Organ and Tissue Donation and Recovery Nursing CE Course

Myth: Older patients are often too old to donate their organs.

Fact: There is no specific age cutoff for organ donation. The oldest organ donor in the United States was 100 years old, and 1 in 3 organ donors is over 50 (Live on Nebraska, 2026; Muco et al., 2023; NIA, 2022).

Myth: Many patients are too sick to donate their organs.

Fact: Eligibility for organ donation is evaluated on a case-by-case basis. Individuals with chronic conditions are encouraged to join the donation registry as they may still be eligible (ATF, 2023; Muco et al., 2023; NIA, 2022).

Myth: Organs are given first to the rich, famous, and influential.

Fact: Medical algorithms are used to assess relative need and stratify potential organ recipients based on numerous objective factors such as time spent on the waiting list, blood type, and match to the available organ; a patient’s income, power, race, and celebrity status are not considered as factors in these decisions (ATF, 2023).

Myth: Organ donation is expensive.

Fact: The efforts to resuscitate a patient at the end of their life may be expensive and often misinterpreted as organ donation costs, but these are separate and are the family’s responsibility. The family is also responsible for the cost of final arrangements. The organ retrieval costs are incorporated into the organ transplant process for the recipient and are not charged to the donor (NIA, 2022). Living donors are reimbursed using the recipient’s insurance (private or public); however, some donors have difficulty maintaining the same insurance coverage as before the donation. Donors may also experience lost wages from needing time off work. The National Living Donor Assistance Center (NLDAC) provides financial assistance to living donors to help cover travel costs, including meals and hotels, lost wages, and additional childcare or eldercare costs (HRSA, 2025a; Lewis et al., 2021; Murray & Kramer, 2022).

The History of Organ Donation in the United States

The National Organ Transplant Act was first passed in the United States in 1984 and established the OPTN. The act specifies that a private, nonprofit organization must run the network under a federal contract. The United Network of Organ Sharing (UNOS) was granted this federal contract in 1986 and has maintained it ever since. Worldwide, there are two systems for acquiring organ donations from individuals: opt-out or opt-in. A country or state that follows an opt-out system assumes that every individual is willing to donate organs and tissues unless they specifically choose to opt out. This system follows presumed consent. The other system is the opt-in system, which the United States follows. In this system, an individual must express their desire to be an organ and tissue donor upon death. In this system, no one is presumed to be a willing donor unless they give express consent. Although 90% of American adults support organ donation, only 60% are registered donors (Etheredge, 2021; HRSA, 2025c; UNOS, n.d.-b).

In the United States, approximately 17 people die daily awaiting organ transplants. There are 103,223 individuals currently on the national transplant waiting list, including children, with a new person added every 8 min. Of those on the list, 43,829 are aged 50 to 64. Every donor can save eight lives and improve the lives of over 75 more people. Of those awaiting an organ transplant, 86% are awaiting a kidney, 9% a liver, and 3% a heart, while the rest are awaiting a pancreas, lung, or other body part, including a hand or an abdominal wall structure. In 2023, the kidney was the most transplanted organ, with 27,332 transplants performed (HRSA, 2025c).

In 2019, then President Donald Trump signed an Executive Order endorsing the development of more transparent, reliable, and objective metrics to measure OPO performance and streamline the matching and delivery of donated organs, thereby reducing the discard rate. It also highlighted the Kidney Accelerated Placement project, a UNOS program designed to accelerate the placement of hard-to-place kidneys, thereby increasing organ utilization. Other improvements included having filters attached to the transplant programs used by OPOs to allow flexibility in listing the specific organs needed, reducing the amount of time that a transplant organization has to respond to the offer of a potential organ, upgrading the organ matching system to include diagnostic images of the organs being donated, and the creation and sharing of new analytic tools to identify further areas of improvement (Murray & Kramer, 2022).

Between June 2025 and June 2026, 26,391 transplants were performed in the United States, with 12,836 donors. During that same time, 42,771 waitlist donors were added. As the medical criteria for organ donation continue to broaden, the organs donated come from different eligibility categories. In 2025, 9,193 individuals were DCD donors, an increase of 1,731 donors from 2021. The discard rate of all organs was 19.98% in 2025, up from 16.51% in 2021. In 2024, 8,199 (48.3%) donors were over age 50, up from 2,986 (34.7%) in 2014. The highest cause of death of donors in 2024 was stroke (27.1%). In 2025, 7,237 (30.42%) individuals became living donors, an increase from 2023, when 6,955 (29.86%) did so. Although kidney donation is typically by living donors, a few other organs have been increasingly donated by living donors. In 2026, through July 17, there were 405 living donor liver transplants, an increase of 105 live-donor transplants since 2021 (HRSA, 2025b; Israni et al., 2024).

Who Can Donate?

