A common misconception among both the public and healthcare providers is that significant medical history automatically disqualifies someone from donation. In reality, very few absolute contraindications to donation exist. Active, untreated sepsis involving a specific organ, active metastatic cancer (with some exceptions), and certain transmissible infections such as untreated Ebola or rabies represent examples of true contraindications. For all other potential donors, including those with cancer history, diabetes, hypertension, hepatitis, or advanced age, the OPO's medical director makes the final determination on a case-by-case basis [7]. Clinicians should never independently rule out a patient as a potential donor; that determination belongs exclusively to the OPO.

Tissue donation can occur following both cardiac death and brain death, and it can be pursued even in cases where organs are not being donated. Importantly, tissue donation can occur up to 12 to 24 hours after cardiac death, making it possible even when the patient was not identified as a potential organ donor in time. This broader window significantly expands the pool of potential tissue donors [10].

This pathway applies to patients who do not meet brain death criteria but have a non-survivable injury or illness, and for whom a decision has been made to withdraw life-sustaining treatment (WLST). Following WLST, organ procurement occurs after the patient experiences cardiac death, typically within 60 to 120 minutes. DCD procurement has expanded significantly over the past decade and now accounts for a substantial proportion of donor cases nationally [1].

The clinical determination of BD/DNC requires [15,16,17]:

Ancillary testing (EEG, cerebral angiography, nuclear perfusion scan, transcranial Doppler ultrasound) may be used when clinical examination/apnea testing cannot be completed or when there is an inability to correct metabolic derangements adequately, but the neurologic examination(s)/apnea test(s) are consistent with BD/DNC [17]. The patient's family should be allowed to be present during the neurologic examination and apnea test; however, they should be informed about the potential for spinal reflexes (e.g., Lazarus sign) and the fact that these movements do not indicate brain function.

Research and best practice consistently support the principle of decoupling (i.e., separating the notification of death or the discussion of withdrawal of life support from the request for donation). When families receive both conversations simultaneously, authorization rates decline and family distress increases [20,21].

The practical application of decoupling means a physician and/or nurse should first meet with the family to explain the patient's neurological status, the meaning of brain death, and what it means for the patient's prognosis, before any mention of donation. Only after the family has had adequate time to process this information should the OPO family support coordinator introduce the topic of donation. In many cases, this means two separate meetings, often with a short interval in between.

Effective culturally sensitive care includes:

Aggressive fluid resuscitation is often required to address diabetes insipidus-driven volume depletion and post-herniation hypotension. Isotonic crystalloids are generally preferred. Vasopressin (antidiuretic hormone) is a cornerstone of donor management. It simultaneously treats diabetes insipidus, supports hemodynamics, and reduces the need for high-dose catecholamine vasopressors. Norepinephrine (≤0.2 mcg/kg/min) is the preferred catecholamine when vasopressin alone is insufficient; alternately, neosynephrine (≤1 mcg/kg/min) may be used. High-dose dopamine (>10 mcg/kg/min) is associated with worse heart and kidney outcomes; a dosage of ≤10 mcg/kg/min should be used [28,29].

The Papworth protocol and subsequent research support the use of hormone replacement therapy in hemodynamically unstable donors. The regimen typically includes: