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 when it is clear that further medical treatment is futile and the patient is going to pass away.
Usually these are patients in the intensive care unit (ICU). But also consider organ donation in a patient with a poor prognosis in the emergency department (ED). It may happen 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? Then call the Organ Centre (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 Centre (24/7)
Information you need to consult the Donor Register
- Treating physician: BIG registration number and telephone number.
- Patient: citizen service number (BSN), gender, initial(s), last name and date of birth.
What does the Organ Centre ask when consulted?
The Organ Centre consults the Donor Register. Is there a 'No' in the Donor Register? Then donation is not possible and the phone call is terminated. For other registrations in the Donor Register, the Organ Centre performs a brief check for contra-indications.
Contra-indications 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.
There are other factors involved 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
Is there a possibility of organ donation after this brief check by the Organ Centre? Then the Organ Centre employee will ensure that the consulting physician is put in contact with the organ donation coordinator (ODC). This phone call takes place even before the breaking bad news conversation, because next of kin sometimes bring up organ donation themselves.
The ODC specializes in the organ donation procedure and can discuss the following topics with you:
- Medical suitability for organ donation
- Logistical planning of the procedure
- Legal aspects: legal validity of registration, incapacity to consent and non-natural death
- Donation conversation: preparing together and possible assistance during the conversation (on location or by phone)
Use this expertise to be well-prepared for the conversation with the next of kin.
Detailed information
Want to know more about donor recognition and consulting the Donor Register?
Model Protocol Donor Recognition
2. Donation conversation about organs
Is donation possible? Then 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?
Is it (also) a tissue donor? View the tips to explain this procedure properly to the next of kin.
Explanation per registration
The registration of the potential donor in the Donor Register is leading for the conversation. View how to conduct the conversation per registration.
Yes, I want to become a donor
How do you discuss the 'yes' registration?
A 'yes' registration is an active choice. The potential donor chose donation themselves.
- Inform the next of kin about the registration.
- Ask the next of kin if they have ever discussed 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 do you have the conversation with?
In practice, you usually have the conversation with the immediate family. Think of the partner, children, or brother/sister. 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 (major) 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 the regular channels: look through the patient's personal belongings to find contact details.
- Does this not work? Then ask the police to reach the next of kin via their channels.
- In the meantime, you are already allowed to 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?
In the event of a 'yes' in the Donor Register, there is consent for donation. This registration is leading. The intention is to let the donation proceed.
It may happen that surviving relatives are convinced that the registration does not match the patient's wishes. Then they can make this plausible:
- Making plausible is not about proof, but about setting out and explaining.
- Your professional judgment as a doctor counts. You decide whether or not to let the donation proceed based on this conversation.
Please note: Only surviving relatives up to the 2nd degree can refute the registration in the Donor Register. Legally, others are not allowed to do this.
- 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 difficulty with donation?
The 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 there something related to their worldview or culture?
- Read how to handle these objections (Model protocol 4.11)
No objection to donation
How do you discuss the 'no objection' registration?
Everyone aged 18 and over is listed in the Donor Register. If you do not actively fill in a choice yourself, you are registered as consenting based on a 'no objection' registration. You were informed of this by 3 letters from the government.
- Inform the next of kin about the registration.
- Ask the relatives whether they ever spoke about donation with the patient.
- Provide an explanation of the procedure.
- Watch the animation below and use the example sentence to explain the registration.
Who do you have the conversation with?
In practice, you usually conduct the conversation in the case of a 'no objection' registration with the immediate family. Think of the partner, children, or brother/sister. 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 (major) 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 the regular channels: look through the patient's personal belongings to find contact details.
- Does this not work? Then ask the police to reach the next of kin via their channels.
- In the meantime, you are already allowed to 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?
In the case of 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. Then they can make this plausible:
- Making plausible is not about proof, but about setting out and explaining.
- Your professional judgment as a doctor counts. You decide whether or not to let the donation proceed based on this conversation.
Please note: Only surviving relatives up to the 2nd degree can refute the registration in the Donor Register. Legally, others are not permitted to do this.
- 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 difficulty with donation?
The 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 there something related to their worldview or culture?
- Read how to handle these objections (Model protocol 4.11)
My partner or family decides for me
How do you discuss the wish for the partner or family to decide?
When registering 'My partner or family decides for me', the patient leaves the decision up to their partner or family.
- Inform the partner or family about the registration.
