In reference to the editorial underscoring the importance of end of life palliative care in critical patients,1 Daga et al. comment on the need to offer such patients the possibility of becoming organ and/or tissue donors.

The relevant role played by Intensive Care Medicine in the success of the Spanish organ donation model has been characterized by high ethical quality. At present there is still an imbalance between the demand for organs and the number of donations, and this has led to the introduction of strategies designed to improve the detection of additional donors on the part of the Spanish National Transplant Organization (Organización Nacional de Trasplantes [ONT]).2 In this regard, donation modalities different from those related to brain death have been developed.

In their letter, the authors comment on care oriented towards donation, and on controlled and non-controlled non-heart beating donation – situations which from the ethical perspective deserve separate analysis.

In relation to care oriented towards donation in patients with catastrophic brain damage in wait of brain death, we must ask ourselves whether donation is able to justify the introduction or maintenance of treatment measures that are futile.3 In any case, from the ethical point of view, such measures should be decided on the basis of positive consent from the patient as assessed from his or her history of values, with full guarantees of the absence of suffering. Palliative care is of particular relevance in this respect, and we must foresee the different possible outcomes, guaranteeing in each scenario quality end of life care, regardless of whether donation finally occurs or not.

In relation to controlled non-heart beating donation, and in addition to patient consent, it is essential for the decisions on limitation of life support to be made by the team caring for the patient independently of the transplant coordination team. Once the decision has been made, the possibility of organ donation would be offered as a right of the patient at the end of life.

Non-controlled non-heart beating donation is little developed outside Spain, and deserves special consideration from the ethical perspective,4 due to the prognostic implications derived from prolonged cardiopulmonary resuscitation and the difficulties in the context of an emergency situation not only for obtaining consent but also for starting the organ preservation procedures. It is very unlikely to be able to determine the patient preferences, unless there are advance directives in the form of a living will. Furthermore, the relatives are not always present, and in such situations the conditions would not be ideal for adopting an adequate informative process.

In coincidence with the authors, we consider that organ donation should form an integral part of end of life care and should be offered as a patient right – ensuring high ethical quality adapted to each situation in our clinical practice.