Introduction: Increased authorization rates are critical to addressing the organ donor shortage. Initiating the authorization conversation with next-of-kin (NOK) at the right time to preserve the option for donation is an important skill in obtaining the best possible outcome.

Method: Authorization and donation outcomes were analyzed retrospectively for 3,617 organ donation conversations with the NOK of medically suitable, vent-dependent patients referred to the OPO between 1/1/2019 and 12/31/2021. OPO transplant coordinators (TC) received specialized training in addition to pro-active, hands-on coaching from a senior administrator on-call to collaborate with hospital care teams in determining the best time to initiate a donation discussion with NOK.  Donation conversations were initiated before pronouncement of brain death to preserve the option of donation in cases where there was 1. a decision to withdraw life sustaining therapies, 2. a decision to limit life-sustaining therapies, 3. early mention of donation by the hospital care team, 4. family initiation of the conversation, 5. when the patient was hemodynamically unstable or 6. when the OPO determined that the NOK was ready based on their understanding of their loved one’s prognosis.

Results: The overall authorization rate over the 3-year study period was 58% and the donation rate was 55%. When NOK initiated the donation conversation, authorization and donation rates were the highest at 90% and 86% respectively. When the donation conversation was initiated based on the NOK’s understanding of the non-survivable nature of their loved one’s injury, authorization and donation rates were 67% and 65% respectively. When the donation conversation was initiated after a decision to withdraw life-sustaining therapies, authorization and donation rates were the lowest at 45% and 42% respectively.

Conclusion: Obtaining authorization for organ donation is a process, not an event. Approaching families at the right time in order to preserve the option of organ donation that might otherwise be lost is critical. OPOs should collaborate with hospital care teams to provide families with end-of-life care that supports their understanding of the non-recoverable nature of their loved one’s injury. OPOs should educate hospital care teams regarding the importance of early referral and collaboration with the OPO before discussing withdrawal of life-sustaining therapies with families because NOK are far less likely to authorize donation if approached after a withdrawal decision has been made.