Paramedic perspectives on organ donation after out-of-hospital cardiac arrest

Background Organ donation after out-of-hospital cardiac arrest (OHCA) remains limited, with most donors identified in hospital settings. Uncontrolled donation after circulatory death (uDCD) offers a potential pathway to expand the donor pool; however, its feasibility in the out-of-hospital environment is unclear, particularly from a paramedic perspective. The aim of this study was to explore operational paramedics’ perceptions of organ donation following OHCA and identify barriers and enablers to implementing out-of-hospital uDCD pathways. Methods Qualitative study using reflexive thematic analysis. Operational paramedics from Australian jurisdictional ambulance services were recruited via purposive and snowball sampling. Participants were registered clinicians authorised for independent practice. Semistructured interviews explored experiences with OHCA, organ donation and uDCD feasibility. Results Nine paramedics participated (predominantly metropolitan varied experience). Five themes were identified: recognising organ donation opportunities requires experience, clinical judgement and shared decision-making; operational feasibility depends on resources, geography and communication; successful implementation requires integrated systems and organisational support; preparing paramedics and the community for practice change; and balancing ethical responsibilities with patient and family wishes. Organ donation was rarely considered during routine OHCA, although participants most commonly associated donation opportunities with severe intracranial pathology. Decision-making was influenced by cognitive load, team dynamics and clinical experience. Barriers included limited access to donor information, resource constraints, geographic variability and clinician discomfort with end-of-life conversations. Enablers included structured guidelines, early consultation with specialist teams, use of mechanical Cardiopulmonary Resuscitation (CPR) and targeted education. Participants emphasised the importance of separating resuscitation goals from donation processes. Conclusions Paramedics view organ donation after OHCA as meaningful but complex. Implementation of out-of-hospital uDCD pathways requires clear clinical governance, structured communication processes, integration with hospital and donation services and targeted training. Addressing ethical, logistical and system-level challenges is essential to support safe and acceptable integration into paramedic practice.