Organ donation procedure
How does the organ donation procedure work? On this page, you will find a step-by-step explanation and all the information you need.
1. Potential donor? Consult the Donor Register
Organ donation always takes place in the hospital. The procedure can start once it is clear that further medical treatment is futile and the patient will pass away.
This usually concerns patients in the intensive care unit (ICU). However, also consider organ donation for a patient with a poor prognosis in the emergency department (ED). It may occur that there is a case in the neurology department. You can consult the ODC about this.
- For children under 18, there is the Child as donor protocol.
- For organ donation after euthanasia there are separate guidelines.
Poor prognosis? Consult the Donor Register
As a doctor on the acute care pathway (ICU and ED), are you dealing with a poor prognosis? Call the Organ Center (OC) to consult the Donor Register, even if in doubt. This is possible 24 hours a day. A BIG registration is required for the consultation. A doctor can also delegate the authority to consult to an employee without a BIG registration.
Call the Organ Center (24/7)
Information you need for consulting the Donor Register
- Attending physician: BIG registration number and telephone number.
- Patient: citizen service number (BSN), gender, initial(s), surname and date of birth.
What does the Organ Center ask when consulted?
The Organ Center consults the Donor Register. Is there a 'No' in the Donor Register? Then donation is not possible and the telephone call is ended. For other registrations in the Donor Register, the Organ Center performs a brief check for contraindications.
Contraindications and conditions
- Is there still circulation? This is a condition for organ donation.
- Is there an untreated malignancy? If so, organ donation cannot proceed. Exceptions are skin or brain tumors.
Other factors also play a role in determining the medical suitability of an organ donor. You will discuss these later with the organ donation coordinator (see below).
Organ donation not (or no longer) possible?
Then consider tissue donation, as this may still be possible.Go to the tissue donation procedure.
Potential organ donor? Organ donation coordinator helps immediately
After this brief check by the Organ Center, is organ donation potentially possible? Then the Organ Center employee ensures that the consulting physician is put in contact with the organ donation coordinator (ODC). This telephone call takes place before the bad news conversation, because next of kin sometimes bring up organ donation themselves.
The ODC is specialized in the organ donation procedure and can go through the following topics with you:
- Medical suitability for organ donation
- Logistical planning of the procedure
- Legal aspects: legal validity of registration, incapacity and unnatural death
- Donation conversation: preparing together and potentially assistance during the conversation (on-site or by telephone)
Use this expertise to be well-prepared for the conversation with the next of kin.
Detailed information
Want to know more about donor identification and consulting the Donor Register?
Model Protocol for Donor Identification
2. Donation conversation about organs
Is donation possible? If so, conduct a donation conversation in which you inform the next of kin of a potential donor about the registration in the Donor Register. You also provide an explanation of the procedure.
The information below concerns the most common situation: a potential donor aged 16 or older who has decision-making capacity. In the Model Protocol, you will find instructions for lack of decision-making capacity at the time of registration.
Are you looking for tips for the tissue donation conversation?
Does it (also) involve a tissue donor? View the tips for explaining this procedure clearly to the next of kin.
Tips for tissue donation conversation
Explanation per registration
The registration of the potential donor in the Donor Register is leading for the conversation. View how to conduct the conversation for each registration.
Yes, I want to become a donor
How do you discuss a 'yes' registration?
A 'yes' registration is an active choice. The potential donor has chosen for donation themselves.
- Inform the next of kin about the registration.
- Ask the next of kin if they have ever spoken about donation with the potential donor.
- Provide an explanation of the procedure.
- Watch the animation below and use the example sentence to explain the registration.
Who are you having the conversation with?
In practice, you usually have the conversation with immediate family. Think of the partner, children, or siblings. Are they unreachable? Then try to postpone the donation until someone has been reached.
According to the law, it is also permitted to inform next of kin. These are all people who play a (significant) role in the patient's life. These are often family members, but they can also be other people who know the patient well and are actively involved in their life.
What can you do to reach next of kin?
- Use regular channels: search the patient's personal belongings to find contact information.
- If that doesn't work, ask the police to reach the next of kin through their channels.
- In the meantime, you may already perform preparatory actions for the donation.
Are next of kin unreachable or can the donation no longer be postponed? Then no donation will take place.
Are the surviving relatives convinced that the registration is incorrect?
A 'yes' in the Donor Register means consent for donation. This registration is leading. The intention is for the donation to proceed.
It may happen that surviving relatives are convinced that the registration does not match the patient's wishes. In that case, they can substantiate this:
- Substantiating is not about providing proof, but about explaining and clarifying.
