Brain Death and Organ Donation in Romania: A Nationwide Survey of Intensivists’ Perceptions and Clinical Practices

<b>Background/Objectives:</b> A persistent mismatch between organ supply and transplant demand affects healthcare systems worldwide, particularly in underdeveloped and transitional systems. Intensive care units (ICUs) represent the primary setting for donor identification following brain death, placing intensive care physicians at the center of organ donation pathways. This nationwide cross-sectional survey aimed to evaluate Romanian intensivists' knowledge, attitudes, and reported clinical practices regarding brain death determination, communication with families, and system-level barriers to organ donation, to identify modifiable factors relevant to transplant policy development. <b>Methods:</b> A prospective, nationwide, questionnaire-based survey was conducted among intensive care physicians in Romania. The structured questionnaire explored their knowledge and attitudes regarding brain death, communication with families, involvement in donation processes, ethical perceptions, and views on the organization of the transplant system. The survey was distributed through the Romanian Society of Anesthesia and Intensive Care, and descriptive exploratory analyses were performed. <b>Results:</b> A total of 117 ICU physicians participated (mean age 41.0 ± 9.9 years). Although 84.6% agreed with the current brain death diagnostic criteria, and 83% considered the protocol sufficiently clear. The mean number of brain-dead patients managed annually was 8.25 ± 12.90. 69.3% of respondents perceived communication competencies as insufficient. 77.8% considered family consent decisive in donation decisions, while 87% supported the establishment of a national donor registry and 77% favored a donor card system. Organ procurement was reported as a priority in only 38.5% of ICUs. Institutional prioritization of organ procurement and structured training was inconsistent. <b>Conclusions:</b> This nationwide survey identifies key educational, organizational, and systemic barriers limiting organ donation performance in Romania. Targeted training, improved communication strategies, integration of donation pathways into routine intensive care practice, and the adoption of national consent instruments represent essential clinical and policy priorities for low-performing transplant systems.