Organ procurement in patients with fatal head injuries. The fate of the potential donor. A 46-month, retrospective review of all victims of fatal head injury at a level 1 trauma center was undertaken to estimate donor organ availability, determine causes of procurement failure, and analyze the functional results of organs transplanted from this group of donors. Causes of procurement failure in 126 patients who died principally from their head injuries included failure of initial resuscitation (14%), ineligibility (28%), failure of physiologic support (14%), and denial of consent (20%). Of 73 eligible donors, 29 (41%) were able to donate one or more vascular organs (heart, liver, kidney). In only one instance was an eligible donor not appropriately identified as such. Failure of physiologic support to prevent early death (25%), and denial of consent (34%) were found to be the two major, potentially remediable causes of procurement failure in this series. Based on this data, an estimated 29 patients/million population/year will survive initially and meet all eligibility requirements for organ donation. Data on 47 kidneys transplanted from the donor group demonstrated a 77% overall graft survival rate at a follow-up period averaging 23 months. Prolonged donor hypotension, but not the use of high-dose vasopressors, adversely affected allograft survival. The current limitations of organ procurement in victims of fatal head injury stem from a limited ability to maintain cardiopulmonary function long enough for the procurement process to be completed and a high overall rate (46%) of denial of consent for organ harvest by next of kin. 