Most individuals can donate, with rare exceptions related to systemic infection (e.g., sepsis, bacteremia) and actively spreading cancer. In specific circumstances, some organs and tissues can be donated despite these conditions. Age is not a disqualifying factor, as neonates and older adults have donated organs and tissues. Organs donated from older donors carry an increased risk and somewhat decreased function, limiting viable donations to the kidneys and the liver in most older adults. Pediatric patients (under the age of 18) require informed consent from a legal guardian or parent to donate tissues or organs. While religious beliefs are a common concern among prospective donors, most religions allow organ and tissue donation as a selfless gift of life. The specifics regarding a handful of common religious organizations and their views regarding organ donation are discussed in Table 1 (Boas, 2025; HRSA, 2025d; NIA, 2022; Timar et al., 2021)

Table 1

Common Religions and Their Views Regarding Organ and Tissue Donation

(Donor Alliance, n.d.; HRSA, 2021c)

Once a potential donor has been identified, their risk for hepatitis C virus (HCV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV) transmission should be assessed. Those at increased risk include those who utilize intravenous (IV) recreational drugs and those who engage in high-risk sexual activities (e.g., multiple sexual partners, unprotected sexual intercourse). If determined to be at increased risk, nucleic acid testing can be performed to test for the three infections. In recent years, advances in nucleic acid testing and antiviral treatment for HCV have allowed donors at increased risk for infection to be considered for organ and tissue donation. With informed consent, donors positive for HCV can donate organs to recipients already known to be infected with HCV or uninfected recipients willing to undergo antiviral treatment after receiving the organ. Antiviral treatment protocols for organ recipients can achieve undetectable HCV levels in over 95% of recipients after 12-24 weeks of treatment. Similarly, donors found to be infected with HIV or HBV may still be permitted to donate organs to recipients with known HBV or HIV infection, assuming informed consent (Centers for Disease Control and Prevention, 2024; Murray & Kramer, 2022; Timar et al., 2021; World Health Organization, 2026a, 2026b).

What Can Be Donated?

Deceased donors often donate solid organs, although living donors can donate one of their kidneys, lungs, or a portion of their pancreas, liver, or intestines. Living donors can donate blood or platelets, via venipuncture, or stem cells via bone marrow, umbilical cord blood, or peripheral blood (with pharmacological provocation using filgrastim [Neupogen]). Filgrastim (Neupogen) stimulates neutrophil proliferation, differentiation, and maturation, thereby increasing the number of mature circulating neutrophils. Deceased donors can donate their kidneys, liver, lungs, heart, pancreas, and intestines. The first-hand transplant occurred in 2005, and the first face transplant was performed in 2007. After the donor's organs have been retrieved, various tissues can be donated within 24 hr of death and stored in tissue banks for later use (Aghedo & Gupta, 2023; HRSA, 2024; Kuter, 2026; Li et al., 2026).

Each donated organ is matched independently with the most suitable recipient, except for heart/lung and pancreas/kidney transplants, which may be matched as a set. UNOS conducts the matching process through the OPTN and in collaboration with local OPOs. The match is based on blood type, body size, the severity of the recipient’s medical condition, the geographic distance between the donor and the recipient, the length of time that the recipient has been on the waitlist, and the recipient’s immediate availability to undergo surgery (OPTN, 2025b).

Additional specific details are considered, with varying importance, for each donated organ. Potential heart recipients are assigned a status code based on the severity of their condition, but physical location is also crucial, given the limited time constraints. Body size is also considered important for heart recipients. A heart transplant is the treatment of choice for patients with severe dilated or restrictive cardiomyopathy, end-stage heart disease secondary to coronary artery disease (CAD), valvular disease, or congenital heart disease (Fine, 2025; Ignatavicius et al., 2021). Heart transplant recipients’ 1-year survival rate is over 90%, but it decreases to 66.9% at 10 years and 52.7% at 15 years in a recent study (Alkhalaileh et al., 2026). Patient education regarding the importance of faithfully adhering to the medication regimen and the value of psychosocial support through participation in a support group and individual psychotherapy is crucial (Fine, 2025; Ignatavicius et al., 2021).

The Donation Process

A living organ donation involves the transplantation of an organ, usually a kidney or a portion of a liver. This procedure was first performed on a pair of identical twins in 1954. Living donations are often conducted between family members for an optimal match of immunological factors and blood type. Organs procured via living donation are preferred over organs from deceased donors, as they are not subject to tissue damage from decreased blood flow, decreased oxygenation, and increased levels of inflammatory proteins associated with the dying process. Recipients also have better outcomes when receiving organs from a living donor. The cost to donors associated with living organ donation can be a deterrent. The recipient and their medical insurance provider cover the direct medical costs. The NLDAC supports donors with funding for additional expenses, such as travel, lodging, and meals (Finger, 2023b; HRSA, 2025a).

The first successful organ donation from a deceased donor was in the 1980s. This was largely due to the development of cyclosporine (Sandimmune), which helps prevent organ rejection. The two currently available methods for deceased donation in the United States include DCD and DBD. These two distinct methods will be discussed in detail, along with the factors that differentiate them. The initial regulations for determining death in a potential organ donor were addressed in the Uniform Determination of Death Act in 1980 by the National Conference of Commissioners on Uniform State Laws and adopted by both the American Medical Association (AMA) and the American Barr Association (Starr et al., 2024; UNOS, n.d.-b; Walters & Kleiman, 2023). Death was defined as “the irreversible cessation of circulatory and respiratory functions” or “of all functions of the entire brain” (Starr et al., 2024, para 1).

DCD refers to the donation of organs following the withdrawal of life support in patients who have suffered a severe neurological injury, and there is no expectation that the patient will have any meaningful survival. These individuals require life support yet do not officially meet the qualifications of brain death. This often occurs after cardiac arrest or due to severe heart disease. Research suggests performing a multimodal neurological prognostication after all instances of significant cardiac arrest but not before an initial 72-hr waiting period. The American College of Cardiology (ACC) and the American Heart Association (AHA) both recommend that cardiac arrest patients be evaluated for the potential of organ donation. In 5% to 10% of cardiac arrest patients, the cerebral edema is so severe that they meet the DBD criteria (see further on). Unfortunately, the DCD process in cardiac arrest patients typically precludes using the heart (unless the WIT is less than 30 min). For any of the organs to be viable for donation, the patient must die within 60 to 120 min following the withdrawal of life support. In about one-third of cases, none of the available organs are viable for donation due to inflammatory and hypoxic tissue damage (American Society of Anesthesiologists, 2022; Boas, 2025; Dominguez-Gil et al., 2021).

