US · guidance
CMS SOM App. A, Tag A-0890
§482.45(a)(4) - Encourage discretion and sensitivity with respect to the circumstances,
views, and beliefs of the families of potential donors;
Interpretive Guidelines §482.45(a)(4)
Using discretion does not mean a judgment can be made by the hospital that certain families
should not be approached about donation. Hospitals should approach the family with the belief
that a donation is possible and should take steps to ensure the family is treated with respect and
care. The hospital staff’s perception that a family’s grief, race, ethnicity, religion or
socioeconomic background would prevent donation should never be used as a reason not to
approach a family.
All potential donor families must be approached and informed of their donation rights.
Survey Procedures §482.45(a)(4)
• Interview a hospital-designated requestor regarding approaches to donation requests.
• Review the designated requestor training program to verify that it addresses the use of
discretion.
• Review the hospital’s complaint file for any relevant complaints.
History
Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
22ca7c4faab655357870e2ad5e61b8bc53256d2807a9f76cf2b576fec3437d90
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