A potential donor has to be identified in the hospital at the first possible instance, and then be reported to the DSO (Transplantationsgesetz in der Fassung der Bekanntmachung vom 4. September 2007). Basically, every patient who suffered a massive primary or secondary brain injury resulting in death despite the maximum amount of medical care can be a potential donor. The circulatory functions need to be maintained artificially. Today, there are only a few absolute contraindications to organ donation (Breidenbach and Banas 2011; Dominguez-Gil et al. 2011; Guide to the safety and quality of organs for transplantation 2013) (see 3.4.).

Basic prerequisites for organ donation are:

Non-heart-beating-donation is not allowed in Germany (Bundesärztekammer 1998; Siegmund-Schultze and Zylka-Menhorn 2008).

The German transplantation law determined that the declaration of whole brain death is a condition sine qua non for organ procurement (Transplantationsgesetz in der Fassung der Bekanntmachung vom 4. September 2007; Breidenbach and Banas 2011). It is defined as the irreversible end of all brain activity with maintained cardiovascular function and artificial ventilation. Brain death has to be examined in accordance with the guidelines of the German Medical Association (Siegmund-Schultze and Zylka-Menhorn 2008).

The guidelines require neurological examinations by two independently acting, qualified physicians, who have experience with patients who have suffered brain injuries. Furthermore, they cannot be actively involved in either organ removal or transplantation. The irreversible and unrecoverable end of all activity of the cerebrum, cerebellum and brain stem has to be attested. During the examination, the donor’s dignity has to be respected at all times. Brain death is a medical-scientific as well as legal criterion for death (Richtlinien zur Feststellung des Hirntodes 1998; Magnus DJ et al. 2014).

An essential, legal requirement is the information on the declared intention of the deceased person towards organ donation. If no written document, e.g. organ donor card, is available, the family will be asked for the patients’ presumable will. But, in the majority of cases the patients’ attitude towards organ donation is unknown. Merely 10 % of potential donors have filled out a donor card. Hence, the dialogue with the next of kin and their consent are particularly important. In this respect, a certain statutory order of authorization has to be ensured: (1) marriage partners/registered partners, (2) children of full legal age, (3) parents, (4) siblings of full legal age, (5) grandparents. The respondents had to be in contact with the deceased for at least the past 2 years (Transplantationsgesetz in der Fassung der Bekanntmachung vom 4. September 2007).

During the dialogue the presumed will of the deceased has to be determined. In case there are no indications for the presumed will, the next of kin will be asked to decide according to their own discretion. A precondition for addressing the next of kin on the subject of organ donation is that they rationally understood the concept of brain death. Exception to this rule is when the next of kin addresses the subject before brain death was declared. Respectful and emphatic conversation skills are important when talking to the next of kin. Also, a separate and quiet room, the precise communication of the relatives’ death, a clear explanation of brain death including checking whether it was understood, comprehensive information about organ donation and tissue donation with a clear priority on organ donation are all very important. The final decision of the next of kin needs to be respected. It is important to reach a stable decision in order to prevent a post-decision discordance (Breidenbach and Banas 2011; Breidenbach and Hesse 2011).

Knowing that their relatives’ corpse is treated respectfully is very important for the next of kin. Also, the knowledge that there are no restrictions regarding the funeral is very important. As a matter of principle, next of kin should be given the opportunity to bid farewell to their loved ones in a dignified manner. This is recommended as it serves the interests of transparency and the prevention of misconceptions (e.g. disfigurement caused by organ removal). Hospitals might engage DSO coordinators to support the family approach. Moreover, the DSO provides family care by organising meetings. Experience has shown that sometimes questions arise weeks later. These questions can be answered at such meetings (Breidenbach and Banas 2011; Grammenos et al. 2012).