From diagnosis to refusal-causes and barriers to organ donation after brain death: a cross-sectional study.

BACKGROUND: Brain death is the essential condition for organ procurement, yet donation rates in Brazil remain insufficient to meet national transplant needs. Understanding both the clinical determinants of brain death and the social or institutional barriers to organ donation is crucial for improving donation outcomes and informing public health strategies. OBJECTIVES: To identify the main causes of brain death and analyze the factors associated with organ non-donation at a university hospital in São Paulo State. DESIGN AND SETTING: This cross-sectional study with a quantitative approach was conducted at a university hospital in São Paulo State, using data from the Organ Procurement Organization affiliated with the Universidade de São Paulo. METHODS: The medical records of all patients diagnosed with brain death between 2001 and 2015 were reviewed. Sociodemographic variables, clinical causes of brain death, and factors related to donation outcomes were assessed using descriptive statistics and chi-square tests. RESULTS: In total, the data of 1,688 cases were analyzed, including those of 574 donors (34%) and 1,114 non-donors. Traumatic brain injury and hemorrhagic stroke were the predominant neurological causes of brain death. No significant association was observed between sex or cause of brain death and donation outcome. Public initiatives such as the 2001 consent law and the 2014 "Green September" campaign showed limited short-term impact on donation rates. CONCLUSION: Although neurological causes account for most cases of brain death, donation outcomes are strongly influenced by social and institutional factors-particularly family refusal and trust in the healthcare system.