On 2nd May 2026, a 41-year-old woman was declared brain-stem dead at Command Hospital in Chandimandir, Panchkula, after suffering a severe brain haemorrhage. She was the wife of a serving Army Colonel and mother of two daughters. Following her death, the family agreed to donate her organs.
The family gave permission to donate the heart, kidneys, liver and pancreas. On 6th May, the Union Health Ministry issued a statement announcing that the donated organs were received by four patients. Among them, one was a 14-year-old boy. This was the first time Command Hospital had performed a heart retrieval.
Apart from the Army Hospital, PGIMER Chandigarh, Army Hospital (Research and Referral) and Indraprastha Apollo Hospital were involved in the process. NOTTO, the Indian Air Force, airport authorities and traffic police played their parts where needed. Within a span of a few hours, different hospitals had to prepare for different organs as the teams at Chandimandir dealt with the donor’s medical condition and retrieval.
The donor was kept on a ventilator to ensure an oxygen supply so that the doctors could retrieve the viable organs, even though the brain stem had permanently stopped functioning. Such medical support does not mean the person can recover and is provided only to maintain circulation while the teams of doctors examine whether the organs can be transplanted.
There are thousands of patients who need an organ transplant in India. However, deceased donation remains limited in the country. According to NOTTO’s statistics, which were discussed in the first article of this series, there were 1,128 deceased donors and 3,403 transplants in 2024. In 2025, the number of deceased-donor transplants jumped to 3,526. The difference between the numbers of donors and recipients is notable, as one donor’s organs can be transplanted into multiple recipients and such surgeries are counted separately.
The brain stem is the part of the brain that connects it with the spinal cord. There are three main parts of the brain stem, which are the midbrain, pons and medulla. Together, they help regulate breathing, blood pressure, heart rate and several reflexes that normally work without a person thinking about them. For example, a person does not need to remind himself to breathe during sleep.
When all functions of this part of the brain permanently and irreversibly cease, the doctors declare the patient brain-stem dead. It is different from being unconscious or suffering a serious brain injury. A person may remain in a coma for several days, weeks or even longer, but some brain functions continue. Depending on the cause and extent of the injury, recovery may still be possible.
Another condition, which is known as a vegetative state or unresponsive wakefulness syndrome, can also be confused with brain-stem death. In such a condition, a person may open their eyes and show periods of sleeping and waking. However, there is no demonstrated awareness of the surroundings. Some brain-stem functions remain active. Neither coma nor a vegetative state is legally the same as death.
Under Section 2(d) of the Transplantation of Human Organs and Tissues Act, 1994, brain-stem death means the permanent and irreversible cessation of all brain-stem functions, certified according to the provisions of the Act. Section 2(e) also recognises death in the cardiopulmonary sense, where the evidence of life has permanently disappeared because circulation and breathing have ceased.
Therefore, there are different medical circumstances in which a person may be declared dead. In the usual situation, the heart stops and the person stops breathing. In brain-stem death, the heart may continue beating for some time, especially when the patient is on a ventilator.
The heart has its own electrical system that produces the impulses responsible for its contractions. It does not need a separate instruction from the brain for every heartbeat. When a ventilator supplies oxygen to the lungs and circulation is maintained, oxygenated blood can continue reaching the organs. The body may remain warm, and a monitor may continue showing a heartbeat, even though the person has died.
This is why relatives of the patient may find brain-stem death difficult to understand. A patient whose chest is moving with the help of a ventilator may not appear dead to someone unfamiliar with the condition. However, once brain-stem death has been properly established, recovery is not possible. The ventilator can support breathing mechanically, but it cannot restore the functions of the brain stem.
Severe head injuries, extensive bleeding inside the brain, certain strokes and prolonged lack of oxygen can cause brain-stem death. These conditions do not always lead to it. Doctors must examine the patient’s condition and establish whether the injury has caused the permanent loss of brain-stem functions.
India has a prescribed procedure for certifying brain-stem death. According to Section 3(6) of the Transplantation of Human Organs and Tissues Act, 1994, a board of medical experts is required to issue a certificate before organs can be retrieved following brain-stem death.