- Your professional judgment as a doctor counts. You decide whether or not to proceed with the donation based on this conversation.
Note:Only surviving relatives up to the 2nd degree can refute the registration in the Donor Register. Others are not legally permitted to do so.
- Who are surviving relatives up to the 2nd degree?(Model protocol 4.7)
- Objection by surviving relatives to the nature of the registration (Model protocol 4.10)
Do surviving relatives have personal objections to donation?
Surviving relatives may also indicate that they personally have difficulty with the donation.
Try to understand and ask further questions about where the objections come from: are there certain assumptions about the procedure, or is something related to their philosophy of life or culture playing a role?
- Read how to deal with these objections (Model protocol 4.11)
No objection to donation
How do you discuss the 'no objection' registration?
Everyone aged 18 and over is in the Donor Register. If you do not actively make a choice yourself, you are registered as having given consent based on a 'no objection' registration. You have been informed of this through 3 letters from the government.
- Inform the next of kin about the registration.
- Ask the relatives if they have ever spoken to the patient about donation.
- Provide an explanation of the procedure.
- Watch the animation below and use the example sentence to explain the registration.
Who are you having the conversation with?
In practice, you usually have the conversation regarding a 'no objection' registration with the immediate family. Think of the partner, children, or siblings. Are they unreachable? Then try to postpone the donation until someone has been reached.
According to the law, it is also permitted to inform next of kin. These are all people who play a (significant) role in the patient's life. These are often family members, but they can also be other people who know the patient well and are actively involved in their life.
What can you do to reach next of kin?
- Use regular channels: search the patient's personal belongings to find contact information.
- If that doesn't work, ask the police to reach the next of kin through their channels.
- In the meantime, you may already perform preparatory actions for the donation.
Are relatives unreachable or can the donation no longer be postponed? Then no donation will take place.
Are surviving relatives convinced that the registration is incorrect?
With a 'no objection' registration in the Donor Register, there is consent for donation. This registration is leading. The intention is for the donation to proceed.
It may happen that surviving relatives are convinced that the registration does not match the patient's wishes. In that case, they can substantiate this:
- Substantiating is not about providing proof, but about explaining and clarifying.
- Your professional judgment as a doctor counts. You decide whether or not to proceed with the donation based on this conversation.
Note: Only surviving relatives up to the 2nd degree can refute the registration in the Donor Register. Others are not legally permitted to do so.
- Who are surviving relatives up to the 2nd degree?(Model protocol 4.7)
- Objection by surviving relatives to the nature of the registration (Model protocol 4.10)
Do surviving relatives have personal objections to donation?
Surviving relatives may also indicate that they personally have difficulty with the donation.
Try to understand and ask further questions about where the objections come from: are there certain assumptions about the procedure, or is something related to their philosophy of life or culture playing a role?
- Read how to deal with these objections (Model protocol 4.11)
My partner or family decides for me
How do you discuss the wish for a partner or family to decide?
With the registration 'My partner or family decides for me', the patient leaves the decision to their partner or family.
- Inform the partner or family about the registration.
- Ask if this registration was known to the partner or family.
- Provide information about the procedure.
- Give them time to process all the information, read it over, and think about the decision.
- Watch the animation below and use the example sentence to explain the registration.
Who are you having the conversation with?
You conduct the donation conversation with next of kin up to the 2nd degree. There are 3 categories:
- Spouse, registered partner, or other life partner of the patient.
- Adult blood relatives up to the 2nd degree: (adopted) children, (adopted) parents, siblings, grandparents, and grandchildren.
- Adult relatives by marriage up to the 2nd degree: children of the spouse (or registered partner), parents-in-law, grandparents-in-law, brothers-in-law, sisters-in-law, sons-in-law, daughters-in-law, and step-grandchildren.
The order determines the decision-making authority:
- First, contact a person from category 1. This person makes the choice. You do not need to ask for permission from a person in a subsequent category.
- Is there no next of kin from category 1, or are they unreachable? Then you approach a person from category 2, and so on.
- You make reasonable efforts to reach next of kin in a category, but you do not have to reach everyone.
Read more in the Model Protocol (4.7): Who are surviving relatives up to the 2nd degree?
Next of kin unreachable?
You do everything possible to reach the next of kin. If no next of kin can be found, the donation will not proceed. You may not ask for permission from those close to the patient, because those close to the patientnothave the authority to decide.
Can consent still be withdrawn?
The partner or family members can withdraw consent until the moment the deceased is taken to the operating room/mortuary for the donation of organs or tissues.
