Legislation recognizing brain death in Asia was first enacted in 1987, initially with Singapore, Taiwan, and Sri Lanka. With greater acceptance of brain death and the development of brain death determination clinical protocols, there has been increased donation following brain death in the last five years comprising 82% of deceased organ donation in 2023. Countries in Asia can be categorized into three groups based on their source for organ transplants:

1. Countries where living donation is of primary source for organ transplant, with the proportion of living donor organ transplants exceeding 50% -- These include: India, South Korea, Turkey, Saudi Arabia, Japan, Sri Lanka, Malaysia, Kuwait, Qatar, Philippines, Kazakhstan, Pakistan, Mongolia, Oman, and Bangladesh.
2. Countries where deceased organ donation is of major source for transplants, with only donation following brain death -- These include: Iran, Thailand, United Arab Emirates, and Singapore.
3. Countries where deceased organ donation is the primary source, with donation following both brain death and circulatory determination of death (DCD) -- These include: China and Israel.

A current area of focus includes improving donor identification and consent through innovative technical approaches. These include exploring increasing donor registration by embedding the interface of donor registries into public hospital portal websites and establishing mechanisms for data sharing between electronic social security cards, health insurance cards and donor registries. Donor identification may be improved through automated electronic donor referrals from hospitals’ electronic health record systems linked to donation administration authorities via virtual private networks.

Engaging in organ donation conversations with bereaved families is a complex and sensitive task, taking place at moments of profound grief. In our experience with donor families, we frequently encounter an immediate "NO" when the question of organ donation is raised. This response, while understandable, is often a reflexive reaction to the shock and emotional intensity of the situation rather than a well-considered decision. However, this initial refusal should not dissuade transplant coordinators from revisiting the conversation, as the opportunity for a "YES" only exists if the question is posed.

A recent survey among members of NATCO India (Network and Alliance of Transplant Coordinators) revealed that 87% of respondents had encountered an initial "NO" from families that later evolved into a "YES." This statistic underscores the importance of persistence, sensitivity, and understanding in these discussions. It also highlights the need to explore the underlying reasons for refusal. By addressing these reasons, coordinators can facilitate more informed and supportive conversations, ensuring that families make decisions based on accurate information rather than initial emotional reactions.

Understanding family dynamics and the grieving process is crucial for those involved in these delicate conversations. As described in Elisabeth Kübler-Ross's model, denial is a natural and often initial reaction to loss, serving as a defence mechanism to cope with the shock and pain of the situation. Recognizing denial as part of the grieving process allows transplant coordinators to approach discussions more effectively, giving families the space they need to process their emotions before revisiting the possibility of donation.

Striking a balance between being overly persuasive and giving up too quickly in the face of an initial "NO" is essential. For professionals working in this field, mastering this balance is key to supporting families through some of the most difficult decisions they will ever face.

The European model of organ donation and transplantation can provide useful insights for Asian countries. The success of programs in countries like Spain, Portugal, Italy, and Croatia, and others, is partly attributed to their structured transplant coordination network at national, regional, and hospital levels. Key elements include the special profile of hospital donor coordinators, continuous training, and an ongoing audit of hospital deaths, which all ensure efficient donor detection and management. There is an emphasis on the training of donor coordinators utilising multiple modalities including master and postgraduate programs, internships abroad, and collaborations with local and international universities. The establishment of hospital organ donation units, engagement with intensive care doctors, and professionalisation and systemisation of donation practice helps to normalise deceased donation.

Specific academic projects supported by the European Union that seek to transfer knowledge to universities and implement these practices include ODISSeA (Organ Donation Innovative Strategies for Southeast Asia) and KeTLOD (Knowledge Transfer and Leadership in Organ Donation), which have been established in Malaysia, Thailand, Myanmar, the Philippines, and China.

The Vitallink Academy is another effective collaboration facilitating an exchange between South Korea, Bangladesh, Mongolia, Vietnam, Philippines, Myanmar, Laos, and Cambodia. Participants from developing programs visit the facilities from South Korea and exchange experiences with other international experts.

The International Society of Nephrology/The Transplantation Society Sister Transplant Center Program, supports the development of transplant programs in low or middle-income countries by partnering with developed programs. These programs, centered on improving kidney transplantation, indirectly benefit deceased organ donation by generating the need for organ donors. Through partnerships, centers can share expertise, protocols, and best practices in deceased organ donation, leading to increased organ availability and higher success rates in transplantation efforts across diverse regions.

Vital to successful collaboration is navigating and understanding cultural, healthcare and donation-transplantation system differences. Building trust and fostering effective communication among diverse teams requires cultural sensitivity and adaptability. For international collaborations, investing in understanding the different local cultures and developing strategies to bridge these gaps is fundamental.

Despite these challenges, professionalization and creating an adequate national organizational framework have been demonstrated to be the most effective ways of improving deceased donation rates. Building strong partnerships and adapting to the unique needs of each country are key for a lasting impact in the region.