Normally, there are four doctors on the board. The first is the registered medical practitioner in charge of the hospital where the death has occurred. The second is an independent medical specialist selected from a panel approved by the appropriate authority. The third is a neurologist or neurosurgeon, while the fourth is the registered medical practitioner who was treating the patient.
The Transplantation of Human Organs and Tissues Rules, 2014, provide for alternative arrangements when a neurologist or neurosurgeon is unavailable. Under the prescribed conditions, appropriately nominated specialists, including an anaesthetist or intensivist who is not part of the transplant team, may participate in certification. The medical board must be constituted in accordance with the applicable legal requirements, and its members must personally examine the patient.
The process is separate from the decision to donate organs. Doctors cannot declare a patient dead because another patient urgently needs a transplant. Similarly, the family’s willingness to donate cannot influence the medical findings. The certification establishes whether death has occurred, while the authorisation for organ retrieval is dealt with separately. Once the medical board completes the required examinations, its findings are recorded in Form 10, the official brain-stem death certificate prescribed under the 2014 Rules. All members of the board must sign the certificate. The form contains information about the patient, the cause of the injury, the examinations performed and the findings recorded by the doctors.
First, the medical team works out what caused the brain injury and whether it is severe enough to have permanently damaged the brain stem. They go through the patient’s history, neurological state and test results. They also have to rule out anything that can temporarily switch off brain function and look like brain-stem death.
Sedatives and muscle relaxants can throw off a neurological exam. So can low body temperature, serious metabolic problems and unstable circulation. Doctors need to be sure the apparent loss of brain-stem function is not down to one of these reversible causes.
Next come the reflexes the brain stem controls. The pupils are checked for a reaction to light, since they normally shrink when light enters the eye. The corneal reflex is tested too: touch the surface of the eye the right way and the person should blink. Doctors also look at eye movements, other neurological responses, and the gag and cough reflexes in the throat and airway. If these are all absent, it suggests the relevant brain-stem pathways have stopped working.
One missing reflex does not settle anything, though. An injury to the eye or its nerves could block a single response by itself. The findings have to be read together, alongside the patient’s overall condition. The NOTTO Transplant Manual lays out the examinations and paperwork involved in certification.
Breathing is one of the key functions checked. Normally, rising carbon dioxide in the blood prompts the brain stem to create an urge to breathe. The apnoea test checks whether the patient makes any effort to breathe on their own when that trigger is present. Qualified doctors carry it out under controlled conditions, watching oxygen levels and circulation the whole time.
It carries risk if blood pressure or oxygen levels become unstable, so the safety conditions have to be in place beforehand. If the test cannot be done or finished safely, the team follows the applicable clinical protocol. The NOTTO Transplant Manual covers this procedure as well.
Indian law requires the assessment to be repeated before brain-stem death is certified. Form 10 has room to record two sets of examinations, and for adults the minimum gap between them is six hours. Doctors must record the findings from both before they complete the certificate.
That six-hour wait is a step in the certification process. It does not mean the person becomes brain-stem dead only once six hours have passed.
Children need extra thought. Under the 2014 Rules, the interval can be longer for infants and children, depending on their age and what the medical board decides. The adult interval cannot simply be applied across the board.
Sometimes doctors also order further tests, such as ones that look at blood flow inside the brain. These help most when the usual clinical examination cannot be completed or cannot be interpreted reliably. They are not needed in every case.
On 3rd August 2026, the Ministry of Health and Family Welfare released the National Brain Stem Death Certification Guidelines, Edition I, at the 16th Indian Organ Donation Day programme in New Delhi. They came out alongside the latest NOTTO annual report and a few other initiatives meant to improve organ donation and transplant services. By the ministry’s account, the guidelines give transplant professionals a practical framework and are meant to help states and Union Territories build up their services.
The need is easy to see. Certification is done by doctors in hospitals with very different resources. Some have neurology, neurosurgery and intensive-care departments, and others rely on a handful of specialists. A common national framework should make the examinations and documentation more consistent.