When the medical community in the United States was standardizing a method for DBD, a universal definition of brain death had to be first established. A patient is considered to be in a persistent vegetative state if the brain no longer performs any cortical function but the brainstem’s functions remain intact. Conversely, brainstem death involves a lack of brainstem reflexes despite a few cortical functions and hypothalamic integrity (such as osmoregulation). Finally, brain death or whole-brain death involves the biological death of the entire brain, with no cortical or brainstem functions remaining (Lewis et al., 2023). The brainstem reflexes include the following:

• the corneal reflex causes the eyelid to blink after lightly touching the cornea
• the pupillary light reflex causes pupillary constriction with direct bright light
• the oculocephalic reflex causes rotation of the patient’s gaze in the opposite direction when the head is rotated to one side or the other briskly
• the oculovestibular reflex causes eye movement when 50 mL of ice water is infused into the patient’s ear canal
• the gag reflex causes throat constriction (a gag) after stimulation of the posterior pharynx with a spatula or tongue depressor
• the cough reflex causes a cough after stimulation of the carina with a bronchial catheter
• the withdrawal reflex to noxious stimuli along the route of cranial nerves (Lewis et al., 2023)

DBD occurs commonly after trauma, stroke, aneurysm rupture or due to a brain tumor. To qualify, the patient must satisfy the three diagnostic qualifications established by the AAN in 1995, which were last revised and reviewed in 2010. The three diagnostic criteria include a patient in a coma with a known underlying cause, the absence of brainstem reflexes, and the presence of apnea (Lewis et al., 2023; Starr et al., 2024).

Discussions With Family

Federal and state laws require hospitals to contact the locally assigned OPO after identifying potential organ donors. The Gift of Life Donor Program (GLDP) encourages hospital staff to refer to the OPO patients who are neurologically injured, dependent on mechanical ventilation, or deemed to have a nonrecoverable condition. A consultation with the OPO is recommended before discussing or even mentioning the possibility of organ donation to a patient or family member; however, this possibility should be considered for every patient who might qualify to increase the overall rates of organ donation worldwide. A premention is acceptable, and the nurse should share brief general knowledge about organ donation with the family if asked. It is the OPO’s responsibility to determine the suitability of the potential donor. To do this, the OPO will ask the medical team several initial screening questions about the patient and their medical status to determine whether they are a potential donor and then assign a representative to travel directly to the hospital to assist if the screening questions indicate a potential donor. The OPO representative will search the state database of registered organ donors and the DMV records regarding organ donor status. They will collect medical and social histories from the electronic medical record and confirm the information with the family when appropriate. Federal law mandates that only certified clinicians who have completed organ donation training approach the family to discuss organ donation. Providers who discuss organ donation with families alone have the lowest consent rate. It is best practice for an OPO member to approach families with the health care team (Haliko & Arnold, 2024; Timar et al., 2021).

When the conversation regarding organ donation occurs with a potential donor family, this conversation must be separated in both time and space from the conversation regarding the patient’s prognosis. For example, if life support will be withdrawn or brain death has been confirmed, these conversations should happen separately from (and before) any conversation regarding organ donation. This concept is called decoupling. When decoupling does not occur, the donation consent rate decreases by roughly one-third. Families must be allowed time to process and accept their loved one’s prognosis before being asked to discuss the next steps. For potential DBD donors, the family should fully understand the concept of neurological death. For potential DCD donors, the family should have already discussed and accepted their loved one’s prognosis and decided to withdraw life support (Haliko & Arnold, 2024; Slater, n.d.; Timar et al., 2021).

Studies indicate that the healthcare provider’s (HCP) perceived skill and personal relationship with the family are important factors cited by families during the discussion and, eventually, the decision to donate the organs of a deceased loved one. Trust must be established first. Organ donation conversations should be held privately, and the HCP(s) present should be very knowledgeable regarding the donation process to answer questions quickly and confidently. These conversations are best had using a multidisciplinary team, and some recommend that a different group of providers should be present for the organ donation conversation than for prior conversations regarding prognosis and withdrawal of support. Information should be communicated clearly, comprehensively, and comprehensibly, focusing on sensitivity, compassion, caring, confidence, positivity, and family well-being. The medical team should outline the roles of various professionals, the step-by-step donation process, and any impact on funeral arrangements. For example, many families are relieved to learn that, in most cases, they can still proceed with an open-casket funeral for their loved one following organ donation. After this conversation, the OPO representative will obtain informed consent from the patient’s legal next of kin or designated decision maker. They are also responsible for logistical details, such as contacting UNOS, which manages the OPTN in the United States, and arranging the transport of organs following procurement (Haliko & Arnold, 2024; Organ Donation & Transplantation Alliance [The Alliance], n.d.; Timar et al., 2021).

