Background There is a shortage of organs for life-saving transplants, and organ donation is an altruistic act that should be supported and encouraged. Patients may indicate their desire to be an organ donor through donor registries, but in most countries transplant coordinators still seek the assent of the family before proceeding with donation. These conversations with families are ethically challenging.

Aim To explore the ethically challenging features of these conversations, in the context of talking with families about organ donation after circulatory death, or DCD.

Methods Review of the literature and of training videos that explore these ethical features.

Results Four ethical tensions are identified:

1. The decision to withdraw life sustaining treatment versus the decision to donate organs.

2. Optimising the quality of the dying process versus optimising the quality and quantity of the donated organs.

3. Obligations to provide balanced informed consent versus the belief that we should promote organ donation.

4. Belief that we need to follow the ‘dead donor rule’ versus increasingly contrived protocols for dying and definitions of death.

Discussion After exploring these four ethical features, we will view segments from a video training tape that illustrate different approaches for resolving these tensions.

Conclusion The important goal of promoting organ donation needs to be pursued with awareness and sensitivity for the ethical tensions inherent in this process.