Organ Donation Core business for every intensive care unit — recognition, diagnosis, referral, donor management, follow-up.

Donation nearly always needs major input from the ICU team. Every deceased-donor transplant in this country begins in a unit like ours — with a grieving family, and a clinician who recognised the possibility in time. This week's map lays out the work that follows: recognition, diagnosis, referral, donor management, and follow-up and review.

The framing worth holding onto: donation is not an afterthought bolted onto death. It is a discipline — identification, diagnosis, and physiological stewardship — that sits squarely inside our skill set. The map below is the whole territory on one page; the notes beneath walk each branch.

Branch 01The registration gap

The Australian numbers are quietly damning. Four in five of us support donation in principle; only about one in three are registered. The gap is not attitude — it is a one-minute administrative act that nobody quite gets around to. And that gap surfaces at exactly the wrong moment: the family conversation in the hospital.

Roughly 2,000 Australians wait on the transplant list, with another 14,000 on dialysis — many of whom a single kidney would release. The lever that moves consent is not persuasion at the bedside; it is a decision made calmly, in advance, and spoken aloud to family. Friction, not conviction, is the enemy.

Branch 02Identifying the donor

This is where the intensivist holds the lever. The single most important idea for trainees: identification is a systems task, not a judgement call. Missed donors are rarely lost to bad medicine; they are lost to a well-meaning clinician who decided in advance that the patient was too old, too complicated, or that the family would surely refuse. None of those are our call to make.

The trigger to refer

Any patient with a devastating, non-survivable brain injury where either brain death is anticipated, or withdrawal of life-sustaining treatment is being considered — for any reason. Refer all patients on an end-of-life pathway: the Organ and Tissue Donation Service wants to know about every one of these, and suitability is theirs to determine, not ours. The two pathways:

• DBD — donation after brain death: the ventilated, heart-beating donor. Refer on suspicion of brain death, not after confirmation.
• DCD — donation after circulatory death: any planned withdrawal is a trigger. This is the one trainees miss, because the patient isn't brain-dead and the mental model of "the donor" never fires.

Refer before you speak

The rule that matters most in practice: contact the donation service before donation is ever raised with the family, and before withdrawal. This preserves the option, and it allows decoupling — separating the conversation about death from the conversation about donation, with the latter led by a trained requester alongside you. Decoupling and trained requesters are among the most robust findings in the field: consent rates rise when the ask is made well, by someone prepared for it, rather than bolted onto a futility discussion by a tired registrar at 3am.

Branch 03Diagnosing death

The governing authority in this country is the ANZICS Statement on Death and Organ Donation — cite it, and know it. Brain death determination follows a fixed architecture, and skipping a step invalidates everything above it.

• Preconditions — a known, catastrophic, irreversible cause; a minimum observation period; normothermia and normotension; no sedatives or neuromuscular blockade; no confounding metabolic or endocrine disturbance; no severe hypoxaemia. Miss one and the exam is void.
• Clinical exam — two doctors, each with the specified experience, neither on the transplant team, examining independently for absent brainstem reflexes: pupillary, corneal, oculovestibular, oculocephalic, gag and cough, and no motor response in the cranial nerve distribution.
• Apnoea test — no respiratory drive at an adequately elevated PaCO₂ from a sound baseline.
• Ancillary testing — cerebral angiography or radionuclide perfusion, required only when clinical testing cannot be completed.

Branch 04Protecting the donor

Brain death is a physiological storm followed by a collapse: vasomotor tone is lost, diabetes insipidus pours out, the myocardium falters, temperature falls, coagulation frays. Management is no longer about the person — it is about protecting the organs for the people waiting. The paradox is this: the ceiling of care hasn't lowered here. It has risen. You are resuscitating for two.

The bedside shorthand for the perfusion targets is the rule of 100s — four numbers that keep the organs viable, sitting on top of the real work: desmopressin for the DI, hormonal resuscitation in the unstable donor, lung-protective ventilation and recruitment, active rewarming, glycaemic control. As for the four numbers themselves — see this week's challenge.