I designate one person to decide
How do you proceed if the patient leaves the decision to one person?
When registering 'I designate one person to decide', the patient leaves the decision to the designated person.
The decision of the person named in the registration is leading for donation. It does not matter to the law how long ago the specific person had contact with the patient.
- Inform this person about the registration.
- Ask if this registration was known to the designated person.
- Provide information about the procedure.
- Give them time to process all the information, read it over, and think about the decision.
- Watch the animation below and use the example sentence to explain the registration.
Who are you having the conversation with?
The designated person is present during the conversation. You provide information necessary to make an informed decision.
Is the designated person unreachable?
You do everything possible to reach this person. If you have not succeeded? Then you can ask the next of kin about the donation request.
Read more in the Model Protocol (4.7): Who are surviving relatives up to the 2nd degree?
If there are no next of kin, the donation will not proceed. You may not ask for consent from relatives. They are, after all,notauthorized to decide.
Can consent still be withdrawn?
The designated person (authorized decision-maker) can withdraw consent until the moment the deceased is taken to the operating room/mortuary for the donation of organs or tissues.
No, I do not want to become a donor
What do you do in case of a 'no' registration?
The patient has explicitly indicated not wanting to be a donor. There is no consent for donation.
Donation will never proceed with this registration.
- Inform the next of kin that there is no consent for donation.
- Watch the animation below and use the example sentence to explain the registration.
Guidance from the ODC
Tell the next of kin that they will receive guidance from an organ donation coordinator (ODC). They can answer questions about the donation procedure. Discuss in advance whether the ODC will join the donation conversation or be available by phone.
How do you explain the procedure?
Is the donation proceeding? Give the next of kin a clear explanation of the procedure. Realize that this is a lot of information and completely new information for most people.
- Listening is more important than speaking. Address concerns and answer questions.
- Dose medical information and avoid jargon.
- Ensure realistic expectations regarding the duration of the procedure.
Do you expect questions related to philosophy of life, religion, or culture?
Contact a spiritual counselor or medical social worker from your hospital. If necessary, ask this person to join the donation conversation.
Tip! Use the discussion chart during the conversation
The discussion chart provides the family with guidance during the donation conversation. The chart depicts the steps of organ donation and includes space for notes. Give the discussion chart to them afterwards.
Order discussion chart (tear-off pad): info@transplantatiestichting.nl
Concluding the donation conversation
- Summarize what you have discussed. Or ask a next of kin who is present at the conversation to do so.
- State the conclusion: donation/no donation.
- Ask if this is correct and if everything is clear.
Tip! Provide information for at home
Provide information for at home afterwards or share the online information.
Detailed information
Extensive explanation of the donation conversation and the legal framework?Model Protocol Donation Conversation
Interesting training for you
3. Registering an organ donor
After the donation conversation and the collection of all data, the organ donor can be registered. What is required for this?
Medical examination of organs
Before registering an organ donor, various medical examinations are still required to assess which organs are suitable for donation, as well as a heteroanamnesis regarding the medical and social history. In addition, blood is always drawn for tissue typing and virology.
The organ donation coordinator (ODC) coordinates these examinations and works together with the attending physician.
Read also:Medical examinations and Heteroanamnesis (Model protocol)
Registration with Eurotransplant
Once all examinations have been completed and the patient is deemed suitable as an organ donor, the ODC registers the organ donor with Eurotransplant. Eurotransplant allocates organs to recipients based on current allocation rules.
Arranging logistics
As coordinator of the donation procedure, the ODC organizes the logistics surrounding the procedure.
- Between the time of donor registration and the start of organ retrieval, there must be 4 to 6 hours between them. For heart donation, this is 8 hours.
- This time is necessary to call in the recipients and make preparations for the transplantation. The exact number of hours required depends on the organs being donated.
The ODC arranges the logistics:
- An operating room is available.
- A retrieval team is called in.
- Cross-match material is sent to the laboratory.
- The transport of the organs.
Detailed information
Want to know more about registration?
4. Determining death
If the donation conversation indicates that donation is possible, the procedure can begin. This can be a DBD or DCD procedure.
- DBD: Donation after Brain Death
In a DBD procedure, death is determined based on neurological criteria (brain death). - DCD: Donation after Circulatory Death
In a DCD procedure, death is determined based on circulatory criteria.
Determining death in the DBD procedure
When brain death is suspected, the DBD procedure is initiated.
- Execute the brain death protocol to determine brain death.
- Brain death determined? Fill out the brain death form.
- Take the donor to the operating room at a time coordinated in advance with all involved professionals and the next of kin. This is several hours after brain death has been determined.