The guidelines have to be read together with the Transplantation of Human Organs and Tissues Act, 1994, and the statutory rules under it. The ministry also announced the e-Pratyaropan platform, the NOTTO mobile app and the Jug Jug Jiyo Abhiyaan at the same event, all aimed at better coordination, digital services and public participation.
Once brain-stem death is certified, the treating doctors have to explain the findings to the family. Relatives often have questions about the tests and whether recovery is possible, and the team needs to address those before bringing up organ donation.
Rule 5 of the 2014 Rules puts a duty on doctors in hospitals with intensive-care facilities to find out what the deceased person wanted and to tell eligible relatives about donation after brain-stem death has been certified. This also applies to doctors working in ICUs of hospitals that are not registered transplant centres.
A hospital may already have flagged the patient as a potential donor before certification because the injury was so severe. If the family then authorises donation, the hospital starts coordinating the medical evaluation of the organs and the retrieval arrangements. That usually involves the transplant coordinator, ICU specialists, retrieval surgeons and the relevant organ-sharing authority.
Someone who wants to donate after death can register a pledge while alive. India has a national digital pledge facility for this. The Aadhaar-based portal launched in September 2023, and in August 2026 the Health Ministry reported more than five lakh Aadhaar-verified pledges since then.
A pledge does not guarantee retrieval, though. The person’s medical condition, the circumstances of death and the rules on consent and retrieval all still apply.
The 2014 Rules use Form 7 to record an individual’s pledge and Form 8 for the declaration and consent given by an eligible relative or the person lawfully entitled to deal with the body. Under Rule 5, the hospital has to check whether the deceased had authorised donation earlier and whether that authorisation was withdrawn. If there is no authorisation, the relatives or the lawful possessor of the body must be told they can authorise or decline.
Form 8 records details of the deceased, the relationship or authority of the person consenting, the deceased’s known wishes, and which organs or tissues are authorised for retrieval. It also covers sharing relevant medical information and taking the blood samples needed to judge whether the organs are suitable. The NOTTO Transplant Manual includes the prescribed forms for pledging, consent and certification.
Yes. Deceased donation is voluntary, and a family is not obliged to authorise retrieval just because the person has been certified brain-stem dead. The NOTTO Transplant Manual tells hospitals to respect a refusal and not make relatives feel guilty. Consent should rest on accurate information and a free choice, not pressure.
Families may also worry about the retrieval itself, the condition of the body and the funeral arrangements. The transplant coordinator and medical team are responsible for explaining the procedure and answering these questions.
If relatives disagree, the hospital follows the legal rules on who is entitled to give consent. A documented refusal by the deceased person also carries legal weight. The 2014 Rules bar retrieval where the person had withdrawn authorisation and made a relevant written refusal.
For anyone under 18, the 2014 Rules provide for authorisation through a parent, or a near relative the parent has authorised, along with the required medical certification.
In June 2026 the Union Health Ministry reported the case of a six-year-old girl, Aakanksha Mahadev Bansod, admitted to AIIMS Nagpur after a tragic incident. She was declared brain dead, and her father agreed to donate her kidneys, which were allocated through the Zonal Transplant Coordination Centre, Nagpur. According to the ministry’s statement of 23rd June, both kidneys went together into one young patient with end-stage kidney disease, using an en bloc technique in which the pair is transplanted as a single graft. It was also AIIMS Nagpur’s first in-house paediatric organ donation.
Children can clearly be deceased donors, but the examinations, consent requirements and organ suitability all have to be judged under the paediatric provisions.
Doctors certify death and assess the organs, but deceased donation also depends on communication between hospitals and teams, and transplant coordinators handle much of that. Under Rule 29 of the 2014 Rules, coordinators can come from medical, nursing or other recognised backgrounds, including social work, psychology, sociology and public health. The rules also provide for induction training and periodic retraining.
Once a potential donor is identified, the coordinator works with the hospital’s medical team. After certification they may help the doctors and family communicate, explain the donation process and help complete the consent documents. If donation is authorised, they contact the organ-sharing organisation and help arrange investigations, paperwork and contact with retrieval teams.
