Nearly Half of Potential Organ Donors Are Never Referred, ICU Audit Reveals

Every year, thousands of people die while waiting for a transplant, and the gap between organ supply and demand keeps widening. Now, a meticulous five-year audit from a Belgian intensive care unit has quantified a sobering contributor to that shortage: nearly half of all potential organ donors who died in the unit were never referred to the transplant coordination team at all. The study, published in Frontiers in Transplantation, examined 183 critically ill patients with devastating brain injuries and found that 82 of them—45 percent—constituted potential missed referrals, meaning they were medically suitable candidates for donation but were simply never reported to the professionals who assess donor viability.

The research team, led by Leda Nobile and Fabio Silvio Taccone at the Hôpital Universitaire de Bruxelles, conducted a retrospective analysis of all patients admitted to their 32-bed mixed intensive care unit between January 2018 and December 2023 who died after hypoxic-ischemic encephalopathy, traumatic brain injury, or subarachnoid hemorrhage. These three conditions account for the vast majority of deceased organ donors worldwide, making them the natural starting point for any audit of donation practices. The investigators deliberately excluded patients with absolute contraindications to donation, such as active malignancy or severe disseminated infection, as well as those whose circulatory failure or multiorgan failure developed despite maximal medical treatment, since organ viability could not reasonably be assured in those circumstances.

What emerged from the data was a pattern that the researchers describe as a kind of blinding effect. Patients in the potential missed referral group were significantly older than those who were referred, with a median age of 73 years compared to 57 years in the referred group. They also carried heavier burdens of chronic disease: 60 percent had arterial hypertension, 49 percent had cardiac disease, and 15 percent had chronic obstructive pulmonary disease, compared to just 3 percent of referred patients. Perhaps most strikingly, every single patient with liver cirrhosis in the entire cohort fell into the missed referral group. These patients also had higher severity scores on admission, suggesting that the treating teams perceived them as too sick to be viable donors.

When the researchers applied binomial logistic regression to identify independent predictors of non-referral, two factors stood out. Older age, analyzed in ten-year intervals, carried an odds ratio of 1.6, meaning that each additional decade of life increased the probability of being misreferred by roughly 60 percent. A history of chronic obstructive pulmonary disease carried an odds ratio of 5.5, making it the strongest single predictor in the model. The researchers caution, however, that the bootstrap confidence interval for the COPD finding was extraordinarily wide, stretching from 2.1 to over a billion, which reflects considerable statistical instability and suggests the association should be interpreted with care rather than treated as a definitive causal signal.

On the other side of the ledger, two characteristics were strongly associated with higher referral rates. Patients whose neurological condition progressed to confirmed brain death—donation after brain death, or DBD—had an odds ratio of 0.04 for being misreferred, meaning they were almost never missed. Similarly, patients admitted with subarachnoid hemorrhage had an odds ratio of 0.20 compared to those with traumatic brain injury. The identification and referral rate in the DBD subgroup reached 0.96, meaning nearly every potential DBD donor was correctly referred. In the donation after circulatory death subgroup, by contrast, the identification and referral rate was just 0.4, with 80 of 134 potential DCD donors never referred at all.

The researchers offer a compelling explanation for this divergence. By definition, all DBD donors progress to brain death, a terminal event that is unambiguous and well recognized by intensive care physicians. But the pathway to potential donation begins well before that point. When patients with devastating neurological injuries develop extra-neurological complications—refractory cardiac conditions, terminal respiratory failure, mesenteric ischemia, or hemorrhagic shock—treating teams appear to withdraw life-sustaining treatment early, perceiving further management as futile. All 13 patients in the cohort who died of non-neurological causes were in the missed referral group. The investigators suggest that this rationale may be valid when the sole objective is patient survival, but becomes harder to justify if organ donation is considered a realistic outcome that could be preserved through timely referral.

Importantly, the researchers are explicit that their findings should not be read as suggesting life-sustaining therapies should be continued primarily to facilitate donation. Decisions about neurological prognostication and withdrawal of treatment must remain entirely independent of organ donation considerations and based exclusively on the patient’s prognosis, values, and best interests. Rather, the results indicate that once an independent end-of-life decision has been reached and donation remains a realistic possibility, referral to the transplant coordination team allows donor suitability to be assessed by professionals with specific expertise, avoiding premature exclusion based solely on the treating team’s perception of medical suitability.

The Belgian context adds another layer to the story. Although Belgian legislation mandates that every hospital establish a multidisciplinary organ donation team and provide dedicated training for donor identification and management, implementation remains heterogeneous. Healthcare professionals responsible for donation frequently combine these duties with routine intensive care work, and structured certification programs currently exist only for nurses, with no equivalent standardized curriculum for physicians. The Spanish model, by contrast, has achieved one of the highest donor rates globally through systematic use of expanded criteria donors—more than 10 percent of Spanish donors are over 80 years old—and through the distinctive role of the transplant coordinator, typically a critical care physician responsible for donor identification, referral, management, and continuous training of ICU staff.

The study has notable limitations that the authors acknowledge candidly. Because patients retrospectively classified as missed referrals were never evaluated by the transplant coordination team or transplant surgeons, organ suitability was never formally assessed. The estimates therefore represent the maximum theoretical number of missed donation opportunities rather than the number of potentially transplantable donors, since a proportion would likely have been excluded following specialist assessment for previously unidentified contraindications, while additional attrition would inevitably result from family refusal, hemodynamic instability, or logistical constraints. The single-center design, the restriction to three specific pathologies, and the inclusion of the COVID-19 pandemic period—though no significant differences in missed referral rates were observed across pandemic phases—further limit generalizability.

Nevertheless, the audit provides a valuable benchmark for quality improvement. The identification and referral rate of 0.55 in the overall cohort was comparable to less well-performing Canadian organizations and to Belgium’s national rate of 0.47 during the same period, but markedly lower than the 0.87 achieved by high-performing Canadian organ donation organizations and the 0.86 reported in the United Kingdom between 2019 and 2024. The key message from the Brussels team is that patients most frequently missed as potential donors were older, more likely to have comorbidities, and did not progress to brain death. Expanding the donor pool, they argue, requires special attention to critically ill patients with extra-neurological complications, even when advanced age and comorbidities are present, along with routine involvement of transplant coordinators and greater awareness among ICU physicians that donation potential may exist despite perceived limitations.

Subject of Research: Potential missed opportunities for organ donation: incidence and risk factors for non-referral among critically ill patients

Article Title: Potential missed opportunities for organ donation: incidence and risk factors for non-referral among critically ill patients

Article References: Nobile, L., Faso, C., Furlan, G., Annoni, F., Labbé, V., Mezidi, M., Lucidi, V., Gustot, T., Vincent, J.-L., & Taccone, F. S. (2026). Potential missed opportunities for organ donation: incidence and risk factors for non-referral among critically ill patients. Frontiers in Transplantation, 5, Article 1924053. https://doi.org/10.3389/frtra.2026.1924053

Image Credits: AI Generated

DOI: 10.3389/frtra.2026.1924053

Keywords: Potential, missed, opportunities, organ, donation, incidence, risk, factors, non-referral, critically, patients, scientific research