- Take the brain death form and the donation form to the operating room.
Detailed information
Want to know more about DBD?
Determining death in the DCD procedure
The DCD procedure starts when the decision has been made to withdraw life-sustaining treatment from a patient and brain death cannot be determined. After stopping treatment and ventilation, the agonal phase follows, and death is determined based on circulatory criteria. The procedure consists of 3 phases:
1. Stopping treatment
- Stopping treatment almost always takes place in the intensive care unit (ICU). Coordinate the timing of the switch-off with the next of kin, the intensive care unit, and the organ donation coordinator (ODC). The ODC arranges the independent retrieval team (ZUT).
- The switch-off can also take place in the operating room (OR), with the advantage that the warm ischemia time is shorter. This decision is always made in close consultation with the next of kin. They must give their consent for this.
2. Agonal phase
The agonal phase is the period between the switch-off and the patient's death.
- The donor is administered intravenous heparin: 300 IU/kg of body weight. This is done at the moment of switch-off or immediately thereafter. Circulation must still be present for this.
- Observation of the perfusion and oxygenation of the organs takes place.
- The ODC records the heart rate, blood pressure, respiration, and oxygen saturation.
For the quality of the organs, the agonal phase should not last longer than 1 to 2 hours.
3. Determining death: 2 crucial moments
A DCD procedure for determining death involves 2 crucial moments.
- Determining circulatory arrest
There must be no doubt about the circulatory arrest:
- Use a fixed arterial line that can measure all changes in arterial pulsations and pressure with sufficient sensitivity and specificity.
- In addition, if necessary, perform non-invasive examinations such as blood pressure measurement, auscultation of the heart, electrocardiography, or echocardiography.
- No-touch period of 5 minutes
After determining circulatory arrest, a no-touch period of 5 minutes follows.
- During the no-touch period, no actions may be performed. The period ends at the moment it is sufficiently certain that the circulatory arrest is permanent.
- Only after the 5-minute no-touch period can death be definitively determined. During the 5-minute no-touch period, the donor may not be transported.
Follow-up:
- Take the donor immediately to the operating room.
- Fill in the donation form and time of death and send it along to the operating room.
Detailed information
Want to know more about DCD?
5. Donor management
Treating the organ donor differs between a DCD and DBD procedure. Read here what you need to do in both procedures.
Donor management DCD
The DCD procedure starts when it has been decided to stop a medical treatment that is no longer meaningful, and when brain death cannot be determined. It takes a number of hours before the treatment is actually stopped. In this phase, providing comfort and maintaining good organ function is important.
When to administer heparin in DCD?
Administering heparin is necessary for good liver, lung, and pancreas quality. Good to know:
- Administer heparin at the time of switch-off.
- Trauma patient with clear external injuries? Then heparin is discouraged.
- Organ donation after euthanasia? Also administer heparin (see guideline organ donation after euthanasia).
Guidelines DCD heart donation
- Be cautious with the administration of inotropes, vasopressors, and other cardiodepressive agents.
- If necessary, preferably use short-acting agents. Try to dose these as low as possible.
- For the functioning of the heart perfusion machine, the donor's hematocrit should ideally be > 0.3 l/l.
Donor management in DBD
Until the organs are retrieved, everything possible is done to maintain or even improve the function of the organs. We call this donor management. View the advice in brief below.
Attention
Below is a brief summary of the recommendations per section. All details and explanations can be found in the Model Protocol.
1. Hemodynamic (in)stability: monitoring
According to current consensus, adequate volume administration is achieved with a low required dosage of vasoactive agents when:
- mean arterial pressure (MAP) 60 – 90 mmHg
- diuresis > 0.5 – 3 ml/kg/hour
- heart rate 60 – 120 / minute
2. Fluid therapy
- Aim for euvolemia in the donor.
- Preferably choose fluid therapy with bolus administration instead of continuous administration to prevent the risk of hypervolemia.
3. Hemodynamic support
- Start with vasopressors and/or inotropes according to the local protocol if hemodynamic goals cannot be met with fluid administration.
- Avoid high doses of beta-agonists in potential heart donors.
4. Treating arrhythmia
Tachycardia
- Exclude reversible underlying causes of tachycardia before starting pharmacological treatment. An underlying cause could be, for example, hypovolemia.
- Poorly tolerated tachycardia should be treated with a beta-blocker. Esmolol is preferred due to its short half-life.
- Preferably choose intravenous administration via a syringe pump.
Bradycardia
- Preferably administer isoprenaline, due to its direct chronotropic effect on the heart muscle.