Several hospitals may be involved, because a donor hospital does not necessarily do every kind of transplant. One might be able to maintain a donor and retrieve organs but not be registered or equipped for heart, liver or lung transplants.
The coordinator does not decide on death and does not choose who receives an organ. Those decisions go through the prescribed medical and allocation procedures.
The organs that can be considered are the kidneys, liver, heart, lungs, pancreas and small intestine. Whether they’re usable depends on the donor’s medical condition and what the recipient needs.
Since people normally have two kidneys, one donor can help two recipients. A liver usually goes to one patient, though a suitable one can sometimes be split between two. The heart needs careful checks of its pumping function and structure. The lungs need assessment of respiratory function, infection risk and other findings. Pancreas and small-intestine transplants are more specialised, and fewer hospitals offer them than kidney or liver transplants.
Donation is not limited to solid organs. Corneas, skin, bone, heart valves and blood vessels can also be donated. Corneal transplants help people whose corneas have been damaged by disease or injury, donated skin can be used for serious burns, and bone and other tissues have uses in reconstructive surgery.
Unlike most solid organs, some tissues can be retrieved after circulatory death, once the heart has stopped and intensive-care support is no longer running. Corneal donation, for instance, may be possible after a death at home if the eye bank is told and retrieval happens within the medically acceptable window. NOTTO’s national awareness booklet says tissues such as corneas, skin, bones and heart valves can be donated after cardiac death, and that donation after a death at home is usually possible within six hours, subject to medical requirements.
Solid-organ donation after circulatory death is possible in selected cases too, but it needs specific protocols and specialist facilities. The NOTTO Transplant Manual treats it as a separate pathway, and it should not be confused with the established process of retrieval after certified brain-stem death.
Once authorisation is in place, the team works out which organs can be used. They start with the donor’s history: cause of death, existing illnesses, medications, earlier organ problems and anything else that could affect function.
Infection is a big concern because some diseases can pass from donor to recipient, so doctors run laboratory tests and review the records. A history of cancer can also matter, depending on the disease and the risk of transmission. Still, a medical condition does not automatically rule out every organ. Someone with a problem in one organ may have another that works perfectly well. It comes down to the individual findings. The NOTTO Transplant Manual gives guidance on donor assessment, organ suitability and pre-retrieval investigations.
Blood group is one of the basics. Doctors also screen for infection and run tests on the organs being considered. Kidney assessment can include blood measures of kidney function and a look at any past kidney disease. Liver assessment uses blood tests and other investigations. For the heart, an echocardiogram can show structure and pumping function. Lung assessment looks at oxygenation, imaging, and any infection or injury. The pancreas and intestine may need more specialised tests.
An organ can look healthy and still not suit a particular recipient. Blood-group compatibility is one factor, and for kidneys, immune compatibility and cross-matching can matter as well. Size can be important, especially for hearts and lungs. The recipient’s condition counts too: someone on the waiting list may be temporarily unfit for major surgery. The final call on using an organ rests with the specialists assessing it and the transplant team responsible for the recipient.
When brain-stem death has been certified and donation is authorised, the hospital may keep up mechanical ventilation and other support until the organs are retrieved. Brain-stem death can cause big swings in blood pressure, body temperature, hormones and fluid balance, which can affect the heart, kidneys, liver and lungs. If circulation becomes unstable, organs that started out suitable can deteriorate.
So intensive-care doctors monitor the donor closely and treat accordingly, with respiratory support, fluid and electrolyte management, cardiovascular monitoring and treatment of infections or other complications. The team keeps checking that the organs remain suitable, because their condition can change between the first assessment and retrieval.
How long this goes on varies. Some cases wrap up fairly quickly, while others need more time for tests, paperwork, allocation and the arrival of retrieval teams. There is no fixed duration. The NOTTO Transplant Manual has guidance for ICU specialists on maintaining organ function after brain-stem death and before retrieval.
