–3 mL/kg/h, euvolemia (CVP 6–8 mmHg), heart rate 60–120, LVEF > 45% and temperature 36–38 °C; restore volume first, then add vasopressors.

Do right now

In this order

First moves

Call the OPO within 1 hour≤ 1 h, before withdrawal

→

Keep supporting the potential donor during OPO evaluation

→

Only OPO or designated requestor asks family

Why each step

Call the OPO within 1 hourNotify the OPO as soon as possible, ideally within 1 hour, after death or an imminent-death trigger — and always before withdrawing any life-sustaining therapy.

Keep supporting the potential donor during OPO evaluationHospitals must work with the OPO to maintain potential donors — ventilation, hemodynamics, fluids — while suitability testing and organ placement take place.

Only OPO or designated requestor asks familyThe family is asked about donation only by an OPO representative or a designated requestor who completed an OPO-approved course, with sensitivity to the family's beliefs — not by untrained treating clinicians.

Management

Orders

Treat donor diabetes insipidus with desmopressin or vasopressinDiabetes insipidus develops in most brain-dead donors (79% in one series): treat with IV desmopressin, or vasopressin infusion when vasopressor support is also needed, and keep sodium below 155 mmol/L.

Consider thyroid hormone and steroids for unstable donorsHormone replacement — levothyroxine 20 mcg IV then 10 mcg/h, and methylprednisolone 15 mg/kg (or hydrocortisone 300 mg) IV — is widely used for hemodynamically unstable donors, though trial evidence is mixed.

Lung-protective ventilation preserves donor lungsVentilate potential donors with lung-protective settings — tidal volume 6–8 mL/kg predicted body weight, PEEP 8–10 cmH₂O, and recruitment after any disconnection — which increases the number of lungs eligible for transplant.

Red flags & don'ts

Avoid harm

Brain death causes hypotension, DI and coagulopathy complicationAfter brain death, a catecholamine storm gives way to vasodilatory hypotension and myocardial dysfunction, with diabetes insipidus, hypothermia, DIC and neurogenic pulmonary edema — all threats to organ viability.

DCD is cancelled if death comes too slowly complicationAfter withdrawal, DCD organs are usable only if death follows within the accepted time limit; 30–40% of potential DCD donations are cancelled for this reason, and families are told beforehand.

Donation after brain death or after circulatory death?

Commonly confused

Who qualifies	Meets brain death criteria
How death is declared	Coma, absent brainstem reflexes, positive apnea test
Time of death	Final apnea-test blood gas result
Main threat to organs	Hypotension, diabetes insipidus, coagulopathy
Transplant team role	None in the death determination

More detail

Reference

Show 7 reference facts

A common imminent-death definition: a ventilated ICU or ED patient with severe acute brain injury and GCS ≤ 5, or one being evaluated for brain death, or with an order to withdraw life-sustaining therapy.

Donor diabetes insipidus is defined as urine output > 4 mL/kg/h with rising sodium ≥ 145 mmol/L, rising serum osmolality ≥ 300 mOsm or urine osmolality ≤ 200 mOsm.

Families of DCD candidates are told that heparin may be given for organ outcomes, where withdrawal will happen, and that comfort medications are ordered and given only by the patient's own team.

Normothermic regional perfusion may follow DCD only after death is declared and the 5-minute observation ends, and the aortic arch vessels (or aorta) must be clamped to prevent any cerebral reperfusion.

DCD donors now make up about 43% of US deceased donors (more than 7,200 in the latest year), usually after catastrophic neurologic injury that does not meet brain death criteria.

Hospitals must work with the OPO, tissue bank and eye bank to review death records so potential donors are identified, and to educate staff on donation.

Correct donor hypernatremia below 155 mmol/L before recovery because high donor sodium is linked to early liver graft failure.

Pearl

Never self-screen a donor: call the OPO for every death and every imminent death, and let the OPO decide.

Sources · 42 CFR 482.45 — Condition of participation: Organ, tissue, and eye procurement (eCFR) · Organ Donation and Transplantation Alliance — Organ donation CMS essentials (referral criteria, imminent death, timely notification ideally within 1 hour) · Association of Organ Procurement Organizations — DCD Guidelines & NRP Safeguards (December 2025) · Kotloff RM et al. Management of the potential organ donor in the ICU: SCCM/ACCP/AOPO consensus statement. Crit Care Med 2015;43(6):1291–1325 (Europe PMC abstract; targets confirmed via s6) · Greer DM et al. Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline (AAN/AAP/CNS/SCCM). Neurology 2023;101:1112–1132 · Management of the brain-dead organ donor. Indian J Thorac Cardiovasc Surg 2021 (summarizes the SCCM/ACCP/AOPO donor goals) · Incidence and treatment of arginine vasopressin deficiency (central diabetes insipidus) in brain death and associations with renal function and hemodynamics in organ donors. J Clin Med 2024;13:7073 · Canadian Blood Services — Standing orders for the medical management of neurologically deceased organ donors, adults (2020) · UNOS — Understanding donation after circulatory death (DCD) · Washington State House final bill report, SHB 1637 (2007) — adoption of the Revised Uniform Anatomical Gift Act · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).