If the initial reaction from the family during the organ donation conversation is reluctance or hesitation, it is acceptable to further explore and discuss the reasons underlying their feelings sensitively . However, the medical team should avoid appearing apologetic, guarded, aggressive, or coercive when talking about organ donation with family members. If the prior discussion was conducted with an untrained staff member or led to a misunderstanding of the facts, a second attempt may be made with a more experienced team and a concrete action plan. A repeat attempt to discuss organ donation with a family may also be reasonable in situations where additional relevant clinical information is now available, the patient in question has since been confirmed as a registered organ donor, or advance directives with specific instructions regarding organ donation have since been located. Unconditional support should be provided to the patient's family before, during, and after the donation process, regardless of whether they elect to provide consent (The Alliance, n.d.).

Assessment and Care of the Potential Organ Donor

Managing a patient after the declaration of brain death but before organ donation can be complicated. Brain death typically leads to a systemic inflammatory response, a catecholaminergic discharge, and diabetes insipidus (DI) with hypovolemia due to the sudden decrease in antidiuretic hormone (ADH) production. The nurse must maintain the patient’s blood pressure to perfuse their organs and prevent hypotension, aiming for a mean arterial pressure of 60 to 65 mm Hg. The patient’s urine output must also be monitored while maintaining euvolemia, aiming for 0.5 to 1 mL/kg/hr. DI typically presents with large amounts of dilute urine output and dehydration (i.e., increased serum osmolality and hypotension). There are no specific recommendations regarding the use of vasopressors or inotropes to maintain perfusion; however, vasopressin (Vasostrict) is preferred for managing DI if it develops. These measures will help protect the kidneys and ensure adequate perfusion of the patient’s other organs. Vasopressin (Vasostrict) is associated with increased organ recovery rates. The medical team should avoid hypervolemia and utilize lung-protective ventilation techniques and lung recruitment strategies as needed to protect the lungs. Insulin, glucocorticoids, and thyroid hormones are commonly incorporated to correct hormonal imbalances. Various tests may be performed to assess the health and viability of the patient’s organs before procurement. All potential heart donors should undergo an echocardiogram. A cardiac angiography may be performed if the donor is over 40 or has multiple cardiac risk factors for premature CAD. A bronchoscopy may be indicated to assess the patient’s anatomy and airway clearance. Additional laboratory or imaging studies may be recommended to further evaluate the health and functioning of the liver, kidneys, and pancreas. Despite the numerous considerations required to optimize potential organ donors following brain death, the primary advantage is that these patients may remain on cardiovascular life support throughout the process. These patients are transported to the operating room to retrieve the organs without any significant period of warm ischemia (Bag et al., 2026; Timar et al., 2021).

Despite the increase in DCD, significant variability persists among OPOs in their use of these donors. Patients who may have the potential to donate organs following cardiac death are managed similarly to the aforementioned considerations, with a primary focus on maintaining euvolemia, hemodynamic stability, and utilizing lung-protective ventilation techniques. These patients may retain some brain function, so they may not require DI or hormonal imbalance management. As previously stated, the health and viability of a donor’s organs following cardiac death are directly related to the length of time between the withdrawal of cardiovascular and ventilatory support, the declaration of cardiovascular death, and the surgical procurement of the organs, known as the WIT. The health of the patient’s organs is optimized if there are less than 60 to 120 min (1 to 2 hr) between the initial withdrawal of life support and organ retrieval/preservation. Often, patients over the age of 65 will not be able to successfully donate healthy organs following cardiac death, while DBD donors may be significantly older (National Research Council, 2022; Seshadri et al., 2023; Timar et al., 2021; Walters & Kleiman, 2023).

Following procurement, tissue biopsies may be performed to assess the organ viability, especially regarding the kidneys. After procurement, most organs must be stored until they can be implanted into the recipient. To preserve the organs ex vivo, safe and reliable methods are needed. Based on the organ being stored, the preservation times vary. Recently developed ex vivo perfusion techniques have improved the health and viability of transplanted organs by reducing the risk of tissue damage during warm and cold ischemia. Normothermic perfusion techniques, such as ex vivo normothermic machine perfusion (EVNMP), have extended the accepted preservation times of some organs, enabling them to be transported farther to the intended recipient. This is because EVNMP maintains oxygen delivery to organs and allows adenosine triphosphate (ATP) production to continue, preventing irreversible cellular injury that occurs with other preservation methods. Currently, EVNMP is used for heart, lung, and liver transplants. Hypothermic perfusion at 32 to 53.6° F (0 to 12° C) is the most beneficial for kidney preservation (Finger, 2023c).

Barriers and Facilitators to Organ Donation

The barriers and facilitators to increasing the number of healthy organs transplanted are numerous, varied, and, at times, difficult to identify and characterize accurately. Experts in the field advocate for increased national public health campaigns that educate the public about the importance and safety of living kidney donation. Social media and technology are unexpected yet potential facilitators of living organ donation. MatchingDonors.com is an internet site, first developed in 2004, that connects those in need of an organ with those willing to donate a kidney or a portion of their liver. As previously stated, additional financial support for living donors is now available to offset hardships, such as lost wages and childcare costs (Lewis et al., 2021; Murray & Kramer, 2022).