- Administer isoprenaline at a dosage of 1 mcg intravenously. Repeat this every minute until the heart rate increases. Or continue treatment with a continuous infusion titrated to the heart rate.
- In case of acute emergency, administer adrenaline.
- If chronotropic medication proves insufficiently effective, consider intravascular pacing.
Atrial fibrillation
- Correct, if possible, potential underlying causes of atrial fibrillation.
- Consider magnesium supplementation.
- Attempt cardioversion – chemical or electrical – to convert the heart rhythm to a sinus rhythm. Heart donation is then theoretically still possible.
5. Hypertension
- Start antihypertensive treatment if systolic blood pressure > 200 mmHg or MAP > 130 mmHg.
- Preferably use a beta-blocker (metoprolol, esmolol, or labetalol) or nitroprusside, nitroglycerin, or nicardipine.
- For potential heart donors, preferably do not use beta-blockers, but rather one of the alternatives.
6. Ventilation
Recommendations for mechanical ventilation in potential lung donation:
- Ventilate the lungs protectively according to current lung-protective guidelines.
- Perform a recruitment maneuver after the apnea test.
- Consider recruitment maneuvers to improve the PaO2/FiO2 ratio.
- Improve lung quality through bronchial toilet or suctioning via bronchoscopy.
- Use a restrictive fluid policy.
- Prevent sputum stasis and suction the tube regularly.
- Insert a nasogastric tube with suction to prevent aspiration.
- Elevate the head of the bed to 30 degrees for proper donor positioning.
- Follow local guidelines for the prevention of ventilator-associated pneumonia.
7. Medication
Corticosteroid recommendation
- Administer 15mg/kg methylprednisolone intravenously after brain death has been established. This has positive effects on organ function after transplantation.
- Repeat this every 24 hours.
Vasopressin analogues recommendation
- Use desmopressin (DDAVP) 1 – 4 mcg IV in case of (suspected) diabetes insipidus. In case of persistent polyuria (> 3 ml/kg/hour), another 1 – 2 mcg of desmopressin IV can be administered. This can be repeated every 6 hours.
- Vasopressin and terlipressin have less effect in the treatment of diabetes insipidus. These agents may play a role in the treatment of hemodynamic instability.
Thyroid hormone recommendation
- Do not administer thyroid hormones as a standard procedure.
- Consider the use of thyroid hormones if hemodynamic instability persists, despite euvolemia and optimal doses of vasoactive medication support. Thyroid hormones increase cardiac contractility. This is due to their chronotropic effect and a reduction in systemic vascular resistance.
Combined hormone therapy recommendation
- Do not choose combined hormone therapy as a standard procedure.
8. Glucose regulation and electrolytes
Recommendations for glucose regulation:
- Follow current practice: aim for a serum glucose value of 6 – 8 mmol/l.
Recommendations for electrolyte disorders:
- Aim for normal values for electrolytes.
- Follow the electrolyte disorders guideline for the treatment of electrolyte disorders.
9. Transfusion thresholds
Recommendations for transfusion thresholds:
- Current practice: Hb > 4.3 mmol/l.
- In case of clinical bleeding, platelets and/or plasma factors.
- Consult with the accepting physician before applying perioperative correction of coagulation factors.
10. Temperature regulation and nutrition
Recommendations for temperature regulation:
- Keep the donor's temperature > 35 °C.
- Consider passive cooling in case of fever.
Recommendations for nutrition:
- Start or continue enteral nutrition according to the local protocol.
11. Prevention and treatment of bacterial infections
Recommendations for the prevention and treatment of infections:
- Collect blood, sputum, urine, and if necessary, wound cultures from all donors. Repeat this after 24 hours if necessary in case of fever.
- Continue antibiotic treatments that have already been started.
- Treat proven infections according to the local or national protocol.
- Administer SDD/SOD according to the protocol.
6. Aftercare following donation
Good aftercare for surviving relatives helps with the grieving process. Clear explanations and good information provision can mean a lot in this regard. On our website, you will find extensive information and support for surviving relatives who have dealt with organ or tissue donation of a loved one.
Comprehensive reference work
Guide to the Quality and Safety of Organs for Transplantation
European guideline with the latest insights and standards for organ donation and transplantation, based on recent scientific research.
- Publication: European Directorate for the Quality of Medicines & Health Care (EDQM), Council of Europe. 9th edition – 2025
Questions? Call the Organ Center
Call the Organ Center to consult the Donor Register or to register a tissue donor. Also in case of doubt or if you have questions.
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