- Ask whether this registration was known to the partner or family.
- Provide information about the procedure.
- Allow time to process all information, read through it, and think about the decision.
- Watch the animation below and use the example sentence to explain the registration.
Who do you have the conversation with?
You conduct the donation conversation with surviving relatives up to the 2nd degree. There are 3 categories:
- Spouse, registered partner, or other life companion of the patient.
- Adult blood relatives up to the 2nd degree: (adoptive) children, (adoptive) parents, brothers, sisters, grandparents, and grandchildren.
- Adult relatives by marriage up to the 2nd degree: children of the spouse (or registered partner), parents(-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 permission from a person in a subsequent category.
- Is there no surviving relative from category 1 or can they not be reached? Then you approach a person from category 2, and so on.
- You make reasonable efforts to reach surviving relatives 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?
Surviving relatives cannot be reached?
You do everything you can to reach surviving relatives. If no surviving relatives can be found, the donation will not proceed. You may not ask the relatives for permission, because relativesnothave the authority to make decisions.
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 handle it when the patient leaves the decision to a single person?
With the registration '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. By law, it does not matter how long ago that specific person has been in 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.
- Allow time to process all information, read through it, and think about the decision.
- Watch the animation below and use the example sentence to explain the registration.
Who do you have 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 you can to reach this person. Were you unsuccessful? Then you can ask the surviving relatives the donation question.
Read more in the Model Protocol (4.7):Who are surviving relatives up to the 2nd degree?
If there are no surviving relatives, the donation will not proceed. You may not ask relatives for consent. After all, they arenotauthorized to make decisions.
Can consent still be withdrawn?
The designated person (who has decision-making authority) 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 the event of a 'no' registration?
The patient has explicitly indicated they do not want 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 be guided by 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 going ahead? Provide the next of kin with a clear explanation of the procedure. Realize that this is a lot of information and completely new to most people.
- Listening is more important than speaking. Address concerns and answer questions.
- Pace the medical information and avoid jargon.
- Ensure realistic expectations about the duration of the procedure.
Do you expect questions related to philosophy of life, religion, or culture?
Contact a spiritual caregiver or medical social worker from your hospital. If necessary, ask this person to join the donation conversation.
Tip! Use the discussion poster during the conversation
The discussion poster offers the family something to hold onto during the donation conversation. The poster depicts the steps of organ donation and leaves room for notes. Give the poster to them afterwards.
Download the discussion poster
Order discussion poster (tear-off pad): info@transplantatiestichting.nl
Concluding the donation conversation
- Summarize what you have discussed. Or ask a next of kin present at the conversation to do this.
- State the conclusion: donation/no donation.
- Ask if this is correct and if everything is clear.
Tip! Provide information to take home
Afterwards, provide information to take home or share the online information.
Detailed information
Detailed 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 collecting all data, the organ donor can be registered. What is needed for this?
Medical examination of organs
Before registering an organ donor, various medical examinations are needed to assess which organs are suitable for donation and 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 collaborates with the treating physician.
Read also: Medical examinations and Heteroanamnesis (Model protocol)
Registration with Eurotransplant
When all examinations have been completed and the patient appears 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 registration of the donor and the start of the organ procurement must be 4 to 6 hours. For heart donation this is 8 hours.
- This time is needed to call in the recipients and make preparations for the transplantation. Exactly how many hours are needed depends on the organs being donated.
The ODC arranges the logistics:
- An operating room is available.
- A procurement team is called up.
- The cross-match material is sent to the laboratory.
- The transport of the organs.
Detailed information
Want to know more about registration?
4. Determination of death
If the donation interview 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 on the basis of neurological criteria (brain death). - DCD: Donation after Circulatory Death
In a DCD procedure, death is determined on the basis of circulatory criteria.
Determination of death in the DBD procedure
If 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.
- Transfer the donor to the operating room at a time coordinated in advance with all involved professionals and the relatives. This is a few hours after brain death has been determined.
- Bring the brain death form and the donation form to the operating room.
Detailed information
Want to know more about DBD?
Determination of death in the DCD procedure
The DCD procedure starts when a 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
- Discontinuation of treatment almost always takes place in the intensive care unit (ICU). Coordinate the time of the switch-off with the loved ones, the intensive care unit, and the organ donation coordinator (ODC). The ODC arranges the independent organ recovery 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 loved ones. They must give permission 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 body weight. This is done at the time of the switch-off or immediately afterwards. 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 must 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 dedicated arterial line that can measure all changes in arterial pulsations and pressure with sufficient sensitivity and specificity.