The 2014 Rules deal directly with costs after certification. Rule 9 says the family must not bear the cost of maintaining the brain-stem-dead donor, or of retrieving, transporting and preserving organs or tissues. Those costs can instead be met by the recipient, an institution, the government, an NGO or society, depending on what the state or Union Territory decides. The Union Health Ministry repeated this in a written Lok Sabha reply on 28 July 2023.
The rule covers only those specific costs. It does not wipe out medical bills from the time the person was alive and being treated.
After the organs have been assessed, the hospital informs the relevant organ-sharing authority, giving details such as blood group, medical findings, available organs and expected retrieval arrangements. The authority then identifies potential recipients under the rules for each organ. The first part of this series covered the waiting-list system and its eligibility requirements. With deceased donation, the difference is that an organ suddenly becomes available and a suitable recipient has to be found for it.
For kidneys, compatibility and the patient’s position under the allocation criteria are considered, and some patients get priority for medical reasons. The NOTTO kidney allocation guidelines look at urgency, blood-group compatibility and other criteria, and describe how organs are shared across city, state, regional and national arrangements. Livers work differently. Some patients need a transplant urgently because they could decline fast without one, and the NOTTO liver allocation policy allows super-urgent listing in specified medical circumstances.
Hence, allocation cannot be summed up as “the next organ goes to whoever has waited longest.”
Yes, where the allocation arrangements permit it. The NOTTO kidney guidelines set out the order: the city waiting list first, then the state, then the relevant ROTTO region, then other ROTTO regions nationally if nobody eligible is found at the earlier level.
Geography matters because organs cannot stay outside the body for long, and how long depends on the organ and the preservation method. The receiving hospital also has to be ready to operate. The patient may need further assessment before surgery, and the transplant team has to confirm the organ is suitable.
Yes. An offer does not guarantee a transplant. The receiving hospital can decline for medical reasons connected to the donor or the recipient. The organ may show disease or poor function, the recipient may have picked up an infection that makes surgery unsafe, or there may be practical trouble getting the recipient and team ready in time. Where the allocation rules allow, a declined organ can be offered to another eligible recipient. But not every organ that’s retrieved or offered ends up transplanted.
Retrieval is a surgical procedure done by qualified teams in an operation theatre. Before it starts, the hospital must have the death certification, consent documents, medical investigations and legal formalities in order. Different specialists take part depending on the organs involved. Taking the heart, liver and kidneys together, for example, can call for surgeons from different fields.
The teams have to coordinate closely, since the organs are going to different recipients. During surgery the specialists examine the organs and follow the proper procedures for retrieval and preservation. The organs are then prepared for transport with preservation solutions, sterile packaging and cooling suited to each one. This reduces damage outside the body but does not stop deterioration. Acceptable preservation time varies by organ, and the receiving team has to be ready to go within it.
When retrieval ends, the incisions are closed and the body is prepared to go back to the family. The whole procedure is meant to be done with surgical care and respect for the deceased.
The 2014 Rules also distinguish registered organ retrieval centres from hospitals authorised to carry out transplants. A hospital can be allowed to retrieve organs without having the facilities to transplant every type, and the central rules set out separate registration provisions and forms for transplant hospitals and retrieval centres.
Some potential donors have injuries that need a police investigation, such as road accidents, suspected assaults and certain other unnatural deaths. Retrieval then has to be coordinated with the medicolegal requirements. An investigation does not automatically block donation, but the hospital has to follow the prescribed procedure.
Rule 6 of the 2014 Rules covers this. Once authorisation and consent are in place, the hospital makes the prescribed request to the relevant police authority so retrieval can happen on time, and the designated post-mortem doctor is informed. Retrieval must not interfere with establishing the cause of death, and findings about the retrieved organs must be documented for the post-mortem record. If the post-mortem is done at another institution, the records and the body are transferred according to the applicable procedure. This lets donation go ahead without compromising the investigation.
After retrieval and any medicolegal formalities, the body is returned to the family for the funeral. The NOTTO Transplant Manual describes what retrieval teams and coordinators are responsible for in handling the body respectfully and returning it.
