Midazolam prescription as a trigger for potential deceased donor identification outside the ICU: a prospective feasibility study

BACKGROUND: Systematic identification of potential deceased organ donors outside the intensive care unit (ICU) remains challenging. Patients receiving palliative sedation are rarely evaluated for donation, particularly in non-critical care settings. OBJECTIVE: To assess the operational feasibility of a semi-automated donor identification strategy triggered by midazolam prescription for end-of-life sedation outside the ICU. METHODS: We conducted a 12-month prospective, single-center feasibility study in a tertiary university hospital in Spain. A daily pharmacy-based screening system identified new midazolam prescriptions outside critical care areas. The transplant coordination team reviewed alerts, assessed medical suitability, and explored donation preferences when appropriate. When consent was obtained, intensive care to facilitate organ donation was initiated within a controlled donation after circulatory determination of death (cDCD) pathway. RESULTS: A total of 1,398 patients were screened (mean 3.8/day). Most alerts (94%) were excluded during rapid electronic review. Ninety-one patients underwent in-depth evaluation; 12 were medically suitable and 8 proceeded to cDCD, resulting in 19 transplanted organs. During the equivalent period in the preceding year, no referrals for organ donation originated from hospitalized palliative care services. CONCLUSIONS: A semi-automated system based on midazolam prescription is operationally feasible and can be integrated into routine hospital practice to support systematic donor identification outside the ICU.