In prior studies, nurses have cited concerns regarding the donation of organs following cardiac death. In a mixed qualitative and quantitative analysis in the UK exploring why parents say yes or no to organ donation following a child’s death (Crane et al., 2025), respondents noted that they felt the restricted 5-min time the family could spend with the child after death was insufficient, a burden, and distressing; that the patient’s death would be prolonged or altered; or that they had concerns surrounding the surgical procedures used to remove organs. Regarding other barriers, cultural or religious objections, mistrust, concerns about child suffering, denial regarding the child’s prognosis, and anger were also cited. Parents were 1.78 times more likely to consent to organ donation following brainstem death as opposed to circulatory death. The consent rate declined in this study, from 59% in 2018/2019 to 37% in 2023/2024 (Crane et al., 2025). In another recent study (Gettis et al., 2024), only 26.4% of families chose to donate their child’s organs. Proposed recommendations for those caring for children eligible for organ donation focused on the following factors:

• use of a skilled and engaged team regarding communication of the child’s death
• synchronous collaboration between the team and family for the family interview
• support for the family’s grieving and beliefs through emotional support and understanding
• discussions regarding news of death should be separate from the organ donation discussion
• understanding of legal, ethical, moral, family, cultural, and organizational guidelines and parameters through competent knowledge, skills, and attitudes (da Silva Knihs et al., 2022)

To increase the success of family conversations, health care institutions should create a team specifically trained and experienced in tissue and organ donation. This team can help streamline the process while minimizing the impact on the donor’s family. These teams typically include a nurse, a social worker, a pastor or other religious leader if desired, and a provider. This additional moral and emotional support for the families often helps them view the experience as positive and rewarding (Muco et al., 2023). The guidelines outlined by the OPO identify the following qualities and characteristics that are essential for those involved in organ donation discussions:

• an attitude that is respectful, compassionate, and genuine without making assumptions
• collaboration with religious and community leaders in the discussion regarding donation
• emphasize and focus on communication and dynamics within the family, sharing in their grief
• advocate for the time needed for the family
• willingness to be a liaison between the family and health care team through building rapport and trust, and identifying needs within the family
• provide real-time education to the care team and hospital staff regarding organ donation
• use appropriate bilingual information and donation forms (The Alliance, n.d.)

Ethical Questions That Remain

For organ donation to be widely accepted and achieve high donation rates, individuals must view the system as trustworthy and transparent. Transplant medicine inherently contains several pertinent ethical considerations, such as the following:

• A provider or health care worker (HCW) caring for a potential donor has a primary obligation to care for the donor, not focusing on preserving organs for donation that may harm the patient. This demonstrates beneficence and nonmaleficence toward the patient under the provider’s care.
• Discussions surrounding organ donation should be focused on helping the potential donor and/or family make the best decision using trust and transparency. This demonstrates respect for the patient’s autonomy.
• Advanced care planning should help patients communicate their future treatment preferences while designating a surrogate decision maker. While some individuals may include organ donation wishes in an advanced directive, those wishes should not take precedence over their stated end-of-life care preferences. This demonstrates beneficence and nonmaleficence toward the patient, as well as respect for the patient’s autonomy.
• Performance metrics, financial incentives, reputational interests of health care organizations, or goals of the organ transplant system should never supersede an HCW or provider’s foremost obligation to prioritize the patient’s best interests. This helps ensure beneficence and nonmaleficence toward the patient.
• Promoting equity in organ donation and transplantation should be a central priority, supported by policies and practices that foster public trust and demonstrate trustworthiness. This demonstrates justice, which helps promote fairness and access to health care that is equitable (Esbensen et al., 2025).

The DDR has been in effect since the beginning of transplant medicine. IDD, or live donation prior to planned withdrawal (LD-PPW), continues to provoke ethical discussions among organ transplant experts. IDD has the potential to be another option for organ donation and may increase the number of quality organs available for transplantation. These patients are anesthetized, and their organs are removed in an operating room under general anesthesia, making organ donation the official cause of death. While performed in other countries, this process has not been sanctioned by the OPTN. An ethics committee review in 2016 cited ethical concerns; specifically, patients with a severe neurological injury who could not provide informed consent of their own accord were of concern to the committee members. The committee found the stress of this ethical dilemma on the surrogate decision maker to be unreasonable. One committee member described this as a political, not an ethical, problem (OPTN, 2025a). The committee cited “potential risks that are too great at this time based on the responses and substantial concern from the nine other committees, lack of community support, and substantial challenges” (OPTN, 2025a, p. 5). There is no data to determine if LD-PPW would lead to an effective increase or decrease in the number of organs available for transplantation. Currently, any surgical program that proceeds with this method of donation in the United States could be held legally liable for accelerating the death of a patient, even with a signed consent form. In Canada, where HCPs have recently been granted legal immunity to facilitate a comfortable and somewhat hastened death by terminally ill patients, transplant teams continue to abide by the “5-minute no touch” rule before initiating the organ and tissue recovery process (Boas, 2025; OPTN, 2025a).

US public opinion may be less divided than in medicine regarding these ethical questions. The US Department of Health & Human Services (HHS, 2025a) surveyed 10,008 Americans aged 18 or older. Among the participants, 53% were registered organ donors (5% said they were unsure of their status). Almost half (47%) of the participants who were not registered as organ donors expressed a wish to donate their organs after death. Approximately half (49%) of the respondents had discussed organ donation wishes with their family. Living donation of specific eligible organs was overwhelmingly positive, with 81% of participants stating they would donate to a family member and 74% to a close friend. 82% of respondents believed that organ donation is beneficial. Just over half (53%) of the respondents were in favor of an opt-out system with presumed consent allowing for organ donation unless a person opts out while living (HHS, 2025a).