Hospitals also have to protect the confidentiality and dignity of donors and recipients. Families often want to know whether the organs were transplanted successfully and how many patients benefited. Hospitals can share that within confidentiality limits, but recipients’ identifying details and private medical information must be protected. Donor and recipient families do not automatically get to meet. The hospital and transplant authorities follow their confidentiality procedures, which the Transplant Manual also discusses.
Some hospitals and state programmes recognise donors and their families with appreciation certificates, remembrance programmes and similar initiatives. In a 2023 written reply to Parliament, the Health Ministry said the National Organ Transplant Programme supports each deceased donor family with ₹10,000 towards a dignified funeral, paid through the respective SOTTO. Whether this help is available now depends on the programme and administrative arrangements. It is also important not to confuse support for legitimate expenses with payment for organs. Commercial dealing in human organs is prohibited under the 1994 Act.
Not every patient with a catastrophic brain injury becomes a donor. A severe injury may not lead to brain-stem death, and doctors cannot proceed to retrieval just because someone is critically ill.
Even after certification, things can go wrong. The family may decline, the legal authorisation may not come through, or some organs may be unusable because of disease, injury or poor function. A hospital may lack trained retrieval specialists or the means to coordinate donation. Teams have to assess organs, find recipients and get the receiving hospitals ready, and delays can hurt organ function, especially if the donor’s circulation becomes unstable.
That’s why the numbers differ at each stage. Potential donors are not the same as certified brain-stem deaths, authorised donations do not always match actual retrievals, and retrieved organs do not always equal transplanted ones. A full picture of deceased donation in India would need to know how many potential donors were identified, how many were formally certified, how many families agreed and how many retrieved organs went unused. But these figures are not consistently published together in the national statistics, so it is hard to say how many possible transplants are lost at each step.
Transplant numbers have grown a lot over the past decade. NOTTO’s historical data shows 837 deceased-donor organ transplants in 2013, and the annual figure has since more than quadrupled. Total organ transplants reached 20,138 in 2025, up from 18,911 in 2024, according to the government’s August 2026 figures. Even so, living donors still account for most transplants, and deceased-donor transplants made up about 17.5 per cent of the total in 2025.
The Union Health Ministry also reported that more than 1,200 families came forward for deceased donation in 2025. That should not be mistaken for the number of deceased donors whose organs were actually retrieved, since the two may not use the same definitions.
The government has taken several steps, including building the NOTTO–ROTTO–SOTTO network, running training for medical professionals and offering financial help under the National Organ Transplant Programme. But the ability to perform transplants is only one piece. Hospitals also need to spot possible donors and certify brain-stem death as the law requires.
A patient with a severe head injury may be admitted to a hospital that does not do transplants. If brain-stem death occurs there, the hospital needs access to authorised medical expertise for certification and a way to alert the organ-sharing organisation. So the availability of trained ICU doctors and transplant coordinators directly affects how many donations happen.
Activity also varies widely between states. Some have established organ-sharing networks and retrieval programmes, while others record very few deceased donations. NOTTO’s state-wise data for 2024 shows these gaps in donor numbers and transplant activity. Public willingness alone does not explain them. Hospital infrastructure, training, certification capacity and administrative coordination all decide whether a donation can go ahead.
The ministry’s 2026 initiatives include the e-Pratyaropan platform, the NOTTO mobile app and the Jug Jug Jiyo Abhiyaan awareness campaign, along with measures to tighten coordination of donation and allocation. The real test is whether hospitals can apply these arrangements consistently, including those that handle emergency and intensive care but do not perform transplants themselves.
India’s legal framework keeps the determination of death separate from the decision to donate. The organs’ medical suitability is then assessed before retrieval, and suitable recipients are found through the allocation system. One deceased donor can provide organs for several patients, but the final number depends on the condition of the organs, the availability of compatible recipients and the medical arrangements made after death.
Once the organs are out, a new stage begins. They have to be preserved and carried to the receiving hospitals within the medically acceptable time. The science, technology and coordination behind that journey make up the next part of India’s organ transplant system.
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