Organ donation - a reflection

Last updated on 12 Mar 2026

We get lots of information and guidance on the science and practicalities of what we are supposed to do as anaesthetists.

However we get very little information or guidance on how to deal with the emotions that ensue from a highly challenging, stressful and psychologically traumatising profession, in which we see and do things to strangers that most people would rather not think about.

I remember the first time I was assigned the deeply unsettling task of accompanying a patient to theatre for organ donation after cardiac death, and it made me feel a whole lot of things that I wasn't expecting and certainly hadn't been warned about.

This is a reflection on the process of organ donation after circulatory death, presented as a letter to my former self, that I hope provides some comfort.

Dear anaesthetist,

The time will come when you are called upon to perform a unique and morally very challenging task - to assist with organ donation - be that after brainstem death testing, or for the particularly difficult withdrawal of treatment with possibility of donation after cardiac death.

I'm not here to tell you the nuances of either of these processes. I'm simply here to inform you of some of the feelings and emotions that may arise that nobody else warned you about.

You'll start with a whiff of excitement.

Curiosity and intrigue will slide in, as with the opportunity to perform any new 'procedure', the sense of drama of undertaking a task that isn't often done - and that many doctors will never see - and you'll wonder if you're up to the task.

The solemn yet compassionate transplant team will calmly explain the plan, what is expected of you and when, and of course the various parameters for organ viability. There might a slight swelling of pride as you realise you're only in this incredibly high-stakes and privileged position because of the diligence and hard work you've put in over the last decade.

This will rather quickly be replaced by a sense of trepidation as you walk round to intensive care to collect the patient. You might be able to make eye contact with a family member or two who still don't quite understand what they've agreed to, and certainly don't know if they've made the right decision.

You'll realise you have no idea of what an appropriate thing to say might be, so you quietly mutter a hesitant, "Thank you" before busying yourself with cables and IV lines.

You'll wonder if you need to take a transfer bag, what you are supposed to do should anything happen in the lift, and realise you're in very unfamiliar ethical territory indeed.

You'll dutifully guide the bed with its comfortingly familiar beeping monitor and precariously swinging catheter bag around to the anaesthetic room, no different to another emergency laparotomy or scheduled re-look, but then the lack of anaesthetic machine or airway equipment and the row of chairs for the family will abruptly remind you why you're here.

You'll triple check the notes for the reassurance that you already know - neuro MDT outcome - best case scenario is permanent vegetative state - family in agreement for withdrawal of treatment and consideration for DCD.

You will feel the deep internal conflict - reassuring yourself over and again that this is the right thing to do - as you deflate the delicate cuff and slide the tube out of his mouth.

You will watch his head dip and his airway obstruct - that ghastly rasping of lungs versus lifeless pharynx - and feel that overwhelming urge to just lift his chin, tilt his head back, anything just to fix it, as you have been training so diligently to do for all these years.

Then the family come in, cries of agony leaping out as the stark realisation hits that their child is now going for good.

Then the mixed feelings come thick and fast.

You'll remind yourself why we're all here. Why a team of highly skilled experts has assembled, why multiple families are sitting in intensive care rooms around the country with the same blend of fear and anxiety but for the opposite reason.

You're hoping he dies quickly.

You'll feel guilty for 'wanting' a patient to die, and then you'll remind yourself that it's better for the patient than the alternative, and that's before you take into account the life-changing benefits for multiple others, and the sense of meaningful closure for the family.

The ventilator was the only support you were giving him - there was nothing else to withdraw - and you'll realise the only way he can pass any time soon is by losing his airway.

This won't feel good.

The noise that has trained its way into your amygdala drags you back to the moment as you hear the saturations start to drop.

The initial prickle of disaster mode activation will subside to a sense of relief - 'well maybe this will all be over quickly'.

Then you will feel your heart sink as he takes a heaving, snoring breath that scrapes past a drying tongue that will never speak again, and you'll feel that ugly sense of conflict rise once more.

You'll try and balance your wish for him to pass - to allow others a chance at a new life, to save the family the horror of watching a loved one slowly suffocate to death - with your intrinsic human instincts that tell you you can't simply watch another human obstruct their airway and asphyxiate.

The initial surge of adrenaline will fade as you realise the saturations aren't dropping, but sitting stubbornly in the mid seventies - not enough to live, not enough to die.