- In addition, perform non-invasive examinations if necessary, such as blood pressure measurement, auscultation of the heart, electrocardiography, or echocardiography.
- No-touch period of 5 minutes
Following the determination of circulatory arrest, a 5-minute no-touch period ensues.
- During the no-touch period, no procedures 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 pronounced. The donor may not be transported during the 5-minute no-touch period.
Next steps:
- Transfer the donor immediately to the operating room.
- Fill in the donation form and time of death and send this along to the operating room.
Detailed information
Want to know more about DCD?
5. Donor management
The management of the organ donor differs in a DCD and DBD procedure. Read here what you need to do in both procedures.
Donor management DCD
The DCD procedure starts when it is decided to stop medical treatment that is no longer meaningful, and when brain death cannot be established. It takes a number of hours before the treatment is actually stopped. In this phase, providing comfort and maintaining good organ function are important.
When to administer heparin in DCD?
The administration of 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 injury? 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 inotropy, vasopressors, and other cardiodepressant 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 is done to maintain or even improve the function of the organs as much as possible. This is called donor management. View the brief recommendations below.
Please note
Below is a brief summary of the recommendations per component. 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, at:
- 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.
- Prefer fluid therapy with bolus administration instead of continuous administration, to prevent the risk of hypervolemia.
3. Hemodynamic support
- Start 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
- Rule out reversible underlying causes of tachycardia before starting pharmacological treatment. An underlying cause may be hypovolemia, for example.
- Poorly tolerated tachycardia must be treated with a beta-blocker. Esmolol is preferred because of its short half-life.
- Prefer intravenous administration via a syringe pump.
Bradycardia
- Preferably administer isoprenaline because of its direct chronotropic effect on the heart muscle.
- Administer isoprenaline at a dose of 1 mcg intravenously. Repeat this every minute until the heart rate increases. Alternatively, continue treatment with a continuous infusion titrated to the heart rate.
- Administer adrenaline in case of acute emergency.
- If chronotropic medication proves insufficiently effective, consider intravascular pacing.
Atrial fibrillation
- Correct potential underlying causes of atrial fibrillation, if possible.
- Consider magnesium supplementation.
- Attempt cardioversion – chemical or electrical – to convert the heart rhythm to a sinus rhythm. Heart donation may then theoretically still be 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, nitroglycerine, or nicardipine.
- For potential heart donors, preferably avoid beta-blockers and instead use one of the alternatives.
6. Ventilation
Recommendations for mechanical ventilation in potential lung donation:
- Ventilate the lungs protectively in accordance with current lung-protective guidelines.
- Perform a recruitment maneuver after the apnea test.
- Consider recruitment maneuvers to improve the PaO2-FiO2 ratio.
- Improve lung quality by bronchial hygiene or by suctioning via bronchoscopy.
- Use a restrictive fluid management policy.
- Prevent sputum stasis and suction the endotracheal tube regularly.
- Insert a nasogastric tube with drainage 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 15 mg/kg of methylprednisolone intravenously after the diagnosis of brain death. 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 routinely administer thyroid hormones.
- Consider the use of thyroid hormones if hemodynamic instability persists despite euvolemia and optimal dosages of vasoactive drug 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 routinely choose combined hormone therapy.
8. Glucose regulation and electrolytes
Recommendations for glucose regulation:
- Follow current practice: aim for a serum glucose level of 6 – 8 mmol/l.
Recommendations for electrolyte disorders:
- Aim for normal electrolyte values.
- 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 the accepting physician before applying perioperative correction of clotting factors.
10. Temperature regulation and nutrition
Recommendations for temperature regulation:
- Keep the donor's temperature > 35 °C.
- Consider passive cooling in case of fever.
Nutritional recommendations:
- 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 wound cultures if applicable from all donors. Repeat this in case of fever after 24 hours if necessary.
- 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 aids in the grief process. Clear explanations and good information provision can make a significant difference here. 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 featuring the latest insights and standards for organ donation and transplantation, based on recent scientific research.
- Published by: European Directorate for the Quality of Medicines & Health Care (EDQM), Council of Europe. 9th edition – 2025
Questions? Call the Organ Centre
Call the Organ Centre to consult the Donor Register or to register a tissue donor. Also available for doubts or questions.
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