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Across Europe, opt-out organ donation systems were designed to make donation decisions clearer: unless a person records an objection, consent is presumed. At the bedside, however, presumed consent is rarely the end of the conversation. In many countries, relatives are still consulted and donation may not proceed when families object, leaving clinicians and donation teams to navigate grief, uncertainty, law, culture, and ethics at once.

That tension is a central challenge for physicians. The policy default may say one thing: The family, facing a death they may not have expected, may be unsure what the patient wanted or they are divided over what to do. Experts said the most effective approach is to use trained donation professionals, clear protocols, and careful communication that places the patient’s known or likely wishes at the center without pressuring relatives.

“The issue is that most countries use a ‘soft’ version of the opt-out policy,” said Baris Pascal Güntürkün, PhD, associate professor of marketing at Vienna University of Economics and Business in Vienna, Austria, whose research examines how organ donation policies shape donation-related behavior. “This means that, in practice, ‘no action’ is not automatically treated as consent, but that family members play a key role in the ultimate decision, either informally or explicitly, depending on the specific legislation.”

The result, Güntürkün told Medscape News Europe, is that a decision that appears settled in law may still be shifted to relatives at the most emotionally difficult moment. “As this decision relates to moral, religious, and ethical dilemmas, it’s likely to cause family conflict,” he said.

The problem is not theoretical. In the UK, where England, Wales, Scotland, and Northern Ireland all now use some form of opt-out or deemed consent, family support remains central in practice. A 2026 Organ Donation Joint Working Group report warned that family consent rates across the UK had fallen to 59%, down from 68% before the COVID pandemic.

What Families Are Weighing

Family refusal is often described as opposition to donation, but researchers say that can oversimplify the decision. A 2025 systematic review in BMJ Open of barriers to conversations about deceased organ donation among adults in the UK identified four recurring themes: cultural beliefs that talking about death can bring bad luck; generational differences, with younger relatives often more open to donation but reluctant to contradict elders; ethnic disparities and communication barriers that can foster mistrust or misunderstanding; and the influence of media reports or personal experience.

Those findings help explain why a physician may be asked to do several things at once: clarify medical facts, protect the patient’s expressed wishes where they are known, respect family dynamics, and avoid turning an end-of-life discussion into a contest of persuasion.

“When disagreement arises among family members, physicians should primarily aim to inform and mediate rather than pressure families toward a specific decision,” Güntürkün said. “This includes listening carefully to concerns, clarifying misunderstandings, acknowledging emotional and cultural sensitivities, and helping relatives identify common ground regarding the patient’s preferences and values.”

Austria’s Lesson: Strong Numbers, Persistent Uncertainty

Austria is often cited as a long-standing opt-out country. Its system dates to 1982, and the country recorded 20.78 deceased organ donors per million population in 2024, according to the International Registry on Organ Donation and Transplantation. Under Austria’s official objection system, individuals who do not wish to donate can enter an objection in the national register. Objections can also be documented in other ways, including relatives conveying that message after a family member’s death.

Even in a mature opt-out system, Güntürkün said, communication can become difficult if the default reduces the likelihood that people will discuss donation while they are alive.

“My experience from Austria suggests that an opt-out policy can unintentionally reduce public and private discussions about organ donation decisions,” said Güntürkün, who recently coauthored a PNAS Nexus study examining whether opt-out systems can make people less likely to actively discuss or record their donation preferences. “When an opt-out policy has been in place for a long time, many people are not aware that they are considered donors after death, and may never have discussed their preferences with friends or family. This can effectively reduce family knowledge about the deceased’s donation preferences and create additional uncertainty during decision-making.”

The study found that opt-out policies were associated with modest gains in deceased donation but declines in living donation, a finding the researchers argued could offset some expected benefits. Vienna University described the results as a warning that presumed consent policies can have unintended consequences if they are treated as a complete solution to organ shortages rather than one part of a broader donation system.

Who Should Lead the Conversation?

Experts caution against assuming that the treating physician is always the best person to initiate the donation discussion. In emergency departments and ICUs, physicians may be focused on death determination, withdrawal of life-sustaining therapy, or maintaining organ viability. The donation conversation may require different training and a different relationship with the family.

“It’s not ideal that the care team in the ICU approach families to inform about the option of organ donation,” said Vanessa Silva e Silva, RN, PhD, associate professor and graduate program director at Brock University School of Nursing in St. Catharines, Ontario, Canada, whose research focuses on organ and tissue donation practice. “They don’t have all the knowledge of the donation processes, and families will have many questions about what happens next. When people who are not trained to have organ donation conversations at end-of-life care initiate these conversations, the results are poor, and families end up unsatisfied with the process.”

Spain’s experience is frequently cited as evidence that opt-out legislation is not enough on its own. The country’s high-performing system relies heavily on trained transplant coordinators and a national, regional, and hospital-level coordination structure. A review of the Spanish model emphasized the role of dedicated professionals who identify potential donors, support clinical teams, and guide family conversations.

“In some cases, it may be more effective to involve dedicated professionals who are specifically trained for this role,” Güntürkün said. “Spain’s organizational model relies on specially trained transplant coordinators and dedicated staff who support families throughout the donation process. These professionals are trained in empathetic communication and family mediation, helping relatives process information, and discuss donation decisions in a structured and supportive way.”

Silva e Silva said organ and tissue donation coordinators can play a central role precisely because they understand both the clinical process and the emotional weight of the decision. ICU physicians and healthcare staff, on the other hand, should be able to focus on determining a patient’s death, withdrawing life-sustaining therapies when there is no prognosis for survival, communicating the medical information to the family, and maintaining the donor organs.

A Clearer Role for Physicians

When physicians are involved in donation conversations, experts said, their role is strongest when it is defined: explain the clinical facts, establish what is known about the patient’s wishes, answer medical questions, and bring in donation specialists early.

“I think one important aspect of preventing family conflict is to start the conversation as early as possible,” Güntürkün said. “Approaching families only after the death of a loved one often means that the conversation takes place during a moment of extreme emotional distress. In such situations, uncertainty about the patient’s wishes can easily escalate into family conflict, and conflict frequently results in inaction and lower donation rates.”

That does not mean asking families to decide before they are ready, experts said. It means not leaving the first substantive discussion of donation until the point at which relatives are overwhelmed, confused, or surprised to learn that the law presumed consent.

Where a patient had explicitly registered a decision or discussed donation with the physician, the doctor may be well placed to explain that history. Where the patient’s wishes are unknown, donation specialists, social workers, chaplains, interpreters, and cultural mediators may be better equipped to help relatives work through questions without feeling coerced.

Institutional support matters, Güntürkün said. “In many cases, families do not need persuasion as much as support in navigating uncertainty and conflict during a highly stressful moment,” he said. “Physicians are often highly trained medically, but receive comparatively limited preparation for emotionally complex family conversations surrounding end-of-life decisions and organ donation. Training in conflict-sensitive communication, mediation, and bereavement support could substantially improve these interactions.”

For physicians, the practical lesson from Europe’s opt-out systems may be that the law can set a default, but it cannot replace communication. Presumed consent does not remove the need to know what the patient wanted, to prepare families before a crisis when possible, and to rely on trained teams when a death has made every question more difficult.

Güntürkün reported having no relevant financial relationships. Silva e Silva reported being a co-owner of VANAMI Research and Training, Inc.