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Missed Organ Donation Opportunities in Patients With Devastating Brain Injury: A Prospective Population-Based Cohort

Andreas H Kramer^1,2,3, Kerry Holliday³, Rachel Wilkins³

¹Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.

Critical Care Medicine

|November 21, 2025

Insights

Missed organ donation opportunities are common, particularly in emergency departments and rural hospitals. Engaging donation specialists significantly reduces these missed chances, improving organ recovery rates.

Area of Science:

Medical Research
Organ Transplantation
Public Health

Background:

Organ donation is critical for saving lives.
Identifying and minimizing missed organ donation opportunities is essential for maximizing donor utilization.

Purpose of the Study:

To determine the incidence and predictors of missed organ donation opportunities.
To identify factors contributing to missed organ donation, aiming to improve donation rates.

Main Methods:

A population-based, prospective cohort study was conducted over 42 months.
Included adult patients in ICUs and EDs who died with devastating brain injury and were mechanically ventilated.
Analyzed data to identify eligible potential donors and instances where families were not approached regarding donation.

Main Results:

16% of eligible potential organ donors represented missed donation opportunities.
Risk factors for missed opportunities included older age, death in EDs or regional hospitals, and death by circulatory criteria.
Cases involving donation specialists showed fewer missed opportunities.

Conclusions:

Missed organ donation opportunities are a significant issue, especially in emergency departments and regional hospitals.
Older patients and potential donors meeting death by circulatory criteria are at higher risk.
Involvement of donation physicians positively impacts the reduction of missed organ donation opportunities.

Read full analysis

Abstract

Objectives:

Determine the incidence and predictors of missed organ donation opportunities.

Design:

Population-based, prospective cohort study.

Setting:

All adult ICU and PICU (medical, surgical, neurologic, and cardiovascular) and emergency departments (EDs) in a Canadian province with a population of 5 million.

Patients:

Consecutive patients that died with devastating brain injury, regardless of etiology, and were mechanically ventilated in the last 12 hours of life over a period of 42 months.

Interventions:

None.

Measurements And Main Results:

Patients were defined as eligible potential donors if they were diagnosed with death by neurologic criteria (DNC), probable DNC (neurologic examination consistent, but without full assessment), or had death by circulatory criteria (DCC) within 2 hours of withdrawal of life-sustaining measures (WLSMs). Missed donation opportunities were defined as occurring when there was no evidence in the medical record that the family of an eligible potential donor was approached regarding donation. Multivariable logistic regression was performed to identify predictors of missed opportunities. There were 3481 patients and 1072 eligible potential organ donors, including 481 with confirmed DNC, 154 with probable DNC, and 437 with DCC within 2 hours of WLSM. There were 172 (16%) missed organ donation opportunities. In multivariable analysis, risk factors included older age (odds ratio [OR] per decade, 1.1 [1.0-1.3]), death in an ED rather than ICU (OR, 5.4 [3.0-10.0]), death in a regional rather than urban hospital (OR, 2.8 [1.7-4.6]), and DCC rather than DNC (6.7 [4.4-10.1]). Missed opportunities were less common when the most responsible physician was a donation specialist (OR, 0.3 [0.2-0.5]). Missed cases categorized as probable DNC were proportionally more common in EDs (45%) than in ICUs (21%; p = 0.0005).

Conclusions:

Missed organ donation opportunities occur with regularity, especially in EDs and regional hospitals, and among older patients and potential DCC donors. Donation physicians are likely to have a positive impact in reducing missed opportunities.

Keywords:

brain death (death by neurologic criteria)brain injuries organ donation organ transplantation

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