Unfortunately, the ethical concerns regarding the lack of equity in access to medical care among individuals of certain racial or ethnic groups also extend into the transplant medicine world. In 2025, more than 27% of individuals on the transplant list were non-Hispanic Blacks. Asian Americans, Pacific Islanders, Native Americans/Alaskan Natives, non-Hispanic Blacks, and Hispanic individuals have higher rates of certain chronic diseases that affect their vital organs; this increases the need for organ transplantation in these groups. Certain blood types are also more common among these populations. Since organs must be matched by donor and recipient blood type, individuals in these groups must register as organ donors. Strategies to address this inequity include community efforts to increase public awareness and education regarding organ donation and improved primary care access to reduce the secondary need for organ donation. While enhanced organ allocation efficiency remains warranted, transitioning from a location-based to a need-based system several years ago improved the equity of organ donation (Lewis et al., 2021; Office of Minority Health, 2026).

Future Research to Optimize Organ Donation, Safety, and Reduce Transplant Need

Most research in the field of transplantation focuses on optimizing the tissue health of donated organs before, during (refer to prior discussion regarding ex vivo perfusion techniques), or after the transplant process. Enhanced early identification of potential organ donors and expansion of existing organ donor criteria are strategies that should be evaluated to address the nationwide organ shortage. Public awareness and education are vital to obtaining consent, as research consistently indicates that donation consent rates are directly related to the public’s level of understanding. The usefulness of mild hypothermia is being explored in managing potential organ donors immediately following brain death declaration. The potential role of immunosuppressants and antioxidants in donors before organ procurement is being studied. Ex vivo perfusion techniques allow more time for organ and tissue assessment before placement. Immediately following reperfusion, significant tissue injury occurs related to inflammation, apoptosis, epigenetic changes, and oxidative stress. Immune therapies targeted at reducing or limiting this damage are ongoing but are struggling to overcome the small number of patients enrolled in their clinical trials. Stem cells, anti-inflammatory T cells, and regenerative agents are being explored to enhance the repair process following this initial tissue damage. Pharmaceutical companies are exploring methods to enhance the effectiveness and reduce the adverse effects of immunosuppressive agents given to organ recipients (Lewis et al., 2021; Timar et al., 2021).

An area that can be expanded upon is the use of organs donated by older adults. Recent studies have demonstrated that older donor age is linked to poor outcomes following the transplantation of a liver, kidney(s), pancreas, heart, and lung; however, the onset of adverse effects varies based on the organ transplanted. A proposed strategy to improve the outcomes of organ donation from older adult donors is prehabilitation conditioning to enhance nutritional status and physical functioning. More organ-specific research is needed to determine the safety and effectiveness of utilizing specific organs from older donors (Weimann et al., 2023).

Tissue transplant-related adverse events can have serious consequences for patient outcomes, making strong prevention protocols essential. Complications may include graft failure; immune reactions; and the transmission of infectious agents such as viruses, bacteria, and fungi. While these events are uncommon, infections can still occur due to improper tissue handling or inadequate donor screening and testing. To reduce these risks, The Joint Commission strengthened its tissue transplant safety standards by elevating them to a National Patient Safety Goal^TM (#9, Tissue Transplant Safety) in 2025. These standards require hospitals to implement and consistently follow safe tissue transplant practices designed to prevent avoidable adverse events and protect patient health (Joint Commission, 2026).

The organ transplantation system is complex and involves multiple agencies and stakeholders nationwide. A committee convened by the Centers for Medicare & Medicaid Services (CMS) and HRSA is the Organ Transplantation Affinity Group (OTAG), a collaborative effort aimed at driving improvements in organ donation, clinical transplant outcomes, system-wide improvements, quality measurement, transparency, and regulatory management. Key priorities put forth by OTAG include the following:

• enhancing collaboration on federal policy development, implementation, and communication to improve transparency and advance progress on national goals.
• harmonizing data across the organ transplantation system to improve system performance and develop a core set of national organ transplantation system performance metrics.
• strengthening accountability to patients, families, and the public by:
• Advancing access to transplantation by collecting data and establishing criteria for standardization and transparency of waitlist practices
• Ensuring a transparent process for intake of stakeholder complaints and ensuring that concerns and recommendations are addressed in a timely manner; and
• Promoting patient safety and engagement (HHS, 2025b, para. 2).

The UNOS information hotline at 800-978-4334 can be contacted for additional details on transplantation. For further information regarding organ and tissue donation, email [email protected] (HRSA, 2021a; UNOS, n.d.-a).

References

Aghedo, B. O., & Gupta, V. (2023). Filgrastim. In StatPearls [Internet]. StatPearls Publishing. Retrieved July 23, 2026, from https://www.ncbi.nlm.nih.gov/books/NBK559282

Alkhalaileh, F., Duarte, G., & Baran, D. A. (2026). Thriving long term after heart transplantation. Canadian Journal of Cardiology, 42(2), 406–413. https://doi.org/10.1016/j.cjca.2025.11.014

American Society of Anesthesiologists. (2022). Statement on controlled organ donation after circulatory death. https://www.asahq.org/standards-and-practice-parameters/statement-on-controlled-organ-donation-after-circulatory-death

American Transplant Foundation. (2023). Facts and myths about organ donation. https://www.americantransplantfoundation.org/about-transplant/facts-and-myths

Bag, R., O’Connor, M. F., Dalton, A., & Marklin, G. F. (2026). Management of the deceased organ donor. UpToDate. Retrieved July 23, 2026, from https://www.uptodate.com/contents/management-of-the-deceased-organ-donor

Boas, H. (2025). Are organ donations expressions of altruism or solidarity? Toward a moral economy of transplantation medicine. Social Theory Health, 23, 9. https://doi.org/10.1057/s41285-025-00221-0

Centers for Disease Control and Prevention. (2024). How HIV spreads. https://www.cdc.gov/hiv/causes/#cdc_causes_risk-risk-factors

