Donation after cardiac death and disorders of consciousness: what could possibly go wrong?

Diaz Milian warns that diagnostic momentum and the premature labelling of patients as organ donors can lead to catastrophic clinical errors. This commentary argues that the problem is even more serious than he imagines. A second, compounding wave of diagnostic ignorance about disorders of consciousness amplifies the dangers he describes. Over the last several decades, the classification of brain states following severe injury has been revised—from coma to the vegetative state, the minimally conscious state (MCS), emergence from the MCS and the more recently identified phenomenon of cognitive motor dissociation. Yet, most clinicians remain unaware of these distinctions and their prognostic and ethical significance. Retracing the neurological evolution of Diaz Milian’s index case through this updated nosology reveals a patient who was likely progressing through successively higher brain states, yet whose neurological trajectory went unrecognised until he was nearly subjected to organ harvesting while conscious and protesting. This commentary calls for temperance in the evaluation of prospective organ donors with severe brain injury, cautioning against the assumption that loss of consciousness following acute injury is inevitably a prelude to death. Unlike end-stage illness, where the loss of consciousness can accompany the dying process, in severe brain injury—where the outcome remains uncertain—it may be the first step towards recovery.