You'll keep him comfortable.

And you'll do it really well.

You'll quietly slide in aliquots of midazolam and morphine as the family grieve, to ensure the harrowing process of suffocation isn't quite so unbearable. You'll reassure them, and yourself, that he's not in pain, that he's not aware, not suffering.

You'll remind the family that the sounds and sights unfolding in front of them are 'natural' even though none of this is natural in the slightest.

It'll flicker across your mind that you could make everyone in the room, everyone in the operating theatre, and all those families waiting in hospitals around the country, happy with a single millilitre of muscle relaxant, just to speed things along.

A process that is going to happen anyway, made slightly quicker for the benefit of everyone involved.

Then you'll feel the guilt of having such a thought at all.

Then you won't know what to think.

You'll phone your boss

Who will reassure you that you're doing okay, and this is just a really difficult thing to do, but it won't make you feel any better.

Time will tick on, and boredom will set in, for you and for the family, who will feel even more guilty that they're experiencing something as selfish as boredom when their loved one is dying in front of them, but not quite fast enough.

The sting of sadness and disappointment will ripple palpably throughout the room as the clock ticks past the hour and the heart is no longer viable for transplant - ironic given the stubbornness and power with which it still continues to clatter away relentlessly inside the chest.

Then the boredom and self doubt will return and the room will go quiet once more.

You'll consider more morphine, or midazolam, just to do something, to be useful, but then you'll realise you'd just be treating a respiratory rate, which is not what you're there to do.

You'll watch helplessly as guilt-ridden hands stroke warm lifeless arms, brush hair out of unseeing closed eyes, and quips of stifled humour flicker back and forth as the family struggle to cope with the horror unfolding in front of them.

Another hour passes

The lungs join the heart as another set of surgical equipment is clicked shut and packed away. Another anonymous family's hopes dashed for yet another day, week, month, who knows?

💡

You'll feel like you should have done something more.

The cardiothoracic team will pack up their meticulously arranged equipment and head off into the night, and you'll feel like you let them down, even though it was never your responsibility to provide them with anything in the first place.

They know that, you know that, and you know that they know that, but it doesn't help. You'll feel like you didn't do a good job, because you don't know what your job is, because what kind of job is this anyway?

You just take away suffering, and you keep doing it, for as long as it takes.

Then it'll just be the kidneys left.

One final hour

Peripheral cyanosis inking insidiously up flaccid fingers as paleolithic survival machinery drives a relentless respiratory effort, the pounding heart rate refusing to dip and the saturations holding as if in spite, demonstrating just what a wonderfully strong heart his would have been to give.

A single ventricular ectopic flits enticingly across the screen, heralding the briefest moment of weakness as the heart searches for glucose, lactate, anything.

The arterial line trace will swing as the thorax sucks achingly against bloated cords and sagging pharynx, deep secretions bubbling menacingly as each ragged breath escapes into the silence of the room.

You'll feel guilty again for wishing death upon another human. You'll try to reassure yourself that you're really wishing for peace, and for life and hope for the families and recipients, a sense of closure for the desperate parents in front of you, but it won't take away the guilt.

The family will look pleadingly at you through bloodshot eyes, and you'll know what they want to ask - but can't bring themselves to do so. Instead they'll ask 'how much longer?' and you'll wheel out the tired and impotent phrase:

it's very variable, everyone's different, we can't say...

Time's up

The clock will click with cruel indifference past the three hour mark and the final decision will be made for the transplant teams to stand down.

No luck today.

You'll feel a wave of simultaneous sadness and relief.

Relief that you can escape, go to the loo, eat something, just go somewhere else, followed by a gutting sadness that the family has been left with nothing. No hope, no validation that their decision to agree to donation was the right thing to do, not even closure, as the broken body of their loved one is wheeled back to intensive care to continue dying for as long as it takes.

💡

This is not normal, this is quite possibly the strangest thing we do - please don't expect to feel comfortable.

Just remember the outcome does not determine how well you did. If can you walk away able to say that you did everything in your power to relieve them of their suffering, then you did great.

If you've had an experience at work that you feel you'd benefit from talking over with an impartial colleague who can relate to how you feel - don't hesitate to get in touch anaestheasier@gmail.com.

It won't be an AI chatbot, it'll be a fellow anaesthetist who knows how you feel.