Crane, E., Scales, A., Mclaughlin, L., Hollinger, R., Mildner, R. J., & Noyes, J. (2025). Understanding why parents say yes or no to organ donation when their child dies: Mixed-methods study. Journal of Advanced Nursing, 82(4), 3617–3638. https://doi.org/10.1111/jan.17091

da Silva Knihs, N., Paim, S. M. S., dos Santos, J., dos Reis Bellaguarda, M. L., Silva, L., Magalhães, A. L. P., Treviso, P., & Schirmer, J. (2022). Care bundle for family interview for pediatric organ donation. Journal of Pediatric Nursing, 64, 56–63. https://doi.org/10.1016/j.pedn.2022.01.010

Dominguez-Gil, B., Ascher, N., Capron, A. M., Gardiner, D., Manara, A. R., Bernat, J. L., Minambres, E., Singh, J. M., Porte, R. J., Markmann, J. F., Dhital, K., Ledoux, D., Fondevila, C., Hosgood, S., Van Raemdonck, D., Keshvjee, S., Dubois, J., McGee, A., Henderson, G. V., … Delmonico, F. L. (2021). Expanding controlled donation after the circulatory determination of death: Statement from an international collaborative. Intensive Care Medicine, 47(3), 265–281. https://doi.org/10.1007/s00134-020-06341-7

Donate Life America. (n.d.). Pediatric donation. Retrieved July 23, 2026, from https://donatelife.net/donation/types/pediatric-donation

Donor Alliance. (n.d.). Religious views on donation and transplantation. Retrieved July 23, 2026, from https://www.donoralliance.org/religious-views-on-donation-and-transplantation

Esbensen, K. L., DeCamp, M., Crigger, E. J., & Sulmasy, L. S. (2025). Ethical issues in organ transplantation: A position paper from the American College of Physicians. Annals of Internal Medicine, 178(12). https://doi.org/10.7326/ANNALS-25-01738

Etheredge, H. R. (2021). Assessing global organ donation policies: Opt-in vs opt-out. Risk Management and Healthcare Policy, 14, 1985–1998. https://doi.org/10.2147/RMHP.S270234

Fine, N. M. (2025). Heart transplantation. Merck Manual Professional Version. https://www.merckmanuals.com/professional/immunology-allergic-disorders/transplantation/heart-transplantation

Finger, E. B. (2023a). Organ preservation: Pathophysiology of organ preservation. https://emedicine.medscape.com/article/431140-overview#a2

Finger, E. B. (2023b). Organ preservation: Practice essentials. https://emedicine.medscape.com/article/431140-overview#a1

Finger, E. B. (2023c). Organ preservation: Techniques of organ preservation. https://emedicine.medscape.com/article/431140-overview#a4

Gettis, M. A., Basu, R., Welling, S., Wall, E., Dutreuil, V., & Calamaro, C. J. (2024). Pediatric death and family organ donation: Bereavement support services in one pediatric health system. Journal of Patient Experience, 11. https://doi.org/10.1177/23743735241226987

Gunst, J., & Souter, M. J. (2024). Management of the brain-dead donor in the intensive care unit. Intensive Care Medicine, 50, 964–967. https://doi.org/10.1007/s00134-024-07409-4

Haliko, S., & Arnold, R. M. (2024). Discussing organ donation with families. Palliative Care Network of Wisconsin. Retrieved October 2, 2023, from https://www.mypcnow.org/fast-fact/discussing-organ-donation-with-families

Health Resources and Services Administration. (2021a). Contact us. https://www.organdonor.gov/about-us/contact-us

Health Resources and Services Administration. (2021b). Glossary. https://www.organdonor.gov/learn/glossary

Health Resources and Services Administration. (2021c) Religion and organ donation. https://www.organdonor.gov/about/donors/religion.html

Health Resources and Services Administration. (2024). What can be donated? https://www.organdonor.gov/learn/what-can-be-donated

Health Resources & Services Administration. (2025a). Living organ donation. https://www.organdonor.gov/learn/process/living-donation

Health Resources & Services Administration. (2025b). Metric dashboards. https://www.hrsa.gov/optn/data-calculators/dashboards-metrics/optn-metrics

Health Resources & Services Administration. (2025c). Organ donation statistics. https://www.organdonor.gov/learn/organ-donation-statistics

Health Resources & Services Administration. (2025d). Who can donate? https://www.organdonor.gov/about/donors.html

Ignatavicius, D. D., Workman, L. M., Rebar, C. R., & Heimgartner, N. M. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care (10th ed.). Elsevier.

Israni, A. K., Zaun, D. A., Martinez, A., Swanner, K., Studenic, E., Lozano, C., McKinney, W. T., Miller, J. M., Hart, A., & Snyder, J. J. (2024). OPTN/SRTR 2024 annual data report: Deceased organ donation. Health Resources & Services Administration. https://srtr.hrsa.gov/adr/2024/DOD/

Joint Commission. (2026). National performance goal #9, tissue transplant safety. https://www.jointcommission.org/en-us/standards/national-performance-goals/tissue-transplant-safety

Kuter, D. J. (2026). Clinical applications of thrombopoietic growth factors. UpToDate. Retrieved July 23, 2026, from https://www.uptodate.com/contents/clinical-applications-of-thrombopoietic-growth-factors

Lewis, A., Kirschen, M. P., & Greer, D. (2023). The 2023 AAN/AAP/CNS/SCCM pediatric and adult brain death/death by neurologic criteria consensus practice guideline, a comparison with the 2010 and 2011 guidelines. Neurology Clinical Practice, 13(6), e200189. https://doi.org/10.1212/CPJ.0000000000200189

Lewis, A., Koukoura, A., Tsianos, G.-I., Gargavanis, A. A., Nielsen, A. A., & Vassiliadis, E. (2021). Organ donation in the US and Europe: The supply vs. demand imbalance. Transplantation Reviews, 35(2), 100585. https://doi.org/10.1016/j.trre.2020.100585

Li, X., Ding, R., & Cai, J. (2026). Organ transplantation: Current status, challenges, and future prospects. MedComm, 7(1), e70567. https://doi.org/10.1002/mco2.70567

Liebman, J., & Schiff, T. (2026). The dead donor rule is far from perfect, but context is key. Journal of Medical Ethics, 52(9), 601-602. https://doi.org/10.1136/jme-2026-11843

Live on Nebraska. (2026). Service above self: 100-year-old veteran becomes U.S.’s oldest organ donor. https://liveonnebraska.org/news/nebraska-veteran-becomes-oldest-organ-donor-in-us/

Muco, E., Yarrarapu, S. N. S., Douedi, H., & Burns, B. (2023). Tissue and organ donation. In StatPearls [Internet]. StatPearls Publishing. Retrieved July 23, 2026, from https://www.ncbi.nlm.nih.gov/books/NBK557431

Murray, R., & Kramer, H. (2022). Realizing the goals of the Advancing American Kidney Health Initiative: Toward a better future for kidney disease research funding. Advances in Chronic Kidney Disease, 29(1), 76–82. https://doi.org/10.1053/j.ackd.2022.01.005

National Institute on Aging. (2022). Frequently asked questions about organ donation for older adults. https://www.nia.nih.gov/health/frequently-asked-questions-about-organ-donation-older-adults

National Research Council. (2022). Realizing the promise of equity in the organ transplantation system. The National Academies Press. https://doi.org/10.17226/26364

Office of Minority Health. (2026). Organ transplants and Black/African Americans. U.S. Department of Health and Human Services. https://minorityhealth.hhs.gov/organ-donation-and-african-americans

Organ Donation & Transplantation Alliance. (n.d.). Effective end-of-life conversations: A collaborative approach between the hospital and OPO. Retrieved July 23, 2026, from https://www.organdonationalliance.org/insight/effective-end-of-life-conversations-a-collaborative-approach-between-the-hospital-and-opo

Organ Procurement & Transplantation Network. (2025a). Ethical considerations of imminent death donation. https://www.hrsa.gov/optn/professionals/resources/ethical-considerations/imminent-death-donation-white-paper

Organ Procurement & Transplantation Network. (2025b). How organ allocation works. Health Resources & Services Administration https://www.hrsa.gov/optn/patients/organ-transplants/how-organ-allocation-works

Organ Procurement & Transplantation Network. (2025c). Living non-directed organ donation. https://www.hrsa.gov/optn/professionals/resources/ethical-considerations/living-non-directed-organ-donation

Seshadri, A., Cuschieri, J., Kaups, K. L., Knowlton, L. M., Kutcher, M. E., Pathak, A., Rappold, J., Rinderknecht, T., Stein, D. M., Young, J., & Michetti, C. P. (2023). Organ donation in the surgical ICU: An American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surgery & Acute Care Open, 8, e001107. https://doi.org/10.1136/tsaco-2023-001107

Slater, A. (n.d.). Supporting donor families through the authorization process. LifeShare University. Retrieved July 23, 2026, from https://www.lifeshareuniversity.org/approaching-donor-families.html

Starr, R., Tadi, P., & Pfleghaar, N. (2024). Brain death. In StatPearls [Internet]. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK538159

Timar, J., Bleil, M., Daly, T., Koomar, S., Hasz, R., & Nathan, H. (2021). Successful strategies to increase organ donation: The Gift of Life Donor Program Philadelphia model. Indian Journal of Thoracic and Cardiovascular Surgery, 37(Suppl 3), 380–394. https://doi.org/10.1007/s12055-021-01219-9

United Network of Organ Sharing. (n.d.-a). UNOS customer service. Retrieved October 6, 2023, from https://unos.org/technology/help-desk/

United Network of Organ Sharing. (n.d.-b). UNOS History. Retrieved July 23, 2026, from https://unos.org/about/unos-history/

U.S. Department of Health and Human Services. (2025a). 2025 national survey of organ donation attitudes and practices: Report of findings. https://www.organdonor.gov/sites/default/files/organ-donor/professional/grants-research/nsodap-organ-donation-survey-2025.pdf

U.S. Department of Health and Human Services. (2025b). The Organ Transplantation Affinity Group (OTAG). https://www.hhs.gov/about/agencies/advisory-committees/organ-transplantation-affinity-group/index.html

Walters, S., & Kleiman, A. M. (2023). Organ donation: Donation after brain death and donation after cardiac death. Open Anesthesia. https://www.openanesthesia.org/keywords/organ-donation-donation-after-brain-death-and-donation-after-cardiac-death

Weimann, A., Ahlert, M., Seehofer, D., Zieschang, T., & Schweda, M. (2023). Old age and frailty in deceased organ transplantation and allocation-A plea for geriatric assessment and prehabilitation. Transplant International, 36, 11296. https://doi.org/10.3389/ti.2023.11296

World Health Organization. (2026a). Hepatitis B. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b

World Health Organization. (2026b). Hepatitis C. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c

